Giulio A.

Santoro
Andrzej P. Wieczorek
Abdul H. Sultan
Editors

Pelvic Floor Disorders

A Multidisciplinary Textbook
Second Edition

123
Pelvic Floor Disorders
Giulio A. Santoro  •  Andrzej P. Wieczorek
Abdul H. Sultan
Editors

Pelvic Floor Disorders

A Multidisciplinary Textbook

Second Edition
Editors
Giulio A. Santoro Andrzej P. Wieczorek
Tertiary Referral Pelvic Floor and Incontinence Department of Pediatric Radiology
Center, IV°Division of General Surgery Medical University of Lublin
Regional Hospital, Treviso Children’s University Hospital
University of Padua Lublin
Padua Poland
Italy

Abdul H. Sultan
Urogynaecology and Pelvic Floor
Reconstruction Unit
Croydon University Hospital
St George’s University of London
London
UK

ISBN 978-3-030-40861-9    ISBN 978-3-030-40862-6 (eBook)

https://doi.org/10.1007/978-3-030-40862-6

© Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
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imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
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This book is dedicated to all the patients, some of whom have suffered whilst
allowing us to learn and improve our skills
Learn from yesterday, live for today, hope for tomorrow.

The important thing is not to stop questioning

Education is not the learning of facts, but the training of the mind to think

Albert Einstein
Foreword

It is indeed a deep honor to be asked to provide a foreword to this comprehensive book on

pelvic floor disorders. The editors Santoro, Wieczorek, and Sultan—a colorectal surgeon, a
radiologist, and urogynecologist—form a unique multidisciplinary team. Together they have
successfully unraveled the complexities of the pelvic floor by holistically dealing with every
aspect: urogynecology, urology, colorectal surgery, radiology, physical therapy, gynecology,
and oncology.
The authors are carefully selected experts in the different subspecialties. The book starts off
with basic pelvic floor anatomy and physiology, thus providing a basis to understand the patho-
physiology of pelvic floor disorders. For each disorder, namely urinary and anal incontinence,
pelvic organ prolapse, constipation, and obstructed defecation, the epidemiology, diagnosis,
conservative and surgical approach are discussed for both primary and recurrent conditions.
Furthermore, other associated conditions such as obstetric anal sphincter injury, pelvic pain,
and female sexual dysfunction are covered in detail. The section on ultrasound and magnetic
resonance imaging contains outstanding quality of reproduced images. This inclusion is impor-
tant as with improved technology, our understanding of the functioning of the pelvic floor has
improved. The book is well referenced and up to date.
This book is a must-read for every clinician, medical or allied health professions, looking
after patients with pelvic floor dysfunction not only in females but also in men and children. It
should hopefully promote a multidisciplinary approach to care, thus reducing anxiety, cost,
and hospital appointments for patients. I would like to congratulate the editors on this master-
piece, which hopefully will bridge the gaps in knowledge and improve the care we provide to
women with pelvic floor disorders.

August 2020 Ranee Thakar

President of the International Urogynecological Association
Consultant Obstetrician and Urogynecologist
Croydon University Hospital, Croydon, UK

David Castro Diaz
General Secretary of the International Continence Society
Functional Urology Unit
University Hospital of Canary Islands
Tenerife, Spain

ix
Preface

The pelvic floor is one of the most complex anatomical and functional areas of the human body
and to this day has remained an enigma. Although it is still empirically divided in anterior,
middle, and posterior compartments, the pelvic floor components act in unison to maintain
bowel, bladder, and sexual function. Pelvic floor disorders represent a significant physical,
social, and economic problem that often poses a challenge to specialists dealing with them.
The reason for this is that the functional mechanisms are so complex and poorly understood
that patient’s symptoms do not always correspond to physical examination findings, because
various co-existing occult conditions are often underestimated. In order to achieve the optimal
treatment, it is mandatory to overcome the fractured uni-disciplinary approach to the pelvic
floor with multidisciplinary teams of experts (colorectal surgeons, urologists, urogynecolo-
gists, gastroenterologists, radiologists, physiatrists) having a unitary vision.
In 2010 we published the book Pelvic Floor Disorders: Imaging and Multidisciplinary
Approach to Management. Since then there have been more than 180,000 downloads of the
online version of the chapters, confirming the huge interest and demand in this field. Major
developments in diagnostics and treatments of pelvic floor disorders over the last few years led
us to work on a new edition: Pelvic Floor Disorders: A Multidisciplinary Textbook. The result
is not simply an update of the previous book, but to a considerable extent providing a compre-
hensive overview of pelvic floor anatomy and physiology, principles and technical aspects of
imaging modalities, mechanisms of pelvic floor trauma during vaginal delivery, epidemiology,
etiology, assessment and management of urinary incontinence and voiding dysfunction, anal
incontinence, pelvic organ prolapse, constipation and obstructed defecation, pelvic pain and
sexual dysfunctions, perineal and perianal fistula, and management of failures or recurrences
after surgery.
This textbook was also produced to meet the needs of education. It is a manual of practical
instructions that we hope could be of great value to both medical students and specialists in the
field. In particular, the various ultrasonographic techniques for the imaging of the pelvic floor
(transperineal, endovaginal, endoanal, endorectal, 2D/3D/4D) are presented in a systematic
way. Hundreds of images and anatomical illustrations have been included to help the reader to
learn how to visualize and interpret ultrasound images but also provide more experienced
examiners with an opportunity to review and re-appraise their techniques. Standardization of
the methodology is fundamental to increase accuracy, reliability, and repeatability, leading to
a wider acceptance of these modalities in the daily practice. Surgical procedures described in
every detail in the text are accomplished by videos on the e-book version. In the Appendix
Section, the algorithms for the treatment of pelvic floor disorders, according to the 6th
International Consultation on Incontinence, summarize step-by-step the approach to these dif-
ferent pathological conditions. These algorithms should be considered for adoption into rou-
tine clinical practice to standardize management in accordance with the best available
evidence-based medicine. This would enable consistent management with a view to reducing
unnecessary surgeries, thereby minimizing the risk of failure, as well as faster and more effec-
tive treatment of postoperative complications.
Our sincere gratitude goes to Springer for supporting the idea of publishing the new edition
as a textbook and, in particular, to Subramaniam Vinodhini, Hemalatha Gunasekaran, Donatella

xi
xii Preface

Rizza and Elisa Geranio for their constant assistance throughout the development of the proj-
ect, organizing every stage of the editorial work. Our deep appreciation to all international
authors who have contributed to many chapters, sharing their knowledge and expertise. Without
their invaluable help, this book would not have been possible. Further, thanks must go to our
hospitals and institutions (Prof. Giacomo Zanus, Chief of IV°Division of General Surgery,
Regional Hospital Treviso, Dr. Francesco Benazzi, CEO of AULSS 2 Marca Trevigiana, Italy;
Medical University of Lublin, Children’s Teaching Hospital, Department of Pediatric
Radiology, Lublin, Poland; Department of Obstetrics and UroGynaecology, Croydon
University Hospital, Croydon, Surrey, UK) whose advanced technological support made it
possible to accomplish this new project.
We hope that this textbook would be a necessary companion to all clinicians involved in the
care of our patients suffering from pelvic floor disorders.

Treviso, Italy Giulio A. Santoro

Lublin, Poland  Andrzej P. Wieczorek
Croydon, UK  Abdul H. Sultan
August 2020
Contents

Part I State of the Art Pelvic Floor Anatomy

1 Pelvic Floor Anatomy�����������������������������������������������������������������������������������������������    3

S. Abbas Shobeiri and John O. L. DeLancey
2 Biochemical Properties and Hormonal Receptors of Pelvic Floor Tissues���������   25
Heinz Koelbl and Ksenia Halpern-Elenskaia
3 The Integral System of Pelvic Floor Function and Dysfunction���������������������������   31
Peter Petros, Michael Swash, and Darren Gold
4 The Pelvic Floor: Neurocontrol and Functional Concepts�����������������������������������   57
Michael Swash and Peter Petros

Part II Pelvic Floor Imaging

5 Principles and Technical Aspects of Integrated Pelvic Floor Ultrasound�����������   73

Andrzej P. Wieczorek, Magdalena Maria Woźniak, Jacek Piłat,
and Giulio A. Santoro
6 Transperineal Ultrasonography: Methodology and Normal
Pelvic Floor Anatomy�����������������������������������������������������������������������������������������������   89
Hans Peter Dietz
7 Endovaginal Ultrasonography: Methodology and Normal
Pelvic Floor Anatomy�����������������������������������������������������������������������������������������������  111
Giulio A. Santoro, Andrzej P. Wieczorek, S. Abbas Shobeiri,
and Aleksandra Stankiewicz
8 Endoanal and Endorectal Ultrasonography:
Methodology and Normal Anorectal Anatomy �����������������������������������������������������  133
Giulio A. Santoro, Luigi Brusciano, and Abdul H. Sultan
9 Technical Innovations in Pelvic Floor Ultrasonography���������������������������������������  147
Magdalena Maria Woźniak, Andrzej P. Wieczorek, Giulio Aniello Santoro,
Aleksandra Stankiewicz, Jakob Scholbach, and Michał Chlebiej
10 Magnetic Resonance Imaging: Methodology and Normal
Pelvic Floor Anatomy�����������������������������������������������������������������������������������������������  171
Jeroen A. W. Tielbeek and Jaap Stoker
11 Dynamic Magnetic Resonance Imaging of the Pelvic Floor:
Technique and Methodology �����������������������������������������������������������������������������������  179
Khoschy Schawkat and Cäcilia S. Reiner

xiii
xiv Contents

Part III Obstetric Pelvic Floor and Anal Sphincter Trauma

12 Mechanisms of Pelvic Floor Trauma During Vaginal Delivery ���������������������������  189

James A. Ashton-Miller and John O. L. DeLancey
13 Posterior Compartment Trauma and Management of Acute
Obstetric Anal Sphincter Injuries���������������������������������������������������������������������������  211
Abdul H. Sultan and Ranee Thakar
14 Neurogenic Trauma During Delivery���������������������������������������������������������������������  223
Kimberly Kenton and Julia Geynisman-Tan
15 Prevention of Perineal Trauma �������������������������������������������������������������������������������  229
Ranee Thakar and Abdul H. Sultan

Part IV Urinary Incontinence and Voiding Dysfunction

16 Overview: Epidemiology and Etiology of Urinary Incontinence

and Voiding Dysfunction �����������������������������������������������������������������������������������������  239
Ian Milsom and Maria Gyhagen
17 Urinary Incontinence and Voiding Dysfunction:
Patient-Reported Outcome Assessment �����������������������������������������������������������������  249
Eduardo Cortes and Linda Cardozo
18 Urodynamics Techniques and Clinical Applications���������������������������������������������  263
Michel Wyndaele and Paul Abrams
19 Ultrasonographic Techniques and Clinical Applications �������������������������������������  277
Andrzej P. Wieczorek, Magdalena Maria Woźniak,
and Aleksandra Stankiewicz
20 Biofeedback���������������������������������������������������������������������������������������������������������������  301
Kari Bø and Paolo Di Benedetto
21 Selection of Midurethral Slings for Women with
Stress Urinary Incontinence�������������������������������������������������������������������������������������  305
Joseph K.-S. Lee and Peter L. Dwyer
22 Tape Positioning: Does It Matter?���������������������������������������������������������������������������  317
Aparna Hegde and G. Willy Davila
23 Colposuspension and Fascial Sling�������������������������������������������������������������������������  329
Fiona Reid
24 Injectable Biomaterials���������������������������������������������������������������������������������������������  339
Tomi S. Mikkola
25 Artificial Urinary Sphincter in Women �����������������������������������������������������������������  343
Amrith Raj Rao and Philippe Grange
26 Pharmacological Treatment of Urinary Incontinence and
Overactive Bladder: The Evidence�������������������������������������������������������������������������  351
Dudley Robinson and Linda Cardozo
27 Intravesical Botulinum Toxin for the Treatment of Overactive Bladder�������������  365
Pawel Miotla and Tomasz Rechberger
28 Sacral Nerve Stimulation for Overactive Bladder and Voiding Dysfunction �����  375
Philip E. V. Van Kerrebroeck
Contents xv

Part V Anal Incontinence

29 Overview: Epidemiology and Aetiology of Anal Incontinence�����������������������������  387

Alison J. Hainsworth, Andrew B. Williams, and Alexis M. P. Schizas
30 Patient-Reported Outcome Assessment in Anal Incontinence�����������������������������  399
Toshiki Mimura
31 Anorectal Manometry����������������������������������������������������������������������������������������������  411
Filippo Pucciani and Iacopo Giani
32 Endoanal Ultrasonography in Anal Incontinence�������������������������������������������������  417
Giulio Aniello Santoro, Luigi Brusciano, and Abdul H. Sultan
33 Transperineal Ultrasonography in the Assessment of Anal
Incontinence and Obstetric Anal Sphincter Injuries���������������������������������������������  437
Cristina Ros-Cerro, Eva Maria Martínez-Franco, and Montserrat Espuña-Pons
34 Magnetic Resonance Imaging ���������������������������������������������������������������������������������  445
Jeroen A. W. Tielbeek and Jaap Stoker
35 Neurophysiological Evaluation: Techniques and Clinical Evaluation�����������������  451
Mitul Patel, Kumaran Thiruppathy, and Anton Emmanuel
36 Behavioral Therapies and Biofeedback for Anal Incontinence ���������������������������  459
Bary Berghmans, Esther Bols, Maura Seleme, Silvana Uchôa, Donna Bliss,
and Toshiki Mimura
37 Sphincter Repair and Postanal Repair�������������������������������������������������������������������  473
Adam Studniarek, Johan Nordenstam, and Anders Mellgren
38 Dynamic Graciloplasty���������������������������������������������������������������������������������������������  483
Piotr Walega and Maciej Walega
39 Injectable and Implantable Biomaterials for Anal Incontinence�������������������������  491
Alex Hotouras and Pasquale Giordano
40 Sacral Neuromodulation for Fecal Incontinence���������������������������������������������������  503
Klaus E. Matzel and Birgit Bittorf
41 Posterior Tibial Nerve Stimulation for Faecal Incontinence���������������������������������  511
Gregory P. Thomas, Carolynne J. Vaizey, and Yasuko Maeda
42 Radiofrequency���������������������������������������������������������������������������������������������������������  517
Luanne Force, Mariana Berho, and Steven D. Wexner
43 Other Surgical Options for Anal Incontinence:
From End Stoma to Stem Cell���������������������������������������������������������������������������������  521
Zoran Krivokapić and Barišić Goran
44 Treatment of Anal Incontinence: Which Outcome Should We Measure?�����������  533
Alison J. Hainsworth, Alexis M. P. Schizas, and Andrew B. Williams

Part VI Pelvic Organ Prolapse

45 Epidemiology and Etiology of Pelvic Organ Prolapse�������������������������������������������  547

Stefano Salvatore, Sarah De Bastiani, and Fabio Del Deo
46 Patient-Reported Outcomes and Pelvic Organ Prolapse �������������������������������������  555
Stavros Athanasiou
xvi Contents

47 Integrated Imaging Approach to Pelvic Organ Prolapse �������������������������������������  577

Giulio A. Santoro, Andrzej P. Wieczorek, Magdalena Maria Woźniak,
Jonia Alshiek, Abbas Shoebeiri, and Abdul H. Sultan
48 Transperineal Ultrasound: Practical Applications �����������������������������������������������  587
Hans Peter Dietz
49 Three-Dimensional and Dynamic Endovaginal Ultrasonography
for Pelvic Organ Prolapse and Levator Ani Damage���������������������������������������������  619
Jonia Alshiek, Ghazaleh Rostaminia, Lieschen H. Quiroz,
and S. Abbas Shobeiri
50 Magnetic Resonance Imaging, Levator Ani Damage, and Pelvic
Organ Prolapse���������������������������������������������������������������������������������������������������������  639
John O. L. DeLancey
51 Dynamic Magnetic Resonance Imaging of Pelvic Floor Pathologies�������������������  653
Cäcilia S. Reiner and Khoschy Schawkat
52 Pelvic Floor Muscle Training in Prevention and Treatment of
Pelvic Organ Prolapse����������������������������������������������������������������������������������������������  661
Kari Bø and Ingeborg H. Brækken
53 Use of Pessaries for Pelvic Organ Prolapse �����������������������������������������������������������  667
Dimos Sioutis and Rohna Kearney
54 Anterior and Posterior Colporrhaphy: Native Tissue Versus Mesh���������������������  675
Bernard T. Haylen
55 Apical Prolapse Surgery�������������������������������������������������������������������������������������������  687
Christopher Maher
56 Laparoscopic Pelvic Floor Surgery�������������������������������������������������������������������������  695
Jan Deprest, Ann-Sophie Page, Albert Wolthuis, and Susanne Housmans
57 The Robotic Approach to Urogenital Prolapse������������������������������������������������������  709
Claire M. McCarthy, Orfhlaith E. O’Sullivan, and Barry A. O’Reilly
58 Concurrent Prolapse and Incontinence Surgery���������������������������������������������������  723
Annette Kuhn
59 Management of Pelvic Organ Prolapse:
A Unitary or Multidisciplinary Approach? �����������������������������������������������������������  729
David Ossin and G. Willy Davila

Part VII Constipation and Obstructed Defecation

60 Epidemiology and Etiology of Constipation and Obstructed

Defecation: An Overview�����������������������������������������������������������������������������������������  737
Mahmoud Abu Gazala and Steven D. Wexner
61 Patient-Reported Outcome Assessment in Constipation and
Obstructed Defecation ���������������������������������������������������������������������������������������������  741
Toshiki Mimura
62 Anorectal Manometry, Rectal Sensory Testing and Evacuation Tests�����������������  753
Mitul Patel, Kumaran Thiruppathy, and Anton Emmanuel
63 Ultrasonography in the Assessment of Obstructive Defecation Syndrome���������  761
Marc Beer-Gabel, Ugo Grossi, Christian Raymond S. Magbojos,
and Giulio A. Santoro
Contents xvii

64 Echodefecography: Technique and Clinical Application��������������������������������������  781

Sthela M. Murad-Regadas, Francisco Sérgio P. Regadas, and Steven D. Wexner
65 Evacuation Proctography�����������������������������������������������������������������������������������������  801
Magdalena Maria Woźniak, Aleksandra Stankiewicz, Alexander Clark,
and Andrzej P. Wieczorek
66 The Abdominal Approach to Rectal Prolapse �������������������������������������������������������  811
Sthela M. Murad-Regadas, Rodrigo A. Pinto, and Steven D. Wexner
67 The Perineal Approach to Rectal Prolapse�������������������������������������������������������������  827
Alison Althans, Anuradha Bhama, and Scott R. Steele
68 The Laparoscopic Approach to Rectal Prolapse ���������������������������������������������������  835
Bart Van Geluwe and Andrè D’Hoore
69 The Role of Robotic Surgery in Rectal Prolapse���������������������������������������������������  847
Adam Studniarek, Anders Mellgren, and Johan Nordenstam
70 Sacral Neuromodulation for Constipation�������������������������������������������������������������  855
Klaus E. Matzel and Birgit Bittorf

Part VIII Pelvic Pain and Sexual Dysfunction

71 Bladder Pain Syndrome/Interstitial Cystitis ���������������������������������������������������������  861

Mauro Cervigni
72 Pelvic Pain Associated with a Gynecologic Etiology ���������������������������������������������  879
Megan B. Shannon and Elizabeth R. Mueller
73 Chronic Idiopathic Anorectal Pain Disorders �������������������������������������������������������  891
Bruno Roche and Cosimo Riccardo Scarpa
74 Female Sexual Dysfunction �������������������������������������������������������������������������������������  909
Dorothy Kammerer-Doak and Rebecca Rogers
75 A Myofascial Perspective on Chronic Urogenital Pain in Women�����������������������  923
Marek Jantos
76 Pharmacological Treatment of Chronic Pelvic Pain ���������������������������������������������  945
Ashish Shetty, Oscar Morice, and Sohier Elneil
77 Idiopathic Chronic Pelvic Pain: A Different Perspective �������������������������������������  951
Peter Petros and Yuki Sekiguchi

Part IX  Fistulae

78 Urogenital Fistulae���������������������������������������������������������������������������������������������������  965

Andrew Browning
79 Rectovaginal Fistulae�����������������������������������������������������������������������������������������������  975
A. Muti Abulafi and Abdul H. Sultan
80 Emerging Concepts in Classification of Anal Fistulae�������������������������������������������  995
Arun Rojanasakul and Charles B. Tsang
81 Ultrasonographic Assessment of Anorectal Fistulae��������������������������������������������� 1003
Giulio Aniello Santoro, Christian Raymond S. Magbojos, Giovanni Maconi,
and Iwona Sudoł-Szopińska
xviii Contents

82 MR Imaging of Fistula-in-Ano ������������������������������������������������������������������������������� 1029

Steve Halligan
83 Surgical Treatment of Anorectal Sepsis ����������������������������������������������������������������� 1041
Charles B. Tsang
84 Management of Anorectal Fistulae in Crohn’s Disease����������������������������������������� 1059
Jeanie Ashburn and Luca Stocchi

Part X Failure or Recurrence After Surgical Treatment:

What to Do When It All Goes Wrong

85 Imaging and Management of Complications of Urogynecologic Surgery����������� 1075

Jonia Alshiek and S. Abbas Shobeiri
86 Surgical Management of Complications After Urogynaecological Surgery������� 1097
Ivilina Pandeva and Mark Slack
87 Endosonographic Investigation of Anorectal Surgery Complications����������������� 1115
Christian Raymond S. Magbojos and Giulio Aniello Santoro
88 Investigation and Management of Complications After
Coloproctological Surgery��������������������������������������������������������������������������������������� 1125
Tim W. Eglinton and Frank A. Frizelle

Part XI Miscellaneous

89 Congenital Abnormalities of the Pelvic Floor: Assessment and Management������ 1139

Paweł Nachulewicz, Magdalena Maria Woźniak, and Agnieszka Brodzisz
90 Male Urinary Incontinence: Assessment and Management��������������������������������� 1159
Nadir I. Osman and Christopher R. Chapple
Appendix: Management Consensus Statement������������������������������������������������������������� 1169
Index����������������������������������������������������������������������������������������������������������������������������������� 1179
Contributors

Paul Abrams  Bristol Urological Institute, Southmead Hospital, Bristol, UK

A. Muti Abulafi  Department of Colorectal Surgery, Croydon University Hospital, Surrey, UK
Jonia  Alshiek  Department of Obstetrics and Gynecology, INOVA Health, Inova Women’s
Hospital, Virginia Commonwealth University, Falls Church, VA, USA
Technion Medical School, Hillel Yaffe Hospital, Hadera, Israel
Alison Althans  Case Western Reserve University School of Medicine, Cleveland, OH, USA
Jeanie Ashburn  Wake Forest University, Baptist Medical Center, Winston-Salem, NC, USA
James A. Ashton-Miller  Pelvic Floor Research Group, Biomechanics Research Laboratory,
Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
Stavros Athanasiou  National and Kapodistrian University of Athens, Athens, Greece
Marc  Beer-Gabel  Neurogastroenterology and Pelvic Floor Unit, Laniado Medical Center,
Natanya, Israel
Bary  Berghmans Pelvic Care Center Maastricht, Maastricht University Medical Centre,
Maastricht, The Netherlands
Mariana  Berho Department of Pathology and Laboratory Medicine, Cleveland Clinic
Florida, Weston, FL, USA
Anuradha  Bhama Department of Colorectal Surgery, Cleveland Clinic Foundation,
Cleveland, OH, USA
Birgit  Bittorf Sektion Koloproktologie, Chirurgische Klinik der Universität Erlangen-
Nürnberg, Erlangen, Germany
Donna Bliss  University of Minnesota School of Nursing, Minneapolis, MN, USA
Kari Bø  Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
Esther Bols  Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
Ingeborg H. Brækken  Department of Global Public Health and Primary Care, University of
Bergen, Bergen, Norway
Agnieszka  Brodzisz Department of Pediatric Radiology, Medical University of Lublin,
Children’s University Hospital, Lublin, Poland
Andrew Browning  Barbara May Foundation, Bowral, NSW, Australia
Luigi Brusciano  XI Divisione di Chirurgia Generale e dell’Obesità, Università degli Studi
della Campania “Luigi Vanvitelli”, Caserta, Italy
Linda Cardozo  Department of Urogynaecology, Kings College Hospital, London, UK

xix
xx Contributors

Mauro Cervigni  Female Pelvic Medicine and Reconstructive Surgery Center, “La Sapienza”
University, ICOT-Polo Pontino, Latina, Italy
Christopher  R.  Chapple Department of Urology, Sheffield Teaching Hospitals NHS
Foundation, Trust, Sheffield, UK
Michał  Chlebiej Faculty of Mathematics and Computer Science, Nicolaus Copernicus
University in Toruń, Toruń, Poland
Alexander Clark  Imaging Department, University Hospitals of North Midlands NHS Trust,
Keele University, Stoke-on-Trent, UK
Eduardo Cortes  Kingston Hospital, London, UK
Andrè  D’Hoore Department of Abdominal Surgery, University Hospitals Gasthuisberg
Leuven, Leuven, Belgium
G. Willy Davila  Department of Gynecology, Section in Female Pelvic Medicine Reconstructive
Surgery, Cleveland Clinic Florida, Weston, FL, USA
Dorothy Mangurian Comprehensive Women’s Center, Holy Cross Medical Group, Fort
Lauderdale, FL, USA
Sarah De Bastiani  IRCCS San Raffaele Scientific Institute, Milan, Italy
John O. L. DeLancey  Norman F. Miller Professor of Gynecology, Female Pelvic Medicine
and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Michigan
Medical School, Ann Arbor, MI, USA
Fabio Del Deo  IRCCS San Raffaele Scientific Institute, Milan, Italy
Jan Deprest  Pelvic Floor Unit, University Hospitals Leuven, Leuven, Belgium
Paolo Di Benedetto  Department of Rehabilitation Medicine, Institute of Physical Medicine
and Rehabilitation, University of Udine, Udine, Italy
Hans  Peter  Dietz Sydney Medical School-Nepean, University of Sydney, Sydney, NSW,
Australia
Peter  L.  Dwyer  Department of Urogynaecology, Mercy Hospital for Women, Melbourne,
VIC, Australia
Tim  W.  Eglinton Division of Colorectal Surgery, Department of Academic Surgery,
University of Otago, Christchurch, New Zealand
Sohier Elneil  Division of Pain Medicine, University College London Hospitals, London, UK
Anton Emmanuel  Gastrointestinal Physiology Unit, University College Hospital, London,
UK
Montserrat  Espuña-Pons Pelvic Floor Unit, Institut Clínic de Ginecologia, Obstetrícia i
Neonatologia (ICGON), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona,
Spain
Luanne Force  Department of Colorectal Surgery, Digestive Disease Center, Cleveland Clinic
Florida, Weston, FL, USA
Frank  A.  Frizelle Division of Colorectal Surgery, Department of Academic Surgery,
University of Otago, Christchurch, New Zealand
Mahmoud  Abu Gazala Department of Colorectal Surgery, Digestive Disease Center,
Cleveland Clinic Florida, Weston, FL, USA
Julia Geynisman-Tan  Department of Obstetrics and Gynecology, Female Pelvic Medicine
and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago,
IL, USA
Contributors xxi

Iacopo Giani  Proctology Unit, USL Toscana Centro, Firenze, Italy

Pasquale Giordano  Royal London Hospitals, Barts Health NHS Trust, London, UK
Darren Gold  UNSW Professorial Surgical Unit, St Vincent’s Hospital Sydney, Sydney, NSW,
Australia
Barišić Goran  Clinical Center of Serbia, Clinic for Digestive Surgery, First Surgical Clinic,
Belgrade School of Medicine, University of Belgrade, Belgrade, Serbia
Philippe Grange  King’s College Hospital, London, UK
Ugo Grossi  Tertiary Referral Pelvic Floor and Incontinence Center, IV°Division of General
Surgery, Regional Hospital, Treviso, Italy and University of Padua, Padua, Italy
Maria  Gyhagen Department of Obstetrics & Gynaecology, Sahlgrenska Academy at
Gothenburg University, Gothenburg, Sweden
Alison J. Hainsworth  Colorectal Surgery, Guy’s and St Thomas’ Hospital, London, UK
Steve Halligan  Centre for Medical Imaging, University College London, London, UK
Ksenia Halpern-Elenskaia  Department of Obstetrics and Gynecology, Medical University
Vienna, Vienna, Austria
Bernard T. Haylen  University of New South Wales, Sydney, NSW, Australia
Aparna Hegde  Tata Center for Urogynecology and Pelvic Health, Mumbai and the Center for
Urogynecology and Pelvic Health, New Delhi, India
Alex Hotouras  Royal London Hospitals, Barts Health NHS Trust, London, UK
Susanne Housmans  Pelvic Floor Unit, University Hospitals Leuven, Leuven, Belgium
Marek Jantos  Behavioural Medicine Institute of Australia, Adelaide, SA, Australia
Dorothy  Kammerer-Doak  Women’s Pelvic Specialty Care of New Mexico, Albuquerque,
NM, USA
Rohna  Kearney Warrell Unit, St Mary’s Hospital, Manchester University Hospitals NHS
Trust, Manchester Academic Health Science Centre, Manchester, UK
School of Medical Sciences, Faculty of Biology, Medicine and Health, University of
Manchester, Manchester, UK
Kimberly Kenton  Department of Obstetrics and Gynecology, Female Pelvic Medicine and
Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL,
USA
Heinz Koelbl  Department of Obstetrics and Gynecology, Medical University Vienna, Vienna,
Austria
Zoran  Krivokapić Clinical Center of Serbia, Clinic for Digestive Surgery, First Surgical
Clinic, Belgrade School of Medicine, University of Belgrade, Belgrade, Serbia
Annette Kuhn  Department of Urogynaecology, University of Bern, Frauenklinik, Inselspital,
Bern, Switzerland
Joseph K.-S. Lee  St Vincents Clinic University of NSW, Sydney, NSW, Australia
Giovanni Maconi  Diagnostica e Fisiopatologia Gastroenterologica, Ospedale Luigi Sacco,
Milan, Italy
Yasuko  Maeda  Western General Hospital, King’s College London, University of London,
Harrow, UK
xxii Contributors

Christian Raymond S. Magbojos  Tertiary Referral Pelvic Floor and Incontinence Center,

IV°Division of General Surgery, Regional Hospital, Treviso, Italy and University of Padua,
Padua, Italy
Christopher Maher  Urogynaecologist Wesley and Royal Brisbane and Women’s Hospital,
University of QLD, Brisbane, QLD, Australia
Eva  Maria  Martínez-Franco Parc Sanitari Sant Joan de Déu, Sant Boi del Llobregat,
Barcelona, Spain
Klaus  E.  Matzel Sektion Koloproktologie, Chirurgische Klinik der Universität Erlangen-
Nürnberg, Erlangen, Germany
Claire M. McCarthy  Department of Obstetrics and Gynaecology, Cork University Maternity
Hospital, Cork, Ireland
Anders Mellgren  Division of Colon and Rectal Surgery, University of Illinois at Chicago,
Chicago, IL, USA
Tomi  S.  Mikkola Department of Obstetrics and Gynecology, Helsinki University Central
Hospital, Helsinki, Finland
Ian Milsom  Department of Obstetrics & Gynaecology, Sahlgrenska Academy at Gothenburg
University, Gothenburg, Sweden
Toshiki  Mimura Division of Gastroenterological, General and Transplant Surgery, Jichi
Medical University, Tochigi, Japan
Pawel Miotla  2nd Department of Gynaecology, Medical University of Lublin, Lublin, Poland
Oscar Morice  University College London Medical School, London, UK
Elizabeth R. Mueller  Female Pelvic Medicine and Reconstructive Surgery, Departments of
Urology, Obstetrics and Gynecology, Loyola University Stritch School of Medicine, Chicago,
IL, USA
Sthela M. Murad-Regadas  Colorectal Surgery at University Hospital, School of Medicine,
Federal University of Ceara, Fortaleza, Ceara, Brazil
Anorectal Physiology and Pelvic Floor Unit, Sao Carlos Hospital, Fortaleza, Ceara, Brazil
Paweł  Nachulewicz  Clinic of Pediatric Surgery and Traumatology, Medical University of
Lublin, Children’s University Hospital, Lublin, Poland
Johan Nordenstam  Division of Colon and Rectal Surgery, University of Illinois at Chicago,
Chicago, IL, USA
Barry A. O’Reilly  Department of Obstetrics and Gynaecology, University College Dublin,
Dublin, Ireland
Department of Urogynaecology, Cork University Maternity Hospital, Cork, Ireland
ASSERT Centre, University College Cork, Cork, Ireland
Orfhlaith  E.  O’Sullivan Department of Obstetrics and Gynaecology, Cork University
Maternity Hospital, Cork, Ireland
Nadir  I.  Osman Department of Urology, Sheffield Teaching Hospitals NHS Foundation,
Trust, Sheffield, UK
David Ossin  Department of Gynecology, Section in Female Pelvic Medicine Reconstructive
Surgery, Cleveland Clinic Florida, Weston, FL, USA
Holy Cross Medical Group, Dorothy Mangurian Comprehensive Women’s Center, Boca
Raton, FL, USA
Contributors xxiii

Ann-Sophie Page  Pelvic Floor Unit, University Hospitals Leuven, Leuven, Belgium

Ivilina  Pandeva Department of Gynaecology, Addenbrooke’s Hospital, University of
Cambridge Teaching Hospital, Cambridge, UK
Mitul Patel  Gastrointestinal Physiology Unit, University College Hospital, London, UK
Peter Petros  University of NSW Professorial Department of Surgery, St Vincent’s Hospital,
Sydney, NSW, Australia
School of Mechanical and Chemical Engineering, University of Western Australia, Perth, WA,
Australia
Jacek  Piłat Department of General and Transplant Surgery and Nutritional Treatment,
Medical University of Lublin, Lublin, Poland
Rodrigo A. Pinto  Department of Gastroenterology, Service of Colorectal Surgery, Hospital
das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
Filippo Pucciani  Department of Surgery and Translational Medicine, University of Florence,
Firenze, Italy
Lieschen H. Quiroz  The University of Oklahoma Health Sciences Center, Oklahoma City,
OK, USA
Amrith Raj Rao  Manipal Hospital, Bangalore, India
Tomasz Rechberger  2nd Department of Gynaecology, Medical University of Lublin, Lublin,
Poland
Francisco Sérgio P. Regadas  Department of Surgery, School of Medicine, Federal University
of Ceara, Fortaleza, Ceara, Brazil
Fiona  Reid The Warrell Unit, Manchester University Hospitals NHS Foundation Trust,
Manchester, UK
Cäcilia S. Reiner  Institute of Diagnostic and Interventional Radiology, University Hospital
Zurich, Zurich, Switzerland
Dudley Robinson  Department of Urogynaecology, King’s College Hospital, London, UK
Bruno  Roche Proctology Unit, School of Medicine, University of Geneva, Clinique
Hirslanden Grangettes, Geneva, Switzerland
Rebecca Rogers  Department of Obstetrics and Gynecology, Albany Medical School, Albany,
NY, USA
Arun Rojanasakul  King Chulalongkorn Memorial Hospital, Bangkok, Thailand
Cristina  Ros-Cerro Pelvic Floor Unit, Institut Clínic de Ginecologia, Obstetrícia i
Neonatologia (ICGON), Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona,
Spain
Ghazaleh Rostaminia  The University of Oklahoma Health Sciences Center, Oklahoma City,
OK, USA
Stefano Salvatore  IRCCS San Raffaele Scientific Institute, Milan, Italy
Giulio  A.  Santoro  Tertiary Referral Pelvic Floor and Incontinence Center, IV°Division of
General Surgery, Regional Hospital, Treviso, Italy and University of Padua, Padua, Italy
Cosimo Riccardo Scarpa  Visceral Surgery Division, Yverdon Hospital, University Hospital
of Geneva, Yverdon les Bains, Switzerland
Khoschy Schawkat  Institute of Diagnostic and Interventional Radiology, University Hospital
Zurich, Zurich, Switzerland
xxiv Contributors

Alexis M. P. Schizas  Colorectal Surgery, Guy’s and St Thomas’ Hospital, London, UK

Jakob  Scholbach Mathematisches Institut, Westfälische Wilhelms-Universität Münster,
Münster, Germany
Yuki Sekiguchi   Women’s Clinic LUNA, Yokohama, Japan
Yokohama City University Graduate School of Medicine, Yokohama, Japan
Maura Seleme  abafi-HOLLAND, Maastricht, The Netherlands
Faculdade Inspirar, Curitiba, Brazil
Megan B. Shannon  Female Pelvic Medicine and Reconstructive Surgery, Virginia Women’s
Center, Richmond, VA, USA
Ashish Shetty  Division of Pain Medicine, University College London Hospitals, London, UK
S.  Abbas  Shobeiri University of Virgina INOVA Campus, Department of Obstetrics and
Gynecology, INOVA Women’s Hospital, Falls Church, VA, USA
Dimos Sioutis  Third Department of Obstetrics and Gynaecology, Attikon Hospital, National
and Kapapodistrian University of Athens, Athens, Greece
Mark Slack  Department of Gynaecology, Addenbrooke’s Hospital, University of Cambridge
Teaching Hospital, Cambridge, UK
Aleksandra Stankiewicz  Imaging Department, University Hospitals of North Midlands NHS
Trust, Keele University, Stoke-on-Trent, UK
Scott R. Steele  Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland,
OH, USA
Luca Stocchi  Mayo Clinic Florida, Jacksonville, FL, USA
Jaap  Stoker  Department of Radiology and Nuclear Medicine, Academic Medical Center,
University of Amsterdam, Amsterdam, The Netherlands
Adam Studniarek  Division of Colon and Rectal Surgery, University of Illinois at Chicago,
Chicago, IL, USA
Iwona  Sudoł-Szopińska Department of Radiology, National Institute of Geriatrics,
Rheumatology and Rehabilitation, Warsaw, Poland
Department of Diagnostic Imaging, Warsaw Medical University, Warsaw, Poland
Abdul H. Sultan  Urogynaecology and Pelvic Floor Reconstruction Unit, Croydon University
Hospital, St George’s University of London, London, UK
Michael Swash  The Royal London Hospital, London, UK
Ranee  Thakar Department of Obstetrics and Gynecology, Croydon University Hospital,
Croydon, Surrey, UK
Kumaran Thiruppathy  Division of Colorectal Surgery, Royal Berkshire Hospital, Reading,
UK
Gregory P. Thomas  Ashford and St Peter’s NHS Trust, Surrey, UK
Jeroen A. W. Tielbeek  Department of Radiology and Nuclear Medicine, Academic Medical
Center, University of Amsterdam, Amsterdam, The Netherlands
Charles  B.  Tsang Department of Surgery, Yong Loo Lin School of Medicine, National
University of Singapore, Singapore
Silvana Uchôa  Universidade Católica de Pernambuco, Recife, Pernambuco, Brazil
Contributors xxv

Carolynne J. Vaizey  St Mark’s Hospital Foundation, Harrow, UK

Bart  Van Geluwe Department of Abdominal Surgery, University Hospitals Gasthuisberg
Leuven, Leuven, Belgium
Philip  E.  V.  Van Kerrebroeck Department of Urology, Maastricht University Medical
Center, Maastricht, The Netherlands
Maciej Walega  Department of Anaesthesiology, University Hospital Düsseldorf, Düsseldorf,
Germany
Piotr  Walega 3rd Department of Surgery, Jagiellonian University Collegium Medicum,
Krakow, Poland
Steven D. Wexner  Digestive Disease Center, Department of Colorectal Surgery, Cleveland
Clinic Florida, Weston, FL, USA
Andrzej  P.  Wieczorek  Department of Pediatric Radiology, Medical University of Lublin,
Children’s University Hospital, Lublin, Poland
Andrew B. Williams  Colorectal Surgery, Guy’s and St Thomas’ Hospital, London, UK
Albert Wolthuis  Pelvic Floor Unit, University Hospitals Leuven, Leuven, Belgium
Magdalena  Maria  Woźniak Department of Pediatric Radiology, Medical University of
Lublin, Children’s University Hospital, Lublin, Poland
Michel Wyndaele  Division of Urology, UMC Utrecht, Utrecht, The Netherlands
 Part I
State of the Art Pelvic Floor Anatomy
 Pelvic Floor Anatomy
S. Abbas Shobeiri and John O. L. DeLancey
Learning Objectives
• To conceptualize pelvic organ support.
• To become familiarize with room analogy and sus-
pension bridge analogy of pelvic organ support.
• To understand the intricate anatomy of the levator
ani subdivisions.
• To understand the role of endopelvic fascia and
connective tissue for pelvic organ support.
1.1 Introduction
Pelvic floor disorders are a spectrum of diseases that include
urinary incontinence (UI), fecal incontinence, and pelvic
organ prolapse (POP) which represent a public health issue
in the United States and around the world [1]. Pelvic floor
disorders are debilitating conditions with 24% of adult
women having at least one of the pelvic floor disorders [2].
This epidemic results in surgery in one of nine women [3]. In
the United States, the National Center for Health Statistics
estimates 400,000 operations per year which are performed
for pelvic floor dysfunction, with 300,000 occurring in the
inpatient setting [4]. Among the Australian women, the life-
time risk of surgery for POP in the general female population
was 19% [5]. In an Austrian study, an estimation of the fre-
quency for post-hysterectomy vault prolapse requiring surgi-
cal repair was between 6% and 8% [6]. A single vaginal birth
S. A. Shobeiri (*)
University of Virgina INOVA Campus, Department of Obstetrics
and Gynecology, INOVA Women’s Hospital,
Falls Church, VA, USA
e-mail: Abbas.shobeiri@inova.org
J. O. L. DeLancey
Pelvic Floor Research Group, Department of Obstetrics and
Gynecology, University of Michigan Medical School,
Ann Arbor, MI, USA
e-mail: delancey@umich.edu
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_1
1
has been shown to significantly increase the odds of prolapse
(OR 9.73, 95% CI 2.68–35.35) with subsequent vaginal
births not shown to be associated with a significant increase
in the odds of prolapse [7].
It is forecasted that the number of American women with
at least one pelvic floor disorder will increase from 28.1 mil-
lion in 2010 to 43.8 million in 2050. During this time period,
the number of women with UI will increase 55% from 18.3
million to 28.4 million. For fecal incontinence, the number of
affected women will increase 59% from 10.6 to 16.8 million,
and the number of women with POP will increase 46% from
3.3 to 4.9 million. The highest projections is that in 2050,
58.2 million women in the United States will have at least one
pelvic floor disorder, 41.3 million with UI, 25.3 million with
fecal incontinence, and 9.2 million with POP. All these fore-
casts, although varied, point the direction to increased preva-
lence of pelvic floor disorders which has important public
health implications. Understanding the causes of pelvic floor
disorders is in its infancy. What is known is that prolapse
arises because of injuries and deterioration of the muscles,
nerves, and connective tissue that support and control normal
pelvic function. This chapter focuses on the anatomy of the
pelvic floor in women and how the anterior, posterior com-
partments are supported by apical and lateral segments.
1.1.1 S
 upport of the Pelvic Organs:
Conceptual Overview
The pelvic organs rely on (1) their connective tissue attach-
ments to the pelvic walls and (2) support from the levator ani
muscles that are under neuronal control from the peripheral
and central nervous systems. In this chapter, the term “pelvic
floor” is used broadly to include all the structures supporting
the pelvic floor with special emphasis on the levator ani
group of muscles.
To convey the pelvic floor supportive structures’ 3D
architecture to the reader, we use the “room analogy.” Using
this analogy, the reader can conceptualize the pelvic floor
3
4 S. A. Shobeiri and J. O. L. DeLancey
Fig. 1.1  Room analogy. © Shobeiri 2013
Fig. 1.2  Room analogy with three compartments separated. © Shobeiri
2013
hiatus as the door out of the pelvis (Fig. 1.1). Using this very
simplified analogy, if one views the pelvic floor hiatus from
the S1 location on the sacrum, the door frame for this room
is the perineal membrane, the walls and the floor the levator
ani muscle, and the ceiling the pubic bone. Pelvic floor con-
tains three viscus hollows (Fig. 1.2). We arbitrarily call these
anterior and posterior compartments with lateral and apical
support segments (Fig. 1.3). The tissue separating the ante-
rior compartment and vagina is pubocervical fibromuscularis
or pubocervical fascia or fibromuscularis. The tissue
­separating the vaginal canal from the posterior compartment
has been called several names: the rectovaginal fibromuscu-
laris or rectovaginal fascia or septum (Fig. 1.4). Some have
even argued that this tissue doesn’t exist which may be due
to its complex anatomy. The term “fascia” is often used by
surgeons to refer to the strong tissue that they sew together
during anterior repairs. This has led to confusion and misun-
ANTERIOR
LATERAL
MIDDLE
POSTERIOR
Fig. 1.3  Room analogy with anterior, middle, and posterior compart-
ments and the lateral walls marked. © Shobeiri 2013
Pubic Bone
Pubocervical Fascia
Rectovaginal Fascia
Levator Ani Muscle
Fig. 1.4  Room analogy: pubocervical fibromuscularis and rectovagi-
nal fascia separating the three compartments. © Shobeiri 2013
derstanding of the anatomy. The pubocervical fibromuscu-
laris and the rectovaginal fibromuscularis are attached
laterally to the levator ani muscle with thickening of adven-
titia in this area. Anatomically, the endopelvic fascia refers to
the areolar connective tissue that surrounds the vagina. It
continues down the length of the vagina as loose areolar tis-
sue surrounding the pelvic viscera. Histologic examination
has shown that the vagina is made up of three layers—epi-
thelium, muscularis, and adventitia [8, 9]. The adventitial
layer is loose areolar connective tissue made up of collagen
and elastin, forming the vaginal tube. Therefore, the tissue
that surgeons call fascia at the time of surgery is best
described as fibromuscularis, since it is a mixture of muscu-
laris and adventitia.
Anteriorly, pubocervical fibromuscularis is attached to
the levator ani using arcus tendineus fascia pelvis (Fig. 1.5).
1  Pelvic Floor Anatomy
Fig. 1.5  Retropubic anatomy showing points of attachments of the
arcus tendineus levator ani (ATLA) and the arcus tendineus fascia pel-
vis (ATFP). The urethra (U) sits on the hammock like pubocervical
fibromuscularis. # denotes the levator ani attachment to the obturator
internus muscle Pubic symphysis (PS). © Shobeiri 2013
Perineal Membrane
Arcus Tendineus
Posterior Arcus
Levator Ani
Fig. 1.6  Room analogy: the line of attachment of the pubocervical fas-
cia to the levator ani is arcus tendineus fascia pelvis. The line of attach-
ment of the rectovaginal fascia to the levator ani is the posterior arcus.
Both are shown as red lines. © Shobeiri 2013
Posterior attachment of rectovaginal fibromuscularis to the
levator ani is poorly understood, but we will refer to it as the
posterior arcus (Fig. 1.6) [10]. The anterior compartment is
home to the urethra and the lower part of the bladder. The
vaginal canal is in the middle, and the posterior compartment
is home to anorectum (Fig. 1.7). This analogy is not far from
reality. When one looks at the pelvic floor structures, the
anterior and posterior compartments are clearly separated as
described (Fig.  1.8). Compartmentalization of the pelvic
floor has led to different medical specialties looking at that
specific compartment and paying less attention to the whole
pelvic floor (Fig. 1.9).
5
Bladder outlet
Vaginal canal
Anal canal
Fig. 1.7  Room analogy: three compartments separation. © Shobeiri 2013
Fig. 1.8  Midsagittal anatomy of an intact cadaveric specimen demon-
strating the three different compartments. Pubocervical fibromuscularis
(PCFM), rectovaginal fibromuscularis (RVF). © Shobeiri 2013
If one looks at the vaginal canal from the side, he or she
can appreciate different levels of support as described by
DeLancey and colleagues [11] (Fig. 1.10). Looking at these
supportive structures from the sagittal view exposes the con-
nective tissue elements that keep the room standing.
Generally, a “suspension bridge” analogy is useful for
describing these structures (Fig. 1.11). Although in the room
analogy, the anterior and posterior compartments house the
pelvic organs, in reality, the pelvic organs are part of the
whole pelvic biomechanical system and play an important
supportive role through their connections with structures,
such as the cardinal and uterosacral ligaments. Adapting this
suspension bridge to the human body and the perineal body
and the sacrum become the two anchoring points of the
bridge. The perineal membrane (Level III) and the uterosac-
ral ligaments (Level I) form the two masts of the suspension
6 S. A. Shobeiri and J. O. L. DeLancey
Fig. 1.9  Room analogy: each area or compartment may be managed
by a different specialist. There is a great need for one specialty that
understands the interaction between different compartments and man-
ages them concurrently as much as possible. © Shobeiri 2013
Perineal Membrane Uterosacral support
Lateral Attachments
III II I
Fig. 1.10 Room analogy: Level I supports are provided by the
uterosacral-­cardinal ligament complex (yellow arrows), which keep the
“room” upright. Level II supports are provided by the lateral tendineus
attachments (red lines). The support is provided by perineal membrane
(green area). © Shobeiri 2013
bridge (Fig. 1.12). The lateral wires are the levator ani mus-
cles of the lateral wall (Fig. 1.13), and the attachments of the
vagina to the levator ani muscles laterally in the mid part of
the vagina form Level II support. The levator ani muscles
and the interconnecting fibromuscular structures support the
bladder and urethra anteriorly, the vaginal canal in the mid-
dle, and the anorectal structures posteriorly (Fig. 1.14).
Like a room or a suspension bridge, the pelvic floor is
subjected to loads that should be appropriate for its design.
Fig. 1.11  Suspension bridge analogy; the depiction of a normal bridge.
© Shobeiri 2013
P
ATLA IS
Post-Arcus USL
Sacrum
Anococcygeal
PB ligament
Fig. 1.12  Suspension bridge analogy; the depiction of a suspension
bridge adapted to human female pelvic floor structures. The red masts
are the ischial spine (IS) and the pubis (P). The blue lines are the levator
ani fibers. The green line is the uterosacral ligaments (USL) continuous
with the posterior arcus line. The anococcygeal ligament provides
anchoring point for the posterior structures. Arcus tendineus levator ani
(ATLA), perineal body (PB). © Shobeiri 2013
PR
PV
PA
LP
Fig. 1.13  Suspension bridge analogy; the depiction of a suspension
bridge adapted to human female pelvic floor structures. The levator ani
fibers have intricate and overlapping paths. The puboanalis (PA) and
puboperinealis form some of the supportive structures of the perineum.
The puborectalis (PR) fibers form the sling behind the rectum.
Pubovisceralis (PV) is a collective term we have applied here to the
iliococcygeus and pubococcygeus fibers. The levator plate (LP) is
formed by overlapping of the PV and PR fibers. © Shobeiri 2013
1  Pelvic Floor Anatomy 7

Bladder IS

Vagina

Rectum
Sacrum
Anus
PB

Fig. 1.14  Suspension bridge analogy; the depiction of different com-

partments of pelvic floor. Ischial spine (IS), pubis (P), perineal body
(PB). © Shobeiri 2013

Should these loads exceed what the pelvic floor is capable of

handling, there would be failure in one or multiple support-
ive elements. The pelvic floor is not a static structure. The
levator ani works in concert with the ligamentous structures
to withstand intra-abdominal pressure that could predispose
to POP and urinary or fecal incontinence during daily activi-
ties (Fig.  1.15). The lower end of the pelvic floor is held
closed by the pelvic floor muscles, preventing prolapse by
constricting the base. The spatial relationship of the organs
and the pelvic floor is important. Pelvic support is a combi-
nation of constriction, suspension, and structural geometry. Fig. 1.15  Right lateral standing anatomic depiction of the three com-
partments exposed to intra-abdominal pressure, which results in activa-
The levator ani muscle has puboperinealis, puboanalis, tion of the muscles to prevent prolapse or urinary and fecal incontinence.
pubovaginalis, puborectalis, pubococcygeus, and iliococcy- Anus (A), bladder (B), cervix (Cx), levator ani (LA), rectum (R),
geus subdivisions (Fig. 1.16). The pubococcygeus is a func- urethra (U), vagina (V). © Shobeiri 2013
tional unit of the iliococcygeus, and these two collectively
are known as the pubovisceralis muscle in some literature. perineal body. Levator ani muscles in this area are poorly
We will avoid this term as it can be confusing. The relation- described, but mostly consist of fibrous sheets that envelop
ship of these muscles to each other is intricate, as they criss- the lateral aspects of the vaginal introitus.
cross in different angles to each other (Figs. 1.17 and 1.18).

1.2.2 Apical Segment

1.2 Anatomy and Prolapse
1.2.1 Overview
Level I support is composed of the uterosacral and cardinal
ligaments that form the support of the uterus and upper one
third of the vagina. Stretching and failure of Level I can
result in pure apical prolapse of the uterus or an enterocele
formation. At Level II, there are direct lateral attachments of
the pubocervical fibromuscularis and rectovaginal fibromus-
cularis to the lateral support segment formed by the levator
ani muscles. The variations of defect in this level will be
described in the following sections. In Level III the vaginal
wall is anteriorly fused with the urethra, posteriorly with the
While Level I cardinal and uterosacral ligaments can be sur-
gically identified supporting the cervix and the upper third of
the vagina [12, 13], as they fan out toward the sacrum and
laterally, they become a mixture of connective tissue, blood
vessels, nerves, smooth muscle, and adipose tissue. The
uterosacral ligaments act like rubber bands in that they may
lengthen with initial Valsalva, but resist any further lengthen-
ing at a critical point in which they have to return to their
comfortable length or break (Fig. 1.19). Level I and levator
ani muscles are interdependent. Intact levator ani muscles
moderate the tension placed on the Level I support struc-
tures, and intact Level I support lessens the pressure imposed
from above on the pelvic floor.
8 S. A. Shobeiri and J. O. L. DeLancey
a b
Fig. 1.16 (a) The relative position of levator ani subdivisions during
ultrasound imaging. Iliococcygeus (IC), puboperinealis (PP), superfi-
cial transverse perinei (STP), puboanalis (PA). Illustration: John
Yanson. From Shobeiri et al. [25], with permission. (b) The levator ani
muscle is color coded: from left to right, light brown = coccygeus mus-
cle (CG), brown = iliococcygeus muscle (IC), magenta = ATLA/ATFP,
red = pubovisceralis muscle (PV), green = puborectalis muscle (PR),
1.2.3 Anterior Compartment
Anterior compartment support depends on the integrity of
vaginal muscularis and adventitia and their connections to
the arcus tendineus fascia pelvis. The arcus tendineus fascia
pelvis is at one end connected to the lower sixth of the pubic
bone, 1–2 cm lateral to the midline, and at the other end to
the ischial spine. A simple case of a distension cystocele
could result from a defect in pubocervical fibromuscularis
(Fig. 1.20).
The anterior wall fascial attachments to the arcus tendin-
eus fascia pelvis have been called the paravaginal fascial
attachments by Richardson et al. [14]. Detachment of arcus
pink = puboperinealis muscle (PP), orange = puboanalis muscle (PA).
The labels are placed to orient the viewer to the relative position of the
other structures in the pelvis. Copyright © Shobeiri 2009. (c) The left
lateral view of the left hemi-pelvis. Arcus tendineus levator ani (ATLA),
bladder (B), external anal sphincter (EAS), iliococcygeus (IC), pubo-
coccygeus (PC), puborectalis (PR), pubic symphysis (PS), urethra (U).
© Shobeiri 2013
tendineus from the levator ani is associated with stress
incontinence and anterior prolapse. The detachment can be
unilateral (Fig. 1.21) or bilateral (Fig. 1.22), causing a dis-
placement cystocele. In addition, the defect can be complete
or incomplete. The surgeon who performs an anterior repair
(Fig.  1.22) in reality worsens the underlying disease pro-
cess. The upper portions of the anterior vaginal wall can
prolapse due to lack of Level I support and failure of utero-
sacral-cardinal complex. Over time this failure may lead to
increased load in the paravaginal area and failure of Level II
paravaginal support. A study of 71 women with anterior
compartment prolapse has shown that paravaginal defect
usually results from a detachment of the arcus tendineus fas-
1  Pelvic Floor Anatomy
cia pelvis from the ischial spine, and rarely from the pubic
bone [15]. Resuspension of the vaginal apex at the time of
surgery, in addition to paravaginal or anterior colporrhaphy,
may help to return the anterior wall to a more normal posi-
tion or at least to prevent future failures. Another scenario
that the surgeon faces is the lack of any tangible fibromus-
cular tissue in the anterior compartment (Fig. 1.23). Plication
of the available tissue may cause vaginal narrowing and
dyspareunia. The knowledge of this condition is essential,
Fig. 1.17  Right hemipelvis of a fresh frozen pelvis showing the over-
lapping of the levator ani subdivisions fibers. Orange arrows: puborec-
talis; blue arrows: iliococcygeus; white arrows: pubococcygeus. Note
the relationship between the iliococcygeus and pubococcygeus fibers.
© Shobeiri 2013
a b
Fig. 1.18 (a) Right hemipelvis of a fresh frozen pelvis with the organs
removed. The puborectalis (PR), iliococcygeus (IC), and pubococ-
cygeus (PC) form the lateral sidewall. Note the relationship between the
iliococcygeus and pubococcygeus fibers. Coccyx (C), pubic symphysis
9
as it will require bridging of the anterior compartment with
autologous fascia lata graft [16]. The commercially avail-
able biologic tissue has had high failure rates for the anterior
compartment and no improvement in the posterior
compartment.
Various grading systems such as Pelvic Organ Prolapse
Quantification (POPQ) system [17] used to describe pro-
lapse do not take into account the underlying cause of the
prolapse. Site of care pelvic floor imaging augments the
physical examination to delineate the pathophysiology of
pelvic organ prolapse.
Fig. 1.19  Right hemipelvis of a fresh frozen pelvis showing the utero-
sacral fibers. The borders of the ligament are shown in dotted line.
Cervix (Cx), coccyx (C), pubic symphysis (PS). © Shobeiri 2013
(PS). © Shobeiri 2013. (b) The same right hemipelvis of a fresh frozen
pelvis with the organs removed. The puboanalis and the puboperinealis
are outlined. These fibers are involved in the stabilization of the anus
and the perineum, respectively. © Shobeiri 2013
10
b fibromuscularis can result in a cystocele. © Shobeiri 2013
Fig. 1.20  Room analogy: (a) an occult pubocervical fibromuscularis
defect can result in an overt cystocele (b). © Shobeiri 2013
Fig. 1.21  Right hemipelvis of a fresh frozen pelvis showing a para-
vaginal defect repair outlined in green. Arcus tendineus fascia pelvis
(ATFP), arcus tendineus levator ani (ATLS), pubic symphysis (PS), ure-
thra (U). © Shobeiri 2013
S. A. Shobeiri and J. O. L. DeLancey
Fig. 1.22  Room analogy: bilateral detachment of the pubocervical
Fig. 1.23  Room analogy: absence or severe deficiency of the pubocer-
vical fibromuscularis can result in a cystocele. © Shobeiri 2013
1.2.4 P
 erineal Membrane (Urogenital
Diaphragm)
A critical but perhaps underappreciated part of pelvic floor
support is the perineal membrane as it forms the Level III
support (Fig.  1.24) and one of the anchoring points in the
suspension bridge analogy. On the anterior part caudad to the
levator ani muscles, there is a dense triangular membrane
called the urogenital diaphragm. However, this layer is not a
single muscle layer with a double layer of fascia (“dia-
phragm”), but rather a set of connective tissues that surround
the urethra; the term perineal membrane has been used more
recently to reflect its true nature [18]. The perineal mem-
brane is a single connective tissue membrane, with muscle
lying immediately above. The perineal membrane lies at the
1  Pelvic Floor Anatomy
a b
Fig. 1.24  Three levels of support. (a) Attachments of the cervix and
vagina to the pelvic walls demonstrating different regions of support
with the uterus in situ. Note that the uterine corpus and the bladder have
been removed. (b) Levels of vaginal support after hysterectomy. Level I
(suspension) and Level II (attachment). In level I the paracolpium sus-
pends the vagina from the lateral pelvic walls. Fibers of Level I extend
both vertically and also posteriorly toward the sacrum. In Level II the
level of the hymen and attaches the urethra, vagina, and peri-
neal body to the ischiopubic rami.
1.2.5 P
 osterior Compartment and Perineal
Membrane
The posterior compartment is bound to perineal body and the
perineal membrane caudad (Level III), paracolpium and the
uterosacral ligaments cephalad (level I), and the posterior
arcus connected to the levator ani laterally (Level II). As in
the anterior compartment, a simple defect in rectovaginal
fibromuscularis (Fig. 1.25) can cause a distention rectocele.
A defect in the posterior arcus also called arcus tendineus
rectovaginalis (ATRV) is associated with a pararectal defect
11
vagina is attached to the arcus tendineus fasciae pelvis and the superior
fascia of levator ani. (c) Close up of the lower margin of Level II after a
wedge of vagina has been removed (inset). Note how the anterior vagi-
nal wall, through its connections to the arcus tendineus fascia pelvis,
forms a supportive layer clinically referred to as the pubocervical fascia
(From DeLancey [11], with permission)
that can be unilateral (Fig. 1.26) or bilateral (Fig. 1.27). Such
defects need to be differentiated from total loss of rectovagi-
nal fibromuscularis that may require augmentation of the
compartment with autologous or cadaveric tissue. Most
often, the separation of the posterior arcus may be apical and
may require reattachment of the posterior arcus to the utero-
sacral ligament or the iliococcygeal muscle.
The fibers of the perineal membrane connect through the
perineal body, thereby providing a layer that resists down-
ward descent of the rectum. A separate Level I support does
not exist for anterior and posterior compartments. In the
room analogy used here, the perineal membrane is analogous
to the door frame. If the bottom of the door frame is missing
(Fig. 1.28), then the resistance to downward descent is lost
and a perineocele develops. This situation can be elusive, as
12 S. A. Shobeiri and J. O. L. DeLancey

a a

b
b

Fig. 1.26 (a) Room analogy: right lateral detachment of the rectovagi-

nal septum can result in a rectocele. © Shobeiri 2013. (b) The surgical
view of the posterior compartment showing the relationship between
the levator ani muscle (LAM), the rectovaginal fibromuscularis (RVF),
and the arcus tendineus fasciae rectovaginalis (ATRV). © Shobeiri 2013
Fig. 1.25  Room analogy: (a) an occult rectovaginal defect can result
in an overt rectocele (b). © Shobeiri 2013

the clinical diagnosis is made by realizing the patient’s need

to splint very close to the vaginal opening in order to have a
bowel movement, and the physical examination may reveal
an elongated or “empty” perineal body (Fig.  1.29).
Reattachment of the separated structures during perineorrha-
phy corrects this defect and is a mainstay of reconstructive
surgery. Because the puboperinealis muscles are intimately
connected with the cranial surface of the perineal mem-
branes, this reattachment also restores the muscles to a more
normal position under the pelvic organs in a location where
they can provide support.
Two-dimensional magnetic resonance imaging (MRI) of
posterior vaginal prolapse has elucidated further how the
posterior vaginal wall fail by studying different 3D charac-
teristics of models of rectocele-type posterior vaginal pro- Fig. 1.27  Room analogy: bilateral detachment of the rectovaginal sep-
lapse (PVPR) in women [19]. Increased folding (kneeling) of tum can result in a rectocele. © Shobeiri 2013
1  Pelvic Floor Anatomy 13

Fig. 1.28  Room analogy: absence or severe deficiency of rectovaginal b

fascia can result in a rectocele. © Shobeiri 2013

the vagina and an overall downward displacement are con-

sistently present in rectocele. Forward protrusion, perineal
descent, and distal widening are sometimes seen as well
(Fig. 1.30).
Three anal canal muscular structures that contribute to
fecal continence are the internal anal sphincter (IAS), the
external anal sphincter (EAS), and the levator plate. The
EAS is made up of voluntary muscle that encompasses the
anal canal. It is described as having three parts:

1. The deep part is integral with the puborectalis. Posteriorly

there is some ligamentous attachment. Anteriorly some
fibers are circular.
2. The superficial part has a very broad attachment to the
underside of the coccyx via the anococcygeal ligament.
Anteriorly there is a division into circular fibers and a
decussation to the superficial transverse perinei.
3. The subcutaneous part lies below the IAS.

The IAS always extends cephalad to the EAS for a dis-

tance of more than 1–2 cm. The internal sphincter lies con-
sistently between the external sphincter and the anal mucosa,
extending below the dentate line by 1 cm. Normally, the EAS
begins below the IAS [20].
The muscle fibers from the puboanalis portion of the leva-
tor ani become fibroelastic as they extend caudally to merge
with the conjoined longitudinal layer also known as the lon-
gitudinal muscle (CLL) that is inserted between the EAS and
IAS (see Figs. 1.29b and 1.31a, b) [21]. The CLL fibers and
the puboanalis fibers cannot be palpated clinically. However,
Fig. 1.29 (a) A perineocele in a patient with need to splint to have a
bowel movement. © Shobeiri 2013. (b) This drawing demonstrates the
right sagittal hemipelvis view of the perineal support structures. The
perineum, a small seemingly insignificant part of the female body, is
packed with muscles and fascial layers that interconnect in an intricate
manner. External anal sphincter (EAS), internal anal sphincter (IAS),
ischiopubic rami (IPR), puboanalis (PA), puboanalis insertion (PAI),
perineal body (PB), puboperinealis (PP), puboperineal insertion (PPI),
pubic symphysis (PS), rectum (R), rectovaginal septum, (RVS), super-
ficial transverse perinei (STP), urethra (U), vagina (V). © Shobeiri
2013
14 S. A. Shobeiri and J. O. L. DeLancey

a b
Normal

c d
Posterior
Prolapse

Downward
Displacement

“Kneeling”

Distal Perineal
Forward Widening Descent
Protrusion

Fig. 1.30  Characteristics of posterior prolapse. Comparison of control the upper two thirds part of the vagina, (3) forward protrusion, (4) peri-
(a, b) and case (c, d) in lateral view (a, c) and oblique view (b, d) show- neal descent, and (5) distal widening in the lower third part of the
ing five characteristic features (c, d) during rest (blue) and Valsalva vagina. Pubis and sacrum are shown in white. The P-IS line is shown in
(pink): (1) increased folding (kneeling), (2) downward displacement in turquoise. © DeLancey 2011

the puboperinealis fibers, which are medially located, can be
palpated as a distinct band of fibers joining the perineal body
(see Figs. 1.29b and 1.32).
Per MRI studies done by Hsu and colleagues, the EAS
includes a subcutaneous portion (EAS-SQ) (see Fig. 1.32),
a visibly separate deeper portion (EAS-M), and a lateral
portion that has lateral winged projections (EAS-W). The
EAS-SQ is the distinct part of the EAS (Fig. 1.33). A clear
separation does not exist between concentric portion of
EAS-M and the winged EAS-W. The EAS-W fibers have
differing fiber directions than the other portions, forming
an open “U-shaped” configuration that cannot be visual-
ized in midsagittal view except in the posterior anus.
These fibers are contiguous with the EAS but visibly sep-
arate from the levator plate muscles, whose fibers they
parallel [22].
1  Pelvic Floor Anatomy
a b
Fig. 1.31 (a) Perineal dissection in a fresh frozen pelvis shows the
relationship of the external anal sphincter (EAS) to the perineal body
(PB) and the puboanalis/puboperinealis complex (PA). Ischiorectal fat
(IRF), Vagina (V). © Shobeiri 2013. (b) Perineal dissection in a fresh
frozen pelvis shows the relationship of the superficial transverse perinei
1.2.6 L
 ateral Segment Comprising
of the Levator Ani Muscle Support
It is generally accepted that the levator ani muscles and the
associated fascial layer surround pelvic organs like a funnel
to form the pelvic diaphragm [23]. Given that we employ
concepts such as pelvic floor spasm, levator spasm, and pel-
vic floor weakness, understanding the basic concepts of pel-
vic floor musculature is essential to formulate a clinical
opinion. The area posterior to the pubic bone is dense with
bands of intertwined levator ani muscles; this defies conven-
tional description of the levator ani as comprising the puborec-
talis, pubococcygeus, and iliococcygeus. The anatomy of
distal subdivisions of the levator ani muscle was further
described in a study by Kearney et al. [24]. The origins and
insertions of these muscles as well as their characteristic ana-
tomical relations are shown in Table 1.1 and Fig. 1.16. Using
a nomenclature based on the attachment points, the lesser
known subdivisions of the levator ani muscles, the muscles
posterior to the pubic bone are identified as pubovaginalis,
puboanalis, and puboperinealis [21]. The pubovaginalis is
poorly described but may be analogous to the urethrovaginal
ligaments. The puboanalis originates from behind the pubic
bone as a thin band and inserts around the anus into the longi-
tudinal ligaments. The puboperinealis, which is most often
0.5 cm in diameter, originates from the pubic bone and inserts
into the perineal body. The four major components of the
levator ani muscle are the iliococcygeus, which forms a thin,
relatively flat, horizontal shelf that spans the potential gap
15
(STP) to the other puboanalis fibers that start inserting at the perineal
level at Fig (a) and then wrap around the anal canal. The ischiocaverno-
sus (ISC) and the bulbospongiosus muscle (BS) are depicted here.
Levator ani muscle (LAM). © Shobeiri 2013
from one pelvic sidewall to the other; the pubococcygeus
muscle, which travels from the tip of the coccyx to the pubic
bone (see Fig.  1.17); the puborectalis muscle, originating
from the anterior portion of the perineal membrane and the
pubic bone to form a sling behind the rectum; and the pubo-
perinealis and puboanalis, which are thin broad fibromuscular
poorly described structures that attach to the perineal body
and anus to stabilize the perineal region.
Margulies and colleagues showed excellent reliability and
reproducibility in visualizing major portions of the levator
ani with magnetic resonance imaging (MRI) in nulliparous
volunteers [25]. Because puboanalis, pubovaginalis, and
puboperinealis are small, they are proven hard to visualize
with conventional MRI. However, these muscles are easily
seen with three-dimensional (3D) endovaginal ultrasonogra-
phy (EVUS) [26].
The shortest distance between the pubic symphysis and
the levator plate is the minimal levator hiatus. This is d­ ifferent
from the urogenital hiatus, which is bounded anteriorly by
the pubic bones, laterally by levator ani muscles, and poste-
riorly by the perineal body and EAS.  The baseline tonic
activity of the levator ani muscle keeps the minimal levator
hiatus closed by compressing the urethra, vagina, and rectum
against the pubic bone as they exit through this opening [27].
The levator ani fibers converge behind the rectum to form the
levator plate. With contraction, the levator plate elevates to
form a horizontal shelf over which pelvic organs rest. The
deficiency of any portion of the levator ani results in weaken-
ing of the levator plate and descensus of pelvic organs [28].
16 S. A. Shobeiri and J. O. L. DeLancey

a (Fig. 1.35a, b). In such cases the ligaments and the endopel-

vic fascia will assume the majority of the pelvic floor load
EAS-M
until they fail as well. Different varieties of levator ani injury
can cause different interesting types of clinical defects. A
Rectum partial defect and separation of the levator ani muscles will
result in a displacement cystocele (Fig. 1.36). However, the
clinician may not be able to distinguish if this is a displace-
ment cystocele due to paravaginal defect and arcus tendineus
EAS-W separation or due to muscle loss. The consequences of this
lack of recognition can be that the surgeon may elect to do an
anterior repair and, by placating the pubocervical fibromus-
SQ-EAS
cularis, make the lateral defect worse. The lack of basic
information about the levator ani status may account for var-
ied results in the anterior repair studies. Additionally, in an
b
attempted paravaginal repair, the surgeon may realize that
(C)Shobeiri there is no muscle to attach the arcus tendineus to.
A visual analogy is that of the pubocervical fibromuscularis
Vaginal epithelium which is a swinging trapezoid (Fig.  1.37a). The mechanical
effect of this detachment allows the trapezoid to rotate down-
Rectovaginal ward. When this happens, the anterior vaginal wall protrudes
Septum through the introitus. Upward support of the trapezoid is also
(Peach)
provided by the cardinal and uterosacral ligaments in Level
I. For this reason, resuspension of the vaginal apex at the time
Bulbospongiosus
(Yellow) of surgery in addition to paravaginal or anterior colporrhaphy
External anal sphincter helps to return the anterior wall to a more normal position.
(Purple) A partial defect (see Fig. 1.37a) is subjected to excessive
forces and may progress over time to involve the apical and
Superficial transverse posterior compartments as well (see Fig.  1.37b). How fast
perinei (Green)
this occurs depends on the strength of the patient’s connective
Internal anal sphincter
(Blue) tissue. One woman with injured muscles may have strong
Anal mucosa connective tissue that compensates and never develops pro-
(Brown) lapse, while another woman with even less muscle injury but
weaker connective tissue may develop prolapse with aging.
Fig. 1.32 (a) Drawing of external anal sphincter (EAS) subdivisions. There are instances of catastrophic injury during childbirth
Anterior portion of model is to the left, posterior to the right. Notice
decussation of fibers toward the coccyx posteriorly. The main body of during which complete muscle loss occurs and the patient
the EAS also has a concentric portion posteriorly that is not shown in presents with a displacement cystocele, rectocele, and varied
this view. Main body of EAS (EAS-M), winged portion of EAS (EAS-­ types of incontinence (Fig.  1.38). This scenario is different
W), subcutaneous EAS (SQ-EAS). (b) Drawing of perineal region as with patients who have a defect in pubocervical and recto-
may be seen after a clean midline episiotomy. The drawing depicts the
relationship of muscles to the rectovaginal septum. © Shobeiri 2013 vaginal fibromuscularis (Fig.  1.39), which develops into a
distention cystocele and rectocele over time. A cystocele and
rectocele repair that can be used for the latter case will worsen
1.2.7 Endopelvic Fascia and Levator Ani
the condition of the first patient with levator damage.
Interactions

The levator ani muscles and the endopelvic fascia work as a

unit to provide pelvic organ support. Under normal condi-
tions, the actions of the levator ani muscles hold the pelvic
floor closed and provide a lifting force to prevent pelvic floor
descent. If the muscles maintain normal tone, the ligaments
of the endopelvic fascia will have little tension on them even
with increases in abdominal pressure (Fig. 1.34a–c). If the
muscles are damaged by a tear or complete separation from
their attachments, the pelvic floor sags downward overtime,
and the organs are pushed through the urogenital hiatus
1.2.8 The Levator Plate
The levator plate has varied definitions and is viewed dif-
ferently by different sources. In MRI, Hsu and colleagues’
modeling views it as a flap valve that requires the dorsal
traction of the uterosacral ligaments and, to some extent,
of the cardinal ligaments, to hold the cervix back in the
hollow of the sacrum. The measurement obtained is called
the levator plate angle (LPA). It also requires the ventral
1  Pelvic Floor Anatomy 17

Vaginal anal
a b

PB

EAS-M

Perineal
Skin

c
Vagina Anal Canal EAS-SQ
IAS

(C)Shobeiri BS Perineum Shobeiri©

STP
RVF EAS-W EAS-SQ
d IRF PR (C)Shobeiri
EAS-M
PA
IAS

Anal Canal EAS LMF

V
IAS

Fig. 1.33 (a) Perineal dissection in a cadaveric specimen shows the
relationship of the subcutaneous external anal sphincter (EAS-SQ) to the
main portion of EAS, the winged portion of EAS, and the superficial
transverse perinei (STP). The internal anal sphincter is marked with the
dotted line. Anal canal (A), main body of EAS (EAS-M), winged portion
of EAS (EAS-W), rectum (R), rectovaginal fascia (RVF), urethra (U),
vagina (V). © Shobeiri 2013. (b) Histological slide showing relationship
of the subcutaneous external anal sphincter (EAS-SQ) to the main por-
tion of EAS (EAS-M) and the internal anal sphincter (IAS). © Shobeiri
2013. (c) Drawing of the mid left sagittal section as seen in Fig. 1.32a.
Bulbospongiosus (BS), external anal sphincter (EAS), internal anal
sphincter (IAS), rectovaginal fibromuscularis (RVF), superficial trans-
verse perinei (STP). © Shobeiri 2013. (d) Histologic slide of the left
coronal view of the anal canal showing the relationship of the anal
sphincter subdivisions to the puboanalis fibers (PA lined with small
arrows pointing downward). The small arrows on the bottom line the
course of the longitudinal muscle fibers (LMF), which is an extension of
the iliococcygeus fibers that become progressively fibrous until they
insert into the anal sphincter complex. The puboanalis and the puboperi-
nealis muscle fibers stabilize the perineum, while the puborectalis (PR)
closes the levator hiatus. External anal sphincter-subq (EAS-Q), external
anal sphincter-main portion (EAS-M), external anal sphincter-winged
portion (EAS-W), internal anal sphincter (IAS), ischiorectal fat (IRF),
vagina (V). © Shobeiri 2013

Table 1.1  Divisions of the levator ani muscles—international stan- pull of the pubococcygeal portions of the levator ani mus-
dardized terminology cle to swing the levator plate more horizontally to close
Origin/insertion the urogenital hiatus. From another point of view, the
Puboperinealis (PP) Pubis/perineal body levator plate is the point where the pubococcygeus, ilio-
Pubovaginalis (PV) Pubis/vaginal wall at the level of the coccygeus, and the puborectalis come together under the
mid-urethra rectum to create the anorectal angle (see Figs. 1.13, 1.17,
Puboanalis (PA) Pubis/intersphincteric groove between internal and 1.18). In e­ ndovaginal ultrasound the movement of the
and external anal sphincter to end in the anal skin
levator plate relative to the transducer can be measured as
Puborectalis (PR) Pubis/forms sling behind the rectum
Iliococcygeus (IC) Tendineus arch of the levator ani/the two sides levator plate descent angle (LPDA) [28]. LPA and LPDA
fuse in the iliococcygeal raphe likely measure different functions. LPDA change has been
Pubococcygeus Pubic symphysis to superficial part of correlated with levator ani deficiency (Fig.  1.40). The
(PC) anococcygeal ligament location of the levator plate depends on the integrity of the
18 S. A. Shobeiri and J. O. L. DeLancey

USL
a b
ATLA
PS
CX
IC
IS
PAM
RVF

V ATRV

R
(C)Shobeiri

CL

↑Ligament
Tension
USL

Balanced Unbalanced
Pressures Pressures
Pulls on
Uterus

© DeLancey
Hiatus Closed Hiatus Open Pressure
Differential
A. Normal B. Levator Injury C. Exposed Vagina

Fig. 1.34 (a) Right lateral standing anatomic depiction of the levator
ani muscle and uterosacral-cardinal complex interaction. © Shobeiri
2013. (b) Drawing of the interaction between the rectovaginal fibromus-
cularis and the uterosacral ligaments. The levator ani muscle and utero-
sacral-cardinal complex give cephalad static support, while the
iliococcygeus fibers give lateral support to the posterior compartment.
The puboanalis and the puboperinealis muscles stabilize the perineum,
while the puborectalis closes the levator hiatus. Arcus tendineus levator
ani (ATLA), arcus tendineus fascia rectovaginalis (ATRV), cervix (CX),
iliococcygeus (IC), ischial spine (IS), puboanalis muscle (PAM), pubic
symphysis (PS), rectum (R), rectovaginal fibromuscularis (RVF), utero-
sacral ligament (USL), vagina (V). © Shobeiri 2013. (c) Diagrammatic
representation of interactions between levator ani muscle, anterior vagi-
nal prolapse, and cardinal/uterosacral ligament suspension. With normal
levator function (A), the vaginal walls are in apposition, and anterior
and posterior pressures are balanced. Levator damage (B) results in hia-
tal opening, and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures. This pressure differen-
tial (C) creates a traction force on the cardinal ligament (CL) and utero-
sacral ligament (USL). From © DeLancey [32] with permission
1  Pelvic Floor Anatomy 19

a a

b b

Fig. 1.36  Room analogy: (a) unilateral levator ani tears may or may
not result in prolapse or incontinence initially, but over time the other
supportive structures will decompensate resulting in pelvic floor laxity
(b). © Shobeiri 2013

levator ani muscles and the integrity of the anococcygeal

ligament (Fig. 1.41a, b).

1.2.9 I nteraction Between Different

Compartments

Understanding the direction and magnitude of vaginal move-

b ment is important to overall quantitative understanding of the
Fig. 1.35  Room analogy: the clinical presentation of a combined cys-
tocele/rectocele may have varied pathophysiologies. Depicted to the
left is a cystocele/rectocele due to pubocervical and rectovaginal fibro-
muscularis defects. (a) Bilateral levator ani tears may or may not result
in prolapse or incontinence initially, but over time the other supportive
structures will decompensate resulting in pelvic floor laxity (b). ©
Shobeiri 2013
prolapse. In a study that developed and tested a method for
measuring the relationship between the rise in intra-­
abdominal pressure and sagittal plane movements of the
anterior and posterior vaginal walls during Valsalva in a pilot
sample of women with and without prolapse, the authors
found that movement of the vaginal wall and compliance of
its support was quantifiable and was found to vary along the
20 S. A. Shobeiri and J. O. L. DeLancey

a b

c d

Fig. 1.37  Conceptual diagram showing the mechanical effect of spine has been lost, allowing the fascial plane to swing downward. (c)
detachment of the arcus tendineus fascia pelvis from the ischial spine. Normal anterior vaginal wall as seen with a weighted speculum in
(a) The trapezoidal plane of the pubocervical fascia. The attachments to place. (d) The effect of dorsal detachment of the arcus from the ischial
the pubis and the ischial spines are intact. (b) The connection to the spine. © DeLancey 2002
1  Pelvic Floor Anatomy 21

b Fig. 1.39  Room analogy: multicompartmental defect—pubocervical

fibromuscularis and rectovaginal septum defects. © Shobeiri 2013

length of the vagina. Compliance was greatest in the upper

vagina of all groups [29]. Women with cystocele demon-
strated the most compliant vaginal wall support (Fig. 1.42).
The direction of movement differs between rectocele and
cystocele. In rectocele, the posterior vaginal wall generally
moves in the direction of the vaginal orifice. In cystocele, the
upper anterior vaginal wall movement is directed toward the
vaginal orifice, and the lower anterior vaginal wall move-
ment is directed toward ventral direction [29].

1.2.10 Nerves

There are three main nerves that supply the pelvic floor:

1. The pudendal nerve supplies the urethral and anal sphinc-

Fig. 1.38  Room analogy: obstetric injuries can be catastrophic or sub-
tle. A complete right unilateral levator ani detachment (avulsion) (a).
Injury to the perineal support (the missing green part of the door frame),
which may result in sliding of the rectovaginal fascia and a clinical peri-
neocele (b). © Shobeiri 2013
ters and the perineal muscles. The pudendal nerve origi-
nates from S2 to S4 foramina and runs through the Alcock
canal, which is caudal to the levator ani muscles. The
pudendal nerve has three branches, the clitoral, perineal,
and inferior hemorrhoidal, which innervate the clitoris,
the perineal musculature, inner perineal skin, and the
EAS, respectively [21]. The blockade of the pudendal
nerve decreases resting and squeeze pressures in the
vagina and rectum, increases the length of the urogenital
hiatus, and decreases electromyography activity of the
puborectalis muscle [30].
2. The levator ani nerve innervates the major musculature
that supports the pelvic floor. The levator ani nerve origi-
nates from S3 to S5 foramina, runs inside of the pelvis on
22 S. A. Shobeiri and J. O. L. DeLancey

Fig. 1.40 (a) Drawing of the a

levator plate angle (LPA)
measured by magnetic
resonance imaging (MRI) vs.
the levator plate descent angle
(LPDA) obtained by 3D
endovaginal ultrasound. The
levator plate position relative
to the pubic levator plate S
ultrasound reference
assessment line (PLURAL) is MRI Horizontal Reference line LPA
shown. A normal LPDA
relative to the reference line B
(PLURAL) is normally 0° to
−15°. Bladder (B), levator
PS
plate (LP), levator plate angle
(LPA) obtained by MRI,
LPDA
levator plate descent angle Pubic Levator Ultrasound Reference Line LP
(LPDA) obtained by 3D
endovaginal ultrasound, pubic
symphysis (PS), sacrum/
coccyx (S). © Shobeiri 2013.
(b) Drawing of the levator
plate angle (LPDA) vs. the b
perineal body descent angle
(PBDA) obtained by 3D
endovaginal ultrasound. The
PBDA is a useful objective
measurement of perineal
descensus in otherwise S
normal individuals. External
anal sphincter (EAS), perineal
MRI Horizontal Reference line
body (PB). © Shobeiri 2013 LPA

PS

LPDA
LP Pubic Levator Ultrasound
PBDA
Reference Line

EAS
PB Shobeiri©

a b

Fig. 1.41 (a) The mid-sagittal view of the right hemi-pelvis with the red
box highlighting the levator plate region. Anus (A), anococcygeal liga-
ment (ACL) bladder (B), external anal sphincter muscle (EAS), internal
anal sphincter (IAS), levator plate (LP), pubic symphysis (PS), rectum
(R), rectovaginal fibromuscularis (RVS), sacrum/coccyx (S), superficial
transverse perinei muscle (STP), urethra (U), uterus (UT), vagina (V). ©
Shobeiri 2013. (b) The mid-sagittal view of the right hemi-pelvis with the
red box highlighting the levator plate region zoomed in from Fig 1.39a.
Anococcygeal ligament (ACL), pubococcygeus (PC), puborectalis (PR),
rectum (R), sacrum/coccyx (S). © Shobeiri 2013
1  Pelvic Floor Anatomy 23

Movement Angle and Distance

Anterior Posterior

0° 0° J J
10 10

1 Normal
1
Cystocele A
-90° Rectocele -90° A

Movement Angle

1 2 3 4 5 6 7 8 9 10 A B C D E F G H I J
0 0
-20 -20
Angle of Movement

Angle of Movement
-40 -40
-60 -60
-80 -80
-100 -100
-120 -120
-140 -140
Location Location

Fig. 1.42  Top Direction and magnitude (mm) of vaginal wall displace- cystocele, and women with rectocele. From D.M. Spahlinger et al. [29]
ment of the anterior and posterior support system. Bottom Angle of dis- with permission
placement (degrees from the horizontal) in normal women, women with

the cranial surface of the levator ani muscle, and provides

the innervation to all the subdivisions of the muscle. PB
ATLA ATFP
3. Motor nerves to the IAS are derived from 1. L5-presacral
LAN
plexus sympathetic fibers and 2. S2–4 parasympathetic
fibers of the pelvic splanchnic nerve. The levator ani mus-
cle often has a dual somatic innervation, with the levator
V
ani nerve (Fig.  1.43) as its constant and main neuronal CG
supply [21, 31].

PP
C
1.3 Summary
IC
PV PA
The knowledge of pelvic floor anatomy and function is
PR
essential for effective ultrasound imaging of pelvic floor
pathologies. With advancing ultrasound technology, new A
ultrasound techniques have increased our ability to detect
pelvic floor defects and have helped us to gain insight into Fig. 1.43  The levator ani nerve in relation to the levator ani muscle
pathophysiology of pelvic floor disorders. complex and pelvic structures. Anal canal (A), arcus tendineus fascia
pelvis (ATFP), arcus tendineus levator ani (ATLA), coccyx (C), coc-
cygeus (CG), iliococcygeus (IC), levator ani nerve (LAN), puboanalis
(PA), perineal body (PB), puboperinealis (PP), puborectalis (PR), pubo-
visceralis (PV), vagina (V). © Shobeiri 2013
24 S. A. Shobeiri and J. O. L. DeLancey

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20. DeLancey JO, Toglia MR, Perucchini D. Internal and external anal
3. Olsen ALSV, Bergstrom JO, Colling JC, Clark AL. Epidemiology
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morphology of the human female levator ani muscle. Am J Obstet
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2003;188(1):108–15.
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5. Smith FJ, Holman CD, Moorin RE, Tsokos N.  Lifetime risk of
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VL.  Vaginal parity and pelvic organ prolapse. J Reprod Med.
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 Biochemical Properties and Hormonal
Receptors of Pelvic Floor Tissues
Heinz Koelbl and Ksenia Halpern-Elenskaia
Learning Objectives
• Thus, the goals of this chapter are to (1) discuss the
ultrastructural components of the pelvic floor and to
review the biochemical processes of pelvic floor
remodeling and (2) to discuss the influence of sex-
ual hormones on pelvic floor function and to give
the advices for the clinical practice.
2.1 I ntroduction: How Complicated Is
That?
Pelvic floor function is very complex and depends on many
factors as anatomical modifications and mechanical strength.
These depend also on many other factors as injury of the
muscles, connective tissue remodeling, and degradation, pel-
vic enervation, and vascularization.
Numerous other predisposing conditions may lead to
abnormalities in pelvic floor tissues, including lifestyle
factors, such as heavy lifting, smoking, and adverse work-
ing environment, and chronic medical conditions, such as
obesity, anemia, malnutrition, or pulmonary disease.
The impact of gene polymorphisms and genetically
predisposed susceptibility on the occurrence of the pelvic
floor function has been proven as well. The aim of this
chapter is to clarify how all these factors affect the biome-
chanical properties and hormonal changes of the pelvic
floor.
H. Koelbl (*) · K. Halpern-Elenskaia
Department of Obstetrics and Gynecology, Medical University
Vienna, Vienna, Austria
e-mail: heinz.koelbl@meduniwien.ac.at; ksenia.halpern@
meduniwien.ac.at
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_2
2
2.1.1 T
 he Role of Reproductive Hormones
on the Pelvic Floor Function During
the Life Span
Reproductive hormones, especially estrogen, have a signifi-
cant impact on the pelvic floor.
Due to the natural hypoestrogenic state, some girls before
the onset of menarche present various voiding dysfunctions
and vaginal problems. Between the age of 9 and 12, estrogen
levels rise. Cyclic changes in estrogen and hormonal changes
during pregnancy markedly bring into focus what estrogen
means to the pelvic floor function [1].
However, pelvic floor is mostly affected in perimeno-
pause and menopause. Menopause, as one example of pro-
longed duration of estrogen deprivation, leads to well-known
consequences such as urogenital atrophy [2].
Women who never leaked urine before may develop uri-
nary leakage. Although the bladder neck and the proximal
urethra form the continence mechanism, the folds in the sub-
mucosal tissues of the urethra can offer an additional seal
affect. If the urethral tissues are thinner and drier from estro-
gen deficiency, they cannot make as tight a closure to prevent
leakage. Sexual intercourse may also become uncomfortable
because of thinner and drier vaginal tissues [3].
Nevertheless, the role of menopause on pelvic floor dys-
functions is unclear. Neither menopausal status nor the
length of hormone deficiency has been clearly associated
with the risk or severity of pelvic floor disorders [4]. As
many as 50% of postmenopausal women complain of uro-
genital symptoms [5].
2.1.2 H
 ormonal Changes and Pelvic Floor
Symptoms
Hormonal changes that occur during a woman’s life span
impact many aspects of female physiology. The lower uri-
nary and female genital tracts are closely related and both
derive embryologically from the urogenital sinus.
25
26
The mutual embryology of the urethra and vagina (from
the urogenital sinus and the Mueller’s ducts), together with
the hormone receptors known to be present in the urethra and
the bladder neck, explains the hormone-dependent cyclical
and trophic changes in the urogenital region that have an
onset shortly after.
As age has been clearly shown to affect the prevalence
and progression of both stress urinary incontinence (SUI)
and pelvic organ prolapse (POP) [6], it is intuitive to believe
that declining sexual hormone levels may contribute to bio-
chemical changes observed within tissues. A loss of estrogen
results in urogenital aging.
Dyspareunia, dysuria, urinary frequency and urgency,
nocturia, incontinence, and thinning of tissues make it sus-
ceptible to trauma, and recurrent infections are all facilitated
by estrogen withdrawal.
In addition to vulvo-vaginal symptoms, lower acid pH of
the estrogen-deficient vagina increases the likelihood of uri-
nary tract infections.
It has been noticed that progesterone has adverse effects
on the female urinary tract function since it is linked to an
increase in the adrenergic tone, provoking a decreased tone
in the ureters, urethra, and bladder [7]. This could be the rea-
son why urinary symptoms worsen during the secretory
phase of the menstrual cycle, and progesterone may be
responsible for the increase in urgency during pregnancy,
although the precise mechanism is not fully figured out.
2.2  he Role of Biochemical Properties
T dinary compliance and elasticity required for vaginal
and Hormonal Receptors of Pelvic
Floor Tissues in Epidemiology
of Pelvic Floor Function
2.2.1 Sexual Hormone Receptors
Estrogen receptors (ERs) are a group of proteins found inside
cells. They are different from peptide hormones, which tend
to be cell surface receptors built into the plasma membrane
of cells. However, some ERs associate with the cell surface
membrane and can be rapidly activated by exposure of the
cells to estrogen. Upon hormone binding, the receptor can
initiate multiple signaling pathways which ultimately lead to
changes in the behavior of the target cells. ERs are present in
the epithelial tissues of the urethra, bladder, and vaginal
mucosa and also in diverse structures of the pelvic floor as
uterosacral ligaments, levator ani muscles, and pubocervical
fascia [8].
ERs are activated by the hormone estrogen (17β-estradiol).
Two classes of ERs exist: nuclear estrogen receptors (ERα
and ERβ), which are members of the nuclear receptor family
of intracellular receptors, and membrane estrogen receptors
H. Koelbl and K. Halpern-Elenskaia
(mERs) (GPER (GPR30), ER-X, and Gq-mER), which are
mostly G protein-coupled receptors.
Once activated by estrogen, the ER is able to translocate
into the nucleus and bind to DNA to regulate the activity of
different genes. There are two different forms of the estrogen
receptor, usually referred to as α and β, each encoded by a
separate gene (ESR1 and ESR2, respectively). Hormone-­
activated ERs form dimers, and, since the two forms are
coexpressed in many cell types, the receptors may form ERα
(αα) or ERβ (ββ) homodimers or ERαβ (αβ) heterodimers.
Estrogen is involved in the increase of the cell maturation
index of epithelial structures. It has been demonstrated that
alterations in the ratio of the estrogen receptor α (ERα) to
ERβ may be related to the development of SUI [9].
Progesterone receptors (PR) are also expressed in the
lower urinary tract, even if with less density than ER [10].
2.2.2 B
 iochemical Properties of Pelvic Floor
Tissues
The female pelvic floor is an anatomically complex structure
made of smooth and skeletal muscles, ligaments, and fascia.
Structurally, the female pelvic organs are supported by pel-
vic floor muscles, cardinal and uterosacral ligaments, and the
endopelvic fascia. The ligaments and fascia are primarily
composed of extracellular matrix (ECM). The latter is made
of a ground substance of proteoglycans and glycoproteins
with collagen, along with elastin, which confers the extraor-
childbirth.
The integrity of the pelvic floor is maintained mostly by
fibrillary ECM components, collagen and elastin. It has been
well described that women suffering from connective tissue
diseases such as Ehlers–Danlos syndrome or Marfan’s dis-
ease have a higher risk of POP and SUI, suggesting that con-
nective tissue disorder is an etiological factor [11].
2.2.2.1 Collagen of Pelvic Floor Tissues
As mentioned above, collagen is playing a major role in the
pelvic floor’s supportive structures. ECM is in constant rear-
rangement with synthesis and breakdown of collagen through
a process of remodeling.
There are 28 types of collagen described in the body, but
the most abundant in the pelvic floor are types I and III.
Type I collagen is considered the strongest, being highly
prevalent in fascia, ligaments, and fibrous tissues. Type III,
reticulate collagen, is also found in the same tissues but tends
to be located on the surface of the fibril.
The arrangement of the different types of collagen into
fibrils of variable sizes confers strength or laxity depending
on the ratio, density, and degree of cross-linking that are
2  Biochemical Properties and Hormonal Receptors of Pelvic Floor Tissues
important for the maintenance of the mechanical properties
of the extracellular matrix, which is tissue-specific.
Several studies have taken a closer look at tissue proper-
ties through the use of human pelvic floor biopsies of women
with either POP or SUI. Here is the small overview on the
distribution of collagen in pelvic floor function and its influ-
ence on the pelvic floor disorders.
Anterior Vaginal Wall
It was found that women with POP have statistically signifi-
cantly less dense staining of collagen type III than women in
the control group after controlling for age, weight, parity,
urodynamic stress incontinence, and menopause [12].
Periurethral Tissue
Weakened pelvic floor support may result from lower colla-
gen content, but also from alterations within the distribution
of collagen fibers. Much more disordered collagen fiber dis-
tribution within periurethral specimens of women with SUI
compared with unaffected controls were detected [13].
Collagen type III is significantly reduced in patients with
SUI and POP.  Some findings are pointing out that women
with SUI have less collagen type III around the urethra
regardless of the degree of pelvic relaxation. So it appears
that collagen has a significant role in the maintenance of uri-
nary continence (Table 2.1) [14, 15].
Cardinal Ligaments
In women with POP, loosely arranged connective tissue
fibers and less dense ECM as well as smaller collagen fibers
were seen under the electron microscope [16].
Uterosacral Ligament
Recent research is going even deeper and analyzes the
molecular mechanisms of the POP development. One excit-
ing example is the transcriptional regulator genes as homeo-
box (HOX). HOX genes are involved in embryonic
development of the urogenital tract. It could be demonstrated
that HOXA11 is essential for organogenesis of the uterosac-
ral ligament. A decreased expression of collagen types I and
Table 2.1  Periurethral connective tissue status, Goepel et al. [14]
Extracellular matrix proteins Continent women Incontinent women
Collagen type 1 +++ ++
Collagen type III +++ ++
Collagen type IV + +
Collagen type V + +
Collagen type VI +++ +
Fibronectin + +
Laminin + +
Vitronectin ++ −(+)
−  =  negative; +  =  weak; ++  =  moderate and +++  =  strong
immuno-reactivity
27
III in uterosacral ligaments is correlated with a decrease in
function of this homeobox gene, HOXA11, involved in the
development of the lower uterine segment and cervix and
can be also associated with POP [17].
Endopelvic Fascia
Diminished collagen levels have been found in multiple
pelvic tissues of women with SUI, including the endopelvic
fasciae [18].
The Arcus Tendineus Fasciae Pelvis (ATFP)
ATFP which provides support to the anterior vagina is com-
prised primarily of parallel bundles of type III collagen fibers
(84%), an intermediate amount of elastin (13%), and very
little smooth muscle. It was shown that menopause in the
absence of hormone therapy is associated with a decrease in
quantity of collagen I in the ATFP, resulting in a decrease in
the ratio of collagen I/(III + V). This may compromise the
tensile strength and an increase susceptibility to anterior
vaginal wall prolapse [19].
Elastin
Another important mechanical component of ECM is elas-
tin, which affords resiliency through its ability to recoil,
returning the collagen fibers to their original configuration
post-loading. The length and amount of elastin could also
change the mechanics of the vagina and are associated with
changes in the phenotype of smooth muscle, which synthe-
sizes the elastin. For example, elastin fibers are smaller and
less expressed in vaginal tissue of women with POP [20].
Tissue strength relies on cross-linkages between elastin
and collagen fibers formed by the enzyme lysyl oxidase
(LOX). A lower elastin content and decreased mRNA expres-
sion of LOX were found in uterosacral ligaments of women
with POP compared with normal controls [21].
Elastin is synthesized and broken down in the female gen-
ital tract and allows for tremendous accommodation and
regeneration after childbirth.
A loss of vaginal elastin can result in widening of the
vaginal opening, which, in turn, could alter the loading con-
ditions of the attached connective tissues and in turn pelvic
organ support.
2.2.3 T
 he Role of Matrix Metalloproteinases
(MMPs) on Pelvic Floor Tissue
Remodeling
Since Jackson et al. described the increased MMP activity in
women with POP, there has been increasing interest in exam-
ining the relationship between collagen degradation and pel-
vic floor disorders (PFD) [22].
28
Collagen breakdown is regulated by matrix metallopro-
teinases (MMPs). These enzymes are secreted as proen-
zymes and require activation. There are 23 different types
identified as being involved in different tissue types. The
interstitial and neutrophil collagenases (MMP-1, MMP-8,
MMP-13) cleave fibrillar collagen, while the denatured pep-
tides are degraded by the gelatinases (MMP-2 and MMP-9).
These enzymes’ actions are further regulated by tissue-­
derived inhibitors of metalloproteinases (TIMPs) that bind to
them and regulate their activity.
The recent findings indicate that women who suffer from
POP have a higher expression level of MMP-1 than women
without POP.
Therefore, enhanced activity of MMPs may explain the
reason for the reduced collagen content in the pelvic connec-
tive tissues, which eventually causes POP.
Also a concurrent decrease in the expression of tissue
inhibitor of matrix metalloproteinase-1 (TIMP-1) is one of
the hypotheses of elevated MMP-1 activity [23]. The role of
an overactive degradation mechanism can be an interesting
linkage, as helical peptide α1, a collagen breakdown product,
is excreted in higher amounts in the urine of women with
SUI [24]. Recent studies show consistent results of the
impact of higher MMP activity in the development of SUI
and POP. The contribution of TIMP to this process remains
to be established [25].
2.3  he Recent Investigations
T blood flow in the periurethral venous plexus is increased, and
and Possibilities for Future Research
The extracellular matrix content of the pelvic floor is the
major focus of recent investigations and pointed for potential
molecular markers of the dysfunction. The identification of
women predisposed to develop PFD would help in the
patients’ management and care. However, it is important to
highlight that the techniques used to measure collagen and
elastin content vary between the abovementioned studies.
Different structures and biopsy sites of the pelvic floor
(vagina wall, arcus tendineus fasciae pelvis, paraurethral tis-
sue, parametrium, and uterosacral ligaments) have been
examined, and further studies are needed to understand the
real process of pelvic floor remodeling.
Future research will deal with the discovery of the genetic
contribution to PFD.  Genetic mutations or polymorphisms
affect the transcription of mRNA coding for a wide variety of
proteins responsible for ECM metabolism. Polymorphisms
have been identified in genes of ECM component proteins,
proteolytic enzymes, regulatory proteins, and receptors.
These mutations may therefore downregulate the synthesis
of collagen and elastin or upregulate their breakdown.
Single nucleotide polymorphisms (SNPs) are the most
abundant type of DNA sequence variation in the human
genome and are also in focus of research. A specific haplo-
H. Koelbl and K. Halpern-Elenskaia
type for the ER β gene is probably associated with an
increased risk of POP [26].
SNPs are present in the progesterone receptor gene that
can alter its expression. Similarly, the estrogen receptor β
gene also contains multiple SNPs affecting its expression.
2.4  ormonal Impact on Vaginal Atrophy,
H
the Role on Pelvic Floor Dysfunction,
and Treatment
Synthesis and metabolism of collagen in the genital and uri-
nary tract are under the control of estrogens [27]. It also
increases the number of muscle fibers in the detrusor muscle
and in the urethral muscles [28].
With an average life expectancy of 75–80 years, women
spend about 25–30 years of their life in menopause, i. e., in a
state of hormone deficiency. Within the scope of menopause
syndrome, signs of degeneration in the urinary and genital
organs caused by estrogen deficiency play a significant role
[29]. Studies have shown lower serum estradiol (E2) levels in
premenopausal women with SUI, with and without concur-
rent POP [9, 30].
The proof of steroid hormone receptors in the female ure-
thra and the associated ability of tissue containing estrogen
receptors to respond to estrogens are the real rationale for
providing hormone replacement. In addition to improving
the degree of proliferation in the vagina and urethra, the
the collagen content in the periurethral connective tissue is
raised, thus improving elasticity [29].
The intensity of the effect of estrogen replacement on the
urethra, for example, depends on the receptor density and the
binding affinity of the estrogen to the receptor. Estriol has a
lower binding capacity on the estrogen receptor complex and
thus a shorter retention time in the cell nucleus. At low doses,
estriol only demonstrates the early estrogen effects, e.g., epi-
thelium proliferation in the vagina and urethra, but not the
late estrogen effects such as proliferation in the endome-
trium. Epithelium proliferation leads to a significant improve-
ment of subjective complaints, and presumably to a
quantitative decrease in urinary leakage due to a “sealing
effect” [31], without any measurable effect on pressure. In
order to achieve an influence on the urethral pressure compo-
nents, a higher estradiol dose or the use of estrogens with
greater receptor binding affinity (estradiol, conjugated estro-
gens), a longer duration of substitution, and possibly even
adjuvant therapy measures such as pelvic floor training are
probably necessary.
The impact of estrogen on tissue may be related to its sys-
temic or local levels, or altered sensitivity from a decreased
amount of receptors noted in genitourinary tissues [9, 32].
Sex hormones may exert their effect through pathways
other than ECM metabolism. An increase in periurethral
2  Biochemical Properties and Hormonal Receptors of Pelvic Floor Tissues
vasculature in postmenopausal women treated with exoge-
nous estrogens possibly improves the periurethral blood
flow, urethral adaptation, and periurethral stability and
thereby increases maximum urethral pressure [33].
Recent studies also indicate that a low estradiol level
might have a negative impact on the lower urinary tract and
continence mechanism and work as a possible risk factor for
female SUI [34].
Interestingly, the WHI study reported that hormone ther-
apy (HT) users ran a higher risk of developing SUI and that
hormonal supplementation with estrogen alone led to a
higher risk for developing UI than an estrogen/progestin
combination [35]. The effect of HT on urinary incontinence
symptoms is still a matter of debate. Some studies conclude
that the route of therapy has different effects, as oral sys-
temic estrogen worsened incontinence, while vaginal estro-
gen improved incontinence [36]. However, this raises the
question why exogenous estrogens seem to be bad and
endogenous estrogens seem to be good for lower urinary
tract symptoms (LUTS). One possible explanation for the
different clinical results could be that the distribution of
estrogen receptors in the bladder and pelvic floor changes
during the different menopausal stages with different
response to exogenous estrogen therapy.
2.4.1 Conclusion: Hormone Therapy
By increasing skin collagen content, mucopolysaccharides
and hyaluronic acid, estrogen therapy encourages the growth
and development of vaginal epithelial cells which make up
the thick layers of the vaginal wall and condone a moist,
supple, and elastic environment [37]. Therefore, locally
administered vaginal estrogens are effective in the treatment
of menopause-related vulval and vaginal symptoms, and a
Cochrane review reported equal efficiency across all prod-
ucts tested: creams, pessaries, tablets, and vaginal rings.
2.5 Summary and Recommendations
for Practice
Both POP and SUI have negative effects on body image, and
consequently only 17% of women are completely positive
about their sex life [38].
Doubtless intensive research should be continued to
improve women’s quality of life.
To date, much effort has been directed toward understand-
ing the mechanism of pathogenesis of PFD based on remod-
eling of ECM and how its turnover is influenced by sexual
hormones.
Current research supports the hypothesis that the ECM
turnover plays an important role in pathophysiology of
29
PFD. Current data also indicates that sex hormones may alter
ECM metabolism by having variable interactions with their
corresponding receptors.
Comprehension of the pathophysiology responsible for
PFD is clinically relevant on various levels. First, identifying
the patient population at risk can lead to preventive strate-
gies. Second, it may allow the development of interventional
therapies that could modify ECM maturation and turnover.
Future research will focus on understanding what processes
control ECM remodeling and aging to offer each single
patient the appropriate therapy.
Future studies addressing the genetic basis of pelvic floor
dysfunction are required, and investigations of biomechani-
cal properties of pelvic floor support should be performed
together with identification of candidate genes for pelvic
dysfunctions to determine the relationship between genetics
and biomechanics in the pelvic floor.
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 The Integral System of Pelvic Floor
Function and Dysfunction
Peter Petros, Michael Swash, and Darren Gold
Learning Objectives
• To understand how five main ligaments cause blad-
der, uterine, and rectal prolapses; how two main
ligaments, pubourethral and uterosacral, cause
bladder, bowel, and pain symptoms.
• To understand the dynamic anatomy of the liga-
ments, connective tissue structures, and muscles
involved in organ support and function.
• To apply an anatomically based diagnostic system
which accurately diagnoses which ligaments are
causing which prolapse and which bladder, bowel,
and pain symptoms.
• To understand the anatomical pathway to pelvic
organ prolapse and bladder, bowel, and pain
dysfunctions.
• To introduce a squatting-based pelvic floor regime
which uniquely strengthen the three involuntary
muscle forces which close and open the urethra and
anus.
• To understand the surgical principles deriving from
the Integral System, in particular, conservation of
uterus, vaginal elasticity, and the importance of
ligament reinforcement.
Electronic Supplementary Material The online version of this
chapter (https://doi.org/10.1007/978-3-030-40862-6_3) contains
supplementary material, which is available to authorized users.
P. Petros (*) · D. Gold
UNSW Professorial Surgical Unit, St Vincent’s Hospital Sydney,
Sydney, NSW, Australia
e-mail: pp@kvinno.com; dandjgold@gmail.com
M. Swash
The Royal London Hospital, London, UK
e-mail: mswash@btinternet.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_3
3
3.1 Introduction
The Integral Theory states that pelvic organ symptoms and
prolapse are both mainly caused by looseness in the vagina
and/or its suspensory ligaments, a consequence of altered
collagen/elastin [1]. The Theory explains how nerves, liga-
ments, and muscles work interactively for organ support
and function, all, in turn, directed by a binary cortical feed-
back system (Fig. 3.1). The Integral Theory System (ITS) is
a management system, entirely anatomical, based on the
Theory [2–5]. Ligament laxity due to collagen defect is the
weak point in the system. It is the basis of the ITS diagnos-
tic and management system. The ITS surgical system dif-
fers considerably from traditional vaginal surgery methods
which either excise the vagina or, more recently, place
mesh sheets behind it [6], with very poor results, >80%
failure at 6 months [6]. In contrast, the ITS surgical meth-
ods are entirely ligament based. The vagina is conserved.
No mesh is placed behind the vagina. Using special appli-
cators, strips of tape are applied in the precise position of
the damaged ligaments. These create a wound reaction and
within 6  weeks, new collagen is created to reinforce the
ligament [5].
3.2  he Integral Theory of Pelvic Floor
T
Function
In its present form, the Integral Theory states that pelvic
organ prolapse (POP), chronic pelvic pain, and bladder and
bowel dysfunction are mainly caused by collagen/elastin
deterioration in five main suspensory ligaments and their
vaginal attachments [6]. The ligaments are listed and shown
in Fig.  3.2a, b. The Integral Theory explains cure for POP
and bladder and bowel dysfunction via the dual function of
the ligaments: i.e., their role in pelvic organ suspension and
as insertion points for three oppositely acting muscle forces.
Lax ligament insertion points weaken muscle forces so they
cannot adequately close the urethral or anal tubes (inconti-
31
32
central
inhibitory or
acceleratory
instructions
PUL
BLADDER
N CX
MUSCLES ATFP
PELVIC RIM
Fig. 3.1  Binary control of bladder and bowel. Schematic 3D sagittal
view. The system is in normal closed mode. The pelvic floor works like
a trampoline which is suspended by PUL (pubourethral ligaments)
anteriorly, ATFP (arcus tendineus fascia pelvis) and CL (cardinal liga-
ments) laterally, and USL (uterosacral ligaments) posteriorly. The
organs are stretched and balanced by three opposite vector forces
(arrows), contracting against PUL and USL (uterosacral ligament).
Afferent impulses from stretch receptors “N” are reflexly suppressed
cortically (white arrow). When required, the cortex activates the defeca-
tion and micturition reflexes: the forward muscles relax, pubococ-
nence), evacuate them (constipation, bladder emptying prob-
lems), or tension the bladder and rectum sufficiently to
prevent inappropriate activation of the micturition and defe-
cation reflexes by peripheral stretch receptors (urinary and
fecal urge incontinence). The pelvic muscles are themselves
often damaged during childbirth, both by direct injury and
by damage to their nerve supply, causing primary weakness
of these muscles, in addition to ligamentous stretch injury.
Symptoms from the pictorial diagnostic algorithm (Fig. 3.2b)
accurately indicate which ligaments are damaged. Due to
childbirth and ageing, all five ligaments may be stretched
and weakened (Fig. 3.3). Each damaged ligament is linked to
a specific prolapse (Fig.  3.2a) and specific symptoms
(Fig. 3.2b).
P. Petros et al.
SPINAL
CORD
efferent
afferent
USL
N
MUSCLES
CL
cygeus for urethra (broken circle) and puborectalis for anus (not
shown); this allows the posterior muscles (posterior arrows) to unre-
strictedly open out the posterior wall of anus and urethra (broken lines)
just prior to bladder/rectal evacuation by smooth muscle contraction
(spasm). If PUL or USL is loose, the muscles contracting against them
(arrows) weaken. Urethra/anus cannot be closed (incontinence) and
opened (emptying problems); neither can the organs be bidirectionally
stretched sufficiently to support “N” and to prevent activation of the
evacuation reflexes (“urge incontinence”). CX cervix
3.3 The Integral System
The Integral System [1, 2] applies the Theory toward a practi-
cal, everyday system for management of female pelvic floor
disorders. Diagnosis of ligament damage is guided by a vali-
dated ligament-specific questionnaire “ITSQ” [7] or other
questionnaire capable of detailing the symptoms in Fig. 3.2b.
The symptoms are transcribed to the pictorial algorithm shown
in Fig. 3.2b. This indicates the sites of ligament damage which
should be confirmed by vaginal examination. Surgery shortens
and reinforces the damaged ligaments, so that the pelvic floor
muscles, even though weakened, can act more efficiently
against them. Surgical treatment consists of precise insertion
of thin strips of tape along the line in any of the five damaged
3  The Integral System of Pelvic Floor Function and Dysfunction 33

tail bone tail bone

a b

public bone public bone

bladder bladder

uterus uterus
3 3
1 2 2
1

4 bowel
4 bowel
vagina
vagina

Anterior ligaments Middle ligments Posterior ligaments

(PUL & EUL) (ATFP & CL) (USL & PB) Front ligaments Middle ligments Back ligaments
(PUL) (ATFP & CL) (USL & PB)
cystocoele 2 rectocoele 4
2 cystocoele 4 rectocoele
uterine/apical prolapse 3
3 uterine/apical prolapse
1 stress
incontinence 1 stress
incontinence

acnormal
S emptying

frequency and
urgency
B UT
nocturia
PS

2 USL
faecal faecal obstructed
ATFP CL incontinence incontinence defecation
PUL 3

EUL 1 pelvic pain

4
PB tethered vagina

Fig. 3.2 (a) How birth damage creates ligament damage to cause pel-
vic organ prolapse (POP). Lower figure—The circles represent damage
to six ligaments and vagina by the fetal head as it descends down the
vaginal canal. The positions of the ligaments create three natural zones,
anterior, middle, and posterior. Upper figure—correlations of damaged
ligaments with a specific prolapse. “1”: damaged PUL (pubourethral
ligament) causes bladder neck opening and stress incontinence. “2”:
damaged CL (cardinal ligament) causes transverse defect; dislocation
of vagina from ATFP (arcus tendineus fascia pelvis) causes lateral/cen-
tral defect. “3”: damaged USL (uterosacral ligaments) uterine prolapse.
“4”: damaged PB (perineal body) causes rectocele. The main ligaments
are indicated in capital letters, two in each zone: PUL, EUL external
urethal ligament (anterior ligaments); ATFP, CL (middle ligaments);
USL, PB perineal body (posterior ligaments). ∗EUL attaches the exter-
nal meatus to the anterior surface of pubic bone. (b) The pictorial diag-
nostic algorithm—prolapse and symptoms are related. 3D sagittal view
sitting position. The three zones contain two ligaments each, and these
may cause specific prolapse or symptoms as indicated. The size of the
bar correlates broadly with the site and probability of symptom causa-
tion. Labelling as in Fig.  3.2a. Tethered vagina is caused by anterior
vaginal scarring in middle zone. The main symptom is unstoppable
urine loss on getting out of bed in the morning. B bladder, PS pubic
symphysis, S sacrum, UT uterus

ligaments (Fig. 3.4) so as to reinforce them, plus reattachment
of stretched or displaced vaginal fascia. Up to 90% cure for
POP and up to 80% for pelvic pain and for bladder and bowel
dysfunction can be achieved by reconstruction of these five
ligaments [8] (Fig. 3.4). Properly taught and administered, this
method has the capacity to reduce care costs due to inconti-
nence, to improve quality of life for older women, and, poten-
tially, to reduce admissions to nursing homes. Data from the
Kamakura group in Japan (Table 3.1) and others confirms that
the functional disorders that commonly present to each of the
34 P. Petros et al.

three relevant surgical specialties (Fig. 3.1) can be improved

or cured with hospital stays of <24 h [8]. It is important to note
that any surgical operation that can effectively shorten and
reinforce uterosacral ligaments (Fig.  3.4) will achieve
improvement in the symptoms listed in Table 3.1. This includes
precisely performed abdominal sacrocolpopexy. In younger
S women, native tissue CL/USL shortening can achieve accept-
USL able symptom cure, especially when POP is minimal. In older
USL
CX postmenopausal women with age-related collagen loss in pel-
CL
ATFP
vic ligaments, native tissue repair gives very poor results, as
was found in the PROSPECT trial. At mean age 60  years,
ATFP
there was >80% failure rate with level 2 vaginal repair at
6 months [7]. Only a tape insertion procedure can create the
VAG new collagen needed to strengthen weak ligaments for high
POP and symptom cure (Table 3.1).
CL

Fig. 3.3  Head stretches ligaments at birth. 3D view from above of

inlet. Cervical ring at full dilatation (10 cm). The uterosacral ligaments
(USL), cardinal ligaments (CL), and vaginal attachments (VAG) to cer-
vical ring (CX) may be overstretched or torn to cause uterine/apical
prolapse, cystocele anteriorly, high rectocele, and enterocele posteri-
orly. As the head exits the birth canal, the perineal body may be dam-
aged and separated to cause low rectocele (perineocele), descending
perineal syndrome, internal and external sphincter damage. ATFP arcus
tendineus fascia pelvis, S sacrum
3.4  art 1: Pubourethral Ligament: How
P
the Midurethral Sling Was Discovered
The Integral System paradigm had its origins in an
endeavor to create a new operation for repair of USI, the
midurethral sling (MUS). Development of the MUS proce-
dure began with two unrelated observations in the mid-

Fig. 3.4  The TFS shortens

and reinforces all five
damaged ligaments. The tape
is applied along the length of
the ligaments to tension and
shorten them: PUL
pubourethral, ATFP arcus
tendineus fascia pelvis, CL
cardinal, USL uterosacral;
deep transversus perinei part
of PB (perineal body). The
tape creates a collagenous
reaction which strengthens
the damaged ligament. Insert:
TFS tool A polypropylene
anchor 11 × 4 mm sits on a
stainless steel applicator. A
lightweight macropore
monofilament tape passes
through a one-way system at
the anchor base which USL
shortens and tensions the
damaged ligament

PUL

CL

ATFP

PB
3  The Integral System of Pelvic Floor Function and Dysfunction 35

Table 3.1  Data from Inoue et al. (mean age 70 years) [8]
Test
Observed 95%- 96%- results H0:
No of cure rate lower upper p ≤ p0 vs.
Variable N cured (%) CI CI H1: p > p0
Prolapse 278 257 92.10 0.891 0.952 ∗
Urgency 133 124 93.20 0.879 0.971 ∗
Nocturia 86 62 72.10 0.597 0.809 /
Day time 132 120 90.10 0.935 0.999 ∗
frequency
Dragging 56 52 92.90 0.862 0.998 ∗
pain
Fecal 52 46 88.50 0.798 0.977 #
incontinence
Lower and upper 95% confidence intervals for the observed relative
frequencies of prolapse, urgency, nocturia, daytime frequency, dragging
pain, and fecal incontinence. Parallelly the results of testing the hypoth- Fig. 3.5  Formation of artificial collagenous neoligaments. Tapes were
esis. H0: p < p0 vs. H1: p > p0 have entered. ∗, #, and / mean significant inserted in the position of the pubourethral ligaments (white arrows).
p values when p0 is setting equal to 0.80, 0.75, and 0.60, respectively. In Specimen of vagina (V), vulva, bladder (B) dissected from a dog
other words these symbols depict that the observed cure rates are sig- 2  weeks after the tape which had been implanted for 12  weeks was
nificant (p < 0.05, binomial tests) removed. Note the significant artificial collagenous neoligament cre-
ated by tissue reaction against the tape (white arrows)

1980s. A hemostat applied immediately behind the
symphysis pubis, at the level of and lateral to the midure-
thra (so that it could not obstruct the urethra), controlled
urine loss on coughing without bladder neck elevation (see
Video 1). The second observation was that an implanted
Teflon tape created a collagenous tissue reaction around it
when implanted. It was hypothesized that a tape implanted
in the exact position of a damaged PUL would create a col-
lagenous neoligament to reinforce it, thereby restoring
function and continence. It is well-­established that liga-
ments with an estimated breaking strength of 300 mg/mm2,
rather than the vagina (breaking strength approximately
60  mg/mm2), are the major structural components of the
pelvic floor. Their strength derives from Type 1 collagen.
During pregnancy collagen is stretched and weakened, and
age also weakens it and reduces its elasticity. It was rea-
soned that, especially in older women, simply suturing a
damaged ligament was not the answer. Only a process
which creates de novo collagen, as in Fig. 3.4, could repair
the PUL.
3.4.1 Development of the Artificial
Collagenous Neoligament for PUL
Repair
Following human cadaver testing on a half pelvis, a surgical
technique was developed in canines (1987–1988) to test the
hypothesis that a precisely inserted tape in the anatomical
position of the PUL would create a collagenous neoligament
(Fig. 3.5). This methodology was tested at the Royal Perth
Hospital animal laboratory in 13 canines [9]. Post-op evalu-
ation comprised extensive histological, bacteriological, bio-
chemical, X-ray, radioactive gallium, and biomechanical
studies, including testing for collagen I and III. It was found
that the new collagen fibers of the neoligament were aligned
in linear formation along the tape [9]. Thus a new surgical
principle, using a thin tape for planned formation of an arti-
ficial collagenous neoligament (Fig. 3.5), was developed [9]
applicable for repair of any damaged ligament in the pelvis
and pelvic floor.
3.4.2 Application of the Neoligament
Surgical Principle to PUL and Other
Ligaments
Between 1988 and 1989, 30 women with genuine stress
incontinence (USI) underwent the prototype MUS operation
for repair of PUL [10] (Fig. 3.6). In 1996, the original MUS
operation evolved to the “tension-free” vaginal tape (TVT)
procedure [11, 12], which was adapted in 1992 to repair the
uterosacral ligaments (USLs) as a posterior sling [13] and,
then, in 2003 as the tissue fixation system (TFS), a tensioned
mini sling applicable to the other three ligaments, CL, ATFP,
and PB [8, 14–17].
3.4.3 C
 linical Relevance of Some Initial MUS
Operation Findings (1988–1989)
Many findings from the prototype midurethral sling opera-
tions are still relevant today:
1. Stress and urge seemed etiologically related (Fig. 3.6a);
they were simultaneously cured in almost all patients ini-
tially, but both symptoms recurred in 50% when the tape
was removed at 6 weeks. The observation of urge inconti-
36
a coronal section view b
RECTUS SHEATH
U
tape
vagina
Rubber
tube
sutures
Fig. 3.6 (a) Prototype midurethral sling. Perspective: coronal section
immediately behind the pubic symphysis. The tape was configured
around the rectus sheath into the vagina, through both ends of a rubber
tube, exiting at its inferior end, both ends secured with interrupted
sutures in holes set 0.5 cm apart and cut sequentially to lower the tape
as required. (b) Standing sagittal X-rays from 1990 prototype MUS,
nence cure was a remarkable result. If a patient has both
USI and urge incontinence without other posterior zone
symptoms (Fig. 3.2b), a high likelihood of cure of both
symptoms can be predicted after MUS.
2. In the prototype midurethral sling operations, the tape
(Fig. 3.6a) was initially set high, at the upper level of the
symphysis. At this level, urine could not flow, and the
­urethra was mechanically obstructed. As the tape was
P. Petros et al.
same patient. Left column: at rest. Right column/straining. Middle
X-ray right, post-op. Intravaginal tape grasped by a hemostat “H”
reveals three-directional forces acting in the position of PUL. Bottom
X-ray, post-op. Bladder neck below symphysis at rest and during strain-
ing. Patient cured
lowered cm by cm (the operation was performed under
LA), symptomatic obstructed micturition resolved. At
about the lower border of the symphysis, the patient
remained continent and was able to pass urine freely, with
no symptoms of obstruction or urgency, showing that the
mechanism of USI cure was not obstructive. Therefore, if
a patient cannot pass urine within about 72 h after MUS,
most likely there is tape compression as a cause. The tape
3  The Integral System of Pelvic Floor Function and Dysfunction
can easily be loosened at 72 h, because collagenized scar
tissue has not yet formed.
3. The tape was found to be always in the midurethral posi-
tion (Fig. 3.6b). When the tape was grasped with a hemo-
stat and the patient was asked to cough and strain,
three-directional vector forces became evident, forward,
backward, and downward around the tape. Understanding
that closure and micturition are activated by external stri-
ated muscles reliant on firm ligaments is the change in
thinking required for those treating the hitherto “incur-
able” conditions detailed in Fig. 3.1 and Table 3.1.
3.4.4 Closure of the Urethra
Imaging studies invalidate pressure transmission theories
and confirm musculoelastic closure. By 1990, Peter Petros
had begun working with the late Ulf Ulmsten in Uppsala,
Sweden. Dynamic abdominal ultrasound studies in 1990
showed distal urethral closure was caused by the vagina
being stretched by forward forces to close the urethra from
behind [2] (Fig. 3.7). Posteriorly, the bladder base and poste-
rior fornix of vagina were actively pulled down by a poste-
rior force acting against the uterosacral ligament [2] (Fig. 3.7
and Video 2). These findings were in accord with earlier
X-ray studies (Fig.  3.6a) [2] which demonstrated surgical
cure of stress incontinence without bladder neck elevation
and three-directional forces acting around a midurethral
PUL fulcrum point. Further studies in 1997 with video X-ray,
electromyograms, and ultrasound (Fig. 3.8a, b) [18, 19] vali-
dated that the closure mechanisms were activated by invol-
untary pelvic muscle forces. Anatomically, the forward force
could only derive from pubococcygeus muscle (PCM), the
posterior force from levator plate (LP), and the downward
force from the conjoint longitudinal muscle of the anus, first
described by Courtney [20]. None of the pressure transmis-
sion studies [16] can explain these X-ray and ultrasound
findings, nor the control of USI with unilateral support of
PUL noted in Video 1 and its ultrasound homologue
(Fig.  3.8b). These observations add to Constantinou and
Govan’s observations that the cough-induced urethral pres-
sure rise preceded and exceeded the abdominal pressure rise
[17] and their statement “This can only be due to a reflex
mechanism” [17].
3.4.5 R
 ole of PUL and Subsidiary Structures
in Normal Urethral Closure
and Incontinence
The pubourethral ligament (PUL) and pubovesical ligaments
(PVL) have a common origin behind symphysis pubis,
37
a BN
bladder
arc
Rotational
Vector
PVL
PU
forces
L E
ZC
LP
PCM
LMA
vagina
b
bladder
arc
PVL
PUL
LP
LMA
PCM vagina
L
Fig. 3.7 (a) Normal urethral closure. This is the schematic urethral
closure mechanism as described in 1990 [2]. ZCE zone of critical elas-
ticity, PVL pubovesical ligament, BN bladder neck, PUL pubourethral
ligament, arc precervical arc of Gilvernert. The directional arrows indi-
cate the vector closure forces. (b) Stress incontinence. The extension of
PUL to “L” (circle) indicates PUL loosening; PCM and LP directional
closure forces weaken; the anterior urethrovesical wall remains
anchored by PVL and arc of Gilvernert. The downward action by LP/
LMA opens out the posterior urethral wall. This is indicated by small
diagonal arrow. The patient loses urine on effort. LMA longitudinal
muscle ani, LP levator plate, PCM pubococcygeus muscle
1–1.5 cm above its lower border (Fig. 3.7a). PUL inserts into
the lateral walls of midurethra and distal part of pubococcygeus
muscle (PCM). PVL inserts into a fibrous thickening on the
anterior surface of the bladder, the precervical arc of Gilvernert.
In Fig. 3.7a the “zone of critical elasticity” (ZCA) is the elastic
part of anterior vaginal wall which allows separate function of
the distal and proximal urethral closure mechanisms.
The distal closure mechanism (PCM) stretches the vagina
forward against PUL to close the distal urethra. Its main
function is to immobilize and seal the distal urethra. The
classical symptoms of EUL defect are small leakages on
walking, moving quickly accompanied by a feeling like “a
bubble of air escaping.”
The proximal closure mechanism (LP/LMA) is the prin-
cipal closure mechanism. The levator plate (LP) contracts
backward against PUL and the immobilized distal urethra.
The PVL tensions the arc of Gilvernert to anchor the anterior
wall of bladder neck, while the posterior vectors LP/LMA
rotate the bladder downward around the arc to close off the
bladder neck, like kinking a hose [2]. Figure  3.8a, b and
38
a arc
PCM
Fig. 3.8 (a) Role of PUL and USL in urethral closure. The change of
shape of the vagina “V” and the positions of bladder “B,” rectum “R,”
and levator plate “LP” relative to the vertical and horizontal bony coor-
dinates (white broken lines) during straining. An elastic vagina is critical
for the correct transmission of muscle forces by directional vectors
(arrows). Upper XR. Resting closed position Urethral closure is main-
tained by tissue elasticity and slow-twitch muscle contraction against the
pubourethral ligament (PUL) anteriorly and uterosacral ligament (USL)
posteriorly. CX cervix, U urethra, Ra anorectal angle, Bv ligamentous
attachment of bladder base to upper vagina. Lower XR. On effort
(Straining down) fast-twitch directional vector forces stretch the distal
vagina and urethra forward against PUL; the bladder base is stretched
backward against PUL; LP pulls downward against USL to close blad-
der neck. Adequate elasticity is required in the bladder neck (BN)
Videos 2 and 3 provide X-ray and ultrasound validation of
the bladder neck and urethral closure mechanisms.
3.4.6 R
 ole of Lax PUL in the Causation
of Urinary Stress Incontinence
A weak PUL (Figs. 3.7b and 3.8b) cannot hold the pelvic
floor tissues in position. They descend on effort with L
­ P/
LMA contraction to open out the posterior urethral wall,
much as during micturition. Corrective surgery requires
P. Petros et al.
BN
bladder
Rotational
Vector
PVL forces
PU
L E
ZC
LP
LMA
vagina
area of vagina “zone of critical elasticity” (see “ZCE” in insert figure) so
as to allow the opposite muscle forces which stretch the vaginal mem-
brane to operate independently of each other. PB perineal body. (b) Role
of PUL in urethral closure. Transperineal ultrasound, patient with USI.
Left figure, REST S symphysis, U urethra, B bladder, a anterior vaginal
wall, p posterior vaginal wall. Middle figure STRAIN a loose PUL as in
Fig. 3.7b allows the posterior pelvic muscles to stretch the vaginal walls
“a” and “b” backward; this action pulls open the posterior urethral wall.
The urethra opens out proximally and distally exactly as in micturition.
Right figure MID/UR ANCHOR When a hemostat (white arrow) sup-
ports (shortens) the pubourethral ligament, the musculoelastic closure is
restored; “a” and “b” tension; distal and bladder neck closure are
restored. LMA longitudinal muscle ani, PCM pubococcygeus muscle,
PVL pubovesical ligament
restoration of PUL to its correct length and reinforcement
with a tape. This restores the muscular closure mechanisms
as in Fig.  3.7a. The classical symptom of PUL defect is
urine loss coincident with effort. PUL laxity causes
USI. Diagnosis is by applied mechanical support of the lax
PUL at midurethra, as shown in Video 1. Figure 3.8b is an
ultrasound demonstration of the anatomical effect of PUL
shortening as in Video 1. This maneuver restores the ana-
tomical geometry and therefore continence [21]. This also
demonstrates why an MUS sling must be shortened during
the procedure.
3  The Integral System of Pelvic Floor Function and Dysfunction 39

3.4.7 E
 xternal Urethral Ligament Laxity:
A Rarely Recognized Cause
of Nonstress Urine Leakage

In the normal patient, the distal closure muscle stretches the

distal vagina forward between PUL and the external urethral
meatus to close the distal urethra (Fig.  3.9). The classical
symptoms of EUL defect are small leakages on walking, or
moving suddenly, accompanied by a feeling like “a bubble of
air escaping.” In patients who leak after MUS, EUL laxity
(Fig. 3.10) needs to be excluded. Because the main bladder
neck closure mechanism is enacted by downward rotation by
LMA, USL weakness may also contribute to USI. In such a
case, other posterior zone symptoms (Fig.  3.2b) will be
present.

3.4.8 Anorectal Closure

Video radiography and ultrasound studies [18, 19] indicated

that the mechanism of anorectal closure (Fig.  3.11a) is
almost identical to that of urethral closure (Fig. 3.8a) except
that the posterior vector forces, LP and LMA, rotate the rec-
tum around a contracted PRM which acts to stiffen the pos-
Fig. 3.10  Appearance of loose external urethral ligament (EUL). Note
terior anorectal wall (Fig. 3.11b). Video 2 shows distal and eversion of the urethral mucosa. The arrows in the position of EUL
proximal urethral closure. It also shows the rectum being indicate prolapse of this ligament. M urethral meatus
pulled backward and downward following angulation of the
levator plate.
1990s, patients reported FI cure following the posterior
sling repair for uterine prolapse [22]. PUL and USL work
3.4.9 Serendipity: Cure of Fecal Incontinence synergistically to close the anorectal angle. With reference
(FI) Following PUL and USL Sling Repair to Fig.  3.11a, either loose PUL or USL may cause fecal
incontinence. Reconstruction of PUL restores contractile
From the commencement of the prototype operations in the strength of PCM and LP.  Reconstruction of USL restores
late 1980s, patients were reporting that both their urinary contractile strength of the downward vector of LMA.  In
and fecal incontinence were cured by the midurethral sling 2008, Hocking reported >90% cure in patients with “double
procedure for urinary stress incontinence. Later, in the mid-­ incontinence,” both USI and FI, following a single MUS
procedure [23] and Abendstein and Liedl reported cure of FI
with posterior sling procedures [24–26]. FI may be caused
equally by PUL and USL laxity. This section deals with
PUL causation. USL causation is dealt with under the USL
section.

EUL PUL

3.4.10 Surgical Repair of PUL by MUS

MUS cures USI by insertion of a tape in the position of the

H
Fig. 3.9  Mechanism of leakage with external urethral ligament (EUL)
laxity. Suburethral vagina “H” and the forward vector PCM (pubococ-
cygeus muscle, red arrow) constitute the distal closure mechanism. If
EUL is loose, the slow-twitch fibers of PCM (arrow) cannot seal the
distal urethra; urine may be lost, usually as a seepage
middle part of the urethra to shorten and reinforce the dam-
aged PUL (Fig. 3.12). Whatever the type of instrument used
to insert the tape, optimal methodology requires prior inser-
tion of an 18-gauge Foley catheter, use of a non-stretch tape
which is inserted so as to touch but not indent the urethra,
cystoscopic checking for inadvertent bladder perforation,
40
Fig. 3.11 (a) Role of pubourethral ligament (PUL) and uterosacral
ligament (USL) in anorectal closure. Resting closed (right figure):
slow-twitch muscle fibers “S” close urethral and anal tubes. Active
closed (continence) (left figure): fast-twitch fibers exaggerate the
actions of “resting closed.” Forward pubococcygeus muscle (PCM)
contraction against PUL (forward arrow) stabilizes the anterior rectal
wall; backward contraction by levator plate (LP) against PUL (back-
ward arrow) stretches the rectum backward. The longitudinal muscle
and testing either by cough or suprapubic pressure for urine
loss during the procedure. To minimize postoperative urinary
retention, it is recommended that the surgeon always tighten
the tape over a No. 8 Hegar dilator or a No. 18 Foley catheter.
If further tightening is required, it should also be done over a
Hegar dilator or catheter. EUL/hammock laxity repair
(Fig.  3.13) should be carried out at the same time as the
midurethral sling repair (Video 4).
P. Petros et al.
ani (LMA) (downward arrow) pulls the anterior margin of down against
USL to rotate the rectum (R) around a contracted puborectalis muscle
(PRM) (yellow) to “kink” the rectum and close the anorectal angle
“Ra.” (b) Anorectal closure (schematic). PRM contracts forward to sta-
bilize the posterior wall of anorectum. LP inserts into the posterior wall
of the rectum. LP contracts backward against PUL to stretch the rectum
backward. LMA contracts downward to rotate the rectum around PRM
to close it. B bladder, CX cervix, PB perineal body, V vagina
3.4.11 Surgical Results for PUL Repair
(Midurethral Sling)
More than 2000 papers have been published on the standard
retropubic and TOT midurethral sling procedures, reporting
cure rates for both between 80 and 90%. TFS was the first
mini sling for USI, performed in September 2003. A ran-
domized clinical trial by Sivaslioglu et al. [27] gave 5-year
3  The Integral System of Pelvic Floor Function and Dysfunction
cure rates for TFS of 89% against 78% for TOT. Nakamura
from the Yokohama Clinic reported a 91% cure rate for ISD
(MUP <20 cm H2O) at 12 months, the operations being per-
formed entirely under local anesthesia, and there were no
tape rejections [28].
Fig. 3.12  Mini sling repair of pubourethral ligament (PUL).  The
vagina immediately below middle part of urethra is opened as per a
standard midurethral sling. The retropubic space is entered, and the
anchors are placed in the position of PUL insertion into the pubic bone
U
Fig. 3.13  External urethral ligament (EUL) hammock suture reinforces
the loose EUL and lax suburethral vagina of Figs. 3.9 and 3.10. Tightening
of the distal supports of the urethra (EUL) with a 20 vicryl suture “S,”
which passes through the musculoelastic layer (f) of the vagina (V) to
41
3.4.12 Zone of Critical Elasticity: Tethered
Vagina Syndrome and Role of Fibrosis
in Incontinence After Post-obstetric
Fistula Repair
Conserving vaginal elasticity is a core surgical principle as
this elasticity is essential for the independent function of the
distal and proximal closure mechanisms [2]. The bladder
neck area of vagina—the “zone of critical elasticity” (ZCE)
(Fig. 3.14)—needs to be elastic so as to allow the two oppo-
site urethral closure mechanisms to work independently of
each other. Scarring in the anterior vaginal wall may link
these independent forces. The stronger posterior forces may
then overcome the anterior forces to forcibly open out the
posterior urethral wall. This will cause sudden uncontrolla-
ble urine loss, the “Tethered Vagina Syndrome” [2, 29]. In
obstetric fistula patients who continue to leak urine after suc-
cessful closure of the fistula, the scarring and fibrosis may be
so severe that there is not even sufficient elasticity at ZCE for
the slow-twitch muscles of the pelvic floor to function ade-
quately. Urinary leakage is constant, day and night. Treatment
requires restoration of elasticity in the anterior vaginal wall
[29, 30]. The most important application of the TVS method-
ology to date has been in obstetric fistula surgery; 95% of
fistula closures are successful but, despite this, urine loss
continues in up to 55% of cases [29]. Browning et al. found
that augmenting the ZCE with a Singapore flap skin graft,
identical in principle to the skin-on Martius flap graft
(Fig.  3.14), produced a dramatic improvement in such
patients. Browning et  al. reported at least a 400% greater
return to dryness than previous attempts at restorative sur-
gery [30]. In first world countries, scarring in the anterior
vaginal wall may be a consequence of the mesh sheets used
for cystocele repair, scarring from vaginal excision, over-­
elevation of vagina by a Burch colposuspension operation or
after fascial bladder neck slings. These may scar or remove
elasticity at ZCE and cause severe uninhibited urine loss,
S EUL
f
tighten it toward the EUL. The EUL attaches the external meatus of the
urethra (U) to the anterior surface of the pubic bone. This operation is
always performed with a No18 Foley catheter in the urethra. The suture is
left slightly loosely tightened
42
PS
H SCAR
Graft-bladder neck area of vegina
Fig. 3.14  Tethered Vagina Syndrome—mechanics and surgical cure.
Right figure. There is a scar over the zone of critical elasticity (ZCE).
The scarring “tethers” the stronger posterior LP/LMA forces (arrows) to
the weaker forward PCM force (arrow). On effort, when the signal is
given to close (classically on getting out of bed in the morning), the
posterior vectors overcome the forward force (“PCM” arrow) to open
out the posterior urethral wall exactly as happens during micturition (see
most characteristically immediately on getting out of bed in
the morning. In a few cases, the leakage may be constant.
Anatomical restoration is by dissection of adherent scar tis-
sue and direct application of abdominal skin, by skin-on
Martius graft, or by the Singapore graft [30] (Video 5).
3.5  art 2: The Uterosacral Ligament
P mesh repair. The ultimate proof that the vagina is not a struc-
“USL”: Cure of Uterine Prolapse
with Posterior Sling
The first posterior sling operation was performed at Royal
Perth Hospital under local anesthesia in 1992. It is our view
that the USL is the most important ligament in the pelvis.
Aside from its structural role, from a functional perspective,
USL plays a key role in normal bladder and anorectal clo-
sure and evacuation and control of the micturition and def-
ecation reflexes. When lax, it can cause POP, chronic pain,
bladder, and bowel symptoms (Fig.  3.2a, b). The USL is
closely linked with the cardinal ligament structurally and
functionally.
P. Petros et al.
PCM
PUL PUL
BLADDER
LP
C
O
ZCE
LMA
Fig. 3.16). The closed urethra “C” is forcibly pulled open to “O.” This
causes a massive unrestrained loss of urine. A skin graft applied to blad-
der neck of vagina (left frame) restores vaginal elasticity in the area of
scarring “scar.” This forces the three-directional muscle to work inde-
pendently of each other again to close the distal and proximal urethra. H
hammock, LMA longitudinal muscle ani, LP levator plate, PCM pubo-
coccygeus muscle, PS pubic symphysis, PUL pubourethral ligament
From a structural perspective, USL laxity causes uterine
prolapse (Fig. 3.15). Uterine prolapse is caused by weak and
elongated cardinal (CL) and uterosacral (USL) ligaments,
not primarily by vaginal damage. It is self-evident from
Fig. 3.15 that the only way uterine prolapse can be cured is
to shorten and strengthen CL and USL. “Native tissue repair”
of the vagina will not strengthen the ligaments, nor will a
tural organ was recently provided by the Lancet PROSPECT
CL
uterus
USL
Fig. 3.15  Both cardinal (CL) and uterosacral (USL) ligaments are
elongated in uterine prolapse. It is self-evident that CL and USL will
elongate to cause uterine prolapse and that shortening and strengthen-
ing of both CL and USL is required for anatomical restoration
3  The Integral System of Pelvic Floor Function and Dysfunction
RCT [5], where native tissue repair of the vagina was com-
pared against vaginal mesh repair. Both methods had >80%
failure rate at 6  months. In contrast, using TFS ligament
repair, the Kamakura [8] and Yokohama [31] units reported
>90% surgical cure rate for third- and fourth-degree POP at
12  months, with minimal deterioration (79% cured at
60 months) [15] and minimal tape erosions. The Yokohama
units reported no tape erosions. It was the view of the
Yokohama unit [28, 31] that the lightweight purpose-knitted
tape, or prevention of tape slippage by the anchor, and pre-
cise mm by mm tensioning of the tape all contributed to their
report of no tape rejections.
3.5.1 Role of USL in Micturition
The mechanisms for micturition and defecation are similar.
With reference to Fig. 3.16, relaxation of the PCM forward
vector (insert) allows the posterior vectors LP/LMA to pull
open the posterior urethral wall. Opening out the urethral tube
as in Fig. 3.16, lower figure, lowers the internal resistance to
urine flow inversely by the fourth power of the radius. For
example, if the radius is doubled, resistance to flow decreases
16 times (2 × 2 × 2 × 2). If USL is loose, the muscle forces
weaken; the urethra cannot be fully opened; and the detrusor
has to empty against a narrower tube (Fig. 3.17). The detrusor
has to work harder to empty the bladder, and the patient expe-
riences this as “obstructed micturition” (Video 6).
PCM
Fig. 3.16 Micturition. Upper XR. Resting closed Directional slow-­
twitch muscle fibers maintain urethral closure distally and at bladder neck
(2). Lower XR. Micturition The forward vector (insert) relaxes. The back-
ward vectors stretch the vagina (V) backward and downward against USL
to open out the posterior urethral wall. The pubovesical ligament attach-
43
An overtight SCP or rectopexy mesh will counteract
the downward vectors; urethra and anus cannot be ade-
quately opened; the patient presents with obstructive def-
ecation or micturition. It has been demonstrated that
correction of a lax USL can improve symptoms of
“obstructive micturition,” reduce residual urine, and, in
some cases, restore normal micturition in women who
needed to self-catheterize [32].
3.5.2 Role of USL in Normal Defecation
The mechanisms of defecation and micturition are almost
identical, except that it is PRM, not PCM which relaxes for
defecation. PCM actually contracts to pull forward the ante-
rior anorectal wall during defecation. The pressure of PRM
on the posterior rectal wall is released (Fig. 3.18). The poste-
rior vectors LP/LMA pull against USL to stretch open the
posterior rectal wall (Fig.  3.18) [33]. This decreases the
internal resistance to evacuation inversely by the third power
of the anal radius [34]; the rectum contracts to empty.
Abendstein cured obstructive defecation syndrome (ODS)
and intussusception with a posterior sling which lifted the
prolapsed vagina and rectum “like the apex of a tent” [25].
This was validated by pre- and postoperative defecating
proctograms. The anatomical rationale was that the USLs
not only suspend the uterus; they also attach to the lateral
walls of the rectum (Video 7).
bladder
arc
PVL
PU
L
E
ZC LP
LMA
vagina
ment to the arc of Gilvernert (PVL, insert figure) prevents the anterior
bladder wall prolapsing into the outflow tract. B bladder, CX cervix, LMA
longitudinal muscle ani, LP levator plate, PCM pubococcygeus muscle,
PUL pubourethral ligament, R rectum, S sacrum, U urethra, USL utero-
sacral ligament, ZCE zone of critical elasticity
44
Fig. 3.17  “Obstructive” micturition is consistent with muscle inability
to open urethral tube. The electromyography (EMG) in the posterior
fornix of vagina shows muscle activity preceding detrusor contraction.
3.5.3 L
 ax USLs: Anatomical Pathways to Pain,
Bladder, and Bowel Dysfunction
The USLs are the anchoring point for the backward/down-
ward vectors which are critical for control of bladder and
bowel function. A fundamental tenet of the Integral System
is that even minor laxity in the USL may cause major symp-
toms of:
• Micturition difficulty and obstructive defecation “ODS”.
• Bladder and bowel urgency and frequency.
• Nocturia.
• Bladder and bowel incontinence.
• Chronic pelvic pain.
The reason a minor change in USL length can cause such
major symptoms is the exponential nature of the control
mechanisms: Poiseuille’s Law governing urine flow (inversely
by the fourth power of the radius) and Gordon’s Law which
governs muscle contractile strength. A striated muscle con-
tracts efficiently only over a limited length [35] (Fig. 3.19). If
the insertion point is loose (Figs. 3.19 and 3.20), the muscle
effectively lengthens and loses contractile force. When a
muscle is already inherently damaged, for example, by partial
denervation, this deleterious effect is magnified.
3.5.4 L
 ax USLs: Role in “Obstructive
Micturition and Defecation” (Organ
Emptying Problems)
X-ray video studies presented here demonstrate that both
bladder and anorectum are actively opened out by the same
P. Petros et al.
The weak muscles cannot “grip” sufficiently to pull open the urethral
tube, and so they have to continually contract to force the urine through
an insufficiently opened tube
posteriorly acting muscle forces, LP/LMA, which contract
against USLs. A loose USL (Fig. 3.20) will cause weaken-
ing of the urethral or anorectal LP/LMA opening forces
[32–35]. The bladder detrusor or rectum then contracts
against an unopened tube. This is perceived by the patient
as “obstructed micturition” or “obstructed defecation,”
with symptoms such as “feeling bladder has not emptied,
“stopping and starting,” multiple emptying, post-micturi-
tion dribble, raised residual urine [32], and, for bowel,
constipation or obstructive defecation (ODS) [25].
Shortening and reinforcing CL/USL by a posterior sling
restores prolapse and the external opening mechanisms
with improvement of “obstructive” symptoms and reduced
residual urine volume for bladder [32] and improved bowel
emptying [25].
3.5.5 L
 ax USL: Pathways from Ligament
Laxity to Symptoms of Urge,
Frequency, and Nocturia
The Integral Theory interprets urgency to micturate or
defecate as an inappropriate activation of the micturition
or defecation reflexes. One important cause is lax PUL or
USL (Fig. 3.21). The directional muscles which contract
against PUL or USL will suffer reduced contractile
strength. The weakened LP/LMA muscles (Fig. 3.21) can-
not stretch the vagina or anorectum sufficiently to support
the stretch receptors “N,” so they now fire off at a lower
volume to activate the micturition or defecation reflexes.
The cortex perceives these impulses as frequency and
urgency symptoms and if this happens at night, nocturia
(Fig. 3.22).
3  The Integral System of Pelvic Floor Function and Dysfunction 45

Fig. 3.18  Anorectal opening (defecation) X-ray defecating procto-­
myogram sitting position. (a) At rest The anorectal angle (ARA) to the
upper left of the green square is angled. The anus is closed. The superior
surface of the levator plate (LP) muscle is almost horizontal. Defecation
mode ARA is opened out by backward and downward vectors LP/LMA
(arrows). Note the insertion of levator plate into the posterior wall of
rectum. The conjoint longitudinal muscle of the anus (downward vector,
LMA) pulls down the anterior margin of the contracted LP. This is iden-
tical with what happens during micturition [21]. (b) The resultant diago-
nal vector (arrow) opens out the ARA. The anterior wall of anus is pulled
forward by pubococcygeus (arrow) further opening out the anal canal
[33]. LMA longitudinal muscle ani, PRM puborectalis muscle

Fig. 3.19  Gordon’s Law—A Maximal

striated muscle contracts muscle
efficiently over a limited 3 2 1 force [%]
length. If a ligament which is 100
the insertion point of a muscle
lengthens, say by “L,” so does Shortened 80
the muscle. Muscle Lengthened muscle ‘L’ Normal length muscle
lengthening say by “L” results 60
in a rapid decrease in muscle
force, shortening more so
40

20

0
2,0 2,5 3,0 3,5 4,0
sarcomere length [µm]
46 P. Petros et al.

Fig. 3.20 Potential
consequences of loose
uterosacral ligaments (USL) as
interpreted by Gordon’s Law.
View from above. The uterus has
prolapsed to first degree. The
USLs have elongated by “L.”
The rectum (R) also has
descended, by virtue of its
attachments laterally to the
elongated USL. The rectum loses
tension. LP (levator plate) inserts
into the posterior wall of R, so
LP also lengthens. LMA
(longitudinal muscle ani) now
has to pull against a lax LP and
USLs. The contractile force and
resulting movement of the
anorectal angle will be
diminished. The large wavy
arrows signify diminished
contractile strength. ATFP arcus
tendineus fascia pelvis, EAS
external anal sphincter, PB
perineal body, PCM
pubococcygeus muscle, PS pubic
symphysis, PUL pubourethral
ligament, S sacrum

Fig. 3.21  Urge incontinence of

urine and feces as interpreted by
CORTEX
Gordon’s Law. If the uterosacral
ligaments (USL) lengthen by “L,”
so do the directional muscles
(arrows) (the wavy form and pink
color of the arrows denote PONS
weakened muscle contractile force)
lengthen by “L” and their
contractile force weakens. The
tissues cannot be stretched
sufficiently to maintain a constant
supporting tension for the stretch
receptors “N.” “N” fire off increased
afferent impulses at a low bladder increased
or rectal volume, and this is efferent
perceived by the cortex as urgency increased
to evacuate. If the quantum of afferent
afferents is sufficient to stimulate PUL
the micturition or defecation BLADDER USL

reflexes, the mechanical dimension

of the reflexes is activated: the N cx
N
forward muscles relax; the
backward muscles open out urethra MUSCLES
or anus; bladder and rectum MUSCLES
ATFP
contract; the patient may CL
uncontrollably lose urine or feces PELVIC RIM

(“urge incontinence”). ATFP arcus

tendineus fascia pelvis, CL cardinal
ligament, CX cervix, PUL
pubourethral ligament

L
3  The Integral System of Pelvic Floor Function and Dysfunction
PCM
LMA
N C
G afferent
USL impulses
LP
Fig. 3.22  Mechanical origin of nocturia—patients asleep. Pelvic mus-
cles (large arrows) are relaxed. As the bladder (broken line outline) fills,
it is distended downward by gravity “G.” If the uterosacral ligaments
(USL) are weak, the bladder base continues to descend; at a critical
point, the cortical closure reflex “C” is overcome; the stretch receptors
“N” now activate the micturition reflex “O” which accelerates the pro-
3.5.6 L
 ax USL: Anatomical Pathway
to Chronic Pelvic Pain
The role of USLs in producing chronic pelvic pain was
described in detail by Heinrich Martius in 1938 [36] but was
rediscovered only in 1996 [37]. Chronic pelvic pain is per-
ceived in the visceral nerve distributions T12-L1 and S2–4,
causing pain in the lower abdomen, groin, lower sacrum
[38], introitus [39], paraurethral tissues [40], the pain of
interstitial cystitis [41], and deep dyspareunia [37]. Inability
of the weakened pelvic muscles to tension the uterosacral
ligaments may cause unsupported nerve plexuses within the
USLs to fire (Fig. 3.23). Objective proof of USLs as the path-
way to chronic pelvic pain origin was obtained by different
types of “simulated operations.” Simulated operations
mechanically support pelvic ligaments, while the physician
directly observes changes in symptoms. Digital support of
PUL can control USI (Video 1). USL support with the lower
blade of a speculum or by a tampon can relieve chronic pain
and urge symptoms. Speaking clinically, the stretch recep-
tors are very sensitive. Digital or mechanical support of the
bladder base stretch receptors N, PUL and USL, will usually
relieve urge symptoms in a clinical situation by inhibiting the
micturition reflex (Video 8). However, excess pressure may
cause urge or even urine loss (Video 9). Wu et al. reported
relief of pelvic pain and suburethral tenderness by insertion
of the lower part of a bivalve speculum to support the poste-
rior fornix [40]. Bornstein relieved vulvodynia pain by local
47
CORTEX
0 PONS
inhibitory
centre
cess of evacuation: the patients is awakened by a feeling of urgency
(nocturia); PCM (pubococcygeus muscle) is actively relaxed by the cor-
tex. If the micturition reflex is not adequately controlled, LP/LMA con-
tracts to open the urethra and the detrusor contracts; the patient may lose
urine on the way to toilet. LMA longitudinal muscle ani, LP levator plate
anesthetic injection into the cervical part of the USLs [39] as
did Petros in three patients with interstitial cystitis, abdomi-
nal pain, and suburethral tenderness [41]. Gunnemann
reversed anterior rectal wall intussusception with a cylindri-
cal vaginal pessary, inserted under ultrasound control [42].
3.6  art 3: Cardinal Ligament (CL): Its
P
Role in Cystocele Causation
Dislocation of CL and anterior vaginal wall from their attach-
ments to the anterior cervical ring is the principal cause of
cystocele (Fig.  3.24). Surgical cure for POP is best per-
formed vaginally, ideally repairing both CL and USL with a
tape (Fig. 3.25) [8, 31, 43]. CL/USL reconstruction will also
improve urinary hesitancy and residual urine [32]. The cervi-
cal TFS tape will reattach the insertion point of ATFP if it is
dislocated from the ischial spine (Fig. 3.25) and so reconsti-
tute the depth of the sulcus on that side.
3.7  art 4: ATFP: Role in Lateral Cystocele
P
and Urinary Stream Diversion
The role of ATFP (arcus tendineus fascia pelvis) is to support
the paracolpium of the vagina in the manner of a sheet strung
across two washing lines. Birth-related dislocation of the
ATFP is almost invariably at the ischial spine. This is
48
Ganglion
Frankenhäuser
L appearance, and its structure is similar to the other pelvic
Fig. 3.23  Pathogenesis of chronic pelvic pain. The Ganglions of the
Frankenhauser and the sacral plexuses are supported by uterosacral
ligaments (USL) at their uterine end. “L” indicates ligament laxity. The
posterior directional forces are weakened and cannot stretch the USLs
sufficiently for them to support the nerves. The unsupported nerves may
be stimulated by gravity or by the prolapse or by intercourse to fire off
and be perceived as pain by the cortex
uniquely corrected by the TFS CL operation [8] (Fig. 3.25).
Stretching of the paracolpium attachment to ATFP is consid-
ered to be the main cause of the more distally located cysto-
cele (“lateral/central defect”). Another cause of this defect
P. Petros et al.
we believe maybe dislocation of the “pubovisceral” muscle.
“Pubovisceral” muscle dislocations have been “rediscov-
ered” in the past 10  years. “Pubovisceral” combines PCM
and PRM. This term is not anatomically accurate. PCM and
PRM are entirely separate muscles with different functions.
Studies by Dietz et al. showed that women with levator avul-
sion defects were twice as likely to show pelvic organ pro-
lapse of stage II or higher, mainly due to an increased risk of
cystocele and uterine prolapse [44]. There was little correla-
tion with incontinence, urinary or fecal. Scheffler et al. [45]
reported a case of diverted urinary stream with response to a
TFS “U-sling” operation. This operation attaches a prolapsed
distal vagina to the ATFP ligamentous origins behind the
symphysis. In the Scheffler case [45], the TFS sling most
probably reattached a unilateral PCM dislocation.
3.8  art 5: Deep Transversus Perinei
P
(DTP): Role in Rectocele
and Descending Perineal Syndrome
The perineal body is an essential inferior supporting struc-
ture for the vagina and anorectum. It is approximately 4 cm
in length. It supports 50% of the posterior vaginal wall [46]
and a significant part of the anterior wall of rectum. In its
distal 2 cm, the PB is densely adherent to vagina and anus.
The PB is attached to the descending ramus by deep trans-
versus perinei (DTP) ligaments (Fig. 3.26). At surgical dis-
section, DTP is distinctively whitish in its macroscopic
ligaments, consisting of collagen, elastin, smooth muscle,
nerve, and blood vessels. It contains small amounts of stri-
ated muscle [47].
3.8.1 A
 natomical and Surgical Significance
of DTP Ligaments
It is not well known that the key structural components of the
perineal bodies are the deep transversus perinei ligaments
which attach PB to the skeleton [47]. The deep transversus
perinei (DTP) ligament is attached to the posterior surface of
the descending ramus, exactly at the junction of the upper 2/3
and lower 1/3. During the second stage of delivery, DTP can
elongate to cause low rectocele (“perineocele”) and “descend-
ing perineal syndrome” (Figs.  3.26 and 3.27). The perineal
body can only be repaired by insertion of a tensioned tape
which penetrates the DTP behind the descending ramus to
repair and elevate the DTPs (Fig. 3.26) [48]. It is not unusual
for one DTP to be destroyed as a result of childbirth.
3  The Integral System of Pelvic Floor Function and Dysfunction 49

a b

Uterus

r
PCF
CL

vagina

Fig. 3.24  Pathogenesis of “high cystocele” (transverse defect). (a) anterior cervical ring allow PCF to rotate down as a cystocele. (b)
Dislocation of cardinal ligament (CL) and the pubocervical fascial Appearance on vaginal examination. The prolapsed CL and the overly-
(PCF) layer of the anterior vaginal wall from their attachments to the ing vagina (V) are located on the lateral side of the cervix (CX)

a b

IS

Fig. 3.25 (a) TFS cardinal (CL) and uterosacral (ULS) ligaments repair. Ligaments are shortened and reinforced by a thin tape placed along their
length. (b) Posterior IVS with a tape on the anterior cervical ring. IS ischial spine (with permission from [43])

3.8.2 PB Function Is Linked to USL Function
The perineal bodies and uterosacral ligaments work as a
unit. The extension of rectovaginal fascia (RVF) from PB to
cervix (Fig. 3.28) helps anchor the PBs when the backward
acting vector (LP) contracts. Tensioning the RVF by LP
“smooths out” the rectal mucosa, and this helps to facilitate
rectal evacuation by reducing frictional resistance to fecal
flow. Structural damage to PB and its RVF attachment may
result in a patient having to splint her perineum to ade-
quately evacuate feces or mitigate anal mucosal prolapse or
hemorrhoidal descent during defecation. In a normal
patient, slow-­twitch levator plate contractions at rest stretch
RVF backward. This helps to prevent mucosal in folding
50
OF OF
Vagina
DTP A DTP
PB PB
Rectocoele
Fig. 3.26  Surgical cure of descending perineal syndrome. Left figure.
Stretched and laterally displaced deep transversus perinei (DTP) liga-
ments. The attachment to perineal body (PB) is also stretched. This
allows protrusion of rectocele into the vagina. Right figure. TP1 is the
Fig. 3.27  Model pathogenesis of deep transverse perinei (DTP) liga-
ments and their causation of the descending perineal syndrome. The
perineal body (PB) is attached behind the upper 2/3 and lower 1/3 of the
descending ramus by DTP ligaments. The PBs are connected in the
midline by fibromuscular tissue (CT). Childbirth may stretch PB and
CT, elongate it, and push DTP laterally. The rectum may protrude as a
rectocele (fingers). The angulated and lengthened DTPs are the ultimate
cause of “descending perineal syndrome”. CT is known in some parts
of Europe as the “central tendon of the perineal body”
and back pressure on the rectal veins which may otherwise
manifest as hemorrhoids or anal mucosal prolapse. The
deep transversus perinei (DTP) ligaments (Figs.  3.26 and
3.27) attach PB to the descending ramus and thus stabilize
it. Loose DTPs may cause the descending perineal syn-
drome. Damage to USL will cause both the vagina and the
P. Petros et al.
TP 2
TP 1
Tape
downward displaced position of DTP. TP2 shows how a tensioned tape
inserted into the body of DTP and tensioned will elevate and restore the
position of DTP, also curing descending perineal syndrome. A anal
canal, OF obturator foramen
rectum to prolapse downward (Fig. 3.28). This may cause
rectal intussusception and symptoms of obstructive defeca-
tion. Inability to stretch the loose rectovaginal fascia and
the attached distal part of rectum upward may contribute to
tissue back pressure. This may cause prolapsed rectal
mucosa, hemorrhoids, and, if the backward pressure is suf-
ficient, possibly contribute to formation of a solitary rectal
ulcer. DTPs have been erroneously called deep transversus
perinei muscles. Histology demonstrates a typical ligament
structure: smooth muscle, collagen, elastin, blood vessels,
and nerves. Anatomically they are in the same position of
“puboperinei muscles.”
3.8.3 S
 urgical Principles Derived
from the Integral System
The implications of differential strength of ligaments and
vagina for pelvic surgery technique are important.
Interpretation of the experimental work of Yamada on tissue
strength is the key to understanding the ligament-based rules
for surgical reconstruction according to the Integral Theory
System [1]. Yamada demonstrated that the breaking strain of
ligaments was approximately 300  mg/mm2 and that of
vagina, 60 mg/mm2 [49]. This means ligaments are primarily
structural, but the vagina is not. X-ray video studies during
straining and micturition confirmed that ligaments do not
stretch significantly during effort or evacuation; only the
3  The Integral System of Pelvic Floor Function and Dysfunction
UT
USL
CX
P of D
RVF
AVF LP
V
R Surgery Using the TFS Tensioned Mini
Venous return
obstructed
PB
Fig. 3.28  Structural effect of loose uterosacral ligaments (USL). The
rectum is held up by USLs like the apex of a tent. Loose USLs may cause
rectal prolapse and anterior rectal wall intussusception (“R,” downward
arrows). The prolapsed rectal mucosa may cause back pressure in the
rectal veins to cause hemorrhoids. CX cervix, LP levator plate, PB peri-
neal body, R rectum, RVF rectovaginal fascia, UT uterus, V vagina
vagina stretched, very significantly. It follows that any recon-
structive surgery has to reinforce the structural part of the
ligaments, which consist mostly of Type 1 collagen and elas-
tic tissue. Only an implanted tape can do this [9]. The vagina
is an elastic organ which plays an important role in transmit-
ting the vector forces to close and open the bladder [2].
Because healing is by scarring and not regeneration, elastic-
ity cannot be surgically reproduced in the vagina. Therefore
the vagina must be conserved. Excision of vagina reduces the
quantum of elastin and Type 3 collagen available for proper
function. Finally, the uterus is the direct or indirect insertion
point for all the ligaments. Mesh sheets create dense colla-
gen which may shrink to cause pain and the Tethered Vagina
Syndrome. Hysterectomy should therefore be avoided where
possible. As well as dividing the cardinal and uterosacral
ligaments, hysterectomy severs the descending uterine artery,
which is the main blood supply of the proximal ends of the
cardinal and uterosacral ligaments. This may cause ligament
atrophy even with cervical preservation. Three rules of sur-
gery evolve from this discussion:
1. A loose ligament must be shortened and reinforced with
thin strips of tensioned tape to create a collagenous neo-
ligament [9]. This was the surgical principle applied in
the original midurethral sling procedure.
2. The vagina must be conserved, not excised.
3. The uterus must not be removed without good cause.
51
The Japanese TFS surgeons [8, 31] have found that fol-
lowing these rules greatly diminishes postoperative pain and
urinary retention and allows the TFS to be performed as a
day procedure under local anesthesia. Once the ligaments
have been shortened and reinforced, the directional muscle
forces act immediately to restore all the functions dependent
on the competent ligaments.
3.8.4 C
 omplications of Total Ligament Repair
Sling
The minimal nature of the TFS tensioned mini sling and its
universal applicability allow surgeons to repair even all five
ligaments at the same time. This method was followed by
the Kamakura and Yokohama units in Japan. Approximately
3600 TFS tapes were inserted into 1495 Japanese patients
between 2007 and 2016 by two units, Kamakura [8] and
Yokohama [31]. Almost all patients were discharged within
24  h. This indicates, in general, that short-term complica-
tions were minimal. However, from a total of 700 patients,
the Kamakura unit had three cases of ileus which presented
some months after the initial surgery and required surgical
intervention. The cause was attributed to inadvertent intra-
peritoneal placement of the tape. In these 700 patients, 6
reported postoperative pain after a 4-ligament TFS repair
(ATFP, cardinal, uterosacral, perineal body ligaments). All
pain settled by 6 weeks except for a patient with hip pain,
which settled by 24 months (Inoue personal
communication).
In 989 TFS tape implants for PB, ATFP, CL, and USL,
the Kamakura unit reported a 1.1% erosion rate for TFS
repair PUL, USL, ATFP, and CL ligaments [8]. However,
initial tape erosion rate for PB TFS was 25%; wrong place-
ment of the TFS was identified as the cause. Following mod-
ification of the insertion technique, the erosion rate fell to
2.5%. The Kamakura unit’s experience with TFS PB repair
emphasized that the TFS ligament repair method is tech-
nique and operator dependent. In 60 POP patients [31], the
Yokohama unit reported one case of hemorrhage requiring
hospitalization for several days, but no transfusion. There
was one case of urinary retention which settled by 2 weeks,
two cervical protrusions requiring cervical amputation.
There were no erosions; five patients had postoperative pain
which settled by 3 months. In 100 USI cases [28], Nakamura
et  al. reported no erosions, 1 bladder perforation (recog-
nized at the time of implant), 6 cases with de novo urgency,
and 2 with postoperative pain; 1 settled in 2 weeks and 1 in
3 months.
52 P. Petros et al.

3.8.5 Role of Muscle in Continence Control

It is evident that firm ligaments are required to enable the

SCP MESH
directional forces which open and close the urethra and anal
tubes. Earlier work on pelvic floor function in post-delivery
and prospective studies [50–56], led by Swash at St. Mark’s
Hospital, delineated direct muscle during delivery and coin-
tail bone
cidental damage to the innervation of the pelvic floor muscu-
lature as being associated with incontinence. The latter was USL
consequent to nerve stretch damage and was shown to be
progressive in association with ageing and especially with
perineal descent, itself a marker for ligamentous damage,
although the latter was not fully recognized at that time.
These findings gave rise to a Unifying Theory by Swash

l
x
rvi

we
bladder ce

bo
et al. [51]. The Unifying Theory postulated that bladder and SSL
bowel symptoms were caused by neurological and muscle
damage occasioned at childbirth. The Integral System is

le
ce
complementary to these findings and expands our under-

sto
e

standing. It emphasizes the role of ligaments, which act as
force transducers of muscle contraction. The latter occur in
carefully modulated sequence in the various pelvic floor
functions of continence and evacuation of bladder and bowel.
There are critical roles for muscles pulling against competent
ligaments for all pelvic floor functions. It follows that at
some point a damaged muscle must affect bladder and bowel
functions. The Swash theory taken together with the Integral
System therefore provides a cogent explanation for the range
of failed symptoms following successful ligament surgery
for prolapse.
3.8.6 Muscle, Ligament, or Both?
The question is “at what point of damage does this hap-
pen?” Results from a blinded experiment carried out by PP
and MS in 47 women with a mean age of 47 years (range
18–78) emphasized the importance of ligaments. A group
of 47 women had muscle biopsies of the PCM at the same
time as a midurethral sling. Almost all biopsies showed evi-
dence of severe muscle damage; 89% were cured the next
day after a midurethral sling (MUS) [57]. It was concluded
that correction of ligamentous laxity can cure incontinence,
even when there is muscle weakness. Clearly more research
is needed to more fully evaluate the role of damaged mus-
cles in those patients who were not cured by ligament
repair.
3.8.7 T
 he Three-Muscle, 3-Month Pelvic Floor
Muscle Strengthening Study
Further insights into this question may be deduced from
Patricia Skilling’s squatting-based pelvic floor study. This
cy
urethra
el
toc
pubic bone r ec
Fig. 3.29  The anatomy of sacrocolpopexy (SCP) or rectopexy mesh.
Schematic sagittal view. Patient standing. SCP mesh is attached to the
sacral promontory. Uterosacral ligaments (USL) are attached at S3-4.
SSL sacrospinous ligament
3-month regime showed very significant improvement in all
pelvic floor symptoms [58, 59], although mainly in younger
women. This regime was oriented mainly toward strength-
ening the three-directional muscle forces which close the
urethra. The regime was home-based. It ran over 3 months
with only four visits. It included electrical stimulation in the
posterior vaginal fornix using a 50 Hz cylindrical probe. Of
147 patients (mean age 52.5 years), 53% completed the pro-
gram. Median QoL improvement reported was 66%, mean
cough stress test urine loss reduced from 2.2 g to 0.2 g; 24-h
pad loss reduced from a mean of 3.7 g to a mean of 0.76 g
frequency; nocturia and pelvic pain were significantly
improved. Residual urine reduced from mean 202  ml to
mean 71 ml. Approximately 3% of patients reported wors-
ening of their stress incontinence, and these were referred
for surgery [58].
3.8.8 I s Rectopexy or Sacrocolpopexy (SCP)
an Anatomically Correct Method
for Restoration of Rectal
Intussusception and Rectal Prolapse?
Using pre- and postoperative X-ray proctography,
Abendstein demonstrated high rates of cure for rectal
intussusception with a posterior sling which was inserted
3  The Integral System of Pelvic Floor Function and Dysfunction
in the position of the uterosacral ligaments [25].
Abendstein’s study confirmed the Integral Theory’s pre-
diction that rectal intussusception in women was mainly
caused by USL prolapse. Because USL is attached to the
lateral walls of the rectum, the rectal wall would also pro-
lapse (Fig.  3.28). Figure  3.29 demonstrates that a mesh
used for rectopexy or sacrocolpopexy is far more vertical
than the natural attachments of rectum to USL. It follows
that if the mesh is too tight, it may impede the downward
acting LMA opening vector for urethra and anorectum to
cause obstructive evacuation symptoms. Alternatively, if it
is too loose, it may not fully restore the intussusception
and mucosal prolapse.
3.9 Conclusion
These and other data presented in the main body of this chap-
ter are consistent with both the Unifying and Integral
Theories. The Skilling study confirmed that pelvic floor
muscles play an important role in all the mechanisms out-
lined in this chapter. Why the exercises do not work so well
in older women may have several explanations, in particular,
postmenopausal collagen loss and more marked muscle
weakness. However, the high cure rates attained by TFS CL/
USL tapes in 70-year-old women plus the muscle biopsy
data tend to indicate that muscle function, though critically
important, is ultimately reliant on a firm ligamentous inser-
tion point.
Take-Home Messages
1. Ligaments suspend organs. Collagen is their main
structural component. Collagen weakens at child-
birth, menopause to cause prolapse, symptoms.
Vagina needs elasticity to function.
2. Opening/closure on anus/urethra is exponentially
controlled. Accurate restoration of tension in PUL
and USL is mandatory to achieve reliable symptom
cure.
3. Longer-term surgical cure for POP/symptoms is not
possible if ligaments are weak. Collagenous neo-
ligaments (MUS, posterior sling, SCP) can only be
created using mesh tapes.
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 The Pelvic Floor: Neurocontrol
and Functional Concepts
Michael Swash and Peter Petros
Learning Objectives
• The pelvic floor is a musculo-elastic structure that,
in women, includes the vagina as a central elastic
structure.
• Impaired pelvic floor elasticity prevents normal
muscle anchoring, causing muscle weakness and
functional disorder, such as pain, urgency, and
incontinence of urine or faeces.
• The motor and sensory innervation of the pelvic
floor is critically important for continence and evac-
uation, through its connexions to spinal cord and
brainstem neural control systems.
• In healthy adults higher-level control systems override
these reflex systems to establish voluntary evacuation.
• Pelvic floor dysfunction in women is often initiated
by obstetric damage to the pelvic floor muscles and
ligaments. In extreme cases, direct anal sphincter
tears are a marker of pelvic floor damage. When the
pelvic floor is incompetent, its motor and sensory
innervation is often progressively damaged by
recurrent stretching during straining at stool.
• Pelvic floor repair procedures should be designed to
improve functional ligamentous elasticity: this can
be effective even when there is established muscle
and nerve damage.
Electronic Supplementary Material The online version of this chapter
(https://doi.org/10.1007/978-3-030-40862-6_4) contains supplementary
material, which is available to authorized users.
M. Swash
Department of Neurology and Neuroscience, Royal London
Hospital and Barts and the London School of Medicine, QMUL,
London, UK
e-mail: mswash@mac.com
P. Petros (*)
UNSW Professorial Surgical Unit, St Vincent’s Hospital Sydney,
Sydney, NSW, Australia
e-mail: pp@kvinno.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_4
4
4.1 Introduction
The pelvic floor is a holistic functional entity, concerned
with urinary and faecal continence and voiding, and sexual
function. In women there are specialised features allowing
childbirth, always a natural process but nonetheless a func-
tion that is associated with risk for damage to both the ante-
rior and posterior components of the pelvic floor [1–4],
including its nerve supply [5]. Sometimes childbirth leads to
urinary or faecal incontinence and organ prolapse as delayed,
chronic problems [6]. In everyday life urinary and faecal
storage (continence) and voiding (micturition and defaeca-
tion) are under voluntary control, although subject to stimu-
lus in relation to sensory input to the central nervous system.
The central nervous system (CNS) control systems for these
functions mature during childhood in relation to the imposed
norms of society that require voiding at appropriate times
and places [7]. It is therefore necessary for the bladder and
rectum to act as storage receptacles until voiding is appropri-
ate and possible. Consequently, for most of the time, the pel-
vic floor maintains bladder and bowel in a continent, storage
mode [7]. As in most neurocontrol systems, there are several
levels of control circuits, following a Jacksonian system of
progressively higher levels of awareness and control. All of
these levels in the control system are modulated by sensory
afferent and descending motor neural command systems [8].
The systems controlling bowel and bladder are analogous to
each other although separately ‘wired’.
4.2 The Urinary and Recto-Anal Systems
The bladder wall consists of smooth muscle innervated by
parasympathetic motor nerve fibres. This parasympathetic
innervation of the detrusor muscle is cholinergic, depen-
dent on muscarinic motor endings on smooth muscle fibres
[9]. These parasympathetic nerve fibres are postgangli-
onic, derived from pelvic parasympathetic ganglia that are
themselves innervated by preganglionic fibres originating
57
58 M. Swash and P. Petros

in the intermediolateral columns of the lumbosacral cord.
Muscle fibres in the bladder base and in the internal ure-
thral sphincter are innervated by sympathetic nerve fibres,
also originating in the intermediolateral cell columns of
the spinal cord, but using norepinephrine as transmitter
[6]. Relaxation of the internal urethral sphincter is depen-
dent, in part, on sympathetic innervation of the muscle,
utilising beta-adrenergic parasympathetic efferents that
release nitric oxide as transmitter. Although it is widely
believed that urinary continence is achieved by low resting
tone in the bladder detrusor muscle, and tonic contraction
of the internal urethral sphincter, this concept is an over-
simplification. Circumferential contraction around a nar-
row tube, such as the urethra, is not, in general, an effective
sphincteric mechanism. A more effective mechanism uti-
lises kinking of the urethra, due to a backward muscular
vector pulling the urethra posteriorly and causing a kink,
thus obstructing any urine flow. This is achieved by con-
traction of the posterior muscle vectors in a backward/
downward direction, i.e. by the levator plate and the con-
joint longitudinal muscle of the anus (Fig. 4.1), a muscle
grouping that has been shown to be in a state of continuous
mild tonic contractile activity in the default storage mode
[10]. The pubococcygeus muscle provides an opposing
force, centered on the urethra. Mild resting contraction of
the puborectalis muscle is a major factor in the mainte-
nance of faecal continence, generating tension and kinking
of the recto-anal junction by opposing muscle forces [11].
In addition to sympathetic motor innervation of the base
of the bladder and internal urinary sphincter muscle, there
is an extensive sensory innervation of the bladder wall and
mucosa [6]. This consists of mechanoreceptors, sensitive to
stretch and distension, and other receptors that signal
inflammatory change, including pain. The receptors respon-
sible for these sensations are complex and interdependent.
The main sensitive area in the bladder is at the bladder base
in the trigone region and in the immediately adjacent proxi-
mal urethra, in the urinary sphincter region. There are simi-
lar anatomical specialisations in the anal canal [12]. Slight
relaxation of the internal anal sphincter allows fractional
extrusion of faecal content into the proximal anal canal,
inducing the ‘sampling reflex’ [13], that acts as a potent
stimulus which, unless voluntarily suppressed, leads to the
initiation of defaecation. Similarly, the increasing sense of
urinary urgency felt when the bladder is full, particularly in
response to a change of posture, such as standing, or cough-
ing, reflects the passage of small quantities of urine into the
proximal urethra within the urinary sphincter pressure
zone, initiating an urgent voiding response. The external
urinary sphincter is innervated by somatic efferent motor
fibres from the S2/S3 spinal segments. This voluntary stri-
ated sphincter muscle does not totally encircle the urethra

Fig. 4.1  Central and

peripheral control of bladder
and bowel. Schematic 3D
sagittal view. System in
default storage mode. Three
directional muscle forces
PCM (pubococcygeus), LP
(levator plate), and conjoint
longitudinal muscle of the
anus (LMA) tense the organs
bidirectionally against the
suspensory ligaments PUL
(pubourethral), CL (cardinal),
and USL (uterosacral) to
prevent activation of
micturition and defaecation
efferent
responses. Green arrows,
neurological pathways; white
arrow, central cortical control afferent
PUL
via the closure reflex. ATFP
arcus tendineus fascia pelvis,
BLADDER USL
CX cervix. N, sensory
receptors in bladder trigone N CX N

MUSCLES
MUSCLES ATFP
CL
PELVIC RIM
4  The Pelvic Floor: Neurocontrol and Functional Concepts
and so is incapable of completely occluding it when con-
tracted [14]. Like the external anal sphincter in faecal con-
tinence, the striated external urinary sphincter, or its smooth
muscle counterpart, is not the major muscle of urinary
continence.
4.3  rinary and Faecal Storage
U
and Voiding
Voluntary urinary voiding occurs in response to increasing
pressure and volume within the bladder, causing excitation
of afferents from bladder trigone sensory receptors, and also
in response to subtle passage of urine into the upper ure-
thra—the equivalent to the sampling reflex within the anal
canal [15]. In babies and young children, or in spinal cord
injury above the sacral level, the response to this afferent
information, signalling the immediate need to void urine, is
a switch in equilibrium from storage to voiding.
4.3.1 Bladder Equilibrium
At the most caudal, and unconscious, level, the change in
command from default storage to voiding occurs at the Onuf
urinary and faecal sphincter spinal nucleus at S2/S3 leading
to bladder detrusor contraction, internal and external urethral
sphincter relaxation, and relaxation of the tonic pubococ-
cygeus contraction [16]. Urine can then flow through the ure-
thra. In health, however, this switch between storage and
voiding is itself controlled by more rostral circuits. These are
the storage and voiding components of the pontine micturi-
tion centre, located in the periaqueductal grey matter of the
pons [6, 16]. This pontine system is itself managed by
higher-level thalamic and cortical mechanisms (see below
and Fig. 4.1). The pressure within the urethra during voiding
varies, non-linearly, according to the urethral resistance.
Urethral resistance is inversely proportional to the fourth
power of the radius of the urethra, as described by Poiseuille’s
Law for flow of a liquid in a narrow tube [17] (see below).
Thus, a widely open urethra requires much less detrusor
pressure to void urine than does a less widely open urethra,
and a focal narrow urethral diameter, as in prostatic enlarge-
ment, may be so resistant to urine flow as to cause difficulty
voiding [18].
4.3.2 The Lumbosacral Loop
In the normal human, the simple spinal mechanism limited
to the sacral spinal cord for urinary voiding and defaecation
described above is subject to modulation from higher CNS
centres. After spinal transection, for example, due to spinal
59
injury, the reflex relationship between the Onuf nucleus and
the bladder and bowel is intact, and urinary voiding and
defaecation are therefore then under strictly lower-level
reflex control, without the possibility of voluntary modula-
tion. Voluntary control of these functions requires supraspi-
nal mechanisms [16].
4.3.3 The Pontine Loop
The first of these supraspinal systems depends on another
‘switch mechanism’ involving the periaqueductal grey
(PAG) matter of the midbrain and the pontine micturition
centre (PMC), first described by Barrington in 1933 [19].
Two groups of neurons have been recognised in this region,
subserving storage (PAG activity) and voiding (PMC activ-
ity), respectively [12]. Sensory information from the bladder
projects from the Onuf system in the sacral cord to this clus-
ter of neurons adjacent to the periaqueductal grey matter in
the midbrain [16].
4.3.4 The Cortical System
The pontine storage and voiding systems also receive
descending input from higher centres including frontal lobe,
insular cortex, and hypothalamus [12, 16]. Neural output
from the pontine PAG projects caudally, initiating motor
commands to the Onuf nucleus and modulating bladder
detrusor contraction in the coordinated response necessary
for voiding. The equilibrium between these two functions is
determined by the balance between sensory input and
descending activity from the brain itself, reflecting informa-
tion regarding timing, and determinations based on learned
social and behavioural rules, thus requiring predominantly
frontal cortical control of the peripheral opening mechanism
(see Figs. 4.1 and 4.2) for both defaecation and micturition.
These concepts have been investigated in some detail using
functional MRI and PET scanning [8]. This work has also
shown activity in a lateral pontine region (the L region) adja-
cent to the PMC that has been found to be to be active during
suppression of the voiding response and therefore in the
maintenance of storage (continence) until a suitable opportu-
nity arises.
4.3.5 C
 entral Representation of Afferent
Information from Bladder and Bowel
Processing of afferent information from the bladder and
bowel therefore involves relaying this information, most of it
carried in autonomic afferents, to the thalamus, and thence to
the insular cortex, a region of the brain concerned with infor-
60
PONS
C
C
inhibitory
centre
0
afferent impulses
C LP
N cular systems, is perhaps more precise and overt than
PCM
LMA
Fig. 4.2  Storage is dominant (C). Micturition is suppressed (green bro-
ken lines). The closed trapdoor represents inactive inhibitory centres.
‘N’, stretch receptors. Arrows, the three-directional vectors (PCM, LP,
LMA). O open (voiding) response (inhibited in this sequence). LMA
levator muscle ani, LP levator plate, PCM pubococcygeus muscle
mation management from internal organs, and therefore in
homeostasis [8, 12, 16]. This region is linked to affective and
social context-driven aspects of brain function in concert with
the anterior cingulate cortex. Prefrontal cortical connexions
to the limbic system, including the suprachiasmatic nucleus,
important in timing cyclic tasks, are dominant in normal
humans in managing both continence and voiding. During
voiding in normal subjects, there is activation of the medial
prefrontal area [20], suggesting that this region is important
in conscious decision-making about voiding. Lesions in pre-
frontal cortex or its deep white matter are classically associ-
ated with uncontrolled micturition in socially inappropriate
circumstances [21, 22]. Such behaviour is characteristically a
feature of prefrontal traumatic brain injury, deep white matter
anterior cerebral infarcts, gliomas, and certain neurodegen-
erative conditions, especially frontal dementia syndromes.
M. Swash and P. Petros
4.3.6 U
 niversal Organisation of CNS Control
Systems
This successive layering of control systems built on a sim-
ple lower-level reflex system is a characteristic common to
the organisation of all mammalian motor systems [23].
Such a system allows modulation of various control points
within the layered systems. Thus the afferent-efferent sys-
tem located in the sacral spinal cord at the Onuf nucleus is
modulated by the ponto-mesencephalic storage and voiding
neurons, which intercede in the balanced storage equilib-
rium that maintains urinary and faecal continence. This
system is itself modulated by time-dependent neuronal sys-
tems, probably mainly of hypothalamic origin, based on the
suprachiasmatic nucleus, which subserves time modulatory
functions in many functional domains, and is also influ-
enced by prefrontal cortical ‘decision-making’ neuronal
circuits and by emotional input from insular and callosal
neuronal systems. Voluntary control of sympathetic and
parasympathetic neuronal systems, in the context of blad-
der and recto-anal and bowel detrusor and sphincteric mus-
control systems involving other autonomic neuronal path-
ways, but it is not unique; for example, smooth muscle
peristalsis in the oesophagus links seamlessly to swallow-
ing itself and to striated muscle activity in the upper
oesophagus as well as control of the cardiac sphincter at the
lower end of the oesophagus.
Like other striated muscles in the body, the local muscu-
lar systems in the pelvic floor contain muscle spindles and
other sensory endings [24], including tendon organs at the
points of insertion of muscles into tendon, and smaller
myelinated and unmyelinated fibres responsible for the
sensation of pain and other nociceptive functions. In addi-
tion Pacinian corpuscles, which signal pressure, are distrib-
uted in fascial planes within the muscles and in the tissue,
especially peritoneum, surrounding the bladder and bowel.
The system thus receives signals not only from the smooth
muscle systems of the bladder and rectum but also from the
mucosa of these organs and from the muscles of the pelvic
floor. The signals include pressure, tension, stretch, and
rate of change of stretch, the letter two types of sensation
representing spindle activity. There is a complex sensory
system intrinsic to receptors on epithelial sensory cells in
the bladder and bowel walls, conferring spatial and tempo-
ral information about bladder and bowel contents, respec-
tively [6]. Clearly, not all these sensations are perceived in
consciousness, but all are important afferent systems that
integrate with central neural pathways in storage and void-
ing of urine and faeces.
4  The Pelvic Floor: Neurocontrol and Functional Concepts
4.4 The Pelvic Floor and Its Innervation
The basic structure of the pelvic floor consists of muscular
and fascial planes positioned in relation to the anorectal,
vaginal, and urethral openings. The perineal musculature
within the pelvic floor functions as a whole during urinary
and faecal storage, which should be regarded as the default
mode, but the anterior and posterior components are capable
of distinct, separate function during micturition and defaeca-
tion, respectively. These functions are under separate but
analogous control within the central nervous system, as
described above. The innervation of the pelvic floor muscu-
lature is largely from somatic efferent and afferent nerve
fibres travelling within the lumbosacral plexus, and therefore
entering these muscles superiorly, but the external anal
sphincter and external urethral sphincter muscles, and the
puborectalis and pubococcygeus muscles, are innervated by
branches of the pudendal nerve, the external urethral and
inferior rectal nerves, that supply these muscles from a cau-
dal aspect. All these nerves are derived from sacral spinal
segments via the lumbosacral plexus [25].
4.5  elvic Floor Dysfunction
P The clinical features of pelvic floor disorders and the use of
in Incontinence
When there is damage to the pelvic floor, for example, from
stretch injury to ligaments, muscles, and pelvic nerves during
a difficult childbirth, or in multipara, the pelvic floor muscu-
lature is functionally at a mechanical disadvantage [26]. If a
muscle tendon is stretched and has lost its normal elasticity,
the force applied during contraction of its muscle will be
reduced, and it will reach its maximum more slowly as the lax
ligaments are tightened more slowly than normal [27]. Since
it is likely that damage to pelvic floor ligaments during a dif-
ficult childbirth will not be equally distributed across all the
pelvic ligaments (see illustrations) within the pelvic floor, the
muscle force vectors resulting from contraction of the pelvic
floor muscles will then be distributed in an abnormal pattern.
This results in voiding dysfunction and difficulty in maintain-
ing urinary and/or faecal storage. There may also be associ-
ated pelvic pain, and, since the anatomy is distorted, there
will be a degree of visible perineal descent on coughing or
straining and, in the extreme case, organ prolapse [14]. These
functional and structural abnormalities usually slowly prog-
ress over time [4]. Very difficult deliveries, especially those
requiring forceps assistance, are frequently associated with
more severe abnormalities in the pelvic floor postpartum,
sometimes with anal sphincter tears. The latter are particu-
larly likely to be associated with ligamentous damage and
61
with damage to the innervation of the pelvic floor muscula-
ture, a combination of abnormality especially associated with
disorders of continence. In the presence of weakness of the
pelvic floor due to lax ligaments, tearing of muscle fibres, and
damage to the somatic innervation of pelvic floor muscles and
sphincters, the central nervous system will adapt and modify
descending motor commands, insofar as it is capable of doing
so, to prevent urinary or faecal leakage. Similarly, adaptations
in CNS function occur in relation to other pelvic floor disor-
ders, for example, urgency. These natural adaptations form
the functional basis for the use of conditioning therapy, or
other neuromodulation procedures, usually based on methods
to facilitate increased sensory awareness [28]. These manage-
ment strategies reinforce the process of maintaining storage
at rest but are unlikely to have any biological effect on the
already damaged system, particularly regarding its multifac-
torial nature. When the innervation of some of the muscles of
the pelvic floor is damaged, there is less capacity for resetting
of control systems.
4.6 Investigation of the Pelvic Floor
investigations such as video cystometry and anorectal
manometry are described elsewhere in this book. Video cys-
tometrograms provide information about pressure/flow rela-
tionships within the urinary system, together with bladder
volumes before and after voiding. This information is essen-
tially descriptive and does not, of itself, provide insight into
the underlying pathophysiology of pelvic floor dysfunction.
Anorectal manometry, similarly, is essentially a descriptive
account of pressures generated within the anal canal, the anal
sphincter region, and the rectum at rest and during attempted
straining at stool. Voluntary straining at stool is not the same
process as normal defaecation. These investigative data must
therefore be interpreted in relation to the historical pathogen-
esis of the pelvic floor dysfunction and the results of quanti-
tative clinical assessment of pelvic floor function made by
careful clinical examination.
Neurophysiological investigation of the pelvic floor mus-
culature and its innervation has been important in defining
clinically relevant abnormalities, but it does not necessarily
guide the surgeon or physician in designing therapy. For
example, pudendal and perineal nerve terminal motor latency
determinations showed that there was damage to the pelvic
floor nerves in women with pelvic floor prolapse, people
with urinary incontinence, and even those with a history of
difficult childbirth without overt pelvic floor symptoms [2,
24, 29]. However, best management of these disorders, when
62 M. Swash and P. Petros

necessary, requires supporting the lax ligaments that accom-

pany damage to the nerve supply of the pelvic floor, thus at
least partially alleviating muscular weakness and resolving
the clinical disorder.

4.7 Urinary Storage: The Default Mode

During urinary storage [14] in women (Figs.  4.2 and 4.3),

three muscle vectors stretch the vagina, like a membrane, in
opposite directions. The voiding response is quiescent, and
afferent sensory activity is reduced (green broken lines).
Tonic activity in the pubococcygeus muscle (PCM) has
stretched the suburethral vaginal hammock forwards against
the pubourethral ligament (PUL) to close the distal urethra.
The levator plate (LP) stretches the proximal vagina and
bladder base backwards against the PUL, further tensioning
the vagina. The longitudinal muscle of the anus (LMA) con-
tracts against the uterosacral ligament (USL) to rotate the
bladder and kink the urethral tube at the bladder neck, main-
taining continence (see Fig. 4.4).

4.8 Urethral Opening: Voiding

The bladder is a highly distensile receptacle which can hold

large amounts of urine, even in excess of 1000 ml. Voiding
via the urethra follows activation of the micturition response
[5, 6] (Fig. 4.5). For urine evacuation to occur, storage must
be suppressed and voiding activated. Normal voiding is
defined as the controlled emptying of the bladder on demand
and rapid recovery to the closed state on completion. Voiding
is activated by both stretch and surface receptors at the blad-
der base that vary in sensitivity from person to person.
Voiding is a neurological feedback system, requiring coordi-
nation by the central nervous system. There are four main
components (Fig. 4.5):
1. The hydrostatic pressure of a full bladder activates blad-
der stretch and mucosal surface receptors (N) that signal
to the cortex via the spinal cord and brainstem (see above).
2. The anterior striated PCM muscles relax.
3. The posterior striated muscles (LP/LMA) stretch open the
outflow tract (Figs. 4.5 and 4.6) reducing internal urethral
resistance to flow.
4. Parasympathetic activation causes bladder detrusor mus-
cle contraction. The bladder contracts as a whole due to
electrical transmission fibre to fibre [30] to expel urine.
Fig. 4.3  Changes in bladder and anorectum when storage is dominant.
Note the change in vaginal shape (V) and the positions of bladder (B),
rectum (R), and levator plate (LP) relative to the vertical and horizontal
bony coordinates (white broken lines) during straining. Vaginal elastic-
ity is critical for transmission of muscle forces by directional vectors
(arrows). Upper XR. Resting closed (storage) phase PUL pubourethral
ligament, USL uterosacral ligament. CX cervix, U urethra, Ra anorectal
angle, Bv ligamentous attachment of bladder base to upper vagina.
Lower XR. On effort (straining down) Directional vector forces (arrows)
stretch the distal vagina and urethra forwards against PUL. The bladder
base and rectum are tensed backwards against PUL by the backward
vector LP (backward arrow). The downward vector (white arrow) pulls
bladder base and rectum downwards against USL to close the bladder
neck (BN) and Ra. Adequate elasticity is required in the anterior vagi-
nal wall ‘ZCE’, a zone of critical elasticity (see insert), for this to occur.
Arc precervical arc of Gilvernet, PB perineal body, PCM pubococ-
cygeus ligaments, PVL pubovesical ligament, S sacrum
4  The Pelvic Floor: Neurocontrol and Functional Concepts 63

inhibitory
centre

efferents
relax 0
PCM

afferent impulses

LP

LMA

Fig. 4.4  Opening (micturition) reflex is dominant. The brain is in

“voiding” (micturition) mode ‘O’. The storage mode is suppressed and
does not appear in the figure. Afferent impulses are upregulated (black
dots). Relaxation of PCM (forward arrow) allows LP/LMA to stretch
the vagina (blue) backwards. This stretches open (funnels) the posterior
urethral wall decreasing resistance to urine flow and reducing the detru-
sor pressure required to void urine. The small black arrow indicates a
slight downward excursion of PUL to facilitate backward stretching of
the vagina. LMA longitudinal muscle ani, LP levator plate, PCM pubo-
coccygeus muscle, PUL pubourethral ligament
In Fig. 4.4, the lower urinary tract is in voiding mode (O) due
to afferent input to the central nervous system. The inhibi-
tory pontine L centre is inactivated (open trapdoor in
Fig.  4.4); the forward vector PCM relaxes (faint broken
lines); LP/LMA vectors stretch the vagina and open the ure-
thra; this action decreases the urethral resistance to flow
Fig. 4.5  Anatomical changes in bladder and anorectum when voiding is
active. Upper XR Resting storage mode. Tonic muscle contraction (for-
ward vector) maintains urethral closure distally and at bladder neck.
Lower XR Voiding. The forward vector (insert) relaxes. Backward vectors
stretch the vagina backwards and downwards against USL to open out the
posterior urethral wall. The pubovesical ligament attachment to the arc of
Gilvernet (PVL, insert figure) prevents the anterior bladder wall prolaps-
ing into the outflow tract. B bladder, CX cervix, LMA longitudinal muscle
ani, LP levator plate, PCM pubococcygeus muscle, PUL pubourethral
ligament, R rectum, S sacrum, USL uterosacral ligament, V vagina
(Poiseuille’s Law, see Fig. 4.10). Urine entering the proximal
urethra further enhances afferent sensory impulses [7], and
the posterior urethral wall is opened out by flattening the tri-
gone, accelerating micturition (Video 1).
64
PS
PCM
PUL PUL
BLADDER
LP
trigone
H efficacy. The weakened PCM and LP/LMA muscles then
C ulate sensory input. Micturition or defaecation responses
0
LMA
Fig. 4.6  The trigone. The trigone extends to the external urethral meatus.
Pubococcygeus muscle (PCM) relaxation is indicated by a broken line
pink arrow. When the upward and forward contracting PCM relaxes,
levator plate (LP) stretches the vagina and trigone backwards into a semi-
rigid structure. Longitudinal mascle ani (LMA) pulls down the trigone. C
closed diameter of urethra (storage reflex dominant), O open diameter of
urethra (voiding reflex dominant). H hammock, PS pubic symphysis,
PUL pubourethral ligaments
4.9  he Bladder Trigone During
T pressure, and urine flow (Fig. 4.7). At the onset of the syn-
Micturition
The trigone (Fig. 4.6) extends from the bladder base to the
tip of the external meatus. Its intrinsic stiffness resembles
that of the anterior vaginal wall. The posterior muscular vec-
tor, the levator plate muscle, stretches the trigone posteriorly.
This reduces urethral resistance to urine flow because the
posterior urethral wall becomes semi-rigid, creating a fun-
nel, as seen in the micturition X-ray.
4.10 N
 eurological Feedback Control
of Anorectal Function
A system similar to that for bladder control operates for ano-
rectal closure and evacuation (Fig. 4.1) (see also Video 2). As
the rectum fills, the stretch and surface receptors (N) send
signals to the cord that are relayed to the frontal cortex.
These can be suppressed voluntarily by the storage response
(white arrow), which activates contraction of the opposed
directional musculoligamentous forces (arrows) that support
the anorectum from below. A further temporary control
mechanism for both bladder and rectum is voluntary upward
contraction of the puborectalis muscle. This counteracts the
downward mechanical pressure of the bladder or faecal con-
tents and diminishes sensory activation (green arrows).
M. Swash and P. Petros
4.11 W
 hen Things Go Wrong: Urge,
Frequency, and Nocturia
Urgency to micturate or defecate represents inappropriate
activation of the micturition or defaecation reflexes. PUL or
USL ligaments (Fig. 4.1) are the effective insertion points
of the three-directional muscle vectors (arrows). If PUL or
USL is lax, their attached muscles (arrows) lose contractile
cannot tense the vagina or anorectum sufficiently to mod-
may be then activated leading to urge urinary or faecal
incontinence.
4.12 Overactive Bladder Syndrome (OAB)
In 1993, it was shown that prematurely activated, but other-
wise normal micturition [31, 32], usually termed urge incon-
tinence but also known as ‘detrusor instability’ or more
recently ‘detrusor overactivity’ (DO), followed the same
activation sequence as normal micturition (Fig. 4.4): first, a
feeling of urgency, then a decrease in urethral pressure (X),
followed detrusor contraction causing increased detrusor
drome, there is a strong afferent phase of urethral sensory
activation, due to urine entering the upper urethra, as the tri-
gone opens out slightly. Conflict between a natural desire to
inhibit this unwanted signal for micturition and the urge to
void produces physiological uncertainty between the storage
(C) and voiding responses, which can be recognised urody-
namically (Fig. 4.8).
4.13 H
 ow Does Detrusor Overactivity
Relate to Feedback Control?
Detrusor overactivity represents a prematurely activated
micturition sequence. Close examination of the urody-
namic patterns in Fig.  4.7 indicates that the micturition
reflex has been activated and bladder (B) and urethra (U)
show identical wave patterns. When the micturition
response is activated, excitation of smooth muscle fibres by
parasympathetic nerve endings in the detrusor muscle
causes the bladder to contract as a whole [30], as seen in the
video X-ray voiding study (see Video 1). However, the
detrusor muscle spasms. It does not relax and contracts
like a striated muscle. What the bladder pressure transducer
is measuring is the repeated striated muscle contractions of
the rhabdosphincter as it tries to close the urethra at the
base of the bladder.
4  The Pelvic Floor: Neurocontrol and Functional Concepts 65

O X
CLOSED
C
C O OPEN

feeling of
urgency
CP

1.0gm
Ou urine loss
Od
Om

Cm

Fig. 4.7  Detrusor overactivity ‘DO’—premature activation of a normal

micturition reflex. Urodynamic graph of a patient with a full bladder under-
CLOSED
going a handwashing test. The binary control system becomes unstable. ‘C’
indicates the storage mode is dominant—the striated muscles are acting to
close the urethra and trigone, causing a rise in urethral pressure (UP). ‘O’
indicates the muscles are relaxing, causing a fall in urethral pressure and
leading to voiding. The sequence of events in a patient with urge inconti-
nence and DO is: (1) A feeling of urgency, (2) A fall in urethral pressure at
X (graph ‘U’), (3) A rise in bladder pressure at Y (graph ‘B’), (4) 1.0 g urine
loss arrow, (graph ‘CP’). U urethral pressure graph, B bladder pressure
graph, CP closure pressure graph (U − B), C closure (continence) reflex, O
opening (micturition) reflex, with its components being: Ou urethral relax-
ation, Od detrusor contraction, Om opening out of the outflow tract by the
OPEN
posterior muscle forces before voiding
after Glieck

Fig. 4.8  Bladder instability. Bladder control swings between storage

4.14 E
 vents Occurring in Detrusor
Overactivity and Overactive Bladder
Syndrome
These are both manifestations of abnormal neurocontrol of the
voiding response. When voiding is activated, there is a sensa-
tion of urgency associated with bladder contraction, beginning
with slow waves of contraction, before the bladder contracts
as a whole during voiding. If it is inconvenient to pass urine,
the urethral closure response intervenes so that urine storage
continues. Urethral closure increases the pressure in the urethra
as well as in the bladder (see ‘C’, Fig. 4.9). However, if there
is sufficient sensory input from bladder and trigone and from
the urinary sampling response in the proximal urethra, urgency
and voiding. Lax ligaments prevent maintenance of the closed storage
position; the bladder now oscillates between storage (continence) and
voiding phases. Because there is a short-time delay in switching
between these two modes, the pressure curves are sinusoidal. This is
clearly illustrated in both ‘U’ and ‘B’ in Fig. 4.7. The process resembles
the feedback systems described in Chaos Theory (see text)
intensifies and micturition resurges. The forward vector PCM
relaxes, and the urethral pressure falls (see ‘O’, Fig.  4.9).
Urodynamically (Fig.  4.8), the switch between storage and
micturition is manifested as a wave pattern (Figs. 4.8 and 4.9).
When the closure response ‘C’ is dominant, the urethra
narrows, and the urethral pressure rises. When the opening
66 M. Swash and P. Petros

(voiding) response ‘O’ is dominant, the striated muscles act-
ing on the urethra relax and the urethral pressure falls. Because
there is a brief delay between the afferent signals from the blad-
der reaching brainstem and higher centres causing this switch
to the voiding response via the pontine micturition centre, the
system may ‘hunt’ between the two states of storage and void-
ing, thus creating a ‘wave pattern’ (Fig. 4.9).
4.15 N
 on-linear Flow Mechanics Enhance
the Storage and Voiding Responses
Bladder and rectum are elastic and expansile receptacles.
The urethral and anal diameters are narrowed during stor-
age and widened during voiding or evacuation by exter-
nally acting striated muscle forces (Fig.  4.10). This
external mechanism causes a non-linear change in resis-
tance to flow that is inversely proportional to the fourth
power of the radius (Poiseuille’s Law; see Fig. 4.10) [17,
18]. Therefore, in the urinary system, the flow response to
narrowing or opening the urethral diameter is very rapid.
For example, young people empty their bladders in just a
few seconds. This concept of internal resistance to flow
within the urethra is key to understanding normal storage
(continence) and voiding (micturition) and abnormal
bladder states, e.g. incontinence, ‘obstructive’ micturi-
tion, and obstructive defaecation. This interpretation is
also important in understanding data from urodynamics,
especially its wide variance, and the results of corrective
surgery.

Fig. 4.9  Unstable phasic

urodynamic bladder pattern
‘DO’. The micturition reflex
has been activated. The
bladder swings between
PRESSURE

‘open’ and ‘closed’ attractors

(see Fig. 4.8). Intravesical
pressure rises, while the C
‘storage’ mode ‘C’ is C
dominant; the pressure falls, C
C
while the ‘voiding’ mode ‘O’
is dominant. Delay in
O O O
switching from closure mode
to open mode produces the
phasic pattern TIME

Fig. 4.10  The pressure/flow 70

relationship as measured
during bench experiments
(unbroken lines) and by 60
computer simulation (broken measured
lines). Note that a 0.75 mm
decrease in tube diameter 50
from 4 mm to 3.25 mm (a
19% decrease) increases the
expulsion pressure by 250% 40
Pressure

(red lines), consistent with

Poiseuille’s Law. After Bush straight tube
3.25mm diam
et al. [17, 18] 30

20

straight tube
10
4mm diam

0
0 5 10 15 20 25 30

Flow Rate (cc/s)

4  The Pelvic Floor: Neurocontrol and Functional Concepts 67

4.16 W
 hy Urodynamic Urethral Pressure
Measurements Correlate Poorly
with Clinical States
During passage of urine, including incontinent leakage, urine
flows from the bladder to the exterior. Bench testing [17] and
mathematical modelling [18] indicate that the key factor
controlling the rate of urine outflow is the diameter of the
urethra (Figs. 4.9, 4.10, and 4.11) which, in turn, regulates
the resistance to flow against the pressure (P) of detrusor
contraction. Whether urine leaks or not depends on the resis-
tance to flow within the urethra (see above). Urodynamic
studies are limited to measurement of intravesical and intra-­
urethral pressures ‘P’ and flow rates. Pressure is derived

Fig. 4.11  Normal micturition

in the female. Upper image:
Voiding X-ray (broken lines,
subscript m) superimposed on
resting X-ray. Clips have been
applied to the midurethra ‘1’,
bladder neck ‘2’, and bladder
base ‘3’. Note downward/
backward displacement of the
clips indicating stretching
open of the posterior urethral
wall. Lower image Note
electromyography (EMG)
activity (arrows) mainly at the
start of micturition—the urine
occupying the urethral tube is
incompressible and helps to
hold the urethra open as long
as it is flowing. LP levator
plate
68
Fig. 4.12 ‘Outflow
obstruction’ in the female—
Lax ligament insertions for
the LP/LMA opening vectors
cannot open the urethra
sufficiently against its elastic
forces. Even with constant
activation of the pelvic
muscles, the stream is slow
and prolonged with
electromyography (EMG)
activity seen throughout the
micturition cycle
from the relation between applied force and transverse ure-
thral area (πr2). Intra-urethral pressure ‘P’, being proportion-
ate to r2, is not what prevents urine loss. Pressure at any point
on the urethral diameter is not a sufficiently sensitive mea-
surement index of incontinence, because it is the resistance
to urine flow, which is proportionate to r2, which prevents
urine loss, not external urethral pressure.
Conversely, for urine to flow easily, there must be ade-
quate external opening of the urethra, by opening out its pos-
terior wall, as shown in the micturition X-ray (Figs. 4.5 and
4.11). If the urethra cannot be opened out adequately, there is
a sensation of obstruction to flow. In Fig. 4.11, the urethra
has been rapidly opened out by prior external muscle con-
traction, so micturition is rapid and effective. Continued
external striated muscle contraction is not required as urine
is incompressible and itself maintains urethral opening. In
contrast, in Fig.  4.12, the urethra cannot be adequately
opened. The posterior muscles LP and LMA (Fig. 4.6) have
to contract repeatedly, and urine flow is slow.
4.17 H
 ow Repeatable Are Urine Flow
Measurements in an Individual?
Urine flow studies measure the volume of urine flowing
through the urethra at a defined diameter expressed as ml/
second. Urine flow is determined by the internal resistance to
flow [17, 18] as discussed above. Individual repeat flow mea-
surements [18] are remarkably variable, because the opening
mechanism assisting micturition is activated by pelvic floor
striated muscle vectors (see EMGs in Fig. 4.12) and detrusor
contractile power may vary from void to void. A very minor
change in urethral diameter causes a profound change in
flow rate.
4.18 Detrusor Underactivity
Detrusor underactivity (DU) is an ill-defined entity. Osman
et al. [33] noted that:
M. Swash and P. Petros
DU is present in 9–48% of men and 12–45% of older women
undergoing urodynamic evaluation for non-neurogenic lower
urinary tract symptoms (LUTS). Multiple aetiologies are impli-
cated, affecting myogenic function and neural control mecha-
nisms, as well as the efferent and afferent innervations.
Diagnostic criteria are based on urodynamic approximations
relating to bladder contractility such as maximum flow rate and
detrusor pressure at maximum flow. Other estimates rely on
mathematical formulas to calculate isovolumetric contractility
indexes or urodynamic "stop tests." Most methods have major
disadvantages or are as yet poorly validated. Contraction
strength is only one aspect of bladder voiding function. The oth-
ers are the speed and persistence of the contraction.
The ‘myogenic function and neural control mechanisms’
mentioned by Osman et  al. [33] are relevant but undefined
concepts, as they are at present impossible to quantify. We
present here an alternative mechanism based on research by
Bush et al. [17] which is consistent with Osman’s conceptual
analysis [33]. If the urethra can be opened by the external mus-
cle forces to 4 mm diameter (Fig. 4.11), urine could flow at a
rate of 7 ml/second with no recordable detrusor pressure. This
does not mean that the bladder is ‘underactive’. The bladder
smooth muscle will contract sufficiently that the bladder can
empty fully. Demonstrable urinary flow indicates that the ure-
thra has been opened sufficiently to lower the internal resis-
tance to a point at which the detrusor force enables flow to
occur. For example, at a flow rate of 20  ml/s (Fig.  4.10), a
50 cm head of pressure from the detrusor is needed to over-
come the internal resistance to flow in a 3.25  mm tube, but
only a 20 cm head of pressure is required for a 4 mm tube. The
graph (Fig. 4.10) illustrates the difference in voiding patterns
in Fig. 4.11 (rapid flow) and Fig. 4.12 (slow flow).
4.19 Low Bladder Compliance
In a study of detrusor instability (now termed detrusor over-
activity) and low compliance [34], the low compliance data
could only be reconciled by considering ‘low compliance’ as
a partially activated micturition reflex. Bladder ‘stiffness’ is
a consequence of smooth muscle contraction by an activated
but modulated micturition reflex.
4  The Pelvic Floor: Neurocontrol and Functional Concepts
4.20 Clinical Variations in Bladder
Symptoms Are Consistent
with the Chaos Theory Feedback
Equation
One of the mysteries of clinical urology is the marked vari-
ability of symptoms such as urgency and nocturia. This vari-
ability is consistent with the classic Chaos Theory [35]
feedback equation Xnext = Xc (1 − X). In Fig. 4.13 the feed-
back control system [34] was tested for compatibility with
the Chaos Theory graph derived from the Chaos Theory
feedback equation Xnext = Xc (1 − X). Calculations were made
(see below) in three functional modes: low afferent activity
(normal mode), increased afferent activity from a micturition
reflex activated but controlled (low compliance mode), and
excessive afferent activity exceeding the ability of the closure
reflex to inhibit the afferent impulses ‘overactive bladder’
mode (see Fig. 4.1). An excess of afferent signals brings the
system into the ‘chaotic zone’ in which equilibrium oscil-
lates between voiding (open) and storage (closed): in this
zone the closure reflex is in unstable competition with the
micturition reflex (see Figs. 4.8 and 4.9). These three func-
OPEN
CHAOTICZONE
unstable
CLOSED
unstable
c
XNEXT
stabled closed
retention
after Glieck
Fig. 4.13  (after Gleick 1987). The graph is that of a classic Chaos
Theory feedback equation Xnext = Xc (1 − X) applied to normal bladder,
low compliance bladder, and unstable bladder (see text). The line ‘c’
represents the sum of cortical and peripheral inhibition via the musculo-­
elastic system (two variables). Xnext can be equated to the number of
afferent impulses. x axis, time; y axis, Xnext. If the control mechanisms
are all working properly, the system is in storage mode. Along line ‘c’,
the voiding response is activated. However, while the peripheral and
central mechanisms remain sufficiently supportive, the feedback sys-
tem maintains the patient dry. Further along ‘c’, there is a bifurcation.
The quantum of afferents is now excessive and exceeds the ability of the
cortex to retain the closed phase; the bladder begins to swing between
the ‘storage’ and ‘void’ attractors. This is ‘detrusor instability’ (DI)
‘overactivity’. The system in the Chaotic Zone is very finely balanced.
Any minor factor, for example, perimenstrual relaxation of the cervix,
will loosen USLs, and the muscle vectors cannot maintain equilibrium.
Afferent activity XNEXT increases, and the system may enter the Chaotic
Zone. The patient is then sometimes dry, sometimes wet
69
tional modes conform with classic Chaos Theory feedback
calculations. As long as the closure reflex mechanisms, both
central and peripheral, can control the increasing sensory
input ‘X’ (X = no of afferent impulses), the patient’s bladder
remains in ‘stable closed’ mode, and the patient is dry. At the
peak of the curve, the reflex closure mechanisms are over-
come by the excessive number of afferent impulses (X) arriv-
ing at the pontine micturition centre and cortex; the
micturition response begins to be activated. The system
becomes unstable and oscillates between ‘open’ and ‘closed’
(Figs. 4.8 and 4.9). Patients may therefore report complete
dryness on some days, yet they may wet four to five times on
other days.
4.21 Concluding Remarks
The neurocontrol systems responsible for appropriate void-
ing of urine and faeces are linked to the default position of
continent storage. The control system is organised on a lay-
ered sequence of neural systems that consist of local pelvic
floor and bladder and anorectal structures—the end-organs—
and spinal, brainstem, and higher-level cortical circuits.
These circuits are integrated and responsive to each other.
When the pelvic floor and its sphincteric systems are dam-
aged, for example, by a difficult childbirth, or prostatic
obstruction, a measure of adaptation in these neural systems
is possible, although little is known about their adaptive
capacity. It is essential that any corrective pelvic floor surgi-
cal procedures should retain the inherent musculo-elasticity
of this system, since this determines the musculotendinous
function necessary for normal function of the pelvic floor
and its sphincteric systems.
References
1. Snooks SJ, Barnes RPH, Swash M.  Damage to the voluntary
anal and urinary sphincter musculature in incontinence. J Neurol
Neurosurg Psychiatry. 1984;47:1269–73.
2. Swash M, Snooks SJ, Henry MM.  A unifying concept of pel-
vic floor disorders and incontinence. J Roy Soc Med. 1985;78:
906–11.
3. Snooks SJ, Swash M, Setchell M, Henry MM.  Injury to innerva-
tion of pelvic floor sphincter musculature in childbirth. Lancet.
1984;2:546–50.
4. Snooks SJ, Swash M, Henry MM, Setchell M. Risk factors in child-
birth causing damage to the pelvic floor innervation: a precursor of
stress incontinence. Int J Colorect Dis. 1986;1:20–4.
5. Sultan AH, Kamm MA, Hudson CN, et al. Anal sphincter disruption
during vaginal delivery. N Engl J Med. 1993;329:1905–11.
6. Smith ARB, Hosker GL, Warrell DW. The role of partial denerva-
tion of the pelvic floor in the aetiology of genitourinary prolapse and
stress incontinence of urine: a neurophysiological study. J Obstet
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7. Fowler CJ, Griffiths D, de Groat WC. The neural control of micturi-
tion. Nat Rev Neurosci. 2008;9:453–6.
8. Holstege G, Sie JAML. The central control of the pelvic floor, chap-
ter 8. In: Pemberton JH, Swash M, Henry MM, editors. The pel-
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9. Abrams P, Andersson KE, Buccafusco JJ, et  al. Muscarinic
receptors, their distribution and function in body systems, and
the implications for treating overactive bladder. Br J Pharmacol.
2006;148:565–78.
10. Neill ME, Parks AG, Swash M.  Physiological studies of the anal
sphincter muscle in faecal incontinence and rectal prolapse. Br J
Surg. 1981;68:531–6.
11.
Parks AG.  Anorectal incontinence. Proc Roy Soc Med.
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12. Trivedi PM, Griffiths DJ. Neurological control of the bowel in health
and disease, chapter 2. In: Fowler CJ, Panicker JN, Emmanuel A,
editors. Pelvic organ dysfunction in neurological disease: clinical
management and rehabilitation. Cambridge: Cambridge University
Press (Medicine); 2010. p. 25–39.
13. Miller R, Bartolo D, Cerveto F, Mortensen NJ.  Anorectal sam-
pling: comparison of normal and incontinent subjects. Br J Surg.
1985;75:44–7.
14. Petros PE, Ulmsten U.  Role of the pelvic floor in bladder neck
opening and closure: 1. Muscle forces. Int J Urogynecol Pelvic
Floor. 1997;8:74–80.
15. Oliver S, Fowler CJ, Mundy A, Craggs M.  Measuring the sensa-
tions of urge and bladder filling during cystometry in urge incon-
tinence and the effects of neuromodulation. Neurourol Urodyn.
2003;22:7–16.
16. Griffiths DJ, Apostolidis A.  Neurological control of the blad-
der in health and disease, chapter 1. In: Fowler CJ, Panicker JN,
Emmanuel A, editors. Pelvic organ dysfunction in neurologi-
cal disease: clinical management and rehabilitation. Cambridge:
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17. Bush MB, Petros PEP, Barrett-Lennard B. On the flow through the
human urethra. Biomechanics. 1997;30:967–9.
18. Petros PE, Bush MB.  A mathematical model of micturition
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Urogynecol. 1998;9:103–7.
19. Barrington FJ. The relation of the hind-brain to micturition. Brain.
1921;44:23–53.
20. Blok BFM, Sturms LM, Holstege G. Brain activation during mictu-
rition in women. Brain. 1998;121:2033–41.
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21. Ueki K. Disturbance of micturition observed in some patients with
brain tumour. Neurol Med Chir. 1960;2:25–33.
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turbances of micturition and defaecation. Brain. 1964;87:233–62.
23. Porter R, Lemon RL. Corticospinal function and voluntary move-
ment. Monographs of the physiological society 45. Oxford:
Clarendon Press; 1995.
24. Swash M. Electrophysiological investigation of the posterior pelvic
floor and anal sphincters, chapter 16. In: Pemberton JH, Swash M,
Henry MM, editors. The pelvic floor: its function and disorders.
London: WB Saunders; 2001. p. 213–34.
25. Kerremans R.  Morphological and physiological aspects of anal
continence and defaecation. Brussels: Editions Arscia; 1969.
26. Petros PE, Swash M. The musculo-elastic theory of anorectal func-
tion and dysfunction. Pelviperineology. 2008;27:89–93.
27. Petros PE, Kakulas B, Swash M.  Stress urinary incontinence
results from muscle weakness and laxity in the pelvic floor.
Pelviperineology. 2008;27:107–9.
28. Enck P, Musial F.  Biofeedback in pelvic floor disorders, chapter
27. In: Pemberton JH, Swash M, Henry MM, editors. The pelvic
floor: its function and disorders. London: WB Saunders; 2001.
p. 393–402.
29. Jones PN, Luboiwski DZ, Swash M, Henry MM. Relation between
perineal descent and pudendal nerve damage in idiopathic faecal
incontinence. Int J Colorectal Dis. 1987;2:93–5.
30. Creed K.  Functional diversity of smooth muscle. Br Med Bull.
1979;3:243–7.
31. Petros PE, Ulmsten U.  Tests for detrusor instability in women.
These mainly measure the urethral resistance created by pelvic
floor contraction acting against a premature activation of the mictu-
rition reflex. Acta Obstet Gynecol Scand. 1993;72:661–7.
32. Petros PE, Ulmsten U.  Bladder instability in women: a prema-
ture activation of the micturition reflex. Neurourol Urodynam.
1993;12:235–9.
33. Osman NI, Chapple CR, Abrams P, et  al. Detrusor underactivity
and the underactive bladder: a new clinical entity? A review of cur-
rent terminology, definitions, epidemiology, aetiology and diagno-
sis. Eur Urol. 2014;65:389–98.
34. Petros PE. Detrusor instability and low compliance may represent
different levels of disturbance in peripheral feedback control of the
micturition reflex. Neurourol Urodynamics. 1999;18:81–91.
35. Gleick J. “Inner Rhythms” in chaos—making a new science.
London: Cardinal Penguin; 1987. p. 275–300.
 Part II
Pelvic Floor Imaging
 Principles and Technical Aspects
of Integrated Pelvic Floor Ultrasound
Andrzej P. Wieczorek, Magdalena Maria Woźniak,
Jacek Piłat, and Giulio A. Santoro
Learning Objectives
• To learn basic principles of physics of ultrasonogra-
phy and their influence on obtained images.
• To familiarize with types of pelvic floor ultrasound
including 2D/3D transperineal ultrasound (TPUS),
2D/3D endovaginal ultrasound (EVUS), and 2D/3D
endoanal ultrasound (EAUS) and their advantages
and limitations.
• To identify various types of transducers and ana-
tomical approaches which can be applied for pelvic
floor ultrasound and distinguish different imaging
possibilities with each type of transducer.
• To learn about existing more advanced ultrasound
options such as Doppler ultrasound, elastography,
three- and four-dimensional US, and tomographic
ultrasound imaging (TUI) and recognize their
possibilities.
5.1 Introduction
Female pelvic floor is one of the most complex regions in the
human body. Pelvic organs with different functionality are sup-
ported by numerous muscular fibers (levator musculature and
perineal musculature) and connective tissue forming ligaments
A. P. Wieczorek (*) · M. M. Woźniak
Department of Pediatric Radiology, Medical University of Lublin,
Children’s University Hospital, Lublin, Poland
e-mail: wieczornyp@interia.pl
J. Piłat
Department of General and Transplant Surgery and Nutritional
Treatment, Medical University of Lublin, Lublin, Poland
G. A. Santoro
Tertiary Referral Pelvic Floor and Incontinence Center,
IV°Division of General Surgery, Regional Hospital, Treviso,
University of Padua, Padua, Italy
e-mail: giulioasantoro@yahoo.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_5
5
and fascia (endopelvic fascia, pubocervical fascia, rectovaginal
septum, perineal membrane, perineal body, uterosacral liga-
ments, cardinal ligaments) and interconnected to somatic and
autonomic nerves and vascular structures. The simplistic divi-
sion in three compartments should be replaced by the current
concept of considering the pelvic floor as a mechanical three-
dimensional apparatus that acts as unit, influencing urinary and
anal continence, sexual satisfaction, and vaginal delivery [1, 2].
Viewing the pelvic floor as a horizontal model rather than as a set
of vertical compartments helps to understand why disorders
observed in one compartment may have their origin in dysfunc-
tion of another compartment or why most females present multi-
compartmental damages. As a consequence, there is a need of an
integrated approach to the management of the pelvic floor disor-
ders involving a multidisciplinary team of clinicians that address
these problems (urologists, gynecologists, colorectal surgeons,
gastroenterologists, radiologists, physiotherapists) [1, 2].
The aim of pelvic floor evaluation is to explain the symp-
toms, identify the causative mechanism and its risk factors,
and finally propose treatment. A thorough history and physi-
cal examination will often provide ample evidence to make a
diagnosis and develop an effective treatment plan. Patients
unresponsive to the initial therapy or with recurrence of
symptoms or candidate to surgery should however further be
investigated using sophisticated tests. Imaging techniques
play a fundamental role in the diagnosis of pelvic floor disor-
ders and are included in the pathways of urinary and anal
incontinence, obstructed defecation, voiding dysfunction, and
pelvic organ prolapse proposed by various scientific societies
(ICS, International Continence Society; IUGA, International
Urogynecological Association; ICI, International
Consultation on Incontinence) [3–5]. Ultrasound, X-ray
(evacuation proctography, cystography, videourodynamics,
barium enema, transit time) and MRI techniques can help to
identify the anatomical or functional abnormalities of the pel-
vic floor. Radiological findings can confirm clinical findings
or discriminate damages that were misled or underestimated
by physical examination alone. Due to costs, access and avail-
ability, and patient compliance, most guidelines recommend
73
74
to perform pelvic floor ultrasound as the first-line or screen-
ing tool modality [3–5].
“Pelvic floor ultrasound” is a synonymous of a large vari-
ety of techniques (translabial, transperineal, endovaginal,
endoanal, 3D/4D acquisitions, dynamic US, assessment of
vascularity patterns, and tissue stiffness—elastography), hav-
ing different advantages and limitations [6, 7]. Understanding
the physics of ultrasound, the mechanism of interactions of
ultrasound beam with tissues, the process of image formation,
the choice of imaging parameters, the optimization of quality
of image (gain, focus, resolution), the identification of arti-
facts, the characteristics of transducers (mechanical and elec-
tronic frequencies, field of view, convex, end-fire, linear) and
scanners, and the different anatomical approaches that can be
used is therefore of utmost importance [8–11]. Despite ultra-
sound is considered operator-­dependent, an adequate training
and use of standardized methodology have demonstrated a
very good intra- and interobserver reproducibility of this
modality [12–14]. Great advance has been made in develop-
ing a very sophisticated ultrasound technology; however the
vertical model for care of disease has limited a clinician’s
understanding to the vertical unit in which the clinician (urol-
ogist, gynecologist, and colorectal surgeon) has an expertise.
The emerging concept of horizontal integration of pelvic
floor dysfunction evaluation and management is expanding to
ultrasound approach that must be integrated and multicom-
partmental [6, 15]. Global or total ultrasound addresses all
pelvic floor anatomy and functionality in one setting, allow-
ing identification of coexisting dysfunctions of the three com-
partments [6].
5.2 Principles of Pelvic Floor Ultrasound
Ultrasound imaging is a technique of generating images
using a very high-frequency sound. Sound is a mechanical,
vibration form of energy. Ultrasound for medical imaging is
generated in special crystalline materials which, when elec-
trically excited, are capable of vibrating at frequencies of
millions of vibrations per second [8]. Operating frequencies
for medical ultrasound are in the 1–40  MHz range, with
external imaging machines typically using frequencies of
1–20 MHz. Higher frequencies are in principle more desir-
able, since they provide higher resolution, but tissue attenua-
tion limits how high the frequency can be for a given
penetration distance. However, one cannot arbitrarily
increase the ultrasound frequency to get finer resolution,
since the signal experiences an attenuation of about 1 dB/cm/
MHz [9].
The velocity of propagation of ultrasonic longitudinal
waves in soft tissues varies depending on the type of tissue,
in single collagen fibers (tendons) equals c  =  1700  m/s, in
A. P. Wieczorek et al.
lung tissue 650 m/s, in bone tissue from 1500 to 4300 m/s
[3]. The speed of ultrasound wave c is determined by the
formula:
C
c=
p
c—speed of sound, C—coefficient of stiffness, p—density.
Different materials respond differently to interrogation by
ultrasound, depending on the extent to which their medium
particles will resist change due to mechanical disturbance.
This medium property is referred to as the characteristic
acoustic impedance of a medium. It is a measure of the resis-
tance of the particles of the medium to mechanical vibra-
tions. This resistance increases in proportion to the density of
the medium and the velocity of ultrasound in the medium.
Acoustic impedance, Z, may be defined as the product of
medium density and ultrasound velocity in the medium [8]:
Z = density ´ velocity
Ultrasound waves are generated by piezoelectric crystals
in the transducers. The number of piezoelectric crystals in
the transducers and the range of frequencies they can operate
in are very important features. In case of 2D technology, the
number usually exceeds 190 elements; in 3D and 4D tech-
nologies, the transducer may be designed as a matrix array,
where the number of piezoelectric elements may be multi-
plied to more than a 1000 elements. The signals generated in
the transducer are subsequently sent to the tissue and received
back by transmit channels. The number of physical active
channels can reach a few hundred (over 500), whereas trans-
mit channels used in post-processing may reach even a few
millions. Ultrasound imaging is based on the signals gener-
ated by the returning echoes at the transducer that are elec-
tronically processed to increase their sizes and organized in
computer memory before being displayed to the user. The
echoes returning from different tissue depths must be sub-
jected to compensation for attenuation differences. Time
gain compensation (TGC) is a process of applying differen-
tial amplification to signals received from different tissue
depths, with echoes originating from longer distances being
amplified to a greater extent than those from shorter dis-
tances in such a way that similar tissue boundaries give
equal-sized signals regardless of their depth in tissue. The
latest generations of scanners have automatic adjustment of
TGC independent from the operator.
The difference between the maximum and minimum val-
ues of the displayed signal is defined as dynamic range, and
it is one of the most essential parameters that determine its
image quality [11]. Nowadays dynamic range may vary
from 70 Db to over 300 Db. Because the dynamic range of
signal sizes may be very wide, the range of signal sizes is
5  Principles and Technical Aspects of Integrated Pelvic Floor Ultrasound
compressed by using logarithmic amplifiers. Pulses with
identical waveforms are repeated each time the crystal is
excited, at a rate known as the pulse repetition frequency
(PRF). The PRF represents the number of pulses or bursts of
ultrasonic energy, released by the transducer in one second,
and is different from the vibration frequency of the trans-
ducer [8].
The most basic but at the same time a crucial mode in
pelvic floor ultrasound is the brightness mode (B-mode). In
B-mode the signals from returning echoes are displayed as
dots of varying intensities (gain). The intensity of a dot (the
brightness) is a relative measure of echo size, with large
echoes appearing as very bright dots, while at the other
extreme non-reflectors, they appear totally dark.
It is important to notice that an ultrasound pulse consists
of a range of frequencies, not a single frequency. For exam-
ple, a pulse from a 5 MHz transducer could be composed of
a range of frequencies from 4 MHz to 6 MHz. This range of
frequencies is called the bandwidth [5]. Another important
feature is use of harmonics imaging. The ultrasound pulse
starts out with a sinusoidal waveform. As the wave passes
through tissue, the wave speeds up very slightly during the
compression phase, and during the refraction phase, the
wave slows slightly. This causes a distortion of the wave and
creates the harmonic frequencies. Harmonics are frequencies
at multiples above the fundamental frequency—the fre-
quency that was emitted from the transducer. The fundamen-
tal frequency is also known as the first harmonic [5]. The
main advantage of the harmonic imaging is increasing the
resolution of the image obtained.
More advanced techniques in pelvic floor ultrasound
include the use of multidimensional imaging—three-­
dimensional (3D) and four-dimensional (4D). The main pre-
requisite for construction of three-dimensional (3D)
ultrasound images is very fast data acquisition. Transducers
for real-time imaging may be classified broadly into two cat-
egories: mechanical transducers and electronic transducers.
In mechanical transducers, the beam sweep is achieved
through physical movement of some part of the transducer,
usually the crystal element(s), whereas in electronic trans-
ducers the beam is swept by electronic activation of crystal
elements, without causing the transducer to move physically.
The collected data are processed at high speed, so that real-­
time presentation on the screen is possible. This is called the
four-dimensional (4D) technique (4D = 3D + real time) [8].
The 3D image can be displayed in various ways, such as
transparent views of the entire volume of interest (render
mode), images of surfaces (surface mode), images in three
perpendicular sections (axial, sagittal, coronal) called multi-
planar reconstruction (MPR), or as a volume 3D box acces-
sible from every side and section. Post-processing options of
3D and 4D images enable numerous manipulations of the
75
image such as zooming, rotating, contrasting, sharpening,
changing the transparency, removing artifacts in order to
present the volumetric image in the most diagnostic
manner.
In order to produce high-quality images, it is crucial to
understand the nature of artifacts in pelvic floor imaging.
The major causes of artifacts include multiple reflections
across acoustic boundaries, acoustic shadowing due to strong
reflectors or absorbers of ultrasound, and poor physical con-
dition of the transducer. Other artifacts may be caused by
refraction of ultrasound, scattering, wave interference phe-
nomena, or less than perfect mechanical and electrical isola-
tion of crystal elements.
Lastly important features influencing the diagnostic value
of pelvic floor ultrasound are the environmental conditions
such as proper room lightning, proper monitor settings
(Fig. 5.1), and the ability of the user to operate the scanner
accordingly.
Summarizing, a variety of factors contributes to the over-
all quality of the ultrasound image. These include the design
of equipment components, especially the transducer; the
choice of imaging parameters, particularly the beam fre-
quency; and the skilled use of the equipment by the operator.
A good-quality image should contain information that is
associated with high spatial resolution (ability to distinguish
between objects in space), high contrast resolution (ability to
distinguish between signals of different size), and high tem-
poral resolution (ability to separate between events in time).
In addition, the image should be free of any avoidable arti-
facts [8].
5.3 Two-Dimensional Transperineal
Ultrasound (2D TPUS)
2D TPUS is performed with the patient placed in the dorsal
lithotomy position, with hips flexed and abducted and a convex
transducer positioned on the perineum between the mons pubis
and the anal margin (perineal approach). The dimension of the
transducer should be large enough to cover in the midsagittal
plane all anatomical structures between posterior margin of the
symphysis pubis and anterior margin of the coccyx/posterior
part of the levator ani, e.g., bladder, urethra, vaginal walls, anal
canal, and rectum. TPUS is a term that should be regarded as
being synonymous with “translabial ultrasound” (transducer
placed on one of the labia majora) or “perineal ultrasound”
(transducer placed between the posterior vaginal wall and anal
canal), while “introital ultrasound” is usually assumed to imply
placement of transducers with smaller footprints (such as end-
fire transvaginal probes or hokey-stick intraoperative transduc-
ers) within the introitus. The general term of “TPUS” is often
adopted for all these techniques. Imaging is usually performed
76
Fig. 5.1  Influence of monitor setting for the quality image
with the patient at rest, during maximal Valsalva maneuver and
during pelvic floor muscle contraction (squeeze test) to dynam-
ically define the position and anatomical relationship between
urethra and bladder, vaginal walls, and the anorectal region
anal canal. In order to avoid false-negative results, transducer
pressure on the perineum must be as small as possible, while
still m
­ aintaining good tissue contact, in order to allow full pel-
vic organ descent [16, 17].
5.3.1 Convex Transducers
Two-dimensional transperineal ultrasound (2D TPUS) in
B-mode represents the most frequently used modality provid-
ing 2D imaging of the pelvic floor in the midsagittal section [6,
16, 17]. It is performed with convex transducers that may differ
depending on frequency and surface of contact (Table 5.1). The
higher is the frequency, the smaller is the shape of convex sur-
face. The conventional “large” convex transducers usually used
for abdominal and obstetrical scanning have low resolution due
to low frequencies, because they must have high penetration to
image deep organs in the patient’s body. They work at frequen-
A. P. Wieczorek et al.
cies ranging from 2 to 6–8 MHz, with a field of view at least
70° (Fig. 5.2a). The number of crystals/piezoelectric elements
in large convex transducers may differ depending on manufac-
turers; however it is around 192 elements placed on a surface of
approx. 50–62 mm length and 8–13 mm width (acoustic aper-
ture). Another type of transducer also used for 2D TPUS scan-
ning is a “small” convex transducer designed primarily for
pediatric or early pregnancy examinations. It is characterized
by higher frequency (from 5 to 9–10 MHz) in comparison to
“large” convex transducers and smaller sizes of acoustic aper-
ture (Table 5.1, Fig. 5.2b). A third type of transducer also suit-
able for 2D TPUS scanning is an endocavitary end-­ fire
microconvex probe used for gynecological/urological pur-
poses. It is characterized by frequency ranging from 5–6 to
8–9 MHz and smallest acoustic aperture (Table 5.1, Fig. 5.2c).
Some scanners have dedicated protocol for urogynecology;
however the operator can adjust the setting to get good-quality
images. The focal zone should be concentrated at the level of
the bladder neck, which is approx. 30–40 mm deep, whereas
the field of view and the ultrasound angle can be regulated to
focus on a certain anatomical structure to obtain better image.
A limitation of the 2D TPUS technique is its sensitivity in
5  Principles and Technical Aspects of Integrated Pelvic Floor Ultrasound 77

Table 5.1  Types and characteristic of convex transducers used in 2D TPUS examinations
Type of probe Example transducer Example ultrasound 2D TPUS image
“Large” 6C2 Fig. 5.2  Two-dimensional transperineal ultrasound performed with
convex BK-Medical 4 different types of transducer. Pelvic floor structures are visualized in
10
the midsagittal section. Differentiation of the external and internal
sphincters and the lumen of anal canal are visible better with

27
higher-frequency (small convex and end-fire) transducer than with
77
lower-frequency (large convex) transducer. (a) Large convex

Primary Abdominal
purpose Obstetrical
Range of 2–6 MHz
frequencies
Number of 192
elements
Image field 62°/71°
Acoustic 62.5 × 13 mm
aperture

a
“Small” 9C2 (b) Small convex
convex BK-Medical
1,5
10
30,7

56

Fig.2 Technical drawing and dimensions (mm)

Primary Pediatric
purpose Early pregnancy
Range of 2–9 MHz
frequencies
Number of 192
elements
Image field 74°/104°
Acoustic 52 × 8 mm
aperture
b
End-fire 8819 (c) End-fire. A anal canal, B bladder, SP symphysis pubis, U urethra
BK-Medical
319
22,1

18,2

Primary Gynecology
purpose Urology
Range of 6–9 MHz
frequencies
Number of 128
elements
Image field 150°
Acoustic 26 × 5 mm
aperture

c
78
Fig. 5.3  Sagittal section of
pelvic floor structures by
two-dimensional transperineal
ultrasound. During Valsalva
maneuver, air trapped into
rectocele (R) produces typical
reverberation artifact.
B bladder, SP symphysis
pubis, U urethra
dynamic studies when the image may be distorted by artifacts
caused by the reflections from gases in the anal canal in patients
with rectocele/enterocele (Fig. 5.3).
5.3.2 Linear/Microconvex Transducers
For introintal use in adult patients and in case of children
and newborns to find out the anatomical disorder in pelvic
floor, higher-frequency transducers (linear, microconvex,
or end-­fire gynecological/obstetrical or urological) can be
used (Table 5.2, Fig. 5.4). Linear transducers provide visu-
alization of superficial pelvic anatomical structures or
subcutaneous fluid collections/fistulas and anorectal mal-
formations that can be missed by low-frequency transduc-
A. P. Wieczorek et al.
ers. Frequency of linear transducers is higher than large
convex transducers and may range from 5–7 MHz even up
to 20–22 MHz. The most common range of frequency var-
ies from 8 to 10–12 MHZ for the transducers dedicated to
small part imaging, breast imaging, and musculoskeletal
scanning. “Hokey-stick” intraoperative linear transducers
are also appropriate for this purpose due to small size,
angulated shape, and high frequency, delivering high-res-
olution image. These transducers can be introduced endo-
vaginally/endoanally with a finger guidance to the
suspected area. Microconvex and end-fire gynecological/
obstetrical or urological transducers have higher frequen-
cies starting from 5 up to 9–12 MHz, with better resolu-
tion than large convex transducers, but are limited by a
small surface of contact (Table 5.2, Fig. 5.4).
5  Principles and Technical Aspects of Integrated Pelvic Floor Ultrasound 79

Table 5.2  Types and characteristic of linear transducers used in 2D TPUS examinations
Type of
probe Example transducer Example ultrasound 2D TPUS image
“Lower-­ 13 L5 Fig. 5.4  Pelvic floor structures by transperineal ultrasound
frequency” BK-Medical visualized with different types of transducers. (a) “Lower-
linear 0
frequency” linear transducer— sagittal section (A anal canal, B
10
bladder, U urethra)

a
66

22
Primary Small parts
purpose MSK (large joints)
Range of 5–13 MHz
frequencies
Number of 192
elements
Image field 49.9 + 2 × 15°
Acoustic 50 × 4 mm
aperture
“Higher-­ 18L5 (b) “Higher-­frequency” linear transducer—sagittal section showing
frequency” BK-Medical intraurethral tumor (T)
linear
97
b
30,5

57

Primary Pediatric small parts

purpose MSK (small joints)
Range of 5–18 MHz
frequencies
Number of 192
elements
Image field 38.4 + 2 × 15°
Acoustic 38.4 × 3.5 mm
aperture

Foot-print/ X18 L5s (c) Foot-print/hokey-stick transducer—the lumen of an ectopic ureter

24
hokey-stick BK-Medical (EU) having the orifice in the urethra
3
17
14
c

9,5

Primary Intraoperative
purpose MSK (finger/toe joints)
Range of 5–18 MHz
frequencies
Number of 150
elements
Image field Trapezoidal: 24.0 mm wide + expansion
angle 2 × 15°
Acoustic 3.5 × 24 mm
aperture
80
5.4 T
 hree-Dimensional/Four-Dimensional
Transperineal Ultrasound (3D/4D
TPUS)
5.4.1 Volumetric Transducers
Volumetric transabdominal probes developed for obstetric
imaging (RAB 8–4, GE Healthcare Ultrasound, Milwaukee,
WI, USA; AVV 531, Hitachi Medical Systems, Tokyo,
Japan; V 8–4, Philips Ultrasound, Bothell, WA, USA; 3D
4–7 EK, Medison, Seoul, South Korea) and other may be
used for 3D/4DTPUS. These transducers combine an elec-
tronic curved array of 4–8 MHz with mechanical sector tech-
nology, allowing fast motorized sweeps through the field of
view, a technology that was pioneered in the Voluson sys-
tems manufactured by Kretztechnik, now GE Healthcare
Ultrasound [18]. For the “pelvic floor” assessment, the sug-
gested set is maximum aperture and acquisition angles (70°
and 85°, respectively), depth of 8  cm, two focal zones at
1.5  cm and 4.5  cm, low or medium harmonics, speckle
reduction 5, and crossbeam 2 [18] (Table 5.3, Fig. 5.5).
An advantage of 3D TPUS compared with 2D mode is the
opportunity to obtain tomographic or multislice imaging (TUI),
for example, in the axial plane, in order to assess the entire
puborectalis muscle and its attachment to the pubic rami, as
described by Dietz et al. [19, 20]. It is also possible to measure
the diameter and area of the levator hiatus and to determine the
degree of hiatal distension on Valsalva maneuver. 4D TPUS
imaging involves real-time acquisition of volume ultrasound
data, which can then be visualized instantly in orthogonal
planes or rendered volumes. This simplifies the assessment of
functional anatomy since 3D data can be archived as a cine
loop, encompassing maneuvers such as squeeze test or Valsalva
maneuver [6]. Similar to DICOM viewer software used in radi-
ology, offline analysis is possible on the actual system or on a
personal computer (PC) with the help of dedicated software.
Similarly as in 2D TPUS, particularly on prolapse assess-
ment, pressure on the perineum must be kept to a minimum
to allow full development of the prolapse [18]. The limitation
of 3D/4D TPUS is a small region of interest (acquisition
angle) not able to cover all pelvic floor organs in patients
with high-grade prolapse and in patients with high BMI.
5.5 T
 wo-Dimensional Endovaginal
Ultrasound (2D EVUS)
EVUS is performed with the patient placed in the same posi-
tion as that adopted for TPUS.  It may be performed with
electronic linear transducer, frequency 4–14  MHz (type
8838, X14L4 BK-Medical, Herlev, Denmark); with elec-
tronic biplane transducer (linear and transverse perpendicu-
lar arrays), frequency 5–12 MHz (type 8848, BK-Medical)
A. P. Wieczorek et al.
[21]; with high-multifrequency (9–16 MHz), 360° rotational
mechanical transducer (type 2052, 20R3 BK-Medical) [21];
or with radial electronic probe (type AR 54 AW, 5–10 MHz,
Hitachi Medical Systems) (Table 5.4, Fig. 5.6 and 5.7).
It is important to keep the transducer inserted into the
vagina in a neutral position and to avoid excessive pressure
on surrounding structures, which might distort the anatomy
[6, 21]. The biplane electronic probe provides 2D sagittal
(linear array) and axial (transverse array) sectional imaging
of the anterior and posterior compartments. Imaging is usu-
ally performed with the patient at rest, during maximal
Valsalva maneuver and during squeeze test. The vascular
pattern of the pelvic floor structures may also be assessed
using color Doppler mode [21, 22].
Dressler et al. [13] reported from good to excellent repeat-
ability and reproducibility of the measurements of the subu-
rethral tape location obtained by pelvic ultrasound performed
with transvaginal end-fire probe. This demonstrates that for
experienced operators which have no access to dedicated
pelvic floor equipment, conventional gynecological trans-
ducers provide adequate results.
5.6 T
 hree-Dimensional Endovaginal
Ultrasound (3D EVUS)
Radial electronic transducer, electronic linear transducer, and
rotational mechanical transducer provide a 360° view of the pel-
vic floor [6, 21]. However with the radial electronic transducer,
the 3D acquisition is freehand, whereas with the linear elec-
tronic transducer and the mechanical transducer, the 3D acquisi-
tion is automatic. The mechanical probe has an internal
motorized system that allows an acquisition of 300 aligned
transaxial 2D images over a distance of 60 mm in 60 s, without
any movement of the probe within the tissue. The set of 2D
images is reconstructed instantaneously into a high-resolution
3D image for real-time manipulation and volume rendering.
However the operator may individually adjust the distance of
acquisition, slice thickness, and time of acquisition which is
subsequently reflected in the image quality obtained (shorter
time and thicker slice thickness are related to lower quality of
the image). An advantage of 3D compared with 2D mode is the
opportunity to obtain sagittal, axial, coronal, and any desired
oblique sectional image. The 3D volume can also be archived
and further post-processed for offline analysis on the ultrasono-
graphic system or on a PC with the help of dedicated software.
The methodology of 2D and 3D EVUS was described by
Santoro and Wieczorek [6, 7, 14, 21]. Detailed ultrasound
morphology of the urethra and its vasculature was described
by Wieczorek et al. [7, 12, 22–24] and Lone et al. [25, 26].
Shobeiri et al. [27] described the ultrasonographic anatomy
of levator ani subdivisions, whereas Santoro et  al. [28]
described the perineal body anatomy.
Table 5.3  Types and characteristic of volumetric transducers used in 3D/4D TPUS examinations
Type of probe Example transducer Example ultrasound 2D TPUS image
“Large” RAB 4–8 Fig. 5.5  Three-dimensional image of pelvic floor structures by 3D TPUS visualized with different types of
volumetric GE Medical transducers. (a) Volumetric “abdominal/obstetrical” transducer—multiplanar reconstruction and surface mode (A
anal canal, B bladder, SP symphysis pubis, U urethra)

Primary purpose Abdomen,

Pediatric, obstetric, and gynecology
Range of frequencies 2–8 MHz
Number of elements 192
Image field 70° × 85°
Acoustic aperture 63.6 × 37.8 mm
“Small” RAB6-D
volumetric GE Medical

Primary purpose Abdominal

Obstetrics, urology, and pediatrics
Range of frequencies 2–8 MHz
Number of elements 192
Image field 90° × 85°
Acoustic aperture 62.2 × 34.0 mm

a
5  Principles and Technical Aspects of Integrated Pelvic Floor Ultrasound

(b) Volumetric “abdominal/obstetrical” transducer—tomographic imaging

b
(continued)
81
Table 5.3 (continued)
82

Endovaginal RIC5-9-D (c) Volumetric endovaginal transducer—multiplanar reconstruction and surface mode
volumetric GE Medical

Primary purpose Obstetrics, gynecology, and urology

Range of frequencies 4–9 MHz
Number of elements 192
Image field 179° × 120°
Acoustic aperture 22.4 × 22.6 mm

c
Matrix RSM 5-14
GE Medical

Primary purpose Gynecology and urology

Small parts, pediatrics, MSK
Peripheral vascular
Range of frequencies 5–13 MHz
Number of elements 960
Image field 37.5 mm (B) × 30° (Volume scan)
Acoustic aperture 54.3 mm × 50.5 mm
A. P. Wieczorek et al.
5  Principles and Technical Aspects of Integrated Pelvic Floor Ultrasound 83

Table 5.4  Types and characteristic of transducers used in 2D/3D EVUS and 2D/3D EAUS examinations
Type of probe Example transducer Example ultrasound 3D EVUS/EAUS image
High-­ 20R3 38

Fig. 5.6  Three-dimensional image of pelvic floor structures by endovaginal

,4

resolution BK-Medical
(3D EVUS) and endoanal (3D EAUS) approaches visualized with different
360°
2
types of transducers. High-resolution 360° transducer: (a) 3D EVUS, (b, c)
54
3D EAUS. A anus, ES external sphincter, IS internal sphincter, R rectum, SP
symphysis pubis, U urethra, V vagina

17

Primary EVUS
purpose EAUS
Range of 9–16 MHz
frequencies
Number of 1
elements
Image field 360°
Acoustic NA
aperture

(continued)
84 A. P. Wieczorek et al.

Table 5.4 (continued)
Type of probe Example transducer Example ultrasound 3D EVUS/EAUS image
Linear X14L4 (d, e) 3D EVUS with linear 360° transducer
360° BK-Medical
2
36

5
15

55
36

θ16.4

Primary EVUS
purpose EAUS
Range of 4–14 MHz
frequencies
Number of 192
elements
Image field 360°
d
Acoustic 65 × 5.5 mm
aperture

e
(f) 3D EAUS with linear 360° transducer. A anal canal, B bladder, ES
external sphincter, IS internal sphincter, PB perineal body, R rectum, SP
symphysis pubis, U urethra, V transducer into vagina

f
(continued)
5  Principles and Technical Aspects of Integrated Pelvic Floor Ultrasound 85

Table 5.4 (continued)
Type of probe Example transducer Example ultrasound 3D EVUS/EAUS image
Linear E14CL4b Fig. 5.7  Axial section of the urethra visualized with linear biplane
biplane BK-Medical transducer. (a) Elastographic image of the urethra during Valsalva
2,5
35
F 32,4 maneuver; (b) compare B-mode gray scale of the urethra image shown
simultaneously to the elastographic image. U urethra; white arrow,
rhabdosphincter muscle at rest (blue, soft); yellow arrow, longitudinal
F 20 smooth muscle during contraction/bladder neck opening (red, hard)
Primary Urology/prostate
purpose Prostate elastography
Range of 4–14 MHz
frequencies
Number of 128 transverse
elements 192 sagittal
Image field 138°/178°
transverse
65 mm + 2 × 15°
sagittal
Acoustic 23 × 5.5 mm
aperture transverse
65 × 5.5
sagittal

5.7 T
 wo-Dimensional Endoanal ring is applied to the probe handle, sealing the probe cover.
Ultrasound (2D EAUS) The cover is filled with a variable amount of degassed water
(approx. 60–100  ml) depending on the compliance of the
Endoanal ultrasound (EAUS) includes examination of the examined section of the bowel. Using a dedicated rectoscope
anal canal (endoanal ultrasound—EAUS) and of rectal region (slightly wider than the standard one), the probe can be
(endorectal ultrasound—ERUS). EAUS is performed with inserted to a depth of 20  cm enabling examination of the
high-multifrequency, 360° rotational mechanical transducer, deeply located lesions and precise assessment of the depth/
linear electronic transducer, or a radial electronic transducer, extend of the infiltration of tumors (Fig. 5.8) as well as precise
as described above for EVUS (2052, 20R3, 8838; E14CL4b
BK-Medical). During examination, the patient may be placed
in a dorsal lithotomy, left lateral or prone position. However,
irrespective of patient position, the transducer should be
rotated so that the anterior aspect of the anal canal is superior
(12 o’clock position) on the screen: the right lateral aspect is
to the left (9 o’clock), the left lateral aspect is to the right (3
o’clock), and the posterior aspect is inferior (6 o’clock) [6].
The recording of data should extend from the upper aspect of
the puborectalis muscle to the anal verge [6, 29] (Table 5.4,
Fig. 5.6). The high-resolution 360° transducers provide mini-
mal slice thickness of 1  mm. The rotating crystal moves
mechanically, and the operator can decide individually and
adjust the distance scanned up from a minimum of 0 mm to a
maximum of 60  mm using two buttons on the probe. The
number and the depth of the focal zone/zones can be also
manually adjusted by the user. The location of the buttons
directly on the probe enables manipulation of the image with-
out the need of changing the position of the transducer intro-
duced endoanally, which is mostly important in rectal Fig. 5.8  3D ERUS. High-resolution 360° transducer. Examination per-
examination performed with a distension of rectal ampulla by formed with degassed water-filled balloon. A ampulla recti, B water
a water-filled balloon. For such type of examination, a special balloon, T tumor
86
assessment of very high fistulas. In the evaluations of fistulas,
it is helpful to use hydrogen peroxide (approx. 2–5 ml) as a
contrast medium that is injected through the external opening.
Hydrogen peroxide allows precise visualization of the anat-
omy of the fistulas and helps to differentiate active tract from
scar tissue. Similar technical solution with the opportunity of
examining the anorectal region is offered with the transrec-
tum composite probe type UST-678 (Hitachi, Japan). This
probe enables scanning with the field of view of 120° (convex
array), on the length of 60 mm (linear array). The frequency
of the transducer can be adjusted from 3 to 9 MHz (convex
array) and from 4 to 10 MHz (linear array). A balloon cover
filled with water and fixed by the dedicated rubber band to the
transducer allows examination of the rectal ampulla.
Compared to the transducers previously described, the new
linear electronic probe (type 8838, BK-Medical), frequency
of 4–4 MHz, or its recent version X14L4 offers similar imag-
ing opportunities (only in sagittal section) (360°, length of
scanning from 0 to 60 mm length, 1 mm minimal slice thick-
ness, manual adjustment of focal zones) with full measure-
ment capabilities as the probes above but with higher
resolution. The limitation of this probe is lack of a system for
the distension of rectal ampulla by a water-filled balloon.
5.8 Three-Dimensional Endoanal
Ultrasound (3D EAUS)
The methodology of 2D and 3D EAUS was described by
Santoro et al. [6, 29]. The mechanical rotational transducer
or the electronic linear transducer allows automatic 3D
acquisition without movement of the probe relative to the
tissue under investigation. After the dataset has been
recorded, it is possible to interrogate the dataset in 3D, with
multiplanar imaging [6]. The 3D image may be rotated,
tilted, and sliced to allow the operator to vary infinitely the
different section parameters and to visualize and measure
distance, area, angle, and volume in any plane [29]. There
are also tools to change the transparency of the dataset (vol-
ume rendering) [29].
5.9 Conclusions
Ultrasound technology provides a variety of transducers with
high range of frequencies, different acoustic aperture, shape,
size, and philosophy of beam formation. Pelvic floor ultra-
sound can be performed both with relatively simple ultra-
sound equipment used for abdominal or obstetrical purposes
and with high-end scanners dedicated for urology or proctol-
ogy. Technical achievements together with Doppler modes,
A. P. Wieczorek et al.
elastography, as well as the opportunity of ultrasound/MR
fusion allow for assessment of female pelvic floor structures
of all three compartments in 2D, 3D, and 4D techniques.
Different anatomical approaches such as TPUS, EVUS,
EAUS, and abilities of post-processing give the clinicians
diagnostic power to understand the anatomy and anatomical
abnormalities. Ultrasound can be used as an extension for
clinically obtained dose of information and its better under-
standing but can be also employed for qualification for cer-
tain surgical procedures. Another advantage of using
ultrasound is the opportunity of detailed diagnosis of post-
surgical complications and explanation of the causes of sur-
gical failure. All these factors make ultrasound the modality
which should be considered as the first choice imaging tech-
nique in diagnostics of female pelvic floor disorders.
Take-Home Messages
• Pelvic floor ultrasound can be performed with a
variety of transducers and anatomical approaches.
• The knowledge of capabilities and limitations of
each type of transducer, anatomical access, and
post-processing options is crucial for performing
pelvic floor ultrasound in a proper way and making
reliable diagnosis.
• Modern ultrasound technologies such as Doppler
ultrasound, elastography, three- and four-­
dimensional ultrasound, and tomographic ultra-
sound imaging (TUI) can enhance significantly the
quality of information obtained; however good
knowledge of the technical aspects of the tech-
niques and their pros and cons is essential.
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 Transperineal Ultrasonography:
Methodology and Normal Pelvic Floor
Anatomy
Hans Peter Dietz
Learning Objectives
• To appreciate the basic methodology of translabial/
perineal ultrasound using 2D and 3D/4D systems.
• To understand the basic functional anatomy of the
female pelvic floor.
• To recognize normal anatomical structures both in
the midsagittal and the axial plane.
• To identify the levator ani and the anal sphincter in
tomographic imaging.
6.1 Introduction
Ultrasound is the primary imaging method in gynecology
and commonly used in urology and colorectal surgery. Hence
it is not surprising that it is increasingly popular in the imag-
ing assessment of pelvic floor anatomy. This development is
long overdue, seeing that pathophysiology and etiology of
many pelvic floor conditions are still poorly understood at
present. The evaluation of urethral and paraurethral anatomy
and pelvic organ mobility has become easier due to recent
technological developments [1]. The same applies to the
assessment of defecatory dysfunction [2]. The advent of 3D
ultrasound now allows access to the axial plane, and 4D
ultrasound enables the observation of function in the form of
maneuvers such as cough, Valsalva, and pelvic floor muscle
contraction [3]. Tomographic techniques are increasingly
used for the assessment of birth trauma to levator ani [4] and
anal sphincter muscles [5] which will become a key perfor-
mance indicator of obstetric services and change maternity
services delivery worldwide [6].
Other techniques such as endovaginal and endo-anal
ultrasound have been used in the investigation of pelvic floor
H. P. Dietz (*)
Sydney Medical School Nepean, University of Sydney,
Sydney, NSW, Australia
e-mail: hpdietz2@bigpond.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_6
6
disorders, but this chapter will exclusively cover translabial
or transperineal ultrasound which, for the sake of simplicity,
the author calls “pelvic floor ultrasound.” This modality is
unique in that it allows a comprehensive assessment of pel-
vic floor structures in one single, noninvasive investigation
of at most 10  min duration. It can replace video cystoure-
thrography, magnetic resonance imaging, defecation proc-
tography, and endo-anal ultrasound in women suffering from
symptoms of lower urinary tract dysfunction, prolapse,
obstructed defecation, and fecal incontinence, using systems
almost universally available. Chapter 48 will cover patho-
logical findings, while this chapter deals with normal
anatomy.
The definition of “normal” is fundamental to the practice
of medicine. Without “normal” there is no “abnormal” and
no basis for therapeutic intervention. This is particularly true
in a newly developed diagnostic field such as pelvic floor
ultrasound. Overdiagnosis, that is, the risk of misinterpreting
findings as abnormal that are in fact within the normal range,
is always a danger. Hence I will try to define “normal,” both
in terms of static anatomy and in terms of “dynamic anat-
omy,” i.e., function, as far as it applies to urogynecological
conditions.
6.2 Basic Technique
The basic requirements for pelvic floor imaging include a
B-mode capable two-dimensional (2D) ultrasound system
with cine-loop function, a 3.5–6  MHz curved array trans-
ducer, and a videoprinter. However, to allow for the full
scope of diagnostic capabilities, 3D/4D imaging is indis-
pensable. For over 20 years, Voluson-type systems have been
the market leaders in the field of 3D/4D ultrasound.
Consequently most of the literature on 3D pelvic floor ultra-
sound is based on the utilization of such systems, even if
most manufacturers now offer equipment that can be
employed usefully. Any 4D capable ultrasound system with
abdominal 4D transducers in an obstetric imaging unit
89
90
should be suitable for pelvic floor ultrasound, provided the
aperture angle is 70° or better and provided the acquisition
angle can be set to at least 70°. For severe prolapse and hiatal
ballooning, aperture and acquisition angles of 80–90° can
become necessary.
The examination is performed in dorsal lithotomy with
the hips flexed and slightly abducted or alternatively in the
standing position. Asking the patient to place her heels close
to the buttocks will result in an improved pelvic tilt. A full
bladder or bowel may prevent full development of pelvic
organ prolapse [7]. Therefore, imaging is best performed
after bladder emptying; otherwise bladder filling should be
specified. Occasionally, catheterization will be necessary.
For preparation of the probe, it is covered with either a
powder-free glove, condom, or thin plastic wrap for hygienic
purposes, after covering the transducer surface with ultra-
sound gel and while avoiding air bubbles between transducer
surface and glove. The probe is then placed on the perineum
after parting the labia, producing a midsagittal view showing
urethra and anal canal at the same time (see Fig. 6.1). Tissue
hydration and scar tissue can affect visibility, but obesity is
virtually never a problem. Conditions are best in pregnancy
and poorest in the senium. The probe can be placed firmly
without causing significant discomfort, unless there is
marked atrophy or vulvitis. During a Valsalva it is essential,
however, not to exert undue pressure to allow full develop-
ment of pelvic organ descent. After scanning the probe is
mechanically cleaned, followed by disinfection with alco-
holic wipes. Sterilization as for intracavitary transducers is
usually considered unnecessary.
On translabial ultrasound, pelvic floor structures are ini-
tially shown in the midsagittal plane [1]. This orientation,
shown in Fig. 6.1, allows imaging of the urethra, the bladder
neck and trigone, the cervix, the rectal ampulla, and the anal
canal. While there is no universal consensus on image orien-
Fig. 6.1  Transducer placement on the perineum (left) with schematic representation of the resulting midsagittal field of vision. Right image
adapted from [1], with permission
H. P. Dietz
tation, the first published translabial images had the perineum
at the top and the symphysis pubis on the left [7], and this is
still the most commonly used orientation. It is particularly
convenient when using three-dimensional (3D)/four-­
dimensional (4D) systems as shown in Fig. 6.2. The top left
image represents the midsagittal plane, with the bottom right
showing a rendered volume of the levator hiatus.
The advent of 3D/4D imaging has given easy, noninvasive
access to the axial plane allowing imaging of the caudal part of
the levator ani muscle and the opening in this muscular plate,
the levator hiatus (Fig. 6.2). The levator hiatus is an important
part of the birth canal and the largest potential hernial portal in
the human body. It is of central importance in the pathophysi-
ology of female pelvic organ prolapse (POP), a highly preva-
lent condition that may require surgery at least once during the
lifetime of 10–20% of the female population [8, 9].
POP is best understood as a hernia through the levator
hiatus. In childbirth the hiatus is distended massively [10],
and the limiting structure, the puborectalis muscle, runs a
substantial risk of permanent damage, either due to irrevers-
ible overdistension or due to actual disruption in the shape of
avulsion, i.e., disconnection from its insertion on the os pubis
[11, 12]. Both forms of trauma seem to be risk factors for
POP and POP recurrence after reconstructive surgery [13–
16]. Hence, imaging of the levator hiatus and puborectalis
muscle in axial plane images is becoming increasingly
popular.
Most recently, the coronal plane has attracted increasing
interest as it provides excellent views of the anal canal, espe-
cially the anal sphincter complex, and volume acquisition is
optimally performed in the coronal plane, as shown in
Fig. 6.3. The increasing prevalence of anal sphincter trauma,
especially in jurisdictions with rising forceps rates such as in
the UK and Australia [17], makes the development of this
method particularly timely and important.
Urethra vagina
and
canal
symphysis
bladder
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 91

Fig. 6.2  Standard representation of female pelvic floor structures on a–c) in the axial plane is given in (d). Often, a and d are of the most inter-
translabial/perineal ultrasound. The midsagittal plane is shown in (a), the est and are combined, leaving out b and c. In d the patient’s right-hand
coronal in (b), the axial in (c). A rendered volume (i.e., the semitranspar- side is represented on the left, as if the pelvic floor was viewed from
ent representation of all pixels in the “region of interest,” the box seen in below. L levator ani, S symphysis pubis. From [74], with permission

transversus
perineum
perinei

IAS
EAS

ischio-
rectal
fossa
a b anal
mucosa

Fig. 6.3  Transducer placement for exo-anal sphincter imaging (left), and schematic illustration of imaged structures in the resulting coronal or
transverse plane (right). EAS external anal sphincter, IAS internal anal sphincter. From [32], with permission
92
Live anatomy of pelvic floor structures as observed on
real-time imaging commonly bears only limited resemblance
to textbook illustrations. The “urogenital diaphragm” is a fig-
ment of the imagination to those performing translabial
ultrasound. The levator plate appears very different from
textbook illustrations derived from cadaver dissection, and
the anal canal is longer and slimmer in reality than in draw-
ings derived from endo-anal ultrasound which necessarily
dilates and shortens this structure. Common forms of pro-
lapse such as cystocele and rectocele appear rather different
from textbook illustrations when imaged live.
Given that cadaver dissection and illustrations derived from
dissection are frequently misleading, it seems a­ ppropriate to
use this chapter to describe the normal anatomy of the pelvic
floor as seen on 3D/4D pelvic floor ultrasound.
6.3  he Anterior Compartment: Urethra
T rather, the os pubis. This anchoring is highly variable,
and Bladder Base
6.3.1 The Urethra
The female urethra is a muscular tube of about 3–3.5 cm in
length, made up principally of a smooth muscle layer (the
longitudinal smooth muscle of the urethra) and the striated
urethral sphincter, which surrounds the smooth muscle like
an elongated, spindle-shaped torus. At rest the smooth mus-
cle is hypoechoic, and the striated muscle hyperechogenic,
as seen in Fig. 6.4. The rhabdosphincter is better appreciated
in the axial plane where it is apparent as a hyperechoic ring
a b
Fig. 6.4  The urethra as seen on translabial 4D ultrasound. The midsag-
ittal plane is on the left (a). Small arrows show the external meatus at
the top, and the internal urethral meatus at the bottom. Large arrows
H. P. Dietz
shape; in the midsagittal plane, it is harder to see due to the
echogenicity of retropubic fibrofatty tissue. Echogenicity of
smooth and striated urethral muscle changes with the angle
of the incident beam, i.e., the angle between urethra and
transducer. On Valsalva the urethra frequently rotates around
the symphysis pubis, changing the angle between urethral
structures and the incident beam; and the hypoechogenic
stripe of urethral smooth muscle seems to disappear
(Fig. 6.5). If the urethra rotates more than 90°, it may “reap-
pear” once the smooth muscle of the proximal urethra is
again more parallel with the incident beam, which often
occurs in severe cystocele.
6.3.2 Paraurethral Tissues
This muscular tube is anchored to the pelvic sidewall or,
with anywhere between 1 and 7 distinct structures [18]
made up of varying amounts of connective tissue and
smooth muscle fibers. These structures are generally
termed the “pubourethral ligaments” and can be visual-
ized in the coronal plane (Fig. 6.6). The functional effect
of those ligaments is commonly observed in the form of
urethral kinking and a demonstration of the concept of
pressure, or rather, force transmission at times of
increased intra-abdominal pressure. Tethering of the ure-
thra to the os pubis is clearly important for urinary stress
continence [19]. Figure 6.7 shows marked urethral kink-
ing, which is common in anterior compartment prolapse.
indicate the urethral rhabdosphincter which appears as two hyperechoic
stripes on the left and as a hyperechoic ring shape on the right (b)
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
a b
Fig. 6.5  Determination of bladder neck descent and retrovesical angle:
Ultrasound images show the midsagittal plane at rest (a) and on Valsalva
(b). A anal canal, B bladder, L levator ani, R rectal ampulla, S symphy-
sis pubis, U urethra, Ut uterus, V vagina. The images demonstrate the
Fig. 6.6  Coronal plane imaging showing the length of the urethra
(large arrow to large arrow) and multiple linear structures (small
arrows) investing the urethral rhabdosphincter surrounding the
hypoechogenic longitudinal smooth muscle/vascular plexus/mucosa of
the urethra
6.3.3 The Bladder Neck and Trigone
The bladder neck, i.e., the urethrovesical junction or inter-
nal meatus of the urethra, is visible as a “notch” or a slight
dimple on translabial imaging. Approximately 1–2 cm dor-
sal to this dimple one will find the inter-ureteric ridge,
93
measurement of distances between interior symphyseal margin and
bladder neck (vertical, x; horizontal, y) and the retrovesical angle at rest
(rva-r) and on Valsalva (rva-s). From [53], with permission
which can be followed laterally to reach the ureteric ori-
fices. The “trigone” or bladder base is formed by thickened
smooth muscle between the internal meatus and the two
ureteric orifices. If desired, color Doppler can be used to
demonstrate ureteric patency. The detrusor muscle
(Fig. 6.8) is usually thinner than the trigone itself. Its thick-
ness is associated with symptoms of the overactive bladder
and with urodynamic detrusor overactivity. Under 50  ml
bladder filling, 5  mm is regarded as the limit of normal
[20–22], but DWT has poor test characteristics for urge uri-
nary incontinence and detrusor overactivity [22, 23].
6.4 The Fornices
The anterior vaginal fornices have been of interest as they
are clinically easily accessible for the assessment of para-
vaginal or bladder fascia, although clinical examination
seems of limited validity and reproducibility [24, 25].
Often, an abnormal fornix means not just fascial damage,
but rather much more severe trauma in the shape of levator
avulsion. However, there may be a subset of women in
whom the levator is intact but the paravaginal fascia is
detached from the arcus tendineus fasciae pelvis, and this
may be evident as a loss of forniceal definition [26]. On
axial plane imaging, the fornices are plainly visible, espe-
cially in their lower reaches (Fig. 6.9). Tomographic imag-
ing on Valsalva seems to be useful in assessing the fornices
more cranially (Fig. 6.10).
94 H. P. Dietz

Fig. 6.7  Midsagittal imaging at rest (left) and on Valsalva (right) in and the large arrow the location of urethral kinking. The variability of
patient with grade II cystocele. There is marked urethral kinking at mid-­ urethral echogenicity relative to the angle between urethra and incident
urethral level, i.e., at the location of urethral tethering to the pelvic side- beam is also clearly apparent
wall. The small arrows indicate external and internal urethral meatus,

a b

c d

Fig. 6.8  Measurement of bladder wall thickness at the dome in four women with non-neuropathic bladder dysfunction. In all cases shown in
images (a–d) residual urine is well below 50 ml. The limit of normality is usually taken to be 5 mm. From [74], with permission
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
Fig. 6.9  The appearance of puborectalis muscle and lateral vaginal
fornices in a rendered volume in the axial plane. The two arrows indi-
cate the fornices. From [75], with permission
6.5  he Central Compartment: Uterus
T
and Vault
The anteverted uterus is visible above the bladder roof, with the
endometrial stripe identifiable as a near-horizontal line that can
be followed to the cervical canal (Fig. 6.11). In retroversion the
cervix may be harder to identify, and small bowel covers the
bladder roof. The cervix may be shadowed by rectal ampulla, if
it is filled with stool and/or gas. A small, atrophic uterus is
sometimes very difficult to locate, especially if high. As the
myometrium is iso-echoic and very similar in echogenicity to
the vaginal walls, identifying the uterus can be a challenge for
the beginner, but often nabothian follicles help in identifying
the cervix. In general, ­moving images are easier to interpret,
and this is especially true for the uterus. In older women and in
an axial uterus, the myometrium can cause acoustic shadowing
due to scattering of ultrasonic energy, and this may also be the
case with fibroids, especially if calcified. After hysterectomy,
the space usually occupied by the uterus is filled by peristalsing
small bowel. The vault itself may at times be easy to locate
(Fig.  6.12); at other times it will be hidden by a full rectum
unless the vault descends beyond the hymen.
95
6.6 The Posterior Compartment
6.6.1 N
 ormal Anatomy in the Midsagittal
Plane
The standard midsagittal orientation is defined by both anal
canal and urethra being visible in one plane which shows the
rectal ampulla, often stool-filled, the anorectal angle, and the
anal canal, a tubular structure about 4.5  cm in length. The
anorectal junction is easy to identify, either due to the hyper-
echoic nature of stool or bowel gas in the rectal ampulla or
due to the iso-echoic anal mucosal folds occupying the space
between the two hypoechogenic linear strips of the internal
anal sphincter (IAS).
6.6.2 The Perineal Body/Transversus Perinei
Ventrocaudal to the anal canal, one can locate the triangular
iso-echoic structure of the perineal body, which is highly
variable in dimensions even in nulliparous women [27]. It
is bounded by the vagina ventrally (outlined more clearly
after a vaginal examination due to bubbles caught in the
vaginal rugae) and the external anal sphincter dorsally. Its
most distinct structure, the transversus perinei muscle, is
also very variable but often identified in the coronal plane
(Fig. 6.13) where, on imaging of the anal sphincter, it often
appears as a linear or wing-like structure, the fibers of
which may contribute to the more cranial aspects of the
external anal sphincter (EAS), occasionally causing a hose
clamp-like appearance.
6.6.3 The Rectovaginal Septum
The rectovaginal septum (RVS) is the cranial continuation
and condensation of the fibromuscular perineal body and
sometimes visible on perineal imaging; see Fig. 6.14. It is a
fascia that prevents herniation of the rectal ampulla into the
lower vagina, given that there is a substantial pressure dif-
ferential between the former (intra-abdominal pressure) and
the latter (atmospheric pressure) [28]. Dynamic testing with
a Valsalva maneuver is required to detect RVS defects as
static appearances do not seem to be predictive of function
[29]. Such defects are very common, even in nulliparae
[30], and represent the only form of prolapse that is clearly
associated with obesity [31].
96 H. P. Dietz

Fig. 6.10  Fornices are assessed by tomographic ultrasound, with eight triangular appearance, with the apex aiming toward the os pubis) and
slices obtained from the plane of minimal hiatal dimensions to 12.5 mm indicated with (∗). From [26], with permission
above this plane. In the figure, the fornices are all intact (i.e., showing a

Fig. 6.11  Anteverted uterus as seen in the midsagittal plane, with the
corpus resting on the roof of the empty bladder. The cervix is just visi-
ble cranial to the rectal ampulla which often obscures a normally situ-
ated cervix. B  bladder, POD  pouch of Douglas, R  rectal ampulla, Fig. 6.12  Appearance of a normal, well-supported vaginal vault in
S symphysis pubis, V vagina. The uterus is outlined by dots; both cervix patient with stage 2 cystocele. The position of bladder (B), vault (V),
and endometrial echo are clearly visible and rectal ampulla (R) are measured against the inferoposterior margin
of the symphysis pubis (S)
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 97

Fig. 6.13  The echogenicity and appearance of the perineum vary slices of the perineum. Sometimes fibers seem to be completely sepa-
greatly even in vaginally nulliparous women. However, in the latter it is rate from the EAS (top row; fat oblique arrows); at other times some
often possible to identify a hyperechoic transverse structure superficial fibers clearly merge with the EAS (bottom row; thin vertical arrows)
to the external anal sphincter (EAS); see those tomographic transverse

a b

Fig. 6.14  Appearance of a presumably intact rectovaginal septum on 3D pelvic floor imaging in orthogonal planes (a–c). Arrow indicates the
location of the septum which appears as a linear hyperechogenic structure in the midsagittal (a) and axial (c) plane
98
6.6.4 T
 he Anal Canal on Tomographic
Imaging
The anal canal and rectal ampulla are conveniently imaged
in the midsagittal plane, but this is not the case for the
anal sphincters. Traditionally, sphincter imaging is under-
taken by endo-anal probes which provide a coronal plane
view of the sphincters, visualizing them as donut- or tar-
get-shaped structures. On pelvic floor ultrasound, this
requires rotation of the transducer to the coronal plane
(see Fig. 6.3). Volume acquisition at 60–70° aperture and
acquisition angle, with harmonics set to “high” and focal
zones adjusted to sit at the depth of the area of interest,
provides optimal imaging. A pelvic floor muscle contrac-
tion and adjustment of transducer pressure may also help
to optimize resolutions. The distance between external
anal sphincter and transducer surface is highly variable,
not the least due to the state of the perineum, but is easily
adjusted by holding the transducer at a rather steep angle
a b
Fig. 6.15  Imaging of the anal sphincters in cross-sectional planes. The
a plane shows the typical donut appearance of the external anal sphincter
(EAS, hyperechogenic) and the internal anal sphincter (IAS, hypoechoic)
in the coronal plane. The standard midsagittal orientation is given in the
H. P. Dietz
(more vertical than horizontal) and by varying the posi-
tion of the transducer relative to the fourchette and anus.
A view of the three sectional planes allows centering of
the sphincter in the volume (Fig. 6.15). The anal canal should
be horizontal in the B (midsagittal) plane and vertical in the
C (transverse) plane, an orientation that helps identify the
cranial extent of the EAS (Fig. 6.16) by locating the fascial
plane between EAS and levator ani. The EAS is then imaged
in tomographic slices, from above the EAS cranially to the
subcutaneous EAS below the termination of the IAS cau-
dally (Fig. 6.17) [32]. Depending on EAS length, which can
vary from 8 to 35 mm in healthy individuals [33], the inter-
slice interval may have to be set to anywhere from 1.5 to
5 mm.
The cranial termination of the EAS is of importance for
the reproducibility of slice location, and several factors may
impact on the identification of this structure. Commonly, the
ventral and dorsal aspects of the EAS show “rotational asym-
metry,” that is, on average the EAS is slightly longer ven-
b plane, providing proof that the entire EAS is included in the volume. An
oblique axial view is represented in the c plane and demonstrates that the
anal canal is properly centered in the volume, i.e., seen as vertical in c.
Reproduced with permission from [74]
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 99

Fig. 6.16  A crucial step in translabial 4D sphincter imaging is the tal plane (usually given in the plane of an orthogonal representation as
identification of the cranial limit of the external anal sphincter (EAS). in Figure 6.16) allows the identification of the fascial plane between
This has to be obtained dorsally, at least in parous women, as the ventral EAS and levator ani (arrows)
aspect of the EAS may have been altered by birth trauma. The midsagit-

Fig. 6.17  Tomographic imaging of normal external and internal anal sphincter (EAS) (left thick line in the reference image); the most caudad
sphincters. The reference plane at the top left shows the midsagittal plane. (bottom right) is placed below the internal anal sphincter (right thick line)
Vertical lines indicate the location of eight coronal slices given in this fig- in the reference image. As a result, the entire EAS should be covered in
ure. The most cranial slice (center top) is located above the external anal this tomographic representation. From [32], with permission
100
Fig. 6.18  Occasionally, a prominent LMA (longitudinal muscle of the
anus, indicated by arrows) may interfere with locating the cranial mar-
gin of the external anal sphincter (EAS), as evident in the midsagittal
reference plane (slice 0) given on the top left of this tomographic repre-
trally than dorsally, but the o­ pposite may also occur. Such
asymmetry however does not seem to affect diagnostic per-
formance [33].
Occasionally, it is possible to distinguish separate compo-
nents of the EAS, with the most distal component often being
more echogenic than the more proximal component of the
muscle. This can lead to ambiguity in the identification of the
cranial EAS margin, since two fascial planes rather than one
may be identified. In this situation one needs to use the more
proximal of the two planes. Another source of inter-­individual
variation is the longitudinal muscle of the anus (LMA) which
can be so thick as to resemble a cranial continuation of the
EAS (Fig.  6.18). Sometimes the cranial termination of the
EAS has to be extrapolated assuming a teardrop-shaped
EAS. In practice, fortunately, these variations in anatomical
appearance are of minor importance and unlikely to interfere
with the diagnosis of sphincter trauma. Finally, it has to be
mentioned that hemorrhoids can adversely affect imaging of
the caudal aspects of the internal anal sphincter.
H. P. Dietz
sentation of the EAS. In such cases, the presumed “drop” shape of the
EAS allows an estimation of its cranial limit, as given here. A small
incidental hemorrhoid in slices 6–8 is indicated by (∗)
6.7 The Levator Ani Muscle
6.7.1 2D Imaging
The puborectalis muscle can be seen on 2D translabial ultra-
sound in a parasagittal plane, with the transducer tilted from
dorsomedially to ventrolaterally as in Fig.  6.19 [34]. The
fibers of the puborectalis muscle may be followed from the
os pubis to the anal canal; more cranial aspects of the levator
usually show a different fiber direction.
6.7.2 Axial Plane
Except when using obsolete side-firing vaginal transducers,
access to the axial plane requires 3D/4D transducers, and
this is the main reason why 4D imaging using abdominal
volume probes has become such an asset to pelvic floor med-
icine over the last 10 years. Noninvasive, easy access to the
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
a b
caudal
Symphysis
pubis
Puborectalis muscle
Pelvic
sidewall
Fig. 6.19  Transducer orientation for imaging of the puborectalis mus-
cle by translabial 2D ultrasound (left image), the resulting parasagittal
view in a schematic drawing (center), and a normal muscle insertion on
a b
Fig. 6.20  Measuring hiatal dimensions as shown in a rendered volume
(a, b) and in an oblique single axial plane (c, d). The region of interest
(ROI) box in (a) (approx. 1.8 cm deep) is located between the symphy-
sis pubis and the levator ani posterior to the anorectal angle. Image (b)
represents a semitransparent view of all pixels in the ROI box on the
left. The determination of hiatal dimensions using a single oblique axial
axial plane has led to this method largely replacing MRI for
imaging of levator trauma, especially in the form of tomo-
graphic imaging. In addition, the levator hiatus, the largest
potential hernial portal in the human body, can be imaged
either as a single plane [35] or with the help of a “rendered
volume” [36], i.e., a semitransparent representation of all
volume pixels in a given space, a technology that was origi-
nally developed for fetal imaging (see Fig. 6.20). Both meth-
ods are equally valid and repeatable and allow quantification
of the “levator hiatus,” through which all forms of uterovagi-
nal and anorectal prolapse can be seen to herniate out of the
abdominal space.
Due to the requirements of childbirth, the hiatus is much
larger in women than in men and constitutes a structural and
functional compromise. The levator ani may be congenitally
overdistensible [35] and vary between individuals and also
between ethnic groups [35, 37], but “ballooning” [38] is
clearly more likely in vaginally parous women due to the fact
that childbirth enlarges hiatal dimensions [39]. Hiatal area is
strongly associated with pelvic organ descent [41] and mod-
erately with prolapse recurrence after pelvic reconstructive
surgery [16, 40, 41], which makes it potentially useful in the
investigation of women with pelvic floor disorders (see
Chap. 48).
101
c
dorsal
ultrasound, with the hyperechogenic muscle fibers clearly visible
(right). Adapted from [34], with permission
c d
plane is shown in (c) and (d). The midsagittal plane on the left (c) dem-
onstrates a line indicating the minimal sagittal diameter of the hiatus,
i.e., the location of the oblique axial plane shown in (d). The dotted line
in (b) and (d) represents hiatal area measurements (21.77 cm2 in (b),
23.05 cm2 in (d)). A anal canal, B bladder, L levator ani, R rectum, S
symphysis pubis. From [36], with permission
6.7.3 Multislice Imaging
Contrary to tomographic imaging with computed tomogra-
phy (CT) and MRI, volume ultrasound produces not just a
series of predetermined slices but rather a volume of infor-
mation that allows us to alter slice orientation arbitrarily,
after completion of an examination that takes only a few
minutes. This has already been mentioned in the context of
sphincter imaging, and it is equally useful in the assessment
of the levator ani, the second major muscular structure to suf-
fer permanent, clinically relevant damage in childbirth.
The primary component of the levator ani complex, both
in childbirth and for pelvic organ support, is the puborectalis
muscle, a V-shaped structure that inserts on the inferior pubic
ramus and the body of the os pubis bilaterally, coursing
around the anorectal junction posteriorly where it defines the
anorectal angle. Dorsally the anococcygeal raphe anchors it
to the coccyx, which explains the commonly used alternative
anatomical term, pubococcygeus [42]. Figure 6.21 shows a
comparison of graphic representation, dissection, and sono-
graphic representation of the intact puborectalis muscle.
As opposed to the anal canal, we are unable to identify the
cranial termination of the puborectalis muscle since it is in
continuity with iliococcygeus and coccygeus muscles.
102 H. P. Dietz

Symphysis Symphysis
pubis pubis

Pubic ramus Pubic ramus

Urethra Urethra

Pubo- Pubo-
rectalis rectalis
Ischiorectal
Ischiorectal
fossa
fossa
Anus Anus

Fig. 6.21  Representation of the puborectalis muscle in a drawing (left), on cadaver dissection (middle), and in a rendered volume, axial plane
(right)

Fig. 6.22  Tomographic imaging of the puborectalis muscle in a nul- 2.5 mm caudad shows the pubic rami further apart. In the right central
liparous patient. The interstice interval is standardized to 2.5 mm. The slice, the pubic rami are usually invisible due to acoustic shadowing.
central slice should show the most inferior aspect of the symphyseal The arrows indicate the location of the pubic rami/the os pubis in the
gap, with the pubic rami appearing hyperechoic. The left central slice three central slices

Hence, we use the symphysis pubis as a reference structure,
with the central slice placed approximately at the plane of
minimal hiatal dimensions showing the symphysis pubis
closing (Fig. 6.22). On tomographic representation, a 2.5 mm
interslice interval allows coverage of the entire muscle [43].
While imaging on pelvic floor muscle contraction results in
clearer images, assessment at rest may be equally valid [44,
45]. Using the minimum criterion of three central positive
slices for the diagnosis of avulsion (see Chap. 48) [46], a
false-positive diagnosis of avulsion seems unlikely [47]. In
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
Fig. 6.23  Measurement of the levator-urethra gap (LUG) between the center of the urethra and the insertion of the puborectalis can be helpful in
difficult cases. The limits of normal for this measurement have been defined as 25 mm in Caucasians and 23.6 mm in East Asians
difficult cases, measurement of the “levator-urethra gap” or
LUG (Fig. 6.23) is useful [48–50]. An equivalent measure-
ment, the levator-symphysis gap or LSG, has been described
on MRI [51]. Cutoffs of 25  mm in Caucasians [48] and
23.6 mm in East Asians [49] have been defined as limits of
normality.
Function of the levator muscle can be ascertained by
measuring muscle thickening and shortening on contrac-
tion, but indirect measures such as bladder neck lift or a
reduction in hiatal dimensions are more practicable (see
Fig.  6.24) and associated with other parameters of pelvic
floor function [52, 53]. However, excellent pelvic floor
functionality may not be evident in high-displacement mea-
surements due to high resting tone and low tissue elasticity;
sonographic measures of pelvic floor function may there-
fore not be superior to other measures of “strength” such as
digital palpation or perineometry.
6.8 Static Versus Dynamic “Normality”
In clinical medicine, we commonly describe “static” nor-
mality which is quite often all there is to see and assess. An
ovary looks “normal” or “not” – it has no “dynamic” nor-
mality. The pelvic floor is very different in this regard how-
ever. Most pelvic floor dysfunction is due to abnormalities
of dynamic anatomy or function. Female pelvic organ pro-
lapse, obstructed defecation, and stress urinary incontinence
are disorders of functional anatomy—problems usually only
become apparent once support structures are put under
strain.
The degree of strain is essential when it comes to measur-
ing organ descent. Assessment of organ descent during a
Valsalva maneuver performed in the supine position after
bladder emptying [54] shows good test characteristics even if
Valsalva pressure is not controlled [55], provided it is per-
formed over a time period of at least 6 s [56] and provided
levator co-activation is avoided [57]. Figure  6.25 demon-
strates the importance of an optimal Valsalva maneuver.
Assessment in the standing position will result in lower
103
organ location, but test characteristics are not improved com-
pared to the supine position [58].
Normality of a quantitative measure such as organ descent
can be defined in at least two ways: mathematically as the
mean plus/minus two standard deviations and against symp-
toms arising from abnormal anatomy, i.e., symptoms of
stress urinary incontinence in the case of urethral mobility
and bladder neck configuration and symptoms of prolapse in
the case of pelvic organ mobility. The mathematical approach
to defining normality requires assessment of nulliparae,
since pregnancy and childbirth are clearly the main environ-
mental confounder. The second approach is appropriate in a
population in which symptoms are common, e.g., in women
who seek assessment or treatment for manifestations of pel-
vic floor dysfunction.
6.9  rethral Mobility and Bladder Neck
U
Configuration
Excessive bladder neck descent or “hypermobility” has been
commonly thought to be responsible for stress urinary incon-
tinence (SUI) and urodynamic stress incontinence (USI), but
“hypermobility” of the bladder neck is usually not defined
numerically. Bladder neck descent as shown in Fig. 6.26 var-
ies greatly in young, healthy, asymptomatic women [59] and
is likely to be genetically determined [60]. It varies between
ethnic groups [61–63] and is associated with stress urinary
incontinence [64, 65]. This association between stress conti-
nence and bladder neck mobility is consistent with the con-
cept of force or pressure transmission through “pubourethral
ligaments” (see above): the more mobile the urethra, the
greater the likelihood of poor function of these ligaments,
and the poorer may be pressure transmission. This concept is
supported by the observation that mobility at the locus of
urethral tethering by pubourethral structures, the mid-ure-
thra, is more strongly associated with continence than blad-
der neck mobility [19].
Recent work suggests a cutoff of 25 mm for the definition
of “bladder neck hypermobility” [66]. However, its associa-
104
Fig. 6.24  Three methods of determining the effect of a pelvic floor
muscle contraction (PFMC) in the midsagittal plane, using 2D transla-
bial ultrasound. The left-hand images in each pair (a, c, e) represent the
resting state; the right-hand images show findings on PFMC. The top
pair illustrates measurement of the levator plate angle (angle between
symphyseal axis and levator hiatus in the midsagittal plane), the middle
H. P. Dietz
pair shows reduction of the anteroposterior diameter of the levator hia-
tus (LH (ap)), and the bottom pair illustrates bladder neck (BN) dis-
placement on PFMC, analogous to the way BN descent is measured on
Valsalva. LA levator ani, SP symphysis pubis. From [53], with
permission
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
Fig. 6.25  Levator co-activation as a confounder of Valsalva effort. The
top row of images shows the midsagittal, and the bottom row the axial
plane. a and d demonstrate findings at rest, b and e a suboptimal
Valsalva confounded by pelvic floor muscle (PFM) activation, and c
tion with stress urinary incontinence is barely strong enough
to use the “symptoms” approach to determining normality,
with an area under the curve of 0.61 on ROC statistics, and
the mathematical approach (mean + 2SD) in young Caucasian
nulliparae would yield 35 mm [59].
The association between proximal urethral rotation and ret-
rovesical angle on the one hand and stress continence on the
other hand is even weaker, with AUCs below 0.6 [66]. However,
an “open” retrovesical angle (RVA) of 140° or higher and proxi-
mal urethral rotation of >45° have been identified as the “ana-
tomical correlate” of stress urinary incontinence since the 1960s
[67, 68]. This has been confirmed on translabial ultrasound [66];
hence, it seems reasonable to define an RVA of <140° and proxi-
mal urethral rotation of up to 45° as normal.
6.10 Pelvic Organ Descent
Organ descent is measured after bladder emptying, supine,
and on maximal Valsalva of at least 6 s duration, controlling
for levator co-activation [56]. The best of three maneuvers is
105
and f a full, appropriate Valsalva. It is evident that, while there is some
bladder neck descent on Valsalva in (b), the levator hiatus in e is in fact
smaller than in (d), indicating a confounding PFM contraction. LA leva-
tor ani. Adapted from [57] with permission
chosen for numerical evaluation. Figure 6.27 shows the mea-
surement of organ descent against a horizontal line placed
through the inferior margin of the symphysis pubis. There is
limited information on the “normality” of pelvic organ
descent in young nulliparous women. In the previously men-
tioned study in 116 nulligravid 18–24-year-old Caucasians
asymptomatic of prolapse, the mean plus two SD yielded
potential cutoffs of 6  mm below the symphysis pubis for
bladder descent, of 5 mm above for uterine descent, and of
24 mm below the symphysis for descent of the rectal ampulla
[69]. These figures are rather close to values obtained by
using the “symptoms” approach, i.e., by utilizing ROC curve
statistics in large symptomatic cohorts. This latter approach
yields cutoffs of 10 mm below the SP for bladder descent, of
15 mm above the SP for uterine descent, and of 15 mm below
the SP for descent of the rectal ampulla [69].
Recent work using clinical prolapse assessment [70] has con-
firmed that “normality” of pelvic organ mobility needs to be rede-
fined, since descent of the uterus to a given level is much more
likely to cause symptoms of prolapse than descent of the ante-
rior or posterior compartments. Current clinical usage of the ICS
106 H. P. Dietz

a
b

c d

e f

Fig. 6.26  Normal mobility of the bladder and urethra demonstrated on
Valsalva. The left image in all three panels is obtained at rest, the right
on maximal Valsalva. “x” and “y” illustrate horizontal and vertical
coordinates used to determine bladder neck mobility in a and b.
“Bladder neck descent” is the vertical component of this movement,
i.e., x-r (rest)  minus  x-s (Valsalva) or, as in this case,
29 mm − 14 mm = 15 mm. In panel c and d, “rva” is the retrovesical
angle given at rest (rva-r, 120°) and on Valsalva (rva-s, 85°). In panel e
and f, urethral rotation is determined by comparing the angle between
the central symphyseal axis and the proximal urethra (i-s [60°] minus i-r
[35°] = 25°). B bladder, C cervix, R rectal ampulla, S symphysis pubis
6  Transperineal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
Fig. 6.27  Quantification of organ decent and hiatal area in patient with
normal organ support, midsagittal plane. Organ descent is measured
against a horizontal line placed through the inferoposterior margin of
POP-Q assessment system [71] may result in abnormal uterine
descent being rated as normal, while a “second-­degree cystocele”
may be diagnosed in a woman with normal bladder mobility.
6.11 Hiatal Dimensions
The same approach, i.e., the “mathematical” and the “symp-
toms” approach, may be used to determine normal values for
hiatal distensibility. Maximal hiatal distension on Valsalva in
the axial plane is known to be strongly associated with POP
and POP symptoms [35, 38], and this is also evident on clini-
cal examination using measurements of the genital hiatus and
perineal body [72, 73]. Conveniently, both “mathematical”
and “symptoms” approaches yield virtually identical cutoffs
when measured in volume data obtained on maximal Valsalva
in the supine position: 25.79 cm2 in 18–24-year-old Caucasian
nulliparae [35] and 25 cm2 in symptomatic older women [38].
Hence, it is suggested that 25 cm2 be used as the limit of nor-
mality for hiatal distension on Valsalva.
6.12 Conclusions
In this chapter I have tried to cover imaging of the normal
pelvic floor by pelvic floor ultrasound, with “normality”
defined not just in the sense of static anatomy but also as
107
the symphysis pubis (a). Panel b shows measurement of the levator
hiatus
“dynamic normality” so that pelvic organ mobility and hia-
tal dimensions under conditions of elevated intra-abdomi-
nal pressure can be classified as normal or abnormal.
Chapter 48 will deal with abnormality, both static and
dynamic.
Take-Home Messages
• Translabial pelvic floor ultrasound is the best-­
documented and most convenient imaging method
currently in use in pelvic floor medicine.
• Simple 2D systems, available since the 1980s, pro-
vide information on organ descent, residual urine,
bladder neck configuration, and urethral anatomy
and mobility.
• 3D/4D imaging via the translabial route allows
axial plane imaging of the levator ani and anal
sphincter.
• In combination with tomographic or multislice
imaging, this enables quick, noninvasive assess-
ment of both structures by standardized, validated
methods.
• Online interactive teaching is available through the
International Urogynecological Association
(IUGA) at https://www.iuga.org/education/pfic/
pfic-overview.
108 H. P. Dietz

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 Endovaginal Ultrasonography:
Methodology and Normal Pelvic Floor
Anatomy
Giulio A. Santoro, Andrzej P. Wieczorek, S. Abbas Shobeiri,
and Aleksandra Stankiewicz
Learning Objectives
• To understand the technical aspects of three-­
dimensional and dynamic endovaginal ultrasound.
• To understand the normal ultrasound anatomy of
the pelvic floor as a prerequisite to understand
abnormality.
7.1 Introduction
Endovaginal ultrasonography (EVUS) has become a valuable
tool in the diagnostic workup of patients with pelvic floor dis-
orders, and it provides sufficient information for clinical deci-
sion-making in many cases [1, 2]. However, with the
conventional two-dimensional (2D) ultrasound (US), there
are many elements of the image that cannot be correctly rec-
ognized as components of a three-dimensional (3D) structure,
or at least not perceived in their true spatial relationships, and
a good deal of relevant information may remain hidden.
G. A. Santoro (*)
Tertiary Referral Pelvic Floor and Incontinence Center,
IV°Division of General Surgery, Regional Hospital, Treviso,
University of Padua, Padua, Italy
e-mail: giulioasantoro@yahoo.com
A. P. Wieczorek
Department of Pediatric Radiology, Medical University of Lublin,
Children’s University Hospital, Lublin, Poland
e-mail: wieczornyp@interia.pl
S. A. Shobeiri
University of Virgina INOVA Campus, Department of Obstetrics
and Gynecology, INOVA Women’s Hospital,
Falls Church, VA, USA
e-mail: Abbas.shobeiri@inova.org
A. Stankiewicz
Imaging Department, University Hospitals of North Midlands
NHS Trust, Keele University, Stoke-on-Trent, UK
e-mail: Ola.Stankiewicz@uhnm.nhs.uk
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_7
7
As the transition toward total digital image acquisition con-
tinues, 3D ultrasound, constructed from a synthesis of a high
number of parallel transaxial 2D images, has been developed
[3]. After a 3D dataset has been acquired, it is immediately pos-
sible to select coronal anterior–posterior or posterior–anterior
as well as sagittal right–left views, together with any oblique
image plane. Three-dimensional US, particularly developed for
obstetric applications during the last 30 years, has been shown
to be a useful adjunct to conventional 2D-US for evaluation of
the lower urinary tract, levator ani complex, pelvic organ pro-
lapse (POP), and anal sphincter imaging [4–7].
In this chapter we will review the methodology of
3D-EVUS (equipment, patient preparation, and patient posi-
tion, technique of examination, manner of performing mea-
surements) and evaluate the anatomy of the female pelvic
floor (anterior, lateral, and posterior compartments) with this
technique, providing a standardization both with regard to
which levels of the pelvic floor and on which scan planes key
anatomic structures can be described and measured.
7.2  echnical Aspects of 3D Endovaginal
T
Ultrasound
We currently use the B-K Medical 5000 scanner (B-K
Medical A/S, Mileparken 34, DK-2730 Herlev, Denmark)
(Fig.  7.1). In order to obtain meaningful ultrasonic images,
the operator must have an overall understanding of the tech-
nique and know how to use the controls available on the ultra-
sound device correctly. It is important to be aware that
inadequate regulation of the equipment produces poor images
and can lead to false-positive or false-negative diagnosis.
Many types of ultrasound transducers have been developed
for endovaginal assessment of the pelvic floor. The types of
endoluminal probes include mechanical radial probes with a
full 360° field, electronic biplanar probes with linear and
transverse curved arrays, and endfire probes. The rotational
transducer (type 2052/type 20R3, B-K Medical, Herlev,
Denmark) has a shaft length of 270 mm, with a double crystal
111
112
Fig. 7.1  BK Medical 5000 scanner with transducer type 2052/type
20R3 (BK Madical, Herlev, Denmark)
rotating at its tip (see Chap. 5) (Fig. 7.2). This probe has a
frequency range from 9 to 16  MHz, with a focal length of
2–5 cm and a 90° scanning plane; it is rotated at 4–6 cycles/s,
to give a radial scan of the surrounding structures. The trans-
ducer has a built-in 3D automatic motorized system (the
proximal–distal actuation mechanism and the electronic
G. A. Santoro et al.
mover are fully enclosed within the housing of the probe) that
allows acquisition of 300 transaxial images over a distance of
60 mm in 60 s, at the touch of a button, without requiring any
movement relative to the investigated tissue (Fig.  7.2). The
data from a series of closely spaced 2D images are combined
to create a 3D volume displayed as a cube (Fig. 7.2) [3]. With
the conventional 2D-US, the screen resolution is measured in
number of pixels (display matrix: 700 × 700 pixel elements),
with each pixel having a value between 0 and 255 (256 levels
of gray). The result seen on the ultrasound monitor is a 2D
image (X and Y plane only) with no depth information.
Adding the third dimension means that the pixel is trans-
formed in a small 3D picture element called a voxel, which
will also have an assigned value between 0 and 255. Ideally, a
voxel should be a cubic structure; however, the dimension in
the Z plane is often slightly larger than that in the X and Y
planes. The depth of the voxel is critical to the resolution of
the 3D image, and this depth is directly related to the spacing
between two adjacent images [3]. As already stated, the voxel
should ideally form an exact cube; however sampling in the Z
plane generally has slightly lower resolution than in the
700 × 700 matrix, due to acquisition speed. High-resolution
3D-US acquires four to five transaxial images sampled per
millimeter of acquisition length in the Z plane. This means
that an acquisition based upon sampling of transaxial images
over a distance of 60 mm in the human body will result in a
data volume block consisting of between 240 and 300 trans-
axial images. High-­resolution data volumes will consist of
typical voxel sizes around 0.15 × 0.15 × 0.2 mm. Because of
this resolution in the longitudinal plane, which is close to the
axial and transverse resolution of the 2D image, this tech-
nique ensures the true dimensions of the 3D data cube are
also present in the reconstructed Z plane and provides accu-
rate distance, area, angle, and volume measurements [7].
As reported in Chap. 5, the electronic endocavitary probe
(type 8838/X14L4, BK Medical), frequency of 4–14  MHz
(Fig. 7.3), 16 mm diameter, offers similar imaging opportu-
nities than the mechanical rotating transducer, but with
higher resolution. This transducer has a built-in linear array
that rotates 360° inside the probe. It has capability for
dynamic 2D and 3D scanning. The probe allows acquisition
of radial 2D images without any movement of the transducer
within the cavity. The set of 2D images is instantaneously
reconstructed into high-resolution 3D cube for real-time
manipulation and volume rendering. The 3D volume can be
archived for offline analysis using BK PC software.
The ability to visualize information in the 3D image
depends critically on the rendering technique [7]. Three
basic types of technique are used.
1. Surface render mode (SRM): an operator or algorithm
identifies the boundaries of the structures to create a wire-­
frame representation. It is the most commonly known ver-
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
Fig. 7.2 The transducer type 2052/20R3 (BK Medical, Herlev,
Denmark) has a crystal that is rotated at 4–6 cycles/s, to give a radial
scan of the surrounding structures. The probe has a built-in 3D auto-
matic motorized system (the proximal–distal actuation mechanism and
sion of render mode and is extensively used by some
medical centers in producing perhaps the very first images
of an unborn baby’s facial contours. Surface rendering
techniques only give good results when a surface is avail-
able to render, such as is possible for the pubovisceral
muscle assessed by 3D transperineal US (see Chap. 6) [4].
This technique, however, fails when a strong surface can-
not be found such as in the subtly layered structures within
the pelvic floor. SRM is, by its requirements, mainly a
superficial postprocessed topographical presentation of an
often rapidly acquired 4D dataset, with a lesser degree of
information inside the depth of the 3D volume of data
compared to high-resolution 3D data volumes.
2 . Multiplanar reconstruction (MPR): three perpendicular
planes (axial, coronal, and longitudinal) are displayed
simultaneously (Fig. 7.4) and can be moved and rotated to
allow the operator to infinitely vary the different section
parameters and visualize the lesion at different angles.
113
the electronic mover are fully enclosed within the housing of the probe)
that allows acquisition of 300 transaxial images over a distance of
60 mm in 60 s
3. Volume render mode (VRM): this is a special feature that
can be applied to high-resolution 3D-US [7]. Under nor-
mal circumstances, an US image has no depth informa-
tion because the lateral resolution of the image must be
kept as high as possible. The image may be compared to
looking at a photographic image on a piece of paper.
Three-dimensional US does not change this fact. All three
of the surfaces visible on the screen when viewing a 3D
volume also have no depth information. This can be com-
pared to looking at a cardboard box from the outside. The
contents of the box remain unknown. Volume rendering
changes the depth information of a 3D data volume, so
information inside the cube is reconstructed to some
extent (Fig. 7.5). This technique uses a ray tracing model
as its basic operation. A beam is projected from each
point on the viewing screen (the display) back into and
through the volume data. As the beam passes through the
volume data, it reaches the different elements (voxels) in
114 G. A. Santoro et al.

2
36

5
15
55

36

φ16.4

Fig. 7.3  The electronic endocavitary probe (type 8838/X14L4, BK Medical) has a built-in linear array that rotates 360° inside the probe

longitudinal
a b c

axial

coronal

Fig. 7.4 Three-dimensional multiplanar reconstruction with 2052 Schematic illustration. Reproduced with permission from: Santoro GA,
probe (BK Medical). (a, b) Axial, coronal, and longitudinal planes are Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders. Springer-­
simultaneously displayed in the same ultrasonographic image. (c) Verlag Italy, 2010
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
a b
Fig. 7.5 Three-dimensional reconstruction with 2052 probe (BK
Medical). (a) Normal mode only provides information of the three sur-
faces of the cube. (b) Volume render mode provides information inside
the dataset. Depending on the various render mode set-
tings, the data from each voxel may be discarded, may be
used to modify the existing value of the beam, or may be
stored for reference to the next voxel and used in a filter-
ing calculation. All of these calculations result in the cur-
rent color or intensity of the beam being modified in some
way. In normal VRM, the following four different post-
processing display parameters can be used [7]:
(a) Opacity: sets the relative transparency of the volume.
The higher the value, the further into the volume the
ray can travel before being terminated. Because of
accumulated brightness as the ray traverses the vol-
ume, the net effect is to make the volume appear
brighter as this control value is increased.
(b) Luminance: sets the inverse of the self-luminance
value for the pixels and should be used in conjunction
115
the cube. Four different postprocessing settings may be used: opacity,
luminance, thickness, and filter
with the opacity control for displaying certain voxel
values for optimal visualization. The final image
impression should be adjusted to the reader’s require-
ments by setting the normal brightness and contrast
controls.
(c) Thickness: sets an upper limit to the penetration of the
rays into the volume. This value is used in conjunc-
tion with the opacity parameter to determine when
the ray traversal is terminated. Increasing the thick-
ness setting allows deeper penetration, and the result
is often a slightly smoother presentation together
with a significant increase in the visual depth impres-
sion of a lesion.
(d) Filter: sets the lower threshold value for pixel intensi-
ties. Pixel values less than the filter value are not included
in determining the intensity of the final ray value. In nor-
116 G. A. Santoro et al.

Transverse plane floor anatomy (Figs. 7.7 and 7.8). 3D data automatic acquisi-
Sagittal plane tion includes the field of view from the bladder neck to the
external meatus of the urethra. We defined four standard lev-
els of assessment in the axial plane (Fig. 7.9) [9].

• Level 1: at the highest level the bladder base can be visu-

2,5
alized on the screen at the 12 o’clock position and the
35 Ø32,4 inferior one-third of the rectum at the 6 o’clock position
(Fig. 7.10).
• Level 2: corresponds to the bladder neck, the intramural
region of the urethra, and the anorectal junction. At this
Ø20 level, the muscles of the lateral compartment can be
accurately evaluated (Fig. 7.11) [9–12]. The levator ani
(LA) is conventionally descripted as made by the
Fig. 7.6  The electronic biplane transducer (type 8848/E14CL4b, BK
Medical) with linear and curved transverse arrays, 21  mm diameter,
frequency range 5–12 MHz, focal range 3–60 mm. The linear array has
a long contact surface (65 × 5.5 mm) and a 90° imaging orientation to
the longitudinal axis

mal VRM, the rendering mode stops each ray when the
value found reaches a specified value of opacity. This is
affected by the setting of some of the controls (opacity,
thickness, and to some extent luminance).

Endovaginal US can also be performed with a biplane

electronic transducer with linear and curved transverse
arrays (type 8848/E14CL4b, BK Medical), 21 mm diameter,
frequency range 5–12  MHz, and focal range 3–60  mm
(Fig.  7.6) [8]. The linear array has a long contact surface
(65 × 5.5 mm) and a 90° imaging orientation to the longitu-
dinal axis. A computer-controlled acquisition of 350 parallel
longitudinal 2D images in 25 s is obtained by connecting the Fig. 7.7  Schematic illustration of 3D endovaginal ultrasonography
probe to a 180° rotation mover (UAO513 BK Medical). For performed by the mechanical rotating transducer (type 2052/20R3, BK
Medical) for the assessment of the pelvic floor. Reproduced with per-
assessment of the anterior compartment, rotation is per- mission from: Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic
formed from the right side (9 o’clock position) to the left side Floor Disorders. Springer-Verlag Italy, 2010
(3 o’clock position) of the patient and for assessment of the
posterior compartment from the 3 o’clock to the 9 o’clock
position. The 8848 transducer provides evaluation of the vas-
cular pattern of the urethra by using color Doppler and allows
a dynamic assessment by asking patient to squeeze, or to
make a Valsalva maneuver.

7.3 Ultrasonographic Anatomy

of the Pelvic Floor

The patient is placed in dorsal lithotomy and the probe is

inserted into the vagina in a neutral position to avoid exces-
sive pressure on surrounding structures that might distort the
anatomy. No patient preparation is required, no rectal or
vaginal contrast is used, and the bladder should be comfort-
ably full of urine.
Fig. 7.8  Schematic illustration of 3D endovaginal ultrasonography
Assessment is initially performed by 2052 or 8838 trans- performed by the electronic endocavitary transducer (type 8838/
ducers to provide a topographical overview of the pelvic X14L4, BK Medical) for the assessment of the pelvic floor
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 117

Level I Level III

Level II Level IV

Fig. 7.9  Four standard levels of assessment of the female pelvic floor muscle, R rectum, STP superficial transverse perinei muscle, U, urethra.
with endovaginal ultrasound (transducer type 2052/20R3, BK Medical). Reproduced with permission from: Santoro GA, Wieczorek AP,
Right side of the image is left side of the patient. A anal canal, B blad- Bartram CI (eds) Pelvic Floor Disorders. Springer-Verlag Italy, 2010
der, BCM bulbocavernosus muscle, PB pubic bone, PVM pubovisceral

a b

Fig. 7.10  3D endovaginal ultrasound (transducer type 2052/20R3, BK visualized on the screen at the 12 o’clock position and the inferior one-
Medical). (a) The transducer is inserted endovaginally until the poste- third of the rectum (R) at the 6 o’clock position
rior fornix. (b) Level 1: at the highest level the bladder base (B) can be
118 G. A. Santoro et al.

puborectalis, pubococcygeus, and iliococcygeus mus-

a
cles. The anatomy of distal subdivisions of the LA was
further described by Kearney et al. [13]. Using a nomen-
clature based on the attachment points of different subdi-
visions of the LA, the muscles posterior to the pubic
bone are identified as the pubovaginalis, puboanalis, and
puboperinealis as the s­ ubdivisions of the pubovisceralis
muscle (PVM) [13]. Margulies et al. [14] demonstrated
excellent reliability and reproducibility in visualizing
major portions of the LA in nulliparous volunteers with
magnetic resonance imaging (MRI). However, because
the puboanalis, pubovaginalis, and puboperinealis are
small, they have proved to be difficult to visualize in the
rigid axial, coronal, and sagittal views of MRI. Shobeiri
et al. [15] identified the subdivisions of the distal LA as
b seen on 3D-EVUS in cadaveric dissections. Endovaginal
scanning was performed as described earlier in this chap-
ter. Echogenic structures suspicious for being superficial
transverse perinei (STP), pubovaginalis, puboperinealis,
puboanalis, puborectalis, and iliococcygeus muscles
were tagged with biopsy needles (MPM Medical,
Elmwood Park, NJ) and marked with 1  ml indigo car-
mine dye for localization. Additionally, any other
unknown structures and possible defects were tagged in
the same manner (Fig.  7.12). After each pelvis was
scanned with US, the findings were recorded digitally
and each pelvis dissected to locate each of the numbered
needles in all the cadaveric specimens (Fig. 7.13) [15]. In
the US imaging and the correlative dissections of the
c fresh-frozen pelvis, the STP was the first muscle visual-
ized (Fig.  7.14). Immediately cephalad to it was the
puboperinealis insertion into the perineal body. In the
dissections, the puboanalis was located deep and lateral
to the puboperinealis and had a wide base inserting itself
into the anorectal fibers. Puboanalis fibers intermixed
with lateral supportive fibers of the rectum to form the
posterior arcus, which in turn fused with laterally located
fibers of the iliococcygeus [15]. The pubovaginalis was a

Fig. 7.11  Level 2 corresponds to the bladder neck, the intramural

region of the urethra, and the anorectal junction. At this level, the mus-
cles of the lateral compartment can be accurately evaluated. (a)
Schematic illustration. (b) Histological (left side) and cadaveric (right
sides) sections of the pelvic floor. (c) 3D endovaginal ultrasound (trans-
ducer type 2052/20R3, BK Medical). The levator ani muscle (LAM) is Fig. 7.12  Ultrasound needle (N) localization of muscles. Sagittal view
completely visualized as a multilayer highly echoic sling. AR anorectal of two needles inserted into the iliococcygeus muscle. Image obtained
junction, R rectum, SP symphysis pubis, U urethra, V vagina by 2052 transducer (BK Medical)
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
• Level 3: corresponds to the midurethra and to the
Fig. 7.13  Gross cadaveric dissection. A needle is seen inserted into the
puboperinealis muscle (PP). The other structures are identified: ATFP
arcus tendineus fascia pelvis, IC iliococcygeus muscle, PA puboanalis
muscle, PB pubic bone or pubic bone insertion, P perineum, STP super-
ficial transverse perinei muscle
short band 3 cm cephalad to the ischiopubic rami, caus-
ing an indentation in the anterior vaginal epithelium. The
puborectalis insertion was lateral, wrapping itself around
the rectum 3 cm cephalad to the anus. By US, the pubo-
perinealis had mixed echogenicity and was located
immediately cephalad to superficial transverse perinei.
The puboanalis was identified as a triangular hypoechoic
area lateral to puboperinealis. The pubovaginalis was
identified as dense muscular bands at the level of the
midurethra in cadavers and as hypoechoic areas causing
heart-shaped angulation of the anterior vaginal mucosa.
All these structures and the iliococcygeus were accu-
rately identified by needle identification during 3D-EVUS
and authenticated by gross dissection (Fig.  7.14) [15].
Shobeiri et al. [15] also performed 3D scans in 50 nul-
liparous volunteers to develop a scoring system for visu-
alization of the pelvic floor muscles. The characteristic
features of each of the five separate levator subdivisions
were determined on a three-level system. Level 1 con-
tained the muscles that insert into the perineal body,
namely, the STP, puboperinealis, and puboanalis mus-
cles. Superficial transverse perinei served as the refer-
ence point. Level 2 contained the attachment of the
pubovaginalis, puboperinealis, puboanalis, puborectalis,
and iliococcygeus to the pubic bone. Level 3 contained
subdivisions visible cephalad to the inferior pubic ramus,
namely, the iliococcygeus which winged out toward the
ischial spine. The visualization of the pubococcygeus
was debatable, and since this structure was not reliably
visualized during pelvic floor dissection, it was not
119
included. Using this system (muscle subdivisions “visi-
ble” or “not visible” at three levels), they calculated the
inter-rater reliability. There was 98% (95% CI: 0.92–1),
96% (95% CI: 0.95–0.99), and 92% (95% CI: 0.88–0.95)
agreement for level 1, 2, and 3 muscles, respectively. κ
values for agreement were calculated for individual mus-
cles as follows: STP and puborectalis, κ  =  1 (excellent
agreement); puboperinealis, pubovaginalis, and puboa-
nalis, κ = 0.645 (good agreement); iliococcygeus, κ = 0.9
(excellent agreement) [15].
upper one-third of the anal canal. To facilitate assess-
ment of the position of these structures and for evalu-
ation of the symmetry between the urethra and anal
canal, a geometric reference point, termed “gothic
arch,” is defined at the 12 o’clock position, specifi-
cally at the point where the inferior branches of the
pubic bone join at the symphysis pubis (SP). The PVM
is completely visualized as a multilayer highly echoic
sling, lying posteriorly to the anal canal and attaching
to the pubic bone (Fig.  7.15) [9, 11, 15]. The fiber
directions of the PVM are oblique to the axial scan
plane, such that the entire muscle loop is not visible in
any one slice. For this reason, we use a plane parallel
to the PVM, tilting the reconstructed axial plane from
the most protruding surface of the SP, anteriorly, to the
lowest border of the PVM surrounding the anus poste-
riorly. The thickness of the PVM can be measured in
the coronal plane at the 3 o’clock (left branch) and 9
o’clock position (right branch) and in the sagittal
plane at the 6 o’clock position. In the same oblique
axial plane, levator hiatus (LH) measurements are
determined [9]. The distance between the inferior mar-
gin of the SP and the inner margin of the PVM is
defined as the anteroposterior (AP) diameter of the
LH.  The transverse diameter of the LH is measured
between the inner margins of the lateral branches of
the PVM at the level of their attachment to the pubic
bone. The LH area can also be calculated (Fig. 7.16).
In the same scan, we determine the area of the para-
vaginal spaces, located between the lateral border of
the vaginal wall and the medial border of the PVM
(Fig. 7.17) [9]. In a study on 20 nulliparous females,
we found that increasing LH area was correlated with
an increase in LH anteroposterior diameter (ρ  =  0.7;
P  =  0.0007) and LH laterolateral (LL) diameter
(ρ = 0.58; P = 0.008). Statistically significant correla-
tions were also found between LH area and age
(ρ = 0.5; P = 0.03) and between the area of the para-
vaginal spaces and age (ρ  =  0.7; P  =  0.00038)
(Table  7.1) [9]. 3D-EVUS yields reproducible mea-
surements of LH dimensions [16–19]. In a study on 27
nulliparous females [19], the overall interobserver
120
Fig. 7.14  Drawing (bottom left): the relative position of the levator ani
subdivisions during ultrasound imaging: Levels 1A–3D are identified in
the individual panels. Midline structures are identified in lateral views
with corresponding colors in the picture insert at the upper left corner of
the ultrasound images at each level. The dotted green vertical line in the
insert corresponds to the relative position in the vagina where the image
is obtained. Level 1A: at 0 cm, the first muscle seen is the superficial
transverse perinei muscle (STP; green) with mixed echogenicity. Level
1B: immediately cephalad to the superficial transverse perinei is the
puboperinealis muscle (PP; yellow) that can be traced to pubic bone
with manipulation of the 3D cube. It comes in at a 45° angle as a mixed
echoic band to join the perineal body. Lateral to it, the puboanalis mus-
cle (PA, pink) is seen as a hypoechoic triangle. Level 2A: this level
marks the attachment of the muscles to the pubic arch. The external
urethral meatus is visible (dark red). The puboperinealis and puboanalis
insertions are highlighted (A anus, U urethra). Level 2B: the pubovagi-
nalis (PV, blue) and puborectalis muscles (PR, mustard) insertions
come into view. The urethra (U) and the bladder are outlined (red) in the
G. A. Santoro et al.
lateral view. Level 2C: the heart-shaped vaginal sulcus (outlined in red)
marks the pubovaginalis insertion. Iliococcygeus (IC) fibers (red) come
into view. The perineal body is outlined in the lateral view. Level 2D:
the puboanalis (PA) is starting to thin out. The puborectalis (PR) is seen
in the lateral view. Level 3A: the puboperinealis (PP) and puboanalis
(PA) become obscure. Anatomically, the puboanalis becomes a thick
fibromuscularis layer forming a tendineus sheet, the rectal pillar (RP).
The perivesical venous plexus (VP) is prominent (purple). The recto-
vaginal fibromuscularis (RVFM, green) is shown in sagittal view as a
continuous mixed echogenic structure approaching the perineal body
and laterally attaching to the RP. Level 3B: the rectal pillar (orange) is
easily seen. The iliococcygeus (IC) becomes prominent and widens.
Level 3C: the iliococcygeus (IC) widens further and inserts into the
arcus tendineus fascia pelvis. Level 3D: the puborectalis (PR) fades out
of view. The puborectalis (mustard) and iliococcygeus (red) are out-
lined in the lateral view showing their entire course. Reproduced with
permission from: Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic
Floor Disorders. Springer-Verlag Italy, 2010
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 121

a b

Fig. 7.15  Level 3: corresponds to the midurethra and to the upper one-­
third of the anal canal. (a) To facilitate assessment of the position of
these structures and for evaluation of the symmetry between the urethra
(U) and anal canal (AC), a geometric reference point, termed “gothic
arch,” is defined at the 12 o’clock position, specifically at the point
where the inferior branches of the pubic bone join at the symphysis
pubis (SP). (b) At this level, the muscles of the lateral compartment can
be accurately evaluated 3D endovaginal ultrasound (transducer type
2052/20R3, BK Medical) lying posteriorly to the AC and attaching to
the SP. IPR inferior pubic rami, LA levator ani, OF obturator foramen,
PV pubovisceral muscle, T transducer. Reproduced with permission
from: Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic floor disor-
ders. Springer-Verlag Italy, 2010

Fig. 7.16  The levator hiatus (LH) indices are measured at level 3. In
this 28-year-old female, the anteroposterior diameter (AP) was Fig. 7.17  Paravaginal spaces (PVS) measured on the right (1) and left
42.6 mm, the transverse diameter (LL) was 32.2 mm, and LH area was (2) sides (1.69 cm2 and 1.55 cm2, respectively). Scan obtained by 8838
12.8  cm2. Scan obtained by 2052 transducer (BK Medical). AC anal transducer (T) (BK Medical). AC anal canal, IPR inferior pubic rami,
canal, IPR inferior pubic rami, LA levator ani, SP symphysis pubis, U LA levator ani, SP symphysis pubis, U urethra
urethra. Reproduced with permission from: Santoro GA, Wieczorek AP,
Bartram CI (eds) Pelvic Floor Disorders. Springer-Verlag Italy, 2010
122 G. A. Santoro et al.

Table 7.1  Biometric indices of the relevant pelvic floor structures

assessed by 3D-EVUS with 360° rotating transducer [9] a Ischiocavernosus
Plane of
Parameter examination Mean SD
Levator hiatus Bulbospongiosus
AP diameter (cm) Tilted axial plane 4.85 0.46
LL diameter (cm) Tilted axial plane 3.29 0.18
Area (cm2) Tilted axial plane 12.0 1.70
Paravaginal space (cm2)
Left side Tilted axial plane 1.05 0.10
Right side Tilted axial plane 1.05 0.10
Pubovisceral muscle thickness (mm)
3 o’clock Coronal plane 6.0 0.5
9 o’clock Coronal plane 6.0 0.6
Superficial
6 o’clock Sagittal plane 5.5 0.7 transverse
Urogenital hiatus Perineal External periner
AP diameter (cm) Tilted axial plane 3.0 0.45 body sphincter
Ischiocavernosus muscle length
(cm) b
Left side Tilted axial plane 3.32 0.22
Right side Tilted axial plane 3.32 0.27
Superficial transverse perinei
muscle length (cm)
Left side Tilted axial plane 2.5 0.20
Right side Tilted axial plane 2.6 0.18
Bulbocavernosus muscles thickness
(mm)
Left side Tilted axial plane 3.15 0.40
Right side Tilted axial plane 3.11 0.28
AP anteroposterior, LL laterolateral, SD standard deviation

repeatability for LH indices was from good to excel-

lent (ICC, 0.655–0.889), and it was independent by
the specialties of the operator (radiologists, urogyne-
cologists, colorectal surgeons), with good to excellent c
interdisciplinary repeatability (ICC, 0.639–0.915).
Shobeiri et  al. [15] have determined that the levator
plate if formed by the puborectalis, pubococcygeus,
and iliococcygeus and minimal levator hiatus is
formed mostly by puborectalis muscle.
• Level 4: at the outer level, the superficial perineal mus-
cles, the perineal body, the distal urethra, and the middle
and inferior one-third of the anal canal can be evaluated
(Fig. 7.18) [9, 20]. To visualize these structures in their
entirety, the reconstructed axial plane is tilted from the
most protruding surface of the SP anteriorly, to the ischio-
pubic rami laterally so that the different insertion points
of the perineal muscles can be seen. The ischiocavernosus
muscles are visualized as two hypoechoic bands extend-
ing from the SP to the ischiopubic rami. The STP muscles
Fig. 7.18  3D-EVUS by 2052 transducer (BK Medical). Level 4: cor-
are visualized as two hypoechoic bands lying transversely responds to the superficial structures of the lower pelvis. (a) Schematic
between the ischial tuberosity and the perineal body illustration. (b) Axial plane. (c) Multiplanar reconstruction. BSM bulbo-
(Fig.  7.18). The bulbocavernosus muscles appear as an spongiosus muscles, EAS external anal sphincter, IAS internal anal
oval hypoechoic structure surrounding the vaginal wall sphincter, PB perineal body, STP superficial transverse perinei muscle
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 123

and extending from the SP to the perineal body (Fig. 7.18).
In the same plane, we can determine the anteroposterior
diameter of the urogenital hiatus (UGH), corresponding
to the SP–perineal body distance [21]. We have also found
that the UGH AP diameter significantly correlated with
LH area (ρ  =  0.58; P  =  0.008) (Table  7.1) [9]. Santoro
et al. [20] performed 3D-EVUS in nulliparous cadavers to
validate this method for the assessment of the perineal
body. The perineal body has a pyramidal shape (Fig. 7.19)
and appears to be divided into two levels: (1) superficial,
which is in contact with the external anal sphincter, the
bulbospongiosus and the STP muscles (Fig. 7.18), and (2)
deep level, connected with the puboperinealis and puboa-
nalis muscles, which are part of the LA muscle (Fig. 7.20).
Moreover the measurements of the perineal body height,
depth, and width in nulliparous females showed excellent
interobserver repeatability (ICC 0.927; ICC 0.969; ICC
0.932, respectively).

a b

Uterus

USL
Bladder

RVF

a LP
gin
Va R
RVF LMA
PB

Fig. 7.19 (a) Schematic illustrations showing that the perineal body EAS external anal sphincter, LMA longitudinal muscle ani, LP levator
(PB) has a pyramidal shape. (b) 3D-EVUS by 2052 transducer (BK plate, R rectum, RVF rectovaginal fascia, USL uterosacral ligament
Medical). The PB pyramidal shape visualized on the longitudinal plane.

a b

Fig. 7.20  The deep level of the perineal body (PB) is connected with EAS external anal sphincter, IAS internal anal sphincter, IRF ischiorec-
the puboanalis (PA) and puboperinealis muscles. (a) Cadaveric dissec- tal fossa, V vagina
tion. (b) 3D-EVUS by 2052 transducer (BK Medical). A anal canal,
124
7.4 Assessment of the Anterior
Compartment
3D-EVUS performed by 2052 transducer allows to visualize the
anterior compartment on the reconstructed longitudinal plane.
Additional information are provided by using the 8848/8838
transducers (Fig. 7.21) (see Chap. 19) [9, 22]. Assessment of the
anterior compartment in the midsagittal section includes mea-
surements of the length (from the bladder neck to the external
urethral orifice) and thickness of the urethra, bladder–symphy-
sis distance (from the bladder neck to the lowest margin of the
a b
Fig. 7.21  Schematic illustrations of endovaginal ultrasonography performed by 8848 (a) and 8838 (b) transducers (BK Medical) for the assess-
ment of the anterior compartment
a b
Fig. 7.22 Longitudinal view of the anterior compartment. (a)
Schematic illustration. (b) Ultrasonographic image obtained by 8848
transducer (BK Medical) using the linear array. Measurements include
bladder neck-rhabdosphincter distance (1), bladder-symphysis distance
G. A. Santoro et al.
SP), rhabdosphincter (RS) length and thickness, and the dis-
tance between the bladder neck and the RS (which is also known
as the intramural part of the urethra) (Fig. 7.22). The striated
urethral sphincter (RS) starts in the upper part of the urethra
approximately 9.1  mm (range: ±0.94  mm) from the urinary
bladder neck. In the transverse section, it has a typical omega
shape, surrounding the ventral and lateral sides of the midure-
thra and creating a raphe connected to the anterior vaginal wall.
Its echogenicity is slightly lower than that of smooth urethral
muscle (Fig. 7.23). The position of the urethra is determined in
the reconstructed coronal plane that allows for recognition of
(2), urethral length (3), rhabdosphincter length (4), and thickness (5). B
bladder, BN bladder neck, EO external urethral orifice, RS rhabdo-
sphincter, SP symphysis pubis, U urethra, V vagina
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
a b
Fig. 7.23 (a) Cadaveric dissection of the midurethra. (b)
Ultrasonographic image obtained by 8848 transducer (BK Medical)
using the axial array. In the axial plane, rhabdosphincter (RS) appears as
a b
Fig. 7.24  Vascularity of the urethra assessed in the axial (a) and longi-
tudinal planes (b). In the midsagittal section, the vascularity appears
distributed in three levels corresponding to 1. intramural part of the
any abnormal angulation of the urethra, which may contribute
to some urinary dysfunctions. Santoro et al. [9] found signifi-
cant correlations among several urethral parameters in nullipa-
rous females: urethral width with urethral length (ρ  =  0.65;
P = 0.002) and urethral thickness (ρ = 0.5; P = 0.02) and ure-
thral volume with urethral thickness (ρ = 0.7; P = 0.002), ure-
thral width (ρ = 0.87; P = 0.0001), urethral length (ρ = 0.75;
P = 0.00005), and RS volume (ρ = 0.5; P = 0.03) [9]. Wieczorek
et  al. [23] reported excellent reliability for urethral measure-
ments (length, width, thickness, and volume) (ICC > 0.8) and
good reliability for rhabdosphincter measurements (ICC > 0.6)
in a group of 24 asymptomatic nulliparous females. The urethra
is surrounded by connective tissue containing numerous ves-
125
a slightly echoic structure overlapping a more echoic smooth urethral
muscle (SM). SP symphysis pubis, V vagina
urethra, 2. midurethra, 3. distal part of the urethra. Scan obtained by
8848 transducer (BK Medical)
sels. In the reconstructed longitudinal plane, these vessels
appear to form three levels (Fig. 7.24). The first level, situated
cranially, is seen below the urinary bladder neck. The second
level is situated in the middle region of the urethra penetrating
from the ventral side to reach the RS. The vessels penetrating
here, on transverse section, have a typical “V” shape (Fig. 7.24).
The third and lowest level is situated below the lower margin of
the SP, in the area of the external ostium. Using 3D color
Doppler imaging, we can observe the global vascularization of
the urethra (Fig. 7.25). It is possible to visualize the spatial dis-
tribution of blood flow, to demonstrate vessel continuity and
vessel branching in different planes, and to evaluate the pattern
of vascularization (density of vessels, branching, caliber
126 G. A. Santoro et al.

changes, and tortuosity). Using special software (Pixel Flux), it
is possible a quantitative assessment of the urethra vascularity,
measuring velocity (V), perfused area (A), perfusion intensity
(I), pulsatility index (PI), and resistance index (RI). Wieczorek
et al. [24] reported that the midurethra had the highest value of
V and lowest value of A.  The intramural part had the lowest
value of I and the highest values of RI and PI. The distal urethra
presented the highest value of I and the lowest value of RI. The
values of V, A, and I were significantly higher in the external
part of the midurethra compared with the internal part. Excellent
interobserver and intraobserver reproducibility was shown in
the majority of parameters for the entire urethra.

7.5 Assessment of the Posterior

Compartment

The posterior compartment is evaluated by using the axial,

sagittal, and coronal planes of the 3D volume acquired by
2052 transducers or by using the biplane (type 8848) or the
linear array (type 8838) transducers (Fig.  7.26) [9].
Assessment includes measurements of the internal (IAS)
and external anal sphincters (EAS). In the axial plane the
IAS appears as a concentric hypoechoic ring surrounding a
more echogenic central mucosa, and the EAS appears as a
concentric band of mixed echogenicity surrounding the
IAS (Fig. 7.27). The thickness of the internal and external
sphincters is taken in the coronal plane at the 3 o’clock and
9 o’clock positions. An echogenic disruption is defined as
a gap. The location of any defect is described using a
Fig. 7.25  Three-dimensional color Doppler imaging. Spatial distribu- clock-­face notation. The longitudinal plane allows exami-
tion of the urethral vessels. Image obtained by 8848 transducer (BK nation of the perineal body, appearing as a pyramidal-
Medical). U urethra. Reproduced with permission from: Santoro GA, shaped, slightly hyperechoic structure anterior to the anal
Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders. Springer-­
sphincter and of the rectovaginal septum (RVS), visualized
Verlag Italy, 2010

a b

Fig. 7.26  Schematic illustrations of endovaginal ultrasonography performed by 8848 (a) and 8838 (b) transducers (BK Medical) for the assess-
ment of the posterior compartment
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy 127

Fig. 7.27  Axial view of the anal complex obtained by 8848 transducer Perineal
(BK Medical) using the transverse array. The external anal sphincter Cranial body
(EAS) appears as a hyperechoic ring surrounding the hypoechoic ring of
the internal anal sphincter (IAS); PVM pubovisceral muscle. Reproduced
Anorectal Junction
with permission from: Santoro GA, Wieczorek AP, Bartram CI (eds)
Pelvic Floor Disorders. Springer-Verlag Italy, 2010

Rectum Anal Canal

as a three-layer-­structure (hyperechoic, hypoechoic, and

hyperechoic layers) between the external margin of the
vagina and the external part of the rectal wall (Fig. 7.28).
Puborectalis
An RVS defect is defined as a discontinuity in this echo- Internal sphincter
graphic pattern. In the mid-­sagittal plane, the anorectal b Longitudinal
angle (ARA), formed by the longitudinal axis of the anal Fibres

canal and the posterior rectal wall, can also be measured at

rest and during maximal pelvic floor contraction and
Valsalva maneuver. Dynamic EVUS is particularly useful
in the evaluation of posterior compartment disorders, pro-
lapse, and obstructed defecation syndrome (see Chaps. 49
and 63).

7.6 Discussion

The pelvic floor is a 3D mechanical apparatus with a com-

plex job description [25]. It involves specialized striated and
smooth muscles, which together with ligaments, fascia, and
nerves provide support for and assist in the function of the
urogenital organs and the anorectum [25]. The pelvic floor c
can be described as a musculotendinous sheet that spans the
pelvic outlet and consists mainly of the symmetrical paired Fig. 7.28  Longitudinal view of the posterior compartment. (a, b)
LA muscle, which is like a funnel and not a flat, 2D structure. Schematic illustrations. (c) Ultrasonographic image obtained by 8848
transducer (BK Medical) using the linear array (PR: puborectalis)
Therefore it is important to use 3D imaging to precisely visu-
128
alize it. When we display a normal 2D-US cross-sectional
view, there are many elements of the image that will not be
correctly recognized as components of a 3D structure, or at
least not perceived in their true spatial relationships. With
conventional ultrasound we are usually looking at a 3D
structure that contains a solid volume of echoes and which
therefore does not readily translate onto a 2D projection. In
routine clinical scanning, the operator forms a mental repre-
sentation of the 3D anatomic or pathological structure while
viewing a large series of 2D slices interactively. In this case
the operator is using manual sense information about the
physical location of the individual slices in building up 3D
subjective impressions. 3D- and indeed 4D-US have been
promoted by different ultrasound companies for several
years. The acquisition of a 3D data volume and the underly-
ing techniques are, however, different from application to
application. The pelvic floor requires extremely high-­
resolution 3D volumes of data for adequate and precise diag-
nostic evaluation. An advantage of working with
high-resolution 3D-US is that the 3D image does not remain
fixed; rather, it can be freely rotated, rendered, tilted, and
sliced to allow the operator to infinitely vary the different
section parameters and visualize the different structures at
different angles to obtain the most information from the data.
After data are acquired, it is possible to select coronal ante-
rior–posterior or posterior–anterior as well as sagittal right–
left views, together with any oblique image plane. The
multiview function allows the reader to see up to six different
and specialized views at once with multiplanar reconstruc-
tion [3, 7, 8]. These functions were only available in com-
puted tomography scan and magnetic resonance imaging and
are deemed very helpful for clinicians in visualizing patholo-
gies, allowing for precise surgery planning and appropriate
patient management. Three-dimensional US allows us to
assess directly the different planes in which anatomic struc-
tures of the pelvic floor are located. It has been shown to be
reliably used in visualization of the pelvic floor structures of
the anterior and posterior compartments in nullipara [4, 22].
The most extensively evaluated pelvic floor structures are
the LH and the LA muscle, because significant correlations
have been reported between LA defects and increased LH
size and pelvic organ descent [26, 27] (see Chaps. 48 and
49). Tilting the axial plane in the acquired 3D data volume
provides a maximal transverse section of the PVM, not oth-
erwise obtainable with conventional 2D-EVUS, thus avoid-
ing the artifacts due to its oblique shape. Our measurements
[9] of PVM thickness (6.0 mm on both sides) in nulliparous
volunteers were consistent with measurements taken on
MRI, which is regarded a gold standard in the assessment of
LA muscle. Tunn et al. [28] found 6.3 mm muscle thickness
bilaterally, and Alt et al. [29] reported similar values (6.4 mm)
on 3 Tesla MR scanner. 3D-EVUS shows excellent interob-
server agreement for identification of LA and moderate to
G. A. Santoro et al.
substantial agreement for identification of its subdivisions,
and it is not affected by women’s age [30]. As the lateral
attachments of the PVM to the pubic bone are also clearly
visualized, 3D-EVUS can be utilized to document major
levator ani trauma, in a similar way to 3D translabial ultra-
sound (TLUS) [31] and MRI [13, 27, 32]. Javadian et al. [32]
found no difference between 3D-EVUS and MRI when com-
paring “normal” versus “abnormal” LA appearance. Similar
results were reported by van Gruting et al. [33] who found
that ultrasound is as good as MRI for the detection of major
LA avulsion, while MRI still remain gold standard when
minor avulsion is suspected. Moreover, LA avulsion seen on
EVUS correlated better with patient’s symptoms than MRI
or 3D-TPUS [33]. Interesting conclusions on LA avulsions
were drawn from the recent multicenter study on correlation
between ultrasound findings and anatomical dissection in the
same cadaver [34]. 3D-TPUS performed in 30 cadavers
identified avulsions in 11 cases (36.7%; one bilateral and ten
unilateral), while anatomical dissection did not confirm any
LA avulsion. However, the perineal ultrasound approach
could represent the major limit in this study. Van Delft et al.
[35] reported a good correlation (ICC 0.72) between
3D-EVUS and 3D-TPUS to analyze hiatus area and antero-
posterior diameter with the patient at rest and to diagnose
levator avulsion. However, palpation correlates only fair
with both methods. Further studies in this field are required.
3D-EVUS allows a detailed evaluation of the LA muscle
subdivisions [15] which are not visualized by TLUS [31].
Although it may be argued that these subdivisions of the LA
muscle are not important, knowing exactly which muscles
are damaged may not be inconsequential in clinical practice.
Many of the functions of the pelvic floor governing micturi-
tion, defecation, and intercourse are only recently under-
stood by describing the LA anatomy. Subdivisions are
important because the muscles exert their action by contrac-
tion. For example, a patient with defecatory dysfunction due
to a detached puboperinealis will not benefit from a posterior
repair. Also, reattachment of the puboperinealis does not
address defecatory dysfunction due to loss of anorectal angle
from a damaged puborectalis.
Biometric indices of the LH determined in the axial tilted
plane in our study on 20 nulliparous females (AP diameter
4.84 cm, LL diameter 3.28 cm, hiatal area 12 cm2) [9] were
consistent to the results published by Dietz et al. [11] in 49
nulliparous females with 3D-TLUS (AP diameter 4.52 cm,
LL diameter 3.75 cm, hiatal area 11.25 cm2) and Tunn et al.
[28] in 20 nulliparous females with MRI (AP diameter
4.1  cm, LL diameter 3.3  cm, hiatal area 12.8  cm2). In the
same tilted axial plane, the paravaginal spaces and urethral
symmetry can be assessed [9]. This deems clinically relevant
as a lateral paravaginal defect can be suspected when a wider
paravaginal space or an asymmetry of the urethra is observed.
It has been hypothesized that paravaginal defects, due to
7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
separation of the endopelvic fascia from the arcus tendineus
fascia pelvis, are the underlying anatomical abnormalities in
anterior vaginal wall descent [36, 37] (see Chap. 49).
Understanding the anatomy of the pelvic diaphragm is
important for urogynecologists and proctologists. Damage to
the perineal muscles and/or perineal body, frequently occurring
during vaginal childbirth, is associated with pelvic organ pro-
lapse [14]. As reported by Orno et al. [38], these muscles can-
not be visualized in their entirety by using 2D-EVUS because
they originate from the walls of the pelvis and converge at the
perineal body from different angles. 3D-EVUS could over-
come this limitation. Tilting the reconstructed axial plane from
the SP, anteriorly, to the ischiopubic rami laterally, we are able
to evaluate the different insertion points and to determine the
dimensions of the superficial perineal muscles. In contrast with
these findings, 3D-TLUS cannot properly assess the perineal
structures due to the shape of the transducer, its position on the
introital area, and a limited field of view of the acquired volume
[37]. In the same scan, the AP diameter of the UGH can also be
measured. Our study confirmed that this diameter had a posi-
tive correlation with LH area [9].
In the diagnostics of the anterior compartment dysfunc-
tions, it is very important to assess the morphology and
­location of the urethra and to evaluate its supportive struc-
tures [28]. High-resolution 3D-EVUS gives the opportunity
to assess the urethral position in three different planes and
allows the anatomy and morphology of the bladder neck and
urethral complex to be quantified [9] (see Chap. 19).
Biometric indices of the urethral complex determined in our
study [9] were comparable to the results reported by Umek
et al. [6] with 3D transrectal US, with regard to both urethral
thickness (11 mm on vaginal vs. 11.5 mm on rectal scans)
and width (14 mm on vaginal vs. 15 mm on rectal scans) and
to RS thickness (3.0  mm on vaginal vs. 2.7  mm on rectal
scans) and volume (0.46 cm3 on vaginal vs. 0.5 cm3 on rectal
scans). Additionally, the mean bladder neck–RS distance
determined in our study (9.1  mm) was consistent with the
measurement reported by using MRI (10  mm) [39].
Moreover, recent study from Xuan et  al. [40] showed that
3D-EVUS has excellent intra- and interobserver repeatabil-
ity for urethral measurements and higher than 2D ultrasound.
Urethral measurements are important indices in diagnostics
of urinary incontinence. Females with urinary incontinence
have smaller RS as compared to continent patients [41].
Santiago et al. [42] have compared ultrasound urethral mea-
surements in patients with radiological diagnosis of bladder
neck funneling and found that smaller RS length and area are
associated with X-ray funneling. They have postulated a cut-
off of 3.5 cm3 urethral volume on ultrasound as reliable as
X-ray funneling in the diagnosis of intrinsic sphincter
deficiency.
The current gold standard for assessment of the posterior
compartment is considered to be endoanal US (EAUS)
129
[3, 7]. EVUS offers an alternative imaging modality of the
anal sphincter complex and has proven to be as accurate as
EAUS [2]. We found that measurements of anal sphincter
thickness by 3D-EVUS were consistent with measurements
reported by using EAUS, TLUS, or MRI [43–45]. However,
regardless of the absolute dimensions of the anal sphincters,
the most relevant utility of US modalities applies in the
detection of localized EAS defects in patients with idio-
pathic fecal incontinence, passive fecal incontinence, or
obstructive defecation disorders. In a recent study by Ros
et al. [46], designed to compare sensitivity and specificity of
2D/3D-­ TPUS and 3D-EVUS with the gold standard
3D-EAUS in detecting residual defects after primary repair
of obstetric anal sphincter injuries, 2D-TPUS and 3D-EVUS
were found not accurate. 3D-TPUS showed good agreement
with 3D-EAUS and high sensitivity in detecting residual
defects. The most important advantage of EVUS compared
to EAUS is the access to the longitudinal plane that allows
assessment of the ARA, rectovaginal septum, and perineal
body [9, 20].
7.7 Conclusion
High-resolution 3D-EVUS provides a detailed assessment of
the pelvic floor for both identifying and measuring specific
anatomic structures and for understanding their complex
spatial arrangements. It is relatively easy and fast to perform,
correlates well with other imaging modalities, and delivers
additional information on the urethral complex and superfi-
cial perineal structures at the same time.
Take-Home Messages
• High-resolution 3D allows real-time manipulation,
volume rendering, and offline analysis.
• Both static and dynamic anatomy of the pelvic floor
muscles and pelvic organs can reliably visualized
by 3D and dynamic endovaginal ultrasonography.
• Levator ani muscle subdivisions can be visualized
in the proper planes in which they are located by 3D
endovaginal ultrasonography.
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raphy. Ultrasound Obstet Gynecol. 2014;43:202–9.
19. Santoro GA, Wieczorek AP, Shobeiri SA, et al. Interobserver and
interdisciplinary reproducibility of 3D endovaginal ultrasound
assessment of pelvic floor anatomy. Int Urogynecol J Pelvic Floor
Dysfunct. 2011;22:53–9.
20. Santoro GA, Shobeiri SA, Petros PP, Zapater P, Wieczorek
AP. Perineal body anatomy seen by three-dimensional endovaginal
ultrasound of asymptomatic nulliparae. Colorectal Dis. 2016;18:
400–9.
21. DeLancey JOL, Hurd WW. Size of the urogenital hiatus in the leva-
tor ani muscles in normal women and women with pelvic organ
prolapse. Obstet Gynecol. 1998;91:364–8.
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22. Shobeiri SA, White D, Quiroz LH, Nihira MA. Anterior and pos-
terior compartment 3D endovaginal ultrasound anatomy based on
direct histologic comparison. Int Urogynecol J. 2012;23:1047–53.
23. Wieczorek AP, Wozniak MM, Stankiewicz A, Santoro GA,
Bogusiewicz M, Rechberger T. 3-D high-frequency endovaginal
ultrasound of female urethral complex and assessment of inter-­
observer reliability. Eur J Radiol. 2012;81:e7–e12.
24. Wieczorek AP, Woźniak MM, Stankiewicz A, et  al. Quantitative
assessment of urethral vascularity in nulliparous females using
high-frequency endovaginal ultrasonography. World J Urol.
2011;29:625–32.
25. DeLancey JO.  The hidden epidemic of pelvic floor dysfunction:
achievable goals for improved prevention and treatment. Am J
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26. Lien KC, Mooney B, DeLancey JO, et  al. Levator ani muscle
stretch induced by simulated vaginal birth. Obstet Gynecol.
2004;103:31–40.
27. DeLancey JO, Morgan DM, Fenner DE, et al. Comparison of leva-
tor ani muscle defects and function in women with and without
pelvic organ prolapse. Obstet Gynecol. 2007;109:295–302.
28. Tunn R, DeLancey JOL, Howard D, et al. Anatomic variations in
the levator ani muscle, endopelvic fascia and urethra in nulliparas
evaluated by magnetic resonance imaging. Am J Obstet Gynecol.
2003;188:116–21.
29. Alt CD, Hampel F, Hallscheidt P, Sohn C, Schlehe B, Brocker
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7  Endovaginal Ultrasonography: Methodology and Normal Pelvic Floor Anatomy
42. Santiago A, Quiroz L, Shobeiri SA. Decreased urethral volume is
comparable to funneling as a predictor of intrinsic sphincter defi-
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in the longitudinal pressure profile of the anal canal related to ana-
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assessment of the anal sphincter complex: normal measurements
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 Endoanal and Endorectal
Ultrasonography: Methodology
and Normal Anorectal Anatomy
Giulio A. Santoro, Luigi Brusciano, and Abdul H. Sultan
Learning Objectives
• To understand the technical aspects of high-­resolution
three-dimensional endoanal and endorectal ultrasound.
• To understand the normal ultrasound anatomy of
the anal canal and the rectal wall.
8.1 Introduction
The anal canal is surrounded by the internal sphincter (IAS),
the longitudinal muscle layer (LM), and the external sphinc-
ter (EAS) [1–3] (Fig.  8.1). The anatomy of the anorectal
region is currently of clinical interest. An intact anal sphinc-
ter complex has a decisive role for continence [4]. It is very
important for gynecologists to know where birth damage
may occur, leading to rupture of the IAS or EAS as well as
the puborectalis muscle (PR) [4]. Knowledge of the correct
anatomy helps to identify defects and to reconstruct them in
a meticulous way to achieve as good a functional result as
possible [4]. With the help of endoanal (EAUS) and endorec-
tal ultrasonography (ERUS), it has become possible to dem-
onstrate clearly the morphology of the anal sphincter
complex and to detect sphincter disruptions or defects. The
G. A. Santoro (*)
Tertiary Referral Pelvic Floor and Incontinence Center,
IV°Division of General Surgery, Regional Hospital, Treviso,
University of Padua, Padua, Italy
e-mail: giulioasantoro@yahoo.com
L. Brusciano
Division of General and Obesity Surgery, Master of Coloproctology,
University of Campania “Luigi Vanvitelli”, Napoli, Italy
e-mail: luigi.brusciano@unicampania.it
A. H. Sultan
Urogynaecology and Pelvic Floor Reconstruction Unit
Croydon University Hospital, St George’s University of
London, London, UK
e-mail: asultan29@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_8
8
results of ultrasound studies have also demonstrated the sex-
ual differences in the ventral part of the EAS [5–11].
The purpose of this chapter is to present the techniques of
EAUS and ERUS and to revise the ultrasonographic anatomy
of the anal sphincter complex in axial, longitudinal, and cor-
onal planes with the use of high-resolution three-dimensional
reconstruction.
8.2 Ultrasonographic Technique
Endoanal ultrasound, as previously reported in Chap. 5 is
commonly performed with high multifrequency, 360° rota-
tional mechanical transducer, linear electronic transducer, or
radial electronic transducer (2052, 20R3, 8838; E14CL4b BK
Medical). During examination the patient is placed in dorsal
lithotomy or in the left lateral decubitus position. Before the
probe is inserted into the anus, a digital rectal examination
should be performed. If there is an anal stenosis, the inserted
finger can be used to check whether easy passage of the probe
will be possible. A gel-containing condom is placed over the
probe, and a thin layer of water-­soluble lubricant is placed on
the exterior of the condom. Any air interface will cause a
major interference pattern. The patient should be instructed
before the examination that no pain should be experienced.
Under no circumstances should force be used to advance the
probe. By convention, the transducer is positioned to provide
the following image: the anterior aspect of the anal canal will
be superior (12 o’clock) on the screen, right lateral will be left
(9 o’clock), left lateral will be right (3 o’clock), and posterior
will be inferior (6 o’clock). Some adjustments may be neces-
sary in the gain of the ultrasound unit to provide optimal
imaging. It is always possible to perfectly depict all layers of
the anal canal circumferentially. This is very important when
assessing the canal at different levels. At the origin of the anal
canal, the “U”-shaped sling of the puborectalis is the main
landmark and should be used for final adjustment.
Three-dimensional ultrasound (3D-US) is constructed
from a synthesis of a high number of parallel transaxial two-­
133
134 G. A. Santoro et al.

Fig. 8.1  Normal anatomy of

the anal canal. The muscularis
propria of the rectal wall
Longitudinal muscle
consists of both circular and
longitudinal smooth muscle
fibers. The circular layer is
continuous with the circular Circular muscle
internal anal sphincter
muscle. The longitudinal Puborectalis
layer extends into the
intersphincteric space of the
anal canal. The external
sphincter extends further
down than the internal Internal hemorrhoidal vein
sphincter. Reproduced with
permission from: Santoro GA, Deep external sphincter
Wieczorek AP, Bartram CI
(eds) Pelvic Floor Disorders.
Springer-Verlag Italy, 2010 Internal sphincter

Superficial external sphincter

Subcutaneous external sphincter

External hemorrhoidal vein

its recent version X14L4 offers similar imaging opportuni-

ties (only in sagittal section) (360°, length of scanning from
0 to 60 mm length, 1 mm minimal slice thickness, manual
adjustment of focal zones) with full measurement capabili-
ties as the probe above, but with higher resolution (Fig. 8.3).
After a 3D dataset has been acquired, it is immediately pos-
sible to select coronal anterior–posterior or posterior–ante-
rior as well as sagittal right–left views, together with any
oblique image plane. The 3D image can be rotated, tilted,
and sliced to allow the operator to infinitely vary the different
section parameters, visualize the assessed region at different
angles, and measure accurately distance, area, angle, and
volume [12].

8.3 Endosonographic Anatomy

Fig. 8.2  Schematic illustrations of the technique of three-dimensional
endoanal ultrasonography performed by 2052 transducer (BK Medical)
for the assessment of the anorectal region. Reproduced with permission
from: Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor
Disorders. Springer-Verlag Italy, 2010
dimensional (2D) images. The 2052 transducer has a built-in
3D automatic motorized system that allows an acquisition of
300 transaxial images over a distance of 60 mm in 60 s, with-
out requiring any movement relative to the investigated tis-
sue (see Chap. 5) [12] (Fig. 8.2). The new linear electronic
probe (type 8838, BK Medical), frequency of 4–14 MHz, or
of the Anal Canal
The normal anatomy of anal sphincters is complex but has a
basic five-layer pattern with subepithelial tissues of moder-
ate reflectivity, the IAS of low reflectivity, and the LM and
the EAS of mixed reflectivity [13, 14]. The ultrasonographer
must have a clear understanding of what each of these five
layers represents anatomically (Fig. 8.3):
1. The first hyperechoic layer, from inner to outer, corre-
sponds to the interface of the transducer with the anal
mucosal surface.
8  Endoanal and Endorectal Ultrasonography: Methodology and Normal Anorectal Anatomy
a b
c External anal sphincter Internal anal sphincter
Probe
Subepithelial tissue Longitudinal muscle
Fig. 8.3  Normal ultrasonographic five-layer structure of the mid-anal
canal. (a) Axial image obtained by 2050 transducer (BK Medical); (b)
axial image obtained by 8838 transducer (BK Medical); (c) schematic
2. The second layer represents the subepithelial tissues and
appears moderately reflective. The mucosa as well the
level of dentate line is not visualized. The muscularis sub-
mucosae ani can be sonographically identified in the
upper part of the anal canal as a low reflective band.
3. The third hypoechoic layer corresponds to the IAS. The
sphincter is not completely symmetric, either in thickness
or termination. It can be traced superiorly into the circular
muscle of the rectum, extending from the anorectal junc-
tion to approximately 1  cm below the dentate line. In
older age groups, the IAS loses its uniform low echo-
genicity, which is characteristic of smooth muscle
throughout the gut, to become more echogenic and inho-
mogeneous in texture [15].
4. The fourth hyperechoic layer represents the LM. It pres-
ents a wide variability in thickness and is not always dis-
tinctly visible along the entire anal canal. The LM appears
moderately echogenic, which is surprising as it is mainly
135
representation. Reproduced with permission from: Santoro GA,
Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders. Springer-
Verlag Italy, 2010
smooth muscle; however, an increased fibrous stroma
may account for this. In the intersphincteric space, the
LM conjoins with striated muscle fibers from the levator
ani, particularly the puboanalis, and a large fibroelastic
element derived from the endopelvic fascia to form the
“conjoined longitudinal layer” (CLL) (Fig. 8.4) [14]. Its
fibroelastic component, permeating through the subcuta-
neous part of the EAS, terminates in the perianal skin.
According to the “Integral Theory” proposed by Papa
Petros, the CLL creates the downward force for bladder
neck closure during effort and stretches open the outflow
tract during micturition [16].
5. The fifth mixed echogenic layer corresponds to the
EAS.  The EAS is made up of voluntary muscle that
encompasses the anal canal. It is described as having
three parts [17]: (1) The deep part is integral with the
PR.  Posteriorly there is some ligamentous attachment.
Anteriorly some fibers are circular and some decussate
136 G. A. Santoro et al.

a b

LL
PA

PC

CLL
SP

PA
MSA

c
LL

PA

CLL

Fig. 8.4 (a) The puboanalis (PA) rises from the medial border of the
pubococcygeus muscle (PC); SP symphysis pubis. (b) Schematic repre-
sentation. Fibers from the longitudinal muscle run through the internal
anal sphincter to form the muscularis submucosae ani (MSA). (c)
Coronal image of the anal canal obtained by 2052 transducer (BK
Medical). The PA joins the longitudinal muscle layer (LL) of the rectum
to form the conjoined longitudinal layer (CLL). Reproduced with per-
mission from: Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic
Floor Disorders. Springer-Verlag Italy, 2010
8  Endoanal and Endorectal Ultrasonography: Methodology and Normal Anorectal Anatomy
Level I
Level II
Fig. 8.5  Three levels of assessment of the anal canal in the axial plane.
Scan obtained by 2052 transducer (BK Medical) (see text). Right side
of the image is left side of the patient. EAS external anal sphincter, IAS
into the deep transverse perinei. (2) The superficial part
has a very broad attachment to the underside of the coc-
cyx via the anococcygeal ligament. Anteriorly there is a
division into circular fibers and a decussation to the
superficial transverse perinei. (3) The subcutaneous part
lies below the IAS.
Ultrasound imaging of the anal canal can be divided into
three levels of assessment in the axial plane (upper, middle,
and lower levels), referring to the following anatomical
structures (Figs. 8.5 and 8.6) [18, 19–21]:
137
PR
IAS EAS
Level III
internal anal sphincter, PR puborectalis. Reproduced with permission
from: Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor
Disorders. Springer-­Verlag Italy, 2010
• Upper level: the sling of the PR, the deep part of the EAS,
and the complete ring of IAS.
• Middle level: the superficial part of the EAS (complete
ring), the CLL, the IAS (complete ring), and the trans-
verse perinei muscles.
• Lower level: the subcutaneous part of the EAS.
The muscles of the lower and the upper part of the anal
canal are different. The first ultrasonographic image recorded
is normally the PR muscle and is labeled “Upper level.” The
PR slings the anal canal instead of completely surrounding it.
138
a b
Level I IAS
Level II
EAS
Level III
Fig. 8.6  Three levels of assessment of the anal canal. (a) Schematic
representation; (b) coronal image and (c) sagittal image obtained by
2052 transducer (BK Medical). The internal sphincter (IAS) ends at the
At its upper end, the PR is attached to the funnel-shaped leva-
tor ani muscle, and the levator ani anchors the sphincter com-
plex to the inner side of the pelvis. The deep part of the EAS is
similar in echogenicity to the PR and cannot be differentiated
from it posteriorly. Anteriorly, the circular fibers of the deep
part of the EAS are not recognizable in females, whereas in
males thin arcs of muscle from the deeper part of the sphincter
may be seen extending anteriorly. Moving the probe a few mil-
limeters in the distal direction will show an intact anterior
EAS forming just below the superficial transverse perinei
muscles, imaged at 11 o’clock and 1 o’clock (Fig. 8.7). This
image, labeled “Middle level,” is a mid-anal projection where
G. A. Santoro et al.
level of the junction between the superficial external sphincter (EAS sp)
(Md middle level) and subcutaneous external sphincter (EAS sc) (Lo
lower level). PR puborectalis, Up upper level
the IAS, CLL, and superficial EAS are all identified. The ante-
rior part of the EAS differs between genders, and anatomic
studies have shown that this difference is already present in the
fetus. In males, the EAS is symmetrical at all levels; in females,
it is shorter anteriorly, and there is no evidence of an anterior
ring high in the canal (Fig. 8.8). In females, fibers between the
transverse perinei fuse with the EAS, so that there is no plane
of dissection between these two structures. In males a plane of
fat persists between the transverse perinei and the EAS.  In
examining a female subject, the ultrasonographic differences
between the natural gap (hypoechoic areas with smooth, regu-
lar edges) and sphincter ruptures (mixed echogenicity due to
8  Endoanal and Endorectal Ultrasonography: Methodology and Normal Anorectal Anatomy
a b
Fig. 8.7  Images of the transverse perinei muscles (TP) in the axial
plane in male (a) and female (b). The anococcygeal ligament (ACL) is
seen as a posterior hypoechoic triangle. Scan obtained by 2052 trans-
scarring, with irregular edges) occurring at the upper anterior
part of the anal canal must be kept in mind. Three-dimensional
longitudinal images are particularly useful to assess these ana-
tomic characteristics of the EAS [22–26] (Figs. 8.8 and 8.9).
EAUS is not able to precisely assess the perineal body because
of the lack of clear limits. Also the proposed use of a finger
introduced into the vagina as a landmark seems to be of poor
benefit, altering its normal configuration due to the digital
compression on the central perineum [27, 28]. At this level, the
anococcygeal raphe is seen as a posterior hypoechoic triangle
(Fig. 8.7). When the probe is pulled further out, the image of
the IAS will disappear, and only the subepithelium and the
subcutaneous segment of the LM + EAS will be seen. This last
image is labeled “Lower level” (Fig. 8.6).
The perianal anatomic spaces are also visualized by
EUAS.  The submucosal (subepithelial) space is defined as
the layer between the external cone surface and the inner
border of the IAS. The intersphincteric space, containing the
longitudinal layer, is located between the IAS and EAS. The
ischioanal space, which surrounds the anal canal, is pyramid
shaped and is located outside the EAS.  The supralevator
space is located superior to the levator ani muscle.
8.4 Endosonographic Anatomy
of the Rectum
The normal rectum is 11–15 cm long and has a maximum
diameter of 4 cm. It is continuous with the sigmoid colon
superiorly at the level of the third sacral segment and courses
139
ducer (BK Medical). Reproduced with permission from: Santoro GA,
Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders. Springer-
Verlag Italy, 2010
inferiorly along the curve of the sacrum to pass through the
pelvic diaphragm and become the anal canal. It is sur-
rounded by fibrofatty tissue that contains blood vessels,
nerves, lymphatics, and small lymph nodes. The superior
one-third is covered anteriorly and laterally by the pelvic
peritoneum. The middle one-third is only covered with peri-
toneum anteriorly, where it curves anteriorly onto the blad-
der in the male and onto the uterus in the female. The lower
one-third of the rectum is below the peritoneal reflection
and is related anteriorly to the bladder base, ureters, seminal
vesicles, and prostate in the male and to the lower uterus,
cervix, and vagina in the female. The rectal wall consists of
five layers surrounded by perirectal fat or serosa (Fig. 8.10).
On ultrasound the normal rectal wall is 2–3 mm thick and is
composed of a five-­ layer structure [28]. There is some
debate as to what the actual layers represent anatomically.
Hildebrandt et al. [29] believe that three layers are anatomi-
cal, while the other layers represent interfaces between the
anatomical layers. Beynon et  al. [30], however, have pro-
duced both experimental and clinical evidence that the five
anatomic layers are recognizable. Good visualization
depends on maintaining the probe in the center lumen of the
rectum and having adequate distension of a water-filled
latex balloon covering the transducer to achieve good acous-
tic contact with the rectal wall. It is important to eliminate
all bubbles within the balloon to avoid artifacts that limit the
overall utility of the study. The rectum can be of varying
diameters, and therefore the volume of water in the balloon
may have to be adjusted intermittently. The five layers rep-
resent (Fig. 8.11):
140 G. A. Santoro et al.

a b

c d

e f

Fig. 8.8  The ventral part of the external sphincter differs between
males (a, c, e) and females (b, d, f) (see text). (a, b) Schematic repre-
sentation. (c–f) Three-dimensional endosonographic reconstructions in
the longitudinal plane. The distance between the anterior anorectal
junction and the external sphincter is called the gap (arrows). EAS
external anal sphincter, IAS internal anal sphincter, MD middle level,
PR puborectalis muscle, UP upper level. Scans obtained by 2052 trans-
ducer (BK Medical) (c, e, f) and 8838 transducer (BK Medical) (d).
Reproduced with permission from: Santoro GA, Wieczorek AP,
Bartram CI (eds) Pelvic Floor Disorders. Springer-Verlag Italy, 2010
8  Endoanal and Endorectal Ultrasonography: Methodology and Normal Anorectal Anatomy 141

a LM c
EAS
d

SC

b
d

SC

Fig. 8.9  External sphincter at three levels of the anal canal in male and s superficial external sphincter, sc subcutaneous external sphincter.
female. (a, b) Schematic representation; (c) Ultrasonographic images in Scans obtained by 2052 transducer (BK Medical). Reproduced with
the axial plane. Male on the left, female on the right. LM longitudinal permission from: Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic
muscle, EAS external anal sphincter, d deep external sphincter, Floor Disorders. Springer-Verlag Italy, 2010

a b

5
4
3
2
1

Fig. 8.10  Diagrammatic representation of the five-layer structure of serosa/perirectal fat interface. Reproduced with permission from:
the normal rectal wall. (a, b): 1, mucosa; 2, submucosa; 3, muscularis Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders.
propria/circular layer; 4, muscularis propria/longitudinal layer; 5, Springer-Verlag Italy, 2010
142 G. A. Santoro et al.

3
T
4
1 2 3 4 5
5

b c

Interface: hyperechoic

Mucosa/MM: hypoechoic

Submucosa: hypoechoic

Muscularis propria: hypoechoic

Serosa/mesorectal fat;
hyperechoic

Fig. 8.11 (a) Schematic and ultrasound representation of the five lay-
ers of the rectal wall in the axial plane: 1, acoustic interface with muco-
sal surfaces; 2, mucosa; 3, submucosa; 4, muscularis propria; 5, serosa/
perirectal fat interface. (b) Ultrasound magnification. (c) Three-­
dimensional reconstruction of the rectal wall in the coronal plane (nor-
mal mode). (d) Three-dimensional reconstruction of the rectal wall in
the coronal plane (volume render mode). Scans obtained by 2052 trans-
ducer (T) (BK Medical). Reproduced with permission from: Santoro
GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders. Springer-
Verlag Italy, 2010
8  Endoanal and Endorectal Ultrasonography: Methodology and Normal Anorectal Anatomy 143

1. The first hyperechoic layer: the interface of the balloon

with the rectal mucosal surface.
2. The second hypoechoic layer: the mucosa and muscularis
mucosae.
3. The third hyperechoic layer: the submucosa.
4. The fourth hypoechoic layer: the muscularis propria (in
rare cases seen as two layers: inner circular and outer lon-
gitudinal layer).
5. The fifth hyperechoic layer: the serosa or the interface
with the fibrofatty tissue surrounding the rectum (meso-
rectum). The mesorectum contains blood vessels, nerves,
and lymphatics and has an inhomogeneous echo pattern.
Very small, round to oval, hypoechoic lymph nodes
should be distinguished from blood vessels which also
appear as circular hypoechoic structures. Endorectal
ultrasound allows an accurate visualization of all pelvic
organs adjacent to the rectum: the bladder, seminal vesi-
cles, and prostate in males (Fig. 8.12) and the uterus, cer-
vix, vagina, and urethra in females (Fig. 8.13). Intestinal Fig. 8.13  Longitudinal view of the vagina. Scans obtained by 2052
loops can also be easily identified as elongated structures transducer (BK Medical)
(Fig. 8.14). Three-dimensional ERUS is also used to visu-
alize the endopelvic fascia. This echogenic layer is a
well-determined structure reaching from the pelvic wall
from one side to the other [31]. Using post-processing
volume render mode (see Chap. 5), it is also possible to
analyze the information inside the 3D volume and visual-
ize the internal mucosal surface (Fig. 8.11).

8.5 Normal Values

The anal canal length is the distance measured between the

proximal canal, where the PR is identified, and the lower bor-
der of the subcutaneous EAS. It is significantly longer in

Fig. 8.14  Sonographic view of the intestinal loops (IL). Scans obtained
by 2052 transducer (BK Medical). Reproduced with permission from:
Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders.
Springer-­Verlag Italy, 2010

males than in females, as a result of a longer EAS, whereas

Fig. 8.12  Coronal view of the bladder (B), seminal vesicles (SV),
prostate gland (P), urethra (U), and obturator foramen (OF). Scans
obtained by 2052 transducer (BK Medical). Reproduced with permis-
sion from: Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor
Disorders. Springer-Verlag Italy, 2010
there is no difference in PR length [32]. In males the anterior
part of the EAS is present along the entire length of the canal
(Figs. 8.9 and 8.10). In females the anterior ring of the EAS is
shorter. Williams et  al. [23] reported that the anterior EAS
occupied 58% of the male anal canal compared with 38% of
the female canal (P  <  0.01). In females the PR occupied a
significantly larger proportion of the canal than in male (61
vs. 45%; P = 0.02). There was no difference in the length of
the IAS between males and females (34.4 vs. 33.2 mm) or in
the proportion of the anal canal that it occupied (67 vs. 73%;
144
P  =  0.12). Normal values for sphincter dimensions differ
between techniques. It is not really relevant to define the true
values of sphincter muscle thickness, because the purpose of
measuring anal sphincters is to distinguish a normal versus
abnormal measurement, regardless of the absolute values.
Measurement should be taken at the 3 o’clock and 9 o’clock
positions in the midlevel of the anal canal. The IAS thickness
varies between 1.8 ± 0.5 mm and increases with age, because
of the presence of more fibrous tissue as the absolute amount
of muscle decreases, measuring 2.4–2.7  mm in individuals
aged less than 55 years and 2.8–3.5 mm in those aged more
than 55 years. Any IAS > 4 mm thick should be considered
abnormal whatever the patient’s age; conversely an IAS of
2 mm is normal in a young patient but abnormal in an elderly
one. The LM is 2.5 ± 0.6 mm in males and 2.9 ± 0.6 mm in
females. The average thickness of the EAS is 8.6 ± 1.1 mm in
males and 7.7 ± 1.1 mm in females. However, EAUS largely
overestimates the size of the EAS due to its failure to recog-
nize and separate the LM.  By using the reconstructed 3D
coronal plane, the anterior longitudinal extent of the EAS can
also be measured (Fig. 8.15). Many studies have specifically
addressed the problems of the reproducibility of EAUS
sphincter measurements [11, 33–36]. Enck et al. [35] exam-
ined a small group of healthy volunteers and concluded that
EAUS did not provide reliable measurements of IAS and
EAS thicknesses. Gold et al. [36] examined 51 patients and
found that measurements of the IAS were more reproducible
than those of the EAS.  These findings are consistent with
results from Beets-Tan et  al. [33], which compared EAUS,
endoanal magnetic resonance imaging (MRI), and phased-­
array MRI for anal sphincter measurement in healthy volun-
teers. EAUS enabled reliable measurement of IAS thickness
only, whereas both MRI modalities enabled reliable measure-
Fig. 8.15  Measurement of the anterior length of the external sphincter
in the coronal plane (arrows). Scans obtained by 8838 transducer 16
MHz frequency (BK Medical)
G. A. Santoro et al.
ment of all sphincter components. Measurement errors of the
LM and EAS are related to the ultrasonographic features of
these muscles, which show low contrast with the surrounding
hyperechoic fatty tissue. Both the inner and outer borders of
the EAS are more difficult to define, leading to less reliable
measurement. In contrast, the IAS is easy to define because it
is a hypoechoic structure that is highlighted against hyper-
echoic fatty tissues. Williams et  al. [23] reported different
results. They found an excellent correlation for the interob-
server measurement of the EAS, IAS, and submucosal width
on endosonography and poor correlation only for the
LM. Frudinger et al. [11] also reported that the EAS thickness
was difficult to define in only 2% of patients at all three levels
examined and in 3% at the subcutaneous level only. A signifi-
cant negative correlation with the patients’ age was also dem-
onstrated in this study, at all anal canal levels. In particular,
the anterior EAS region was found to be significantly thinner
in older subjects. The high inherent soft tissue contrast makes
MRI a more reliable imaging method to measure anal sphinc-
ter components [37–43]. Multiplanar EAUS, however, has
enabled detailed longitudinal measurement of the compo-
nents of the anal canal [8, 12, 44]. Williams et al. [23] reported
that the anterior EAS was significantly longer in men than
women (30.1 mm vs. 16.9 mm; P < 0.001). There was no dif-
ference in the length of the PR between men and women,
indicating that the gender difference in anal canal length is
solely due to the longer male EAS. The IAS did not differ in
length between males and females. Regadas et al. [24] dem-
onstrated the asymmetrical shape of the anal canal and also
confirmed that the anterior EAS was significantly shorter in
females. West et  al. [44] reported similar results, with IAS
and EAS volumes found to be larger in males than in females.
Regardless of the absolute values of the anal sphincter dimen-
sions, the most relevant utility of EAUS application is the
detection of localized sphincter defects, where its benefit has
been proven [45–47]. It has been suggested that measuring
sphincter thickness is important when EAUS cannot depict
any sphincter damage, to exclude diffuse structural sphincter
changes associated with idiopathic fecal incontinence, pas-
sive fecal incontinence, or obstructive defecation disorders
[48–50]. A postulated association between manometric func-
tion of the sphincters and their sonographic appearance, how-
ever, has remained controversial in the literature. Some
authors have found no correlation between muscle thickness
and muscle performance—either resting or squeeze pres-
sures. Scanning anal sphincter muscle may allow determina-
tion of its integrity, but not its morphometric properties.
EAUS is currently regarded by the International
Consultation on Incontinence (ICI) as the diagnostic tool of
choice in the investigation of anal incontinence [4]. Recently,
3D endovaginal ultrasound (3D-EVUS) and transperineal
ultrasound (3D-TPUS) have been proposed as alternative
imaging modalities to describe anal sphincter integrity
8  Endoanal and Endorectal Ultrasonography: Methodology and Normal Anorectal Anatomy
[51–54]. Advantages of the endovaginal and transperineal
route include availability of commonly used transducers,
absence of distortion of the anal canal, and better patient
acceptability. However, a significant difference was found in
both the IAS and EAS thickness when comparing measure-
ments obtained on TPUS and EAUS. The average thickness
of the IAS was greater on TPUS than on EAUS, and the aver-
age thickness of the EAS was less on TPUS than on EAUS
[52]. There is some evidence that the external compression
of the perineum on TPUS may distort normal anatomy,
mainly in the anterior quadrant of the anal canal [52]. TPUS
measurements may also be altered by the change in angle
involved in introital placement of the transducer. Comparative
studies of these different modalities in the identification of
sphincter defects will be described in Chap. 32.
8.6 Conclusions
High-resolution 3D-EAUS/ERUS provide a detailed assess-
ment of the anatomy of the anal canal (puborectalis muscle,
internal and external sphincters, conjoined longitudinal
layer, transverse perinei muscles) and of the five-layer struc-
ture of the rectal wall.
Take-Home Messages
• The normal ultrasononographic anatomy of the anal
canal has a basic five-layer pattern with subepithe-
lial tissues of moderate reflectivity, the IAS of low
reflectivity, and the LM and the EAS of mixed
reflectivity.
• Ultrasound imaging of the anal canal can be divided
into three levels (upper, middle, lower) of assess-
ment in the axial plane. The muscles of the lower
and the upper part of the anal canal are different. In
males, the EAS is symmetrical at all levels; in
females, it is shorter anteriorly, and there is no evi-
dence of an anterior ring high in the canal.
• On ultrasound the normal rectal wall is 2–3  mm
thick and is composed of a five-layer structure.
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 Technical Innovations in Pelvic Floor
Ultrasonography
Magdalena Maria Woźniak, Andrzej P. Wieczorek,
Giulio Aniello Santoro, Aleksandra Stankiewicz,
Jakob Scholbach, and Michał Chlebiej
Learning Objectives
• To familiarize with recent ultrasound technical
innovations including three-dimensional volume
render mode, maximum intensity projection, man-
ual segmentation and sculpting, fusion imaging,
PixelFlux, framing, color vector mapping, motion
tracking, elastography, contrast-enhanced ultra-
sound, and automatic calculation systems.
• To understand the future potential of ultrasound
technical innovations in clinical practice.
9.1 Introduction
Recently, several new ultrasound techniques have been
developed that could significantly improve the diagnostic
value of ultrasonography (US) in pelvic floor disorders.
Three-dimensional (3D) and real-time four-dimensional
M. M. Woźniak (*) · A. P. Wieczorek
Department of Pediatric Radiology, Medical University of Lublin,
Children’s University Hospital, Lublin, Poland
e-mail: mwozniak@hoga.pl; wieczornyp@interia.pl
G. A. Santoro
Tertiary Referral Pelvic Floor and Incontinence Center,
IV°Division of General Surgery, Regional Hospital, Treviso,
University of Padua, Padua, Italy
e-mail: giulioasantoro@yahoo.com
A. Stankiewicz
Imaging Department, University Hospitals of North Midlands
NHS Trust, Keele University, Stoke-on-Trent, UK
e-mail: Ola.Stankiewicz@uhnm.nhs.uk
J. Scholbach
Mathematisches Institut, Westfälische Wilhelms-Universität
Münster, Münster, Germany
e-mail: contact@chameleon-software.de
M. Chlebiej
Faculty of Mathematics and Computer Science, Nicolaus
Copernicus University in Toruń, Toruń, Poland
e-mail: meow@mat.umk.pl
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_9
9
(4D) imaging have been introduced into routine medical
practice [1–4]. These techniques overcome some of the
difficulties and limitations associated with conventional
two-­dimensional (2D) US.  Although 2D cross-sectional
images may provide valuable information, it is often dif-
ficult to interpret the relationship between different pelvic
floor structures because the 3D anatomy must be recon-
structed mentally. Three-dimensional reconstructions may
closely resemble the real 3D anatomy and can therefore
significantly improve the assessment of normal and patho-
logic anatomy. Complex information on the exact location,
extent, and relation of relevant pelvic structures can be dis-
played in a single 3D image. Interactive manipulation of
the 3D data on the computer also increases the ability to
assess critical details.
In this chapter the new methods of 3D-US, including vol-
ume render mode (VRM), maximum intensity projection
(MIP), and brush/shaving options with manual segmenta-
tion (sculpting), will be described. A variety of other
advanced ultrasonographic techniques, including fusion
imaging, PixelFlux, framing, color vector mapping, motion
tracking, elastography, contrast-enhanced ultrasound, and
automatic calculation systems, will also be presented. It
seems likely that these new diagnostic tools will be increas-
ingly used in the future to provide more detailed informa-
tion on the morphology and function of examined organs, to
facilitate planning and monitoring of operations, and for
surgical training.
9.2 Volume Render Mode
Volume render mode is a technique for analysis of the
information inside a 3D volume by digitally enhancing
individual voxels [1]. It is currently one of the most
advanced and computer-­ intensive rendering algorithms
available for computed tomography (CT) scanning [5, 6]
and can also be applied to high-resolution 3D-US data vol-
ume [1, 6]. Four fundamental post-processing functions
147
148 M. M. Woźniak et al.

can be used in VRM: opacity, luminance, thickness, and
filter. By using these different post-processing display
parameters, the volume-­ rendered image provides better
visualization when there are not any large differences in the
signal levels of pathologic structures compared with sur-
rounding tissues [1]. Thus, it is successfully applied for
more precise assessment of some pathological conditions,
such as anal sphincter defects, fistulous tracts in perianal
sepsis (Fig. 9.1), and invasiveness of the submucosal layer
in early rectal cancer [7]. Moreover, it seems to be a very
promising method for detailed evaluation of the integrity of
or injuries to the pelvic floor muscles (Figs. 9.2, 9.3, and
9.6), visualization of the spatial distribution of the vascular
networks supplying the urethra, and assessment of the loca-
tion of tapes or meshes after pelvic floor surgery (Figs. 9.4
and 9.5). Most recent advanced volume render mode
includes volume-rendering mode of four-­ dimensional
translabial ultrasound; this technique appeared very useful
in the assessment of the association between a widened
vaginal canal with concealed uterine prolapse [8] (Fig. 9.6).

a b

Fig. 9.1  Effects of image processing (volume render mode with filtering) on fistula tract views after hydrogen peroxide injection through an
external opening (a, b). Scan obtained by endoanal ultrasound with 2050 transducer (BK Medical)

a b

Fig. 9.2 (a) Visualization of the puborectalis muscle in different muscle. A anal canal, U urethra, V transducer into vagina. Scan obtained
oblique planes (∗). (b) Post-processing manipulation (volume render by endovaginal ultrasound with 2050 transducer (BK Medical)
mode with high opacity and luminance) improves the visibility of the
9  Technical Innovations in Pelvic Floor Ultrasonography 149

a b

Fig. 9.3  Visualization of puborectalis muscle showing defect on the left side (white arrows). (a) Normal mode, (b) volume render mode. A anal
canal, U urethra, V transducer into vagina. Scan obtained by endovaginal ultrasound with X14L4 transducer (BK Medical)

a b

Fig. 9.4  Visualization of the position of a trans-obturator tape (TOT) in the coronal plane. In the left side, the sling appears dislodged (∗). (a)
Normal mode, (b) volume render mode. Scan obtained by endovaginal ultrasound with 2050 transducer (BK Medical)

9.3 Maximum Intensity Projection
Maximum intensity projection (MIP) is a 3D visualization
modality involving a large amount of computation [3]. It can
be defined as the aggregate exposure at each point, which
tries to find the brightest or most significant color or intensity
along an ultrasound beam. Once the beam is projected
through the entire volume, the value displayed on the screen
is the maximum intensity value found (the highest value of
gray or the highest value associated with a color). Conversely,
if the value displayed on the screen is the minimum value
found, this is termed minimum intensity projection (MinIP).
It has been reported in the literature that the application of
MIP to 3D color US allows visualization of the distribution of
blood vessels in tumors, providing additional information for
management. Ohishi et al. [9] found that 3D images with MIP
150 M. M. Woźniak et al.

a b

Fig. 9.5  Visualization of the position of two trans-obturator tapes pubis, V transducer into vagina. Scan obtained by endovaginal ultra-
(TOT) in volume render mode (marked with white and yellow arrows). sound with X14L4 transducer (BK Medical)
(a) The coronal plane, (b) the sagittal plane. A anal canal, SP symphysis

Fig. 9.6  Visualization of hiatus with a 4D transperineal ultrasound (TPUS) showing left-sided defect (white arrows). (a) Surface render mode, (b)
tomographic ultrasound imaging (TUI). Scan obtained by transperineal ultrasound with RM6C transducer (General Electric)
9  Technical Innovations in Pelvic Floor Ultrasonography 151

mode improved evaluation of the entire vasculature of a tumor
compared to cross-sectional 2D images. Hamazaki et al. [10]
reported that 3D color Doppler US with MIP mode appeared
to be useful for the differential diagnosis of subpleural lesions.
Motohide et al. [11] considered this technique an efficient and
safe modality as an intraoperative navigation system for liver
surgery. In a preliminary study in nulliparous females, we
found that application of MIP reconstruction allowed visual-
ization of the patterns of urethral vessels (spatial distribution
and localization of vessels) (Fig. 9.7) [12].
9.4 Brush Options:
Segmentation—Sculpting
Sculpting is a post-processing tool that allows the examiner
to mark volume voxels, during off-line assessment of 3D-US
imaging (version 7.0.0.518—BK Medical 3D Viewer), so
that they are not displayed in the rendering operations. The
marking process uses a standard projection method to map
screen locations within a boundary of the volume data. There
are two methods available: (1) in the first technique, the vox-

Fig. 9.7  Midsagittal view of a

urethral vasculature with
color Doppler mode (a),
normal render mode (b), and
maximum intensity projection
(c). B bladder, BN bladder
neck, DU distal urethra, RTZ
Retzius plexus, U urethra.
Scan obtained by endovaginal
ultrasound with 8848
transducer (BK Medical)

c
152 M. M. Woźniak et al.

els are marked in a mirror volume which gives the possibility a

of turning the marking on and off or inverting it; (2) in the
second technique, the voxels are replaced with some marker
value. This method requires reloading of the volume to turn
off the sculpting.
Various sculpting tools are possible, giving different
degrees of control over what is removed: (1) to draw an out-
line and then remove everything within that outline to a given
depth or through the entire volume; (2) to draw an outline
and then remove everything outside the outline; or (3) to use
a shaving tool that marks a few voxels at a time around the
point of the cursor. The depth of sculpting can be a percent-
age of the total or a given value in millimeters from the sur-
face of the volume. As pelvic structures vary in shape and lie
in different oblique planes, we recommend performing a
sculpting on every section of some millimeters’ length or
even on every image of 300 transaxial images collected dur-
ing 3D data acquisition (Figs.  9.8 and 9.9). Sculpting was
b
originally developed for enhancing static volumes of the
fetus by removing the placenta [13]. Its introduction into
­pelvic imaging might facilitate the assessment of pelvic floor
structures (Figs. 9.10 and 9.11), allowing comparison of the
morphology in different disorders.

9.5 Fusion Imaging

Fusion imaging is based on a simultaneous capturing of

scans obtained by two different examinations, e.g., CT/MRI
(magnetic resonance imaging), US/MRI, CT-PET (positron
emission tomography), and MRI-PET, providing the infor-
mation gathered by both modalities fused. This technique
ensures a compensation for the deficiencies of one method
and retains the advantages of another one. Fusion imaging is
performed by using dedicated software, on a graphic work- c
station, where the data are transferred using the Digital
Imaging and Communications in Medicine (DICOM) sys-
tem. The volume-rendering mode allows simultaneous pro-
jection of the 3D dataset of two different studies to be fused.
The datasets are labeled with color to allow the user to
­identify the separate studies. The color labeling is arbitrary
and depends on the user’s preference. The registration pro-
cess requires an individual manipulation and is achieved by
superimposing the two datasets with the use of 3D volume
projection. It is, however, mostly conducted in the 2D slice
views, due to easier visualization of the superimposed datas-
ets, and in the transverse planes, as these provide better scan-
ning resolution. The user works in the standard directions of
sagittal, coronal, and transverse and updates the registration
in each of these views. Final image registration is based on
anatomical adjustment of the imaging studies (Fig. 9.11).
Fusion imaging is commonly used in the diagnosis of
cancer patients. Kim et al. [14] showed an additional diag- Fig. 9.8  Sculpting of the levator ani muscle. (a) Axial view obtained by
endovaginal ultrasound with 2050 transducer (BK Medical). (b) The
outlining of the levator ani muscle. (c) The levator ani muscle is removed
9  Technical Innovations in Pelvic Floor Ultrasonography
Fig. 9.9  Two methods of sculpting: (1) the levator ani muscle is outlined and is cut off (left) and (2) outlining of the levator ani muscle with cutoff
of all the structures lying beyond (right). Scan obtained by endovaginal ultrasound with 2050 transducer (BK Medical)
Fig. 9.10 Levator ani muscle reconstruction using the sculpting
method. Scan obtained by endovaginal ultrasound with 2050 transducer
(BK Medical)
nostic value of fused MR/PET images in comparison with
PET/CT in the detection of metastatic lymph nodes in
patients with uterine cervical cancer. Another study reported
that the fusion of real-time transrectal ultrasound (TRUS)
and prior MR images of the prostate facilitated MRI-guided
interventions such as prostate biopsies, cryoablation, brachy-
therapy, beam radiation therapy, or direct injection of agents
outside of the MRI suite [15]. Moreover, the image fusion
between color Doppler TRUS and endorectal MRI appeared
to improve the accuracy of pathological staging in patients
153
Fig. 9.11  Three-dimensional reconstruction of the middle third of the
anal canal using the sculpting method. The two rings of the internal
(hypoechoic) and external (hyperechoic) sphincters are clearly visual-
ized. Scan obtained by endoanal ultrasound with 2050 transducer (BK
Medical)
with prostate cancer [16]. MRI and TRUS fusion has the
potential for follow-up of anorectal fistulae and abscesses
and staging of anal and rectal tumors [17].
Similarly, CT/MRI fusion images were performed for
abdominal, cervical, and intracranial regions assessment [18].
We assessed the application of US/MRI fusion imaging
for the visualization of pelvic floor structures in nulliparous
females. For the fusion process, T1-weighted axial scans
were used. Fusion imaging was performed on a laptop with
the use of dedicated software, and once it was completed, a
3D reconstruction of the levator ani muscle and the anatomi-
cal alignment was conducted (Fig.  9.12). Both methods
appeared to be highly concordant in the visualization of this
154 M. M. Woźniak et al.

a b

Fig. 9.12 Axial views of the female pelvis. (a) MRI scan. (b) provided by each technique. (c) Fusion imaging of the three-­dimensional
Endovaginal ultrasound with 2050 transducer (BK Medical). Both reconstruction of the levator ani muscle (brown, US image; green, MR
images were captured simultaneously to allow fusion of the information image)
9  Technical Innovations in Pelvic Floor Ultrasonography
muscle; however, MRI, due to a wider field of view than the
ultrasound transducer, provided more information about sur-
rounding structures.
9.6 PixelFlux
PixelFlux is dedicated software that allows an automated
calculation of blood perfusion in arbitrary regions of interest
(ROIs) of different organs [19, 20]. The basic principle of
this software is the requirement that measurements must be
reliable (Fig. 9.13). For this reason:
1. Perfusion measurements should not be influenced by the
external settings of the US device. Any parameters that
impact the perfusion depiction must be kept constant
throughout. One of these parameters is pulse repetition
frequency (PRF), higher PRF permits higher Doppler
shifts to be detected, and lower PRF allows recording of
lower velocities. The calibration of the image, which con-
sists of setting the scale and the maximum Doppler veloc-
ity, is automatically provided by the software, particularly
when DICOM files are used.
2. Perfusion measurements must not rely on the subjective
visual impression of the examiner, as this may lead to
serious misinterpretation. To avoid operator dependency,
Fig. 9.13  Color Doppler ultrasound for the assessment of the vascularity of the whole urethral complex in PixelFlux. A anal canal, SP symphysis
pubis, U urethra. Sagittal scan of the mid-urethra obtained by endovaginal ultrasound with X14L4 transducer (BK Medical)
155
when opening a video or DICOM file, the software auto-
matically finds the scale indicating the colors used for per-
fusion depiction and allows a standardized measurement.
Perfusion measurements must yield constant results when
comparing the perfusion of the same patient at different
times. In order to assess the perfusion in an authentic way, it
is thus crucial either to take into account the perfusion in
similar points of the cardiac cycle, e.g., by always comparing
the systolic or diastolic perfusion, or to compute the “aver-
age perfusion” during a complete heart cycle. The key step of
the perfusion measurement technique is the definition of the
ROI. The ROI can be arbitrarily chosen by the examiner, tak-
ing any desired size or shape. ROI can also be defined as a
parallelogram, which has proved useful in measuring renal
parenchymal perfusion [20], or can be derived from another
freehand outlined ROI by a dartboard-like scheme, which is
adapted to ring-like structures such as the rhabdosphincter
muscle or the inner ring of the urethra, including the longitu-
dinal smooth muscle, the circular smooth muscle, and the
submucosa layer of the urethra.
After choosing the ROI, the software automatically calcu-
lates the perfusion of the region in every frame of the video
assessed. The following parameters are computed: (1) the
velocity V, which corresponds to the color hue of the pixels
inside the ROI; (2) the perfused area A, given by the amount
156
of perfused pixels inside the ROI; and (3) the perfusion
intensity, I. This parameter is defined as the ratio:
I = V ´ A / AROI ent patients or examination of the same patient at different
where AROI denotes the total area of the ROI. Consequently, the
perfusion intensity increases with the perfusion velocity but
decreases if less of the total area of the ROI is globally per-
fused. These three parameters are computed for each single
frame of the video examined. Based on the periodic changes
due to the cardiac cycle, the program then automatically calcu-
lates the heart period and takes into account only one or mul-
tiple full heart cycles. The quantification of complete heart
cycles accomplishes the need for a time-­independent perfu-
sion measurement as outlined above. Figure  9.14 shows a
heart cycle recognized by the software (the parts of the chart
highlighted in red and blue, respectively).
Another key parameter of the PixelFlux software is “per-
fusion relief.” It shows the local distribution of perfusion
intensity, like a map depicting the height of mountains
(Fig. 9.14). This tool can be used to gain a visual impression
of the vasculature, showing areas with different local perfu-
sion (Fig. 9.15).
The PixelFlux technique enables a quantitative assess-
ment of blood perfusion. The program is completed by an
Fig. 9.14  PixelFlux technique. Analysis form shows the heart cycles and the values of velocity, intensity, and area within the region of interest
M. M. Woźniak et al.
internal database, facilitating the handling of large amounts
of patient data, including features for comparison of differ-
times. It appears a very promising method for evaluating the
vasculature of pelvic structures in females at risk for devel-
oping urinary incontinence or organ prolapse. In addition, it
could be used to analyze the perfusion intensity in women
suffering from any pelvic floor disorder, in order to define
whether the severity of their symptoms correlates with perfu-
sion parameters.
Using the PixelFlux software for assessment of the blood
perfusion in the urethra of nulliparous females, we found that
the intramural and distal part of the urethra had poorer vas-
cular intensity than the mid-urethra. Interestingly, we did not
observe any difference between the perfusion intensity in the
inner (including the longitudinal smooth muscle, the circular
smooth muscle, and the submucosa) and outer (correspond-
ing to the rhabdosphincter muscle) rings of the mid-urethra
[12, 21]. Lone et al. studied vascularity of the urethra in con-
tinent women using color Doppler high-­frequency endovagi-
nal ultrasonography and showed that compared to continent
nulliparous women, continent ­multiparous women demon-
strated a significant reduction in the vascularity parameters
in all measured variables when parity was accounted for [22].
9  Technical Innovations in Pelvic Floor Ultrasonography
Fig. 9.15  PixelFlux technique. Region of interest includes the mid-­ correspond to regions with moderate or low perfusion velocity). Scan
urethra. Analysis form showing the local perfusion relief (red areas cor- obtained by endovaginal ultrasound with 9C3 transducer (BK Medical)
respond to regions with high perfusion velocity; white and black areas
The same authors in the 1-year prospective follow-up study
assessing urethral vascularity using 2D color Doppler high-
frequency endovaginal ultrasonography in women treated for
symptomatic stress urinary incontinence found out that there
is no change in vascularity parameters in women who opt for
conservative or surgical treatment of SUI [23]. In the study
by Yeniel et al., the authors attempted to find out if overactive
bladder microvasculature disease is a component of systemic
atherosclerosis and found that all atherosclerosis indicators
were significantly associated with OAB and that there was a
significant relationship between OAB and decreased bladder
neck perfusion. Additionally, there were correlations of OAB
severity with systemic atherosclerosis and impaired vascular
perfusion of the bladder. Decreased perfusion at the bladder
neck, the Framingham scores in severe OAB, and the cor-
relation between them suggest that OAB microvascular dis-
ease may be a component of systemic atherosclerosis rather
than a separate process [24].
9.7 Framing
The motion of pelvic structures can be observed in real time
by using dynamic ultrasound while asking patients in a
supine or standing position to strain or to cough. The data
can be registered as video files for off-line examination.
157
Dynamic US, however, provides an abundance of informa-
tion that cannot be captured by the observer alone, as it
occurs too fast.
Framing is a modality that provides a detailed visual-
ization of the motion sequences of specific structures.
With use of dedicated software (VIRTUAL-DUB), it is
possible to analyze consecutive frames of a video file, by
cutting off the frame without decompression. It has poten-
tial application in the assessment of functional disorders
of the pelvic floor.
9.8 Motion Tracking and Color Vector
Mapping
Our ability to understand pelvic floor dysfunction arises
from understanding the complex functional interactions
among pelvic organs, muscles, ligaments, and connective tis-
sue. Dynamic US imaging provides a quantitative evaluation
of pelvic floor structures. Measurements of bladder neck dis-
placement, urethral inclination, and retrovesical angle at rest
and during pushing or straining give important information
in patients with urinary incontinence [25]. However, due to
small dimensions and different velocities and movements of
the pelvic structures, it is not possible to describe their inter-
actions precisely.
158
Motion tracking is a modality for the assessment of bio-
mechanical properties of tissues and organs [26].
Computer-­aided vector-based perineal ultrasound appears
to be a feasible and valuable tool for the assessment of
bladder neck mobility, allowing the user to distinguish
between women with and without stress urinary inconti-
nence [27, 28]. Peng et al. [29] reported that motion track-
ing may be used for the assessment of puborectalis and
pubococcygeus contraction, by evaluating the displace-
ment of the anorectal angle (ARA) during perineal US. To
map accurately the trajectory of the ARA, every frame was
indexed to the same rigid landmark (the symphysis pubis—
SP). A template of the SP was initially defined in the first
frame of the ultrasonographic video file, then it was com-
pared with the second image with different offset in both
the x and y direction. The matching procedure employed
some equations and was repeated until the last image
frame. The relative displacement of the ARA to the SP was
obtained by subtraction of the SP from the ARA. Results
of this study showed that during cough, the ARA moves
toward the SP (ventrally) in continent women and away
from the SP (dorsally) in urinary-incontinent patients. In
addition, the amplitude of ARA maximal caudal displace-
ment was smaller in continent women compared to incon-
tinent patients [29]. Constantinou [30] described the
dynamics of female pelvic floor function using urodynam-
ics, ultrasound imaging with motion tracking, and MR, in
terms of determining the mechanism of urinary conti-
nence. Among these modalities, motion tracking provided
quantitative measures (displacement, velocity, accelera-
tion, trajectory, motility, strain) of pelvic floor muscles.
On the basis of these parameters, the status of continent
and asymptomatic women could be clearly distinguished
from those with incontinence.
We developed a novel computer software for quantitative
assessment of the motion of pelvic structures. This software
was originally applied to 3D echocardiographic scans to
evaluate the kinetics of the cardiac walls in patients with
heart infarction [31, 32]. The process of analysis consisted of
several main steps:
• Filtering: to improve the US image quality and to remove
the noise; the diffusion algorithm was applied, as it dra-
matically enhances the structure boundaries and reduces
the speckle noise.
• Description of the motion: recovery of transformation,
which aligns the reference frame with all the other frames
using intensity-based 3D volume registration; this allows
to visualize local deformation of spatial objects.
• De-noising procedure using time-averaging technique:
the deformation fields are used to generate new datasets
elastically aligned with the reference frame T0; the noise
M. M. Woźniak et al.
in the datasets is smoothed, and the boundaries of the
image structures are preserved.
• Segmentation step using the averaged dataset by iterative
deformable boundary approach.
• Reconstruction of the motion by applying the deforma-
tion field operator.
For description of the motion, vector displacement was
calculated as a total displacement (relative to the reference
frame T0) and displacement between consequent time frames
which can be seen as an instantaneous velocity. To visualize
the motion occurring on the surface (twisting), the instanta-
neous velocity vectors were decomposed into tangential and
normal components.
Different techniques can be used to visualize the local
variations of the motion as follows:
• Color-based visualization according to length values of
displacement vectors. It is the preferred modality when
we deal with small moving surfaces.
• Vector-based visualization: for significant motion it is
preferred to visualize vector values using the arrows rep-
resenting the length and spatial orientation of moving
matter.
• Line-paths-based visualization: in this method, the small
set of surface points is selected, and the path of their
motion is visualized. Colors of the line segments repre-
sent various time frames. This method enables estimation
of the viability of the heart using a single image. In addi-
tion to the line-paths method, we may also generate the
“activity surface.” Using this technique, total path length
values (in a single cardiac cycle) for every surface point
can be visualized. Thus it allows easy detection of moving
regions and evaluation of how significant this motion is,
as well as estimation of the spatial extent of pathological
regions on single static image. Line-paths visualization
contains complete information about the motion, whereas
activity surfaces show the overall surface activity more
clearly [32].
The motion tracking procedure described above can be
applied to assessment of the function of pelvic structures.
The data are collected using transperineal and endovaginal
ultrasound scanning in B mode, during straining and Valsalva
maneuver, and registered as video files. The data are then
analyzed with the use of color and vector mapping (Fig. 9.16).
We believe that this modality could enhance our knowledge
of pelvic organ dysfunction, facilitating the diagnosis of
injuries or deficiency of pelvic muscles after childbirth that
is not detectable by conventional imaging techniques. It can
also be useful to evaluate muscle strength after biofeedback
treatment.
9  Technical Innovations in Pelvic Floor Ultrasonography
a b
d e
Fig. 9.16 (a) Longitudinal section of the posterior compartment.
Color and vector mapping were applied for the assessment of the mus-
cles’ motion. AC anal canal, ARA anorectal angle, EAS external anal
sphincter, PR puborectalis muscle, R rectum. (b–d) During straining,
upward movement of the puborectalis is visualized. This movement
9.9 Elastography
Elastography uses ultrasonic imaging to observe tissue
shear deformation after applying a force that is either
dynamic (e.g., by thumping or vibrating) or varying so
slowly that it is considered “quasi-static” (e.g., by probe
palpation). The deformation may be represented in an elas-
ticity image (elastogram), or as a local measurement, in one
of three ways:
1. tissue displacement which may be detected and displayed
directly, as in the method known as acoustic radiation
force impulse (ARFI) imaging,
2. tissue strain which may be calculated and displayed, pro-
ducing what is termed strain elastography (SE), or,
159
c
f
closes the anorectal angle, assuring continence. (e, f) During Valsalva
maneuver, the puborectalis activity is suppressed, whereas the external
sphincter opens. Scans obtained by endovaginal ultrasound with 8848
transducer
3. in the dynamic case only, the data may be used to record
the propagation of shear-waves, which are used to calcu-
late either.
(a) regional values of their speed (without making images)
using methods referred to herein as transient elastogra-
phy (TE) and point shear-wave elastography (pSWE), or,
(b) images of their speed using methods referred to
herein as shear-wave elastography (SWE) which
includes 2D SWE and 3D SWE [33].
The strain measurements (including SE and ARFI) are
displayed as a semitransparent color map called an elasto-
gram, which is overlaid on the B-mode image. Typically, low
strain (stiff tissue) is displayed in blue, and high strain (soft
160
tissue) is displayed in red, although the color scale can vary
depending on the ultrasound vendor [34, 35]. A pseudo-­
quantitative measurement called the strain ratio can be used,
which is the ratio of strain measured in adjacent (usually nor-
mal) reference tissue region of interest (ROI) to strain mea-
sured in a target lesion ROI. A strain ratio > 1 indicates that
the target lesion compresses less than the normal reference
tissue, indicating lower strain and greater stiffness [36]. In
shear-wave elastography (SWE), measurement of the shear-­
wave speed results in qualitative and quantitative estimates
of tissue elasticity [37]. The elasticity measurements, using
SWE or 2D SWE, may be expressed as either shear-wave
velocity (m/s) or Young’s modulus (kPa) [38].
9.9.1 Endovaginal Elastography
Strain elastography (SE) is a technique of parametric imaging
that allows quantification of the elasticity of tissue.
Kreutzkamp et al. [39] attempted to determine if the elasticity
of paraurethral tissue correlates with urethral mobility and
urinary incontinence (UI). One region of interest was placed
in the tissue between the urethra and vagina at midlevel of the
urethra bordering the urethral wall. The second ROI was set
at the level of the os urethra internum in the tissue of the blad-
der neck in one line to the first ROI. The authors measured
elasticity in both ROIs with TDI-Q (Tissue Doppler Imaging-
Quantification Software) and calculated the ratio between
ROIs. Mobility of the urethra was quantified by measuring
the angle between a line parallel to the urethra and a line par-
allel to the bladder neck during stress and rest. SE analysis
was feasible in all cases. A correlation between urethral
mobility and elasticity of the paraurethral tissue was found. In
case of increasing urethral mobility, the paraurethral tissue
close to the bladder neck seems to be more elastic, and the
patients reported about more symptoms of UI. No noticeable
correlation between UI and urethral elasticity was shown. SE
may be a useful technique for direct quantification of tissue
elasticity and assessment of pelvic floor biomechanics [39].
Female striated urogenital sphincter contraction mea-
sured by shear-wave elastography during pelvic floor muscle
activation was described by Aljuraifani et  al. [40]. The
authors used ultrasound shear-wave elastography (SWE), a
noninvasive real-time technique to estimate tissue stiffness.
As muscle stiffness can be used as an estimate of muscle
force, SWE provides an opportunity to study contraction of
the periurethral musculature. Stiffness in a region expected
to contain the striated urogenital sphincter (SUS) was quanti-
fied using SWE at rest and during a pelvic floor muscle con-
tractions performed at 10%, 25%, and 50% of maximal
voluntary contraction (MVC). Two repetitions were per-
formed for 10 s. The authors showed that during contraction,
stiffness increased in the region of the SUS in all participants
M. M. Woźniak et al.
and at all contraction intensities. Multiple regions of
increased stiffness were detected, with 95.8% of regions sit-
uated ventral to the mid-urethra within the anatomical area
of the SUS.  The increase in stiffness was greater for 50%
MVC than both 10% and 25% MVC contraction intensities
(P  <  0.01). The study has proven that stiffness increases
within the anatomical region of the SUS during voluntary
pelvic floor muscle contractions with predictable response to
changes in contraction intensity. These observations support
the potential for ultrasound SWE to study SUS function non-
invasively [40] (Fig. 9.17).
Chen et al. [41] described quasistatic elastography with a
reference standoff pad as a promising quantitative method
evaluating the elastic modulus of the perineal body. The
authors used an UltraSONIXR P500 ultrasound system
equipped with elastography software. Approximately 1  Hz
freehand sinusoidal compression loading of the perineum
was used to measure the relative stiffness of the perineal
body compared to that of a custom reference standoff pad
with a modulus of 36.7  kPa. Measurements were made in
20  healthy nulliparous women. Preliminary data, despite
their limitations, provided a first order in vivo estimation of
the nulliparous perineal body modulus [41].
Xie et  al. [42, 43] evaluated the levator ani before and
after Kegel exercise in women with pelvic organ prolapse
(POP) stage I/II by transperineal elastography. The patients
underwent conventional transperineal ultrasound and elas-
tography. For each patient, the levator ani was located and
evaluated in the state of Valsalva. After Kegel exercises for
12  weeks, transperineal ultrasound and elastography were
repeated. The elasticity images were assessed using a four-­
point scale scoring system. The authors showed that the
mean elastography score was statistically significantly higher
for the levator ani after Kegel exercises (2.90 ± 0.48) than for
the baseline score (1.90 ± 0.29) (p = 0.025). Transperineal
elastography was an effective and useful tool in the evalua-
tion of the levator ani in patients with POP-Q stage I/II
before and after Kegel exercises [42, 43].
Masslo et  al. [44] introduced elastography as a new
method for sonographic assessment of levator avulsion
injury in postpartum pelvic floor trauma. The authors showed
that the elastographic evaluation revealed more trauma-­
suspicious lesions than the B-mode investigation. In conclu-
sion sonographic elastography assessment in a new
examination plane shows postpartum trauma of the pelvic
floor in women after vaginal delivery. This new method may
help to identify women with a higher risk of postpartum pel-
vic floor disorders [44].
Egorov et al. [45, 46] designed a prototype of vaginal tac-
tile imager (VTI) for visualization and assessment of elastic
properties of pelvic floor tissues. The prototype of the VTI
included a transvaginal probe, an electronic unit, and a lap-
top computer with a data acquisition card. The vaginal probe
9  Technical Innovations in Pelvic Floor Ultrasonography
Fig. 9.17  Assessment of urethral complex elasticity in an incontinent
female during rest and Valsalva maneuver. Four selected frames demon-
strating different elasticity of the urethra and paraurethral structures at
various states of urethral contraction/rest. Blue represents low elastic-
comprised of a tactile sensor array and a tilt sensor. The tac-
tile sensor array is installed on the probe head surface con-
tacting with the vaginal wall during the examination
procedure. The probe head measures 48  mm in length,
20  mm in width, and 14  mm in height having ellipsoidal
cross section. The tactile sensor array (Pressure Profile
Systems, Inc., CA) comprises of 120 capacitive pressure sen-
sors, which provide 2D pressure pattern being contacted
with vaginal wall. A pilot clinical study performed with 13
patients demonstrated that tactile imaging allows quantita-
tive evaluation of elastic properties of vaginal walls by means
of the elasticity index and has a potential for differentiation
of normal tissue and diseased tissue under prolapse condi-
tion. VTI allows imaging of a vaginal wall with increased
rigidity due to implanted mesh grafts following reconstruc-
tive pelvic surgery [45, 46].
161
ity/high stiffness (hard tissues); red represents high elasticity/low stiff-
ness (soft tissues). Images obtained by the endovaginal ultrasound with
E14C4t transducer (BK Medical)
Sturm et al. demonstrated that [47] ultrasound shear-wave
elastography bladder measurements correlate well with blad-
der storage pressure and shear-wave speed measurements
differ between compliant and noncompliant bladders. This is
the first known study to demonstrate that shear-wave elastog-
raphy is promising as a bedside modality for the assessment
of bladder dysfunction in children [47].
9.9.2 Endoanal Elastography
Allgayer et al. [48, 49] analyzed endosonographic elastogra-
phy of the anal sphincter in patients with fecal incontinence
and found that the IAS, a smooth muscle, and the EAS, a
striated muscle, have different elastogram color distribu-
tions, probably reflecting their different elastic properties.
162
The absence of significant correlations with the major clini-
cal and functional parameters suggests that in routine clini-
cal practice ultrasound, real-time elastography may not yield
additional information in patients with fecal incontinence.
There may be exceptions, particularly in irradiated patients
[48, 49]. Moreover real-time elastography in patients with
fecal incontinence following anorectal surgery with quanti-
tation of sphincter elastic properties yields no further diag-
nostic and prognostic information compared to conventional
EUS in irradiated and non-irradiated patients and, therefore,
cannot be regarded as a new tool in the assessment of those
patients. Our data further confirm the view that defined
sphincter defects may be a major risk factor for an unfavor-
able outcome [49].
Elastography can distinguish malignant from benign
tumors (malignant tumor mean strain ratio value over 1.25
and benign tumor mean strain ratio value below 1.25). In
terms of cancer staging, elastography, along with TRUS,
is useful to distinguish pT0 stage from pT1 stage, with
better results than MRI, including pretreatment biopsy.
Elastography, additional to TRUS, does not bring additional
information regarding T2 and T3 staging, as TRUS is suf-
ficient for final cancer staging. To our knowledge, the char-
acterization of pathological lymph nodes did not include
their elasticity, but, by our experience, these appear more
rigid than perirectal fat during elastography [50]. Li et  al.
demonstrated that SWE is a promising tool that yields valu-
able quantitative data additional to that provided by ERUS
examination in rectal lesions. The cutoff value 61.3 kPa for
Emean may serve as a complementary tool in diagnosis of
rectal lesions [51].
9.10 Contrast-Enhanced Ultrasound
(CEUS)
9.10.1 Rectal Cancer
This application of EAUS has not yet been fully explored in
relation to rectal tumors, but there are many studies in other
areas of interest, where it has demonstrated its importance in
the characterization of tumoral lesions [50]. Immediately
after the injection of the contrast medium, the microbubbles
reach the rectum, especially the areas where microcircula-
tion is more abundant. The images must be stored for further
analysis of loading and unloading curves and for a more
objective interpretation, according to the time intervals
acquired on these curves. In order to calculate these curves
and easily identify the differences between them, one or
more ROIs must be manually selected on the equipment, one
for the tumor-bearing region and another for an apparently
tumor-free region. The most important time-intensity param-
eters that can be acquired on the loading and unloading
curves are the following: contrast arrival time in the ROI
M. M. Woźniak et al.
(AT), maximum contrast medium enhancement (time to
peak, TTP), maximum contrast intensity (peak intensity, PI),
area under the curve (AUC), loading time (WIT), ascending
slope (AS), and echo intensity (EI) . With the help of these
parameters, CEUS offers very good interobserver variability
[50, 52, 53].
The contrast agent is homogeneously retained by all rec-
tal adenomas, and, compared to tumor-free rectal wall, the
contrast medium becomes visible later and with lower
intensity. Difficulty may arise in case of larger adenomas
with increased uptake. Adenocarcinomas are irregular, and,
compared to the tumor-free rectal wall, the contrast medium
loads faster, and contrast maximum enhancement occurs
earlier [54]. Specifically, aggressive tumors with high
degree of angiogenesis have an increased inhomogeneous
contrast uptake. An exception to this rule is that of large
tumors with intratumoral necrosis, which can have a low
contrast uptake or even no uptake [50]. Enhanced intensity
negatively correlates with histologic grade; however, none
of other parameters correlates with TNM stage and histo-
logic grade [53].
9.10.2 Contrast-Enhanced Voiding
Urosonography (ceVUS)
The most common pediatric application of US con-
trast agents is contrast-enhanced voiding urosonography
(ceVUS), i.e., the intravesical application of US contrast
agents via a bladder catheter for the evaluation of vesicoure-
teral reflux. The procedure and its diagnostic accuracy are
well-­established and documented [55]. Contrast-enhanced
voiding urosonography (ceVUS) has become a well-estab-
lished method for the diagnosis and treatment monitoring of
vesicoureteral reflux (VUR) in children, particularly after
the recent approval for this application in children in the
USA and in Europe [56]. It is a very safe technique [57,
58], which can be used both in diagnostics and monitor-
ing of treatment of VUR as well as intraoperatively during
endoscopic anti-­reflux therapy [59]. It enables very accurate
assessment of urethra, both in females and in males [60].
Other indications for ceVUS include bladder rupture and
urogenital malformation [55].
The introduction of three-dimensional static (3D) and
real-time (4D) techniques with ultrasound contrast agents
opens up new diagnostic opportunities for this imaging
modality [61–63]. 2D ceVUS and 3D/4D ceVUS allow to
diagnose the same number of vesicoureteral refluxes; how-
ever, there is a statistically significant difference in grading
between the two methods. Thus 3D/4D ceVUS appears at
least a valid, if not even a more conspicuous technique com-
pared to 2D ceVUS [61–63] (Fig. 9.18).
Contrast-enhanced urosonography (ceVUS) and its modi-
fications such as contrast-enhanced urethrography can be
9  Technical Innovations in Pelvic Floor Ultrasonography 163

Fig. 9.18  Contrast-enhanced urosonography (ceVUS) in a pediatric according to 2D ceVUS graded as III and according to 4D ceVUS
patient with recurrent urinary tract infections. Two-dimensional (2D) graded as IV.  Images obtained by the endovaginal volumetric trans-
(a) and four-dimensional (4D) (b) images of vesicoureteral reflux, ducer RIC5-9D (General Electric) from transabdominal access
164 M. M. Woźniak et al.

Fig. 9.19 Contrast-enhanced
urethrography in an
adolescent female patient with
urinary incontinence showing
ectopic ureter entering the
proximal urethra (arrows).
Images obtained by the
pediatric volumetric
transducer RNA5-9D
(General Electric) from
transperineal access.
B bladder, U urethra

performed also in order to diagnose other congenital abnor- 9.11 A

 utomatic Ultrasound Calculation
malities, e.g., dystopic ureters (Fig.  9.19) or posterior ure- Systems
thral valves in boys [62].
Ultrasound technology is rapidly evolving. The development
of three-dimensional (3D) ultrasound in late 1980s enabled
9.10.3 Contrast-Enhanced Ultrasound acquisition and analysis of volume data. This has important
Genitography implications for clinical practice because assessment of 3D
structures with a two-dimensional (2D) imaging modality
Anorectal malformation is a group of congenital anomalies requires either making assumptions about the shape of the
involving the distal anus and rectum (see chapter Congenital structure or simply ignoring its 3D conformation. A recent
Abnormalities of the Pelvic Floor: Assessment and development in ultrasound technology is automatic identifi-
Management). The diagnosis as such is usually straightfor- cation and measurement of certain structures within an
ward by clinical inspection and digital palpation. The role of acquired 3D dataset. These applications aim to facilitate and
imaging is to give an anatomical overview of the malforma- increase accuracy and reproducibility of ultrasound exami-
tion and to assist treatment decisions by providing relevant nations [65]. Various vendors offer different software,
data on the necessity of immediate surgical intervention, to enabling different measurements and post-processing calcu-
accurately characterize the complex anatomy of anorectal, lations. These include among others software-enabling vol-
cloacal and genitourinary, pelvic, and perineal structures in ume manipulation, analysis and optimization of ultrasound
order to allow for detailed surgical planning and to allow data sets, as well as automatic/semiautomatic calculations,
early detection of associated anomalies which is essential to for example, by General Electric (GE), SonoAVC, or by
prevent potential life-threatening complications. Contrast-­ Samsung, 5D.
enhanced dynamic US genitography with perineal access is One of the automatic calculation systems is SonoAVC
one of the modalities which should be considered in such (automatic volume calculation; GE Medical Systems) or 5D
cases [64]. Follicle (Samsung) which is a new software program
9  Technical Innovations in Pelvic Floor Ultrasonography
designed to provide automatic volume calculations of fluid-­
filled areas. It is either incorporated into the ultrasound
machine or installed on a personal computer for off-line
analysis of the datasets acquired by any ultrasound machine
of the same manufacturer. SonoAVC/5D Follicle identifies
and quantifies hypoechogenic regions within a 3D dataset
and provides automatic estimation of their absolute dimen-
sions, mean diameter, and volume. Because each different
volume is color-coded separately, the software is an ideal
tool for studying follicular development within the ovary.
The software is valid and provides accurate measurements
[66] and reliable report (Fig. 9.20).
Another type of automatic calculations has been devel-
oped for the grading of cystocele.
The transperineal ultrasound (US) has recently emerged
as an alternative tool for cystocele grading. The cystocele
severity is usually evaluated with the manual measurement
of the maximal descent of the bladder (MDB) relative to the
symphysis pubis (SP) during Valsalva maneuver. However,
this process is time-consuming and operator-dependent. In
this study, we propose an automatic scheme for cystocele
Fig. 9.20  Three-dimensional (3D) endoanal examination of adoles-
cent girl with polycystic ovaries syndrome (PCOS) with the use of
SonoAVC—a software enabling automatic calculation of the number,
dimensions, and volumes of the ovarian follicles. (a) Each follicle is
165
grading from transperineal US video. A two-layer spatiotem-
poral regression model is proposed to identify the middle
axis and lower tip of the SP and segment the bladder, which
are essential tasks for the measurement of the MDB.  Both
appearance and context features are extracted in the spatio-
temporal domain to help the anatomy detection. Experimental
results on 85 transperineal US videos show that our method
significantly outperforms the state-of-the-art regression
method [67].
9.12 Conclusions
A number of new ultrasonographic techniques have been
developed recently which carry the potential of significant
improvement of the diagnostic value of ultrasound in pelvic
floor disorders. Three-dimensional (3D) and real-time four-­
dimensional (4D) imaging techniques enable to overcome
limitations of conventional two-dimensional (2D)
US. Complex information on the exact location, extent, and
relations of relevant pelvic structures can be displayed with
coded automatically with a different color. (b) Report from the exami-
nation listing each follicle in both ovaries. Images obtained by the endo-
vaginal volumetric transducer RIC5-9D (General Electric) from
endoanal access
166 M. M. Woźniak et al.

Gynecology Report

Gynecology Report Page 1/2

Patient / Exam Information Date of Exam: •••••

Patient ID ••••• LMP Gravida

Name ••••• ••••• ••••• Expected Ovul. Para
DOB,Age •••••,16 Day of Cycle AB
Sex Other Day of stim. Ectopic

Perf. Phys. ••••• Ref. Phys. ••••• Sonographer •••••

Comment Indication

SonoAVC™ (Semi-)Automatic
Left Ovary Right Ovary
Total#: 24 Total#: 30

Nr. d(V) dx dy dz mean d V Nr. d(V) dx dy dz mean d V

mm mm mm mm mm cm³ mm mm mm mm mm cm³
1 9.6 21.0 8.2 6.1 11.8 0.47 1 9.9 15.9 9.9 7.3 11.0 0.51
2 8.7 13.5 8.7 6.6 9.6 0.34 2 9.7 17.3 9.8 7.2 11.5 0.48
3 7.3 13.4 8.0 4.4 8.6 0.20 3* 7.1 7.3 7.0 7.0 7.1 0.19
4 5.5 7.7 5.7 4.8 6.1 0.09 4 7.0 12.4 6.9 4.4 7.9 0.18
5 5.5 7.5 5.4 4.7 5.9 0.09 5 6.7 10.8 6.3 5.8 7.6 0.15
6 5.4 8.1 5.4 4.8 6.1 0.08 6 5.9 8.3 6.3 4.4 6.4 0.11
7 5.4 7.6 5.7 3.7 5.7 0.08 7 5.8 9.7 5.6 4.8 6.7 0.10
8 5.3 7.4 5.8 3.6 5.6 0.08 8* 5.0 5.6 4.7 4.7 5.0 0.06
9 5.1 6.3 5.9 3.9 5.3 0.07 9 4.9 6.6 5.2 4.1 5.3 0.06
10 5.1 7.8 5.3 3.8 5.6 0.07 10 4.8 6.5 5.4 3.9 5.3 0.06
11 4.8 7.6 5.1 3.0 5.2 0.06 11 4.8 7.2 4.3 3.8 5.1 0.06
12 4.1 5.3 4.5 3.1 4.3 0.04 12 4.2 7.0 3.7 3.1 4.6 0.04
13 4.1 6.5 5.2 2.3 4.7 0.04 13 4.1 5.4 4.3 3.4 4.4 0.04
14 3.7 6.8 4.1 2.2 4.3 0.03 14 4.0 6.2 4.6 2.3 4.4 0.03
15 3.6 5.0 3.9 2.6 3.8 0.03 15 3.9 5.5 3.9 3.1 4.2 0.03
16 3.6 6.3 3.6 2.4 4.1 0.02 16 3.7 5.4 3.7 2.8 4.0 0.03
17 3.6 6.6 3.6 2.1 4.1 0.02 17 3.4 5.2 4.1 2.0 3.8 0.02
18 3.4 4.7 4.0 2.2 3.6 0.02 18 3.4 4.7 4.2 2.1 3.7 0.02
19 2.7 5.0 2.6 2.0 3.2 <0.01 19 3.4 7.3 3.2 1.8 4.1 0.02
20 2.7 4.2 2.7 1.9 2.9 <0.01 20 3.2 4.4 3.6 2.4 3.5 0.02
21 2.5 3.7 2.9 1.6 2.7 <0.01 21 3.2 4.1 3.5 2.3 3.3 0.02
22 2.4 3.8 3.1 1.3 2.7 <0.01 22* 3.1 3.2 3.1 3.1 3.1 0.02
23 2.3 3.3 2.4 1.7 2.5 <0.01 23 3.0 3.9 3.5 2.6 3.3 <0.01
24 2.2 3.6 2.0 1.5 2.4 <0.01 24 3.0 4.0 3.5 2.0 3.2 <0.01
25 2.8 3.0 2.8 2.6 2.8 <0.01
26 2.6 4.1 3.0 1.6 2.9 <0.01
27 2.3 3.4 2.7 1.5 2.5 <0.01
28 2.3 3.3 2.4 1.6 2.5 <0.01
29 2.2 2.9 2.7 1.4 2.3 <0.01
30 2.2 3.9 2.1 1.3 2.5 <0.01

1/2
21.12.2016 10:30:55

Fig. 9.20 (continued)
9  Technical Innovations in Pelvic Floor Ultrasonography 167

Name: ••••• Patient ID: •••••

2D Generic Value m1 m2 m3 m4 m5 m6 Meth.

Dist.
D 2.84 cm 0.84 7.44 3.47 1.03 4.04 0.21 avg.
Vol. 3 Dist.
D1 5.01 cm 4.94 5.08 avg.
D2 2.82 cm 2.91 2.73 avg.
D3 2.28 cm 2.50 2.05 avg.
Vol 16.829 cm³ 18.817 14.886

Date: ••••• Perf. Physician: ••••• Sonographer: •••••

1/2
21.12.2016 10:30:55

Fig. 9.20 (continued)
168
the use of 3D techniques. A variety of other advanced
­ultrasonographic techniques will be increasingly used in the
future to provide more detailed information on the morphol-
ogy and function of examined organs, to facilitate planning
and monitoring of surgical procedures, diagnosing postop-
erative complications, and for surgical training.
Take-Home Messages
• There is a number of recent ultrasound technical inno-
vations including three-dimensional volume render
mode, maximum intensity projection, manual seg-
mentation and sculpting, fusion imaging, PixelFlux,
framing, color vector mapping, motion tracking, elas-
tography, contrast-enhanced ultrasound, and auto-
matic calculation systems which should be considered
in diagnostics of pelvic floor disorders.
• Ultrasound technical innovations carry the potential
of much more advanced diagnostics in future clini-
cal practice however require high-end equipment
and software and highly professional and well-
trained medical personnel.
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 Magnetic Resonance Imaging:
Methodology and Normal Pelvic Floor
Anatomy
Jeroen A. W. Tielbeek and Jaap Stoker
Learning Objectives
• Describe the anatomy of the female pelvic floor.
• Recognize the pelvic compartments.
• Identify the anal sphincter, levator ani, and ischio-
coccygeus muscles.
10.1 Introduction
The female pelvic floor region encompasses several struc-
tures, including sphincters, several anatomical layers, and
supportive elements. Muscular and ligamentous structures
are major constituents of these pelvic floor structures and can
be visualized by magnetic resonance imaging (MRI). In this
chapter the anatomy of the female pelvic floor is described,
based on T2-weighted turbo spin-echo sequences, with
images obtained with either an endoluminal coil or an exter-
nal phased array coil. In this sequence, muscles are relative
hypointense (gray) and ligaments and fascia hypointense
(black), while fat and smooth muscle are hyperintense
(white). Firstly the three different compartments are
described: an anterior compartment containing the bladder
and urethra, a middle compartment containing the vagina
and uterine support, and a posterior compartment containing
the rectum and anal sphincter (Fig. 10.1). Secondly, the sup-
portive structures of the multilayered pelvic floor are pre-
sented in a concise manner, describing the prominent pelvic
floor structures visualized on MRI. For more details readers
are referred to an additional textbook [1].
J. A. W. Tielbeek · J. Stoker (*)
Department of Radiology and Nuclear Medicine, Academic
Medical Center, University of Amsterdam,
Amsterdam, The Netherlands
e-mail: j.a.w.tielbeek@amsterdamumc.nl;
j.stoker@amsterdamumc.nl
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_10
10
10.2 T
 he Anatomy of the Female Pelvic
Floor
Adequate knowledge of the anatomy of the female pelvic
floor is crucial to comprehensively evaluate pelvic anatomic
and functional abnormalities. Traditionally, the female pel-
vic floor is divided into three compartments: the anterior,
middle, and posterior compartment (Fig. 10.1) [2]. However,
this approach does not fulfill the complexity of pelvic floor
failure. Therefore, a radiologist should assess all three com-
partments simultaneously [3].
The pelvic floor comprises three layers, which from cra-
nial to caudal include the endopelvic fascia, the pelvic dia-
phragm, and the perineal membrane.
The endopelvic fascia is an adventitial layer covered by
parietal peritoneum, enveloping the pelvic organs and sup-
portive structures (e.g., parametrium). This layer is not
directly visualized on MRI except for some condensations.
The pelvic diaphragm is a supporting shelf for the pelvic
organs. It consists of the levator ani and ischiococcygeus
(also known as coccygeus) muscle. The most caudal layer of
the pelvic floor, the perineal membrane, is composed of con-
nective tissue and the deep transverse peroneus muscle.
The superficial muscular layer of the female perineum
includes the superficial transverse perineal muscle, bulbos-
pongiosus and ischiocavernosus muscles (“the urogenital
triangle”), and the external anal sphincter. For support, the
superficial transverse perineal muscle is important and has
close relation to the perineal membrane.
10.3 The Anterior Compartment
The anterior compartment consists of the bladder, urethra,
and urethral support. The precise anatomy of the urethral
support and the relative contribution of the structures
involved are complex and have not yet been fully elucidated.
Here the principal structures are discussed.
171
172 J. A. W. Tielbeek and J. Stoker

Fig. 10.1  Schematic figure

in the sagittal plane shows the Anterior Middle Posterior
three different anatomic compartment compartment compartment
compartments of the female
pelvis: the anterior
compartment, containing the
bladder (B) and urethra (U);
the middle compartment,
containing the uterus (Ut),
cervix, and vagina (V); and
the posterior compartment, Ut
containing the rectum (R),
anal canal, and anus. A fourth
compartment called the
cul-de-sac (violet) is also
shown. PS pubic symphysis

B R
V
PS

CUL-DE-SAC

The urethral sphincter complex consists of a circular
proximal portion (urethral sphincter proper), a sling that
passes on the vaginal wall laterally to attach to the puborectal
muscle (urethral compressor), and a circular portion that sur-
rounds the distal urethra and vagina (urethrovaginal sphinc-
ter) [4].
The female urethra closes the urinary bladder and is
important for maintaining urinary continence. It is made up
of two main components: an inner mucosa and an outer mus-
cular coat. The latter comprises an inner smooth muscle
layer and an outer striated muscle layer (Fig.  10.2). These
layers are easily appreciated on MRI, with their distinct dif-
ferences in intensity. The smooth muscular layer (lisso-
sphincter) is a cylinder, while the external urethral sphincter
(rhabdosphincter) is a ring at the middle of the urethra, but
relatively thin posteriorly and deficient superiorly and
inferiorly.
Anterior to the urethra, a sling-like structure can be iden-
tified (Fig. 10.2). This structure courses just anterior to the
urethra and has lateral attachments to the levator ani muscle.
Although this structure has been identified as the periurethral
ligament [5] and the inferior extension of the pubovesical
muscle [6], it may also represent the compressor urethrae.
The compressor urethrae and urethrovaginal sphincter are
urethral supportive structures with multiple (inter)connec-
tions and have previously been considered part of the deep
transverse perineal muscle [7]. The compressor urethrae
forms a broad arching muscular sheet close to the urogenital
hiatus and adjacent to the rhabdosphincter (Fig.  10.2). It
compresses and elongates the urethra. The urethrovaginal
sphincter comprises striated muscle fibers encircling the
vagina. The urethrovaginal sphincter blends anteriorly with
the compressor urethrae and posterior fibers may extend to
the perineal body.
The urethra is supported by a layer of supportive tissue
formed by the endopelvic fascia (see Sect. 10.6). The urethra
is at the level of the pelvic diaphragm, bordered by the most
medial part of the pubococcygeus muscle (i.e., the pubovagi-
nal muscle) (Fig. 10.3), which inserts posteroinferiorly into
the perineal body.
10  Magnetic Resonance Imaging: Methodology and Normal Pelvic Floor Anatomy
Fig. 10.2  Endovaginal axial oblique T2-weighted turbo spin echo. The
compressor urethra (curved arrow) is anterior to the urethra and attaches
to the levator ani muscle. The urethra has a multilayered appearance
which is central the mucosa/submucosa (U), bordered by the relative
hyperintense smooth muscle lissosphincter (LS) and the relative
hypointense striated rhabdosphincter (RS). The pubococcygeus muscle
part of the levator ani muscle (arrow) is attached to the pubic bone
(PB). Anteriorly the pubococcygeus part of the levator ani muscle
courses (arrowheads) from the tendineus arc of the levator ani at the
internal obturator muscle (IOM) (anterior part has origin at pubic bone)
and, posteriorly, the iliococcygeus (open arrow). Anorectal junction
(A), pubic symphysis (PB), vaginal wall (V)
10.4 The Middle Compartment
The middle compartment consists of the uterus, cervix, and
vagina. The uterus and vagina are supported by several structures
that, to aid understanding, can be divided into several levels.
The adventitial endopelvic fascia is an important part of the
supportive structures for the uterus and vagina. It covers the
parametrium (broad ligament), which comprises the most supe-
rior layer and gives lateral support. The fascia extends to the
paracolpium and has been indicated as level I vaginal support
[8]. Support at this level also includes the round ligaments.
The uterosacral and cardinal ligaments are condensations
of the endopelvic fascia and form the major constituents of
the second level of vaginal support [8–10]. The uterosacral
ligaments run from the posterolateral aspect of the cervix to
173
Fig. 10.3  External coil axial oblique T2-weighted turbo spin echo
shows the lateral support of the vagina by the levator ani (curved
arrow). The puboanalis (PA) courses to the longitudinal layer. The
triangular-­
shaped (ischio)coccygeus muscle (C) is visible with its
attachment at the ischial spine (ISp). Aorectal junction (AR), internal
obturator muscle (IOM), rectum (R), urethra (U), vagina (V)
the presacral fascia. The cardinal ligament arises from the
area of the greater sciatic foramen and courses to the uterine
cervix. Both the cardinal and sacrouterine ligaments sur-
round the cervix and envelop the superior part of the vagina.
Both ligaments give lateral support. The anteromedial part of
the vagina is suspended by the endopelvic fascia (pubocervi-
cal fascia), with attachment to the tendineus arc of the pelvic
fascia. The vagina also has lateral support from the medial
part of the levator ani (level III support) (Fig. 10.3) and from
the perineal membrane [8, 10, 11].
10.5 The Posterior Compartment
10.5.1 The Posterior Compartment Contains
the Rectum and Anal Sphincter
The rectum acts as a reservoir at the end of the gastrointesti-
nal tract and is crucial in maintaining continence. Within the
mucosa there are distension-sensitive nerve endings, while in
the muscular wall, nerve endings are more sensitive to the
174 J. A. W. Tielbeek and J. Stoker

intensity of distension. The muscularis propria of the rectum

comprises two layers: an outer longitudinal layer and an
inner circular layer. The latter is continuous with the anal
internal sphincter, while the former is continuous as the lon-
gitudinal layer in the intersphincteric space.
The rectum is supported anteriorly by the anovaginal septum
and laterally by the rectal ligaments (or rectal pillars) of the endo-
pelvic fascia. Posterior support is given by the presacral fascia.
The anal sphincter closes the gastrointestinal tract until
there is an appropriate time point for evacuation. It is a mul-
tilayered cylindrical structure, 5–6  cm in length (average
5 cm) [12] (Figs. 10.4, 10.5, 10.6, and 10.7). The innermost
layer is the lining, which changes along the axis of the
sphincter (colonic-type epithelium, non-keratinized cuboidal
epithelium, keratinized stratified squamous epithelium). The
subepithelium seals off the anal canal. Subsequent layers are
the cylindrical smooth muscle of the internal sphincter, often
separated from the longitudinal layer by a thin fat-containing
layer that represents the surgical intersphincteric space. The
outermost layer comprises striated muscle, with the external
sphincter as the lower half and the sling-like puborectal mus- Fig. 10.5  Endoanal coronal oblique T2-weighted turbo spin echo. The
cle (part of the pubovisceralis) as the upper half of this layer. relative hyperintense internal anal sphincter (IS) is bordered by the
intersphincteric space with the longitudinal layer (LL). The outer layer
of the anal sphincter is formed by the external sphincter (lower half)
10.5.1.1 The Internal Anal Sphincter
and puborectal muscle (PR). LA, iliococcygeal part of the levator ani
The internal sphincter is easily recognized on MRI as a cir- which attaches to the internal obturator muscle (IOM) fascia at the ten-
cular hyperintense structure. The internal sphincter is dineus arc of the levator ani (curved arrow). ES external anal sphincter,
approximately 2.9  mm thick on endoluminal MRI [12] IAS ischioanal space, R rectum

Fig. 10.4  External coil axial oblique T2-weighted turbo spin echo
shows the pubovisceral muscle (curved arrow), puborectal muscle
(PR), and puboanal muscle (short arrows). The puboanal muscle
courses to the longitudinal layer (LL). IS internal sphincter, IOM inter-
nal obturator muscle, VI vaginal introitus
Fig. 10.6  External coil coronal oblique T2-weighted turbo spin echo. The
internal anal sphincter (IS) and outer striated muscle layer formed by the
external sphincter (ES; lower half) and puborectal muscle (PR; upper half)
are readily appreciated; the intersphincteric space (ISS) is in between. LA,
iliococcygeal part of the levator ani which attaches to the internal obturator
muscle (IOM) fascia at the tendineus arc of the levator ani (curved arrow).
ES external anal sphincter, IAS ischioanal space, R rectum
10  Magnetic Resonance Imaging: Methodology and Normal Pelvic Floor Anatomy
Fig. 10.7  Endoanal axial oblique T2-weighted turbo spin echo through
the lower half of the anal sphincter. Relatively hyperintense mucosa/
submucosa with hypointense muscularis submucosae ani (MM). The
internal anal sphincter (IS) is relatively hyperintense and forms a ring.
The external sphincter (ES) ring is relatively hypointense. The hyperin-
tense fat-containing intersphincteric space is between the internal and
external anal sphincter. This space contains the relatively hypointense
longitudinal layer (LL). ACL anococcygeal ligament, B bulbospongio-
sus muscle, VI vaginal introitus
(Figs.  10.6 and 10.7). The inferior border of the internal
sphincter is approximately 1 cm above the inferior edge of
the sphincter complex (i.e., inferior edge of the external
sphincter) (Fig. 10.6). The internal sphincter is important for
the resting tone of the anal sphincter.
10.5.1.2 T  he Intersphincteric Space
and Longitudinal Layer
The intersphincteric space is the fat-containing space between
the internal sphincter and the outer striated muscle layer (i.e.,
external sphincter and puborectal muscle). The width, and there-
fore the visibility on MRI, varies ­considerably. As it contains fat,
it is seen as a bright line on T2-­weighted MRI (Fig. 10.6).
The longitudinal layer (also named the longitudinal mus-
cle) courses through the intersphincteric space (Figs.  10.4
and 10.6). This structure is the continuation of the smooth
muscle longitudinal layer of the rectum and has striated mus-
cle contributions from the pubovisceralis (puboanalis)
(Figs. 10.3 and 10.7) and fibroelastic contributions from the
endopelvic fascia [13]. The longitudinal layer is approxi-
mately 2.6 mm thick on endoanal MRI.
The longitudinal layer forms a network with extensions to
the perineal skin and the ischioanal fossa. These extensions
are not visualized on MRI.
175
10.5.1.3 T  he Outer Striated Layer: External
Anal Sphincter
The external sphincter is the lower half of the outer striated
layer of the anal sphincter [12, 15] (Figs. 10.4 and 10.6). The
external sphincter extends approximately 1  cm beyond the
internal sphincter and forms the lower edge of the anal
sphincter. In females the external sphincter is approximately
2.7  cm high posteriorly and laterally and approximately
1.4 cm anteriorly [12]. The external sphincter has a thickness
of 4.1 mm on endoluminal imaging. Some external sphincter
fibers are posteriorly continuous with the anococcygeal liga-
ment, while others extend to the superficial transverse peri-
neal muscle and perineal body anteriorly.
Voluntary closure and reflex closure are the important
functions of the external sphincter, while it also adds to the
sphincter tone.
10.5.1.4 T  he Outer Striated Layer: Puborectal
Muscle
The puborectal muscle, which is the principal subdivision of
the pubovisceralis part of the levator ani (see Sect. 10.7.1),
forms the upper outer striated layer of the anal sphincter
(Figs. 10.4, 10.5, and 10.7). It is approximately 2.9 cm high
and 5.7 mm thick and forms a sling that is open anteriorly
[12]. The puborectalis courses anterior oblique, with bilat-
eral attachment to the pubic bone, and borders the urogenital
hiatus. The muscle has several functions, most importantly
reflex contraction to sudden increase in abdominal pressure.
10.5.1.5 Anal Sphincter Support
The anal sphincter is supported anteriorly by the perineal
body and related supportive structures, while lateral support
is given by the levator ani muscle and superficial transverse
perineal muscle (Fig. 10.8). Posterior support is given by the
anococcygeal ligament and superior support by the continu-
ity with the rectum. The fibroelastic network—which trans-
verses the anal sphincter—is continuous outside the anal
sphincter and gives additional support.
10.6 The Endopelvic Fascia
The endopelvic fascia, the most superior layer of the pelvic
floor, covers the levator ani muscles and pelvic organs in a
continuous sheet [13].
The endopelvic fascia—an adventitial layer—is attached
at both lateral sides to the tendineus arc of the pelvic fascia.
The latter is attached to the levator ani muscle as well as to
the pubic bone. This layer of anterior vaginal wall and endo-
pelvic fascia suspended between the tendineus arcs at both
sides forms a “hammock” underlying and supporting the
urethra [14]. Contraction of the levator ani muscles results in
compression of the urethra to the pubic bone, as the tendin-
eus arc of the pelvic fascia and therefore the vaginal wall are
both elevated. Also the urogenital hiatus is closed.
176
Fig. 10.8  External coil axial oblique T2-weighted turbo spin echo
demonstrates the perineal body (P) with attachment of the transverse
perineal muscle (arrowhead; left transverse perineal muscle visible
at contiguous slice), external sphincter (ES), and bulbospongiosus
muscle (B). The external sphincter (arrow) and internal sphincter
(IS) show variable degrees of atrophy. G gluteal muscle, IS internal
sphincter, LL longitudinal layer in intersphincteric space, VI vaginal
introitus
10.7 The Pelvic Diaphragm
The pelvic diaphragm is a prominent part of the pelvic floor
as visualized on MRI. It constitutes the levator ani and the
ischiococcygeus (or coccygeus) muscles. The pelvic dia-
phragm is a supporting shelf for the pelvic organs (Fig. 10.5).
In physiological conditions, the pelvic diaphragm has a
dome-shaped form in the coronal plane as a result of the con-
stant muscle tone of the levator ani and ischiococcygeus
muscles combined with fascial stability. The pelvic dia-
phragm is transversed by the urogenital hiatus with the ure-
thra, vagina, and rectum. The urogenital diaphragm is closed
by the pelvic diaphragm.
10.7.1 The Levator Ani Muscle
The levator ani muscle consists of three muscles: the
iliococcygeus, pubococcygeus, and pubovisceralis
(puborectalis).
The iliococcygeus muscle and pubococcygeus muscle
arise from the ischial spine, the tendineus arc of the levator
ani muscle, and the pubic bone. The tendineus arc
(Figs. 10.4 and 10.5) is a linear fascial condensation of the
internal obturator muscle, the major constituent of the pel-
vic sidewall.
J. A. W. Tielbeek and J. Stoker
The iliococcygeus arises from the posterior half of the
tendineus arc (Figs. 10.2, 10.4, and 10.5) inserting into the
coccyx and the midline anococcygeal raphe. The anococcy-
geal raphe is formed by the interdigitation of iliococcygeal
fibers from both sides [16]. The iliococcygeus forms a sheet-
like layer and is often largely aponeurotic.
The pubococcygeus arises from the anterior half of the
tendineus arc (Fig. 10.2) and the periosteum of the posterior
surface of the pubic bone at the lower border of the pubic
symphysis (Fig.  10.2); its fibers are directed posteriorly,
inserting into the anococcygeal raphe and coccyx.
The pubovisceralis forms a sling around the urogenital
hiatus. This muscle has several constituents. Most important
is the puborectalis which is a U-shaped sling around the anus
(see Sect. 10.5) and is attached posteriorly to the anococcy-
geal ligament. The puboanalis is another part of the pubovis-
ceralis which courses to the anal longitudinal muscle
(Figs. 10.3 and 10.7). A further component is the pubovagi-
nal muscle which has attachments to the lateral vaginal walls
and courses to the perineal body [17].
10.7.2 The Ischiococcygeus Muscle
The posterior part of the pelvic diaphragm is formed by the
ischiococcygeus.
This muscle arises from the tip of the ischial spine, along
the posterior margin of the internal obturator muscle
(Fig. 10.3). This triangular shelflike musculotendinous struc-
ture forms the posterior part of the pelvic diaphragm. The
sacrospinous ligament is at the posterior edge of the ischio-
coccygeus muscle and is fused with this muscle.
10.8 T
 he Perineal Membrane
(Urogenital Diaphragm)
The perineal membrane is a fibromuscular layer directly
below the pelvic diaphragm. The diaphragm is triangular in
shape, spans the anterior pelvic outlet, and is attached to the
pubic bones. The perineal membrane is crossed by the ure-
thra and vagina and is attached medially to the lateral vaginal
walls.
Formerly it was often referred to as the urogenital dia-
phragm and described as a trilaminar structure. Two of these
three layers (namely, the deep transverse perineal muscles
and the superior fascia) are currently thought not be present
as layers within the perineal membrane. The deep transverse
perinei fibers are now thought to be part of the compressor
urethrae and the urethrovaginalis part of the external urethral
10  Magnetic Resonance Imaging: Methodology and Normal Pelvic Floor Anatomy
sphincter muscle, which lies above the perineal membrane,
or transverse fibers inserting into the vagina.
The superficial transverse perinei spans the posterior edge
of the perineal membrane (Fig.  10.3). Both insert into the
perineal body and external sphincter.
The perineal body is situated between the urogenital
region and the anal sphincter. Many muscular and fascial
structures interconnect: the longitudinal muscle of the ano-
rectum, external anal sphincter, pubococcygeus muscle
(pubovaginalis), perineal membrane, superficial transverse
perineal muscle, and bulbospongiosus (Fig. 10.3). The peri-
neal body is important for support, as the muscular and fas-
cial constituents of the perineal body have (bony)
attachments.
10.9 Conclusion
The authors review the anatomy of the female pelvic floor
region in this chapter. To understand its function and prob-
lems, it is crucial to differentiate the anterior, middle, and
posterior compartments and different layers of the pelvic
floor.
Take-Home Messages
1. The female pelvic floor is divided into three com-
partments: the anterior, middle, and posterior
compartment.
2. The pelvic floor comprises three layers: the endo-
pelvic fascia, the pelvic diaphragm, and the peri-
neal membrane.
3. The external sphincter is the lower half of the outer
striated layer of the anal sphincter.
177
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ED, McGuire EJ, editors. Female urology. 1st ed. Philadelphia:
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ter anatomy and age- and sex-related variations at high spatial reso-
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Wound Ostomy Continence Nurs. 1998;25:63–74.
 Dynamic Magnetic Resonance Imaging
of the Pelvic Floor: Technique
and Methodology
Khoschy Schawkat and Cäcilia S. Reiner
Learning Objectives
• To gain an overview on how dynamic pelvic floor
MRI is performed and interpreted.
• To get familiar with recommendations for standard-
ized imaging and reporting of MRI findings.
• To understand the three-compartment model of the
pelvic floor and frequently applied reference
systems.
11.1 Introduction
The pelvic floor is a complex anatomic and functional unit. It
provides pelvic support, maintains continence, and coordi-
nates relaxation during urination and defecation. Pelvic floor
dysfunction encompasses multiple clinical conditions and is
a major healthcare concern, since the lifetime risk of under-
going a single operation for prolapse or incontinence by age
80 is 11%, with up to 29% patients requiring reoperation
[1–3]. Correct and complete diagnosis by clinical examina-
tion alone is particularly challenging in cases of multicom-
partment problems. However, a correct diagnosis is crucial
for therapy guidance and often requires a multidisciplinary
approach [1].
Over recent years, magnetic resonance imaging (MRI)
has gained increasing acceptance as an imaging modality for
evaluation of the pelvic floor. The advantages of MRI are
well-known and include the lack of radiation, an excellent
soft tissue contrast, and multiplanar imaging without super-
imposition of structures. In particular posterior compartment
pathologies (e.g., enterocele and intrarectal intussuscep-
tions) are missed by physical exam but are well depicted by
MRI [4, 5].
K. Schawkat · C. S. Reiner (*)
Institute of Diagnostic and Interventional Radiology, University
Hospital Zurich, Zurich, Switzerland
e-mail: khoschy.schawkat@usz.ch; caecilia.reiner@usz.ch
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_11
11
There is general agreement that MRI of the pelvic floor
encompasses static (morphologic) and dynamic MRI
sequences [6]. Static MRI means imaging of the anatomical
morphology of the pelvic floor with the patient at rest to
delineate components of the pelvic floor support system.
Dynamic (cine) MRI means that the pelvic floor is imaged at
rest and under stress, i.e., with the pelvic floor at rest, at
squeezing, at straining, and during defecation or urination.
When the posterior compartment is in the focus of interest,
dynamic pelvic floor MRI is often called MR defecography
(MRD). At MRD images are also obtained in the defecation
phase yielding important additional information of pelvic
floor abnormalities compared to rest, squeeze, and straining
phase alone [7]. In addition to the clinical exam, MRI can
diagnose additional unexpected abnormalities and may influ-
ence the choice of the surgical therapy in approximately 42%
of the cases [8].
11.2 Patient Positioning
Dynamic pelvic imaging may be performed in an open-­
configuration MR system in the sitting position, or in a
closed-configuration MR system in the supine position.
Although the sitting position is the physiological position
during defecation, dynamic pelvic MRI is usually performed
in the supine position. This is primarily due to the limited
availability of open-configuration MR magnets, which would
allow examination in the physiological sitting position.
The influence of body position on defecation has been
investigated only in a limited number of studies. A study of
patient positioning during MRD showed that MRD in the
supine position and in the seated position are equally effec-
tive in identifying most of the clinically relevant abnormali-
ties of the pelvic floor [9]. In a study comparing MRD in
supine and sitting position, no differences in pelvic floor
descent were found during the evacuation phase suggesting
that the maximum extent of pelvic floor descent is more
influenced by the muscle elasticity than by gravity force
179
180
[10]. In a study by Bertschinger et  al. [9], all intussuscep-
tions found in upright positions were missed in the supine
position. However, the evacuation phase was not performed
in this study. Knowing that most pelvic floor pathologies
show their full extent during evacuation, these results should
be interpreted with caution [6, 7]. To minimize straining
efforts and to facilitate evacuation in the supine position, the
knees should be elevated (with a pillow or wedge with firm
consistency which can be positioned underneath the patient’s
knee) [6, 11].
Recommendations for Practice
• Patient cooperation is critical to obtain a useful
examination. Therefore, a preexamination training
is recommended on how to correctly perform the
maneuvers during the MRD examination.
• An essential part of MRD is to encourage and coach
the patient during the examination in order to obtain
a viable MRD study.
• Bladder voiding 2 h before the examination is rec-
ommended, and ideally the bladder is moderately
filled during the examination.
• To facilitate the evacuation process in supine posi-
tion, the knees should be elevated by putting a pil-
low underneath the knees.
11.3 Patient Preparation
Patient cooperation is critical for a useful examination.
Therefore, a preexamination training is recommended on
how to correctly perform the maneuvers during the dynamic
phase of the examination and the evacuation phase. The
patient should be instructed to repeat the evacuation process
until the rectum is emptied [6]. To minimize patients discom-
fort as much as possible and to protect the scanner from soil-
ing, a diaper pant should be offered to the patients.
Bladder voiding 2  h before the examination is recom-
mended, and ideally the bladder is moderately filled during
the examination [6]. Otherwise a markedly distended blad-
der might mask pelvic organ prolapse. The administration of
luminal contrast agent for MRI of the pelvic floor varies in
different studies, from use of no contrast agent to filling of
the rectum, vagina, urethra, and bladder with contrast agent;
placement of markers in the vagina or rectum; or placement
of urethral catheters [12–14]. Vaginal filling with 20  ml
ultrasound gel is helpful for better demarcation; however, the
resent guideline from the European Society of Urogenital
Radiology (ESUR) and Gastrointestinal and Abdominal
Radiology (ESGAR) working group does not recommend
general application [6]. In our current imaging protocol, we
do not perform retrograde filling of the bladder. With regard
K. Schawkat and C. S. Reiner
to the middle compartment, the soft tissue contrast is usually
high enough to allow identification of all anatomical land-
marks. Therefore, we do not perform any tagging of the
vagina. Exceptions may be specific queries before surgery is
performed, such as reconstruction of the pelvic floor in
severe uterus prolapse.
For evaluation of the posterior compartment of the pelvic
floor, experts agree that the rectum should be filled with con-
trast agent. The contrast material in the rectum not only
allows for better delineation but also allows studying the
actual act of defecation. This is of importance, as some dis-
orders of the pelvic floor, such as rectal prolapse or intussus-
ceptions, only appear in their full size during defecation [7].
Immediately before the examination, the rectum is filled
with the rectal enema. The volume of enema used is variable
and ranges between 120 and 250 ml [6]. Some investigators
administer contrast agent until the patient feels a sustained
desire to defecate. Others use a standardized volume of con-
trast agent. Although it is not known if the amount of contrast
agent administered influences the extent of structural pelvic
floor disorders, in our experience, 250–300  ml of enema
gives the best results. In general, a larger amount of gel
(180–200 ml) likely improves the capacity of the patient to
defecate [6]. However, the time needed to evacuate the con-
trast agent, and thus the assessment of the evacuation ability,
depends on the amount of contrast agent. Therefore, it is nec-
essary to standardize the volume administered. The viscosity
of the contrast agent should be similar to that of normal rec-
tum content because the manifestations of pelvic floor
pathologies vary with different fecal consistency [15–17].
Authors recommend ultrasound gel [18–20] or mashed pota-
toes [9, 21, 22]. Depending on the sequence used for dynamic
MRI, the rectal enema may be doped with a small amount of
standard extracellular gadolinium-based MR contrast agent.
Neither premedication nor oral or rectal preparation for
bowel cleansing is necessary before imaging [6].
The technologist plays a crucial role in obtaining a diag-
nostic study. It is their important responsibility to put the
patient at ease prior and during the examination as well as to
encourage the patient to perform the maneuvers correctly
during the examination communicating with the patient via
microphone and headphone [1].
11.4 Imaging Protocol
Dynamic pelvic MRI can be performed in supine position on
all commercially available closed- or open-configuration
MR systems with horizontal access. So far there is no data
available, whether 1.5 T or 3.0 T magnets are preferably for
dynamic pelvic floor MRI.  For MRI with the patient in
supine position, a pelvic phased-array coil covering the pel-
vis is used. After filling the rectum, the examination starts
with a localizer sequence. The imaging protocol usually
includes static and dynamic sequences. For static imaging
11  Dynamic Magnetic Resonance Imaging of the Pelvic Floor: Technique and Methodology 181

non-fat-suppressed high-resolution static T2-weighted compartment contains the vagina, and the posterior compart-
sequences (e.g., turbo spin echo, TSE; fast spin echo, FSE; ment contains the rectum. Although the three-compartment
rapid acquisition with relaxation enhancement, RARE) in model is used for interpretation of pelvic organ prolapse, the
three planes are recommended [6]. Alternatively, an isovolu- pelvic floor should be considered as one unit since the three
metric three-dimensional T2-weighted sequence could be compartments work as one entity and combined defects are
used, which can be reconstructed in all imaging planes. common.
Subsequently, dynamic MRI is performed as the central part The three compartments of the pelvic floor are assessed
of pelvic floor MRI.  For dynamic MRI in the different for morphological changes at different pelvic floor positions.
­positions (at squeezing, at straining, and during defecation), Besides the qualitative assessment, quantitative evaluation of
various MR sequences can be used, with similar results. imaging findings is important, because the extent of these
Newest recommendations state to use a steady-state (e.g., findings may influence further management. Metric mea-
FISP, GRASS, FSIF, SSFP, T2-FFE) or balanced-state free surements of the position of the three compartments during
precession sequence (e.g., trueFISP, FIESTA, B-FFE) in the dynamic sequences are assessed with regard to functional
midsagittal plane [6]. Alternatively, T1-weighted multiphase abnormalities and help to assess the grade of pelvic organ
gradient-recalled echo (GRE) sequences may be used. If the prolapse, grade of anterior rectoceles, and enteroceles [6].
T1-weighted multiphase GRE sequence is used, the rectal
enema is usually tagged with a small amount of a gadolinium-­
based contrast agent. Which sequence is used depends on the 11.5.2 Reference Systems
scanner. Breath holding is required for the dynamic
sequences, and therefore they should not exceed 20 s each
The use of reference points and lines to determine the pres-
[6]. For the evacuation phase, it is important to have aence and extent of pelvic organ prolapse is helpful. The most
sequence that offers the possibility to acquire images over a
used reference line is the pubococcygeal line (PCL), which is
long time period without the necessity to reload the sequence.
defined on midsagittal images as the line joining the inferior
This is particularly important in patients with a long prolon-
border of the symphysis pubis to the last or second-last coc-
gation period. Only during evacuation the full extent of pel-
cygeal joint. The position of the base of the bladder (anterior
vic organ prolapse is visible and therefore is an essential
compartment), the cervix, or vaginal vault (middle compart-
component of MRD examinations [7]. ment) and the anorectal junction (posterior compartment) is
measured at a 90° angle to the PCL in the different pelvic
floor positions (at rest, squeezing, straining, and evacuation)
11.5 Image Analysis as shown in Fig.  11.1. The anorectal junction (ARJ) is
defined as the cross-point between a line along the posterior
11.5.1 Three-Compartment Model wall of the distal part of the rectum and a line along the cen-
tral axis of the anal canal. To determine pathologic pelvic
Image analysis is performed according to the three-­ floor descent, the measurements are made on the images,
compartment model of the pelvic floor [23]. The anterior which show maximal organ descent, usually during maximal
compartment contains the bladder and urethra, the middle straining or evacuation. For grading of pelvic floor descent

a b c

Fig. 11.1  36-year old female patient with a minimal descent of the ante- rior compartment), the vaginal vault (2, middle compartment), and the
rior compartment and a moderate descent of the posterior compartment anorectal junction (3, posterior compartment) is measured perpendicular
during defecation. On MR images obtained at rest (a), at squeezing (b), to the PCL. Note the small anterior rectocele during evacuation. B blad-
and during evacuation (c) the position of the base of the bladder (1, ante- der, P symphysis pubis, PCL pubococcygeal line, R rectum, U uterus
182
using the PCL system, the pelvic floor working group pro-
poses to apply the “rule of three”: prolapse of the organ
below the PCL by ≤3 cm is mild, by 3–6 cm is moderate, and
by >6 cm is severe (Table 11.1) [6]. However, these diagnos-
tic thresholds are based on data mainly assessed at straining
and not during defecation. Flusberg et al. observed that addi-
tional anterior, middle, and posterior compartment descent
was seen during defecation compared to the straining phase.
The authors concluded that looking at pelvic floor descent
only during straining may underestimate the findings as
higher degrees of pelvic floor descent, and additional pelvic
floor pathologies are detected as patients progress from
straining to defecation [7] (Fig. 11.2).
Beside the three-compartment model with the PCL as a
reference line, which is mainly used by surgeons and gastro-
enterologists, the second known system for grading pelvic
floor abnormalities is the “HMO system,” which is mainly
used by urologists and gynecologists [24]. The HMO sys-
tem distinguishes pelvic organ prolapse and pelvic floor
relaxation, which are two separate but often coexistent
pathologic entities. In pelvic floor relaxation, the pelvic
floor, with its active and passive support structures, becomes
weakened, leading to hiatal descent and widening. The
degree of pelvic floor relaxation is measured at maximal
Table 11.1  Grading of pelvic organ descent using the pubococcygeal
line (PCL) [1]
Grade Measurementsa
Small organ descent <3 cm below the PCL
Moderate organ descent 3–6 cm below the PCL
Large organ descent >6 cm below the PCL
a
As measured for anterior, middle, and posterior compartment during
maximal straining or during defecation. Anterior and middle compart-
ment descent of 1 cm below PCL during straining considered normal.
Posterior compartment descent of 2–3 cm below PCL during straining
considered normal
a b
Fig. 11.2  Midsagittal steady state free precession T2-weighted image
obtained at rest (a) and straining (b) and T1-weighted image at evacua-
tion (c) with the posterior compartment (anorectal junction) 1.5 cm
K. Schawkat and C. S. Reiner
straining with two reference lines: the H line, which repre-
sents hiatal widening and extends from the inferior aspect of
the symphysis pubis to the posterior wall of the rectum at
the level of the ARJ, and the M line, which represents hiatal
descent and extends perpendicularly from the PCL to the
posterior end of the H line (Fig. 11.3). Lesions of the pelvic
musculofascial support result in widening of the hiatus and
descent of the levator plate. Thus, the H and M lines tend to
elongate with pelvic floor relaxation, representing levator
hiatal widening and levator plate descent, respectively.
Abnormal pelvic floor relaxation is present, when the H line
exceeds 6 cm and when the M line exceeds 2 cm in length
(Table  11.2) [25]. Pelvic organ prolapse constitutes the
O-component in the HMO system and is defined as any
organ descent below the H line.
The choice of reference line mainly depends on the radi-
ologist and referring clinician, as none of the systems have
shown clear superiority. The different reference systems
show only moderate to poor agreement with clinical stag-
ing of pelvic organ prolapse [26]. Using structured report-
ing helps radiologists and referring physicians with
interpretation and understanding of dynamic pelvic floor
MRI [1, 6].
11.5.3 Anorectal Angle
The anorectal angle (ARA), which is defined as the angle
between the posterior wall of the distal part of the rectum
and the central axis of the anal canal, can be measured at
rest, squeezing, and straining. It is a measure for the mobil-
ity of the anorectum and expresses the functioning of the
puborectalis muscle. It must be noted that the reproduc-
ibility of ARA measurements has been debated and ques-
tioned in several studies [27, 28], whereas another study
c
(rest), 2.5 cm (straining), and 4.5 cm (evacuation) below the pubococ-
cygeal line. The maximum descent of rectal descent is only seen during
evacuation
11  Dynamic Magnetic Resonance Imaging of the Pelvic Floor: Technique and Methodology 183

Fig. 11.3  Midsagittal steady state free precession T2-weighted image Fig. 11.4  Measurement of the anorectal angle (ARA). The anorectal
obtained at straining shows landmarks used in the HMO-system. The angle is measured between a line drawn along the posterior border of
landmarks are the inferior aspect of the symphysis pubis (A) and the the distal part of rectum and a line drawn through the central axis of the
posterior wall of the rectum at the level of the anorectal junction (B). anal canal
The H line (H) represents the anteroposterior hiatal width and extends
from A to B. The M line (M) represents hiatal descent and extends per-
pendiculary from the pubococcygeal line (PCL) to the posterior end of 11.5.4 Evacuation Ability
the H line
Most institutions perform MRD in a closed configuration
Table 11.2  Grading of pelvic floor relaxation and pelvic organ descent MR imaging scanner in supine position, and for practical
according to the HMO system [1] purposes the defecation phase is often excluded. However,
Grade H-linea M-linea O-linea it has been shown that the defecation phase yields impor-
Normal <6 cm 0–2 cm Cranial to H-line tant additional information on the presence and degree
Small 6–8 cm 2–4 cm 0–2 cm caudal to H-line of pelvic floor abnormalities [7, 34, 35]. Furthermore,
Moderate 8–10 cm 4–6 cm 2–4 cm caudal to H-line in pelvic floor abnormalities such as obstructed defeca-
Large ≥10 cm ≥6 cm ≥4 cm caudal to H-line tion (OD), parameters assessed during defecation such
As measured during maximal straining or during defecation
a
as delayed initiation of evacuation, impaired evacuation,
and prominence of puborectalis are relevant findings.
found the ARA was a consistent and reliable parameter Also intussusception is frequently only visible when the
[29]. Normal values for ARA are reported in literature [30, intrarectal gel is evaluated at the end of the defecation
31]. At rest values vary between 85° and 101° [13, 32, 33]. phase. Therefore it is of upmost importance to perform the
The pelvic floor working group recommends measuring evacuation phase and encourage the patient to repeat the
the ARA at rest, squeezing, and straining [6]. At squeezing defecation maneuver if the first attempts were not success-
the active contraction of the puborectalis muscle is respon- ful. Inability to evacuate can be caused by morphologic
sible for the sharpening of the ARA by 15–35%, while at changes (e.g., retaining rectocele, enterocele, intussus-
straining the puborectalis muscle relaxes, and the ARA ception) or functional inability to relax the puborectalis
becomes more obtuse by 15–20% than when measured at muscle (dyssynergic defecation). At least two-thirds of
rest (Fig.  11.4). Although normal values also exist for the contrast material in the rectum should be evacuated
squeezing and maximum straining because of the wide within 30  s [6]. If no evacuation of rectal content or a
range, it is more important to describe the changes of the delayed evacuation is present although the compliance is
ARA during different pelvic floor maneuvers instead of good and no structural obstacles exist, dyssynergic def-
reporting measured values [11]. ecation should be considered.
184
Future Directions
• To obtain and establish a state-of-the-art MR exam-
ination of the pelvic floor with structured reporting
across different institutions for better comparison of
MRD examinations.
• To establish the defecation phase as an indispens-
able part of MRD for evaluation of the full extent of
pelvic floor disorders also in a close configuration
MRI in lying patients position.
11.6 Normal Findings
At rest and during squeezing, the anterior compartment rep-
resented by the bladder base, the middle compartment
defined by the vaginal vault, and the peritoneal reflection
including small bowels and sigmoid should be above the
level of the PCL. The posterior compartment represented by
the anorectal junction is located within 2 cm below the PCL
at rest. On sagittal images obtained at maximal squeezing
through contraction of the puborectalis muscle, the anorectal
junction is pushed anteriorly and superiorly, and the ARA
decreases by 15–35° [1, 36]. The ARA increases by 15–20°
and becomes more obtuse during straining and defecation
because the puborectalis muscle relaxes and thereby the ano-
rectal junction moves inferior and posterior compared to the
normal position at rest [36]. During straining the bladder
base and the vaginal vault can normally descent up to 1 cm
below the PCL and the ARJ up to 3 cm below the PCL. This
means that a “small” ARJ descent following the “rule of
three” (<3 cm below the PCL) is not considered pathologic.
Rectocele, which is a bulge of the anterior or less fre-
quently the posterior rectum wall, is found frequently in
asymptomatic subjects and if smaller than 2 cm are consid-
ered normal [37] (Fig. 11.1). Small intussusceptions of the
rectal wall are considered to be normal findings during def-
ecation, observed in nearly 80% of healthy subjects [26].
During evacuation the relaxation of the puborectalis muscle
and the external sphincter allows an opening of the anal
canal, and in healthy subjects at least 2/3 of the contrast
enema is evacuated within 30 s.
11.7 Conclusion
Due to its inherent physical properties, MRI is a highly
suitable imaging modality for imaging the pelvic floor and
has become an integral part of assessment and treatment
planning for pelvic floor dysfunction. MRI provides a
global integrated approach to the pelvic floor rather than a
compartmentalized view. The development of fast MR
K. Schawkat and C. S. Reiner
sequences allows dynamic pelvic MRI to be performed in a
clinical applicable setting. MRI has tremendous potential
as a tool for attempts to understand the complex pathophys-
iology of the disorders of the pelvic floor. Available recom-
mendations on how to perform and interpret MRD help to
guarantee a standardized and complete evaluation of the
pelvic floor.
Take-Home Messages
• Pelvic floor dysfunction encompasses multiple clin-
ical conditions and is a major healthcare concern
which often requires a multidiciplinary diagnostic
team. In order to assess the optimal therapy strat-
egy, MRD is an essential part of the diagnostic
workup.
• MRI of the pelvic floor includes static (morpho-
logic) and dynamic (cine) MRI sequences to depict
noninvasively and with high contrast resolution all
three pelvic floor compartment pathologies without
the use of ionizing radiation and with minimal
patients discomfort and preparation.
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 Part III
Obstetric Pelvic Floor and Anal Sphincter Trauma
 Mechanisms of Pelvic Floor Trauma
During Vaginal Delivery
James A. Ashton-Miller and John O. L. DeLancey
Learning Points
• The tissues surrounding the distal birth canal and
urogenital hiatus are viscoelastic in nature; that is,
their stretch not only depends on the magnitude of
the dilation force but also on the time that it acts.
• There is an enormous, ±20-fold, range above and
below the mean variation in the longer of the two
time constants describing how rapidly these visco-
elastic birth canal tissues can stretch in healthy
women.
• An urgent research priority is that insights are
needed into the role that advancing age plays on the
efficacy of hormonal ripening and the resulting vis-
coelastic response of the distal birth canal tissues to
dilation.
• The pubovisceral muscles are the last muscles to
be stretched by the fetal head, stretch the most of
any levator muscle during labor, and are the most
likely to be injured due to that stretch. There is
magnetic resonance imaging confirmation of these
injuries.
• The nerves innervating the anal sphincter are the
nerves that are most stretched during labor and
J. A. Ashton-Miller
Biomechanics Research Laboratory, Department of Mechanical
Engineering, University of Michigan, Ann Arbor, MI, USA
Department of Biomedical Engineering and Internal Medicine,
University of Michigan, Ann Arbor, MI, USA
e-mail: jaam@umich.edu
J. O. L. DeLancey (*)
Pelvic Floor Research Group, Department of Obstetrics and
Gynecology, University of Michigan, Ann Arbor, MI, USA
Department of Mechanical Engineering, University of Michigan,
Ann Arbor, MI, USA
e-mail: delancey@umich.edu
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_12
12
likely the most likely to be injured due to excessive
stretch.
• Seventy-five percent of women can give birth to any
fetal head size without risk of injury, 5% will
require instrumented delivery, while 20% will need
special attention to minimize injury risk.
• While the pubovisceral muscle is the structure that
is most likely to be injured in a difficult labor, there
is now also a proven risk of pelvic fracture that must
be considered if a woman reports postnatal pain.
Injuries to structures other than the pubovisceral
muscles remain to be elucidated.
12.1 B
 iomechanics of the Second Stage
of Labor
As many are aware, biomechanics is the application of the
principles of mechanics to biological systems. At the begin-
ning of the second stage of labor, a mother and her fetus can
be considered a biomechanical system, the input to the sys-
tem being the expulsive force developed by the mother due
to intrauterine and intra-abdominal pressures and the output
from the system being the progress of the fetal head along
the birth canal towards crowning (Fig. 12.1).
The biomechanical elements of the system include the
fetal head and its geometry and deformability, as well as the
geometric arrangement of the soft tissues that form the birth
canal and their constitutive material properties. Many ques-
tions arise when thinking about this system: How much do
the maternal soft tissues of the pelvic floor have to stretch
during the second stage? Can normal tissues stretch this
much or only tissues in pregnancy? Which tissues are
stretched the most and why? Which tissues are most likely to
be injured and why? How does the pelvic floor prepare for
birth? Why does it or does it not recover from birth? How
and how much does hormonal “ripening” affect the ability of
189
190
Fig. 12.1  An extraordinary challenge. During the second stage of
labor, the fetal head, often averaging 10  cm in diameter, has to be
pushed through a much smaller urogenital hiatus, averaging about
2.5 cm in diameter. The mechanical interactions between the mater-
nal expulsion force, the molding of the fetal head, and the dilation of
the birth canal are dictated by the constitutive properties, or biome-
chanical characteristics, and architecture of each of the tissues
involved. The illustration is from Bumm J.F., Grundriss zum Studium
der Geburtschifte. J.F.  Bergmann: Munich & Weisbaden, Fig.  164,
pg. 185, 1922
the pelvic floor tissues to stretch? Which women will have an
easy birth, and which women will have a difficult birth and
why? Which women are likely to have long second stages
and why? We shall see in this chapter that biomechanics can
help to provide answers to some of these questions and, for
those not yet answered, it can suggest fruitful future avenues
of endeavor. We shall also see that both simple and more
complex mathematical models can provide valuable insights
that would be difficult, if not impossible, to obtain experi-
mentally in laboring women.
It is known that the soft tissues of the pelvic floor nor-
mally prepare for vaginal birth in advance by being “soft-
ened” by hormonal action and an increase in the size of the
levator hiatus due to pelvic floor muscle sarcomerogenesis,
but none of these preparatory changes could ever result in
vaginal birth by themselves. The mechanics of vaginal birth
demand first that a mechanical force must act on the fetus
to push it along the curve of Carus. What force might that
be? It is the uterine expulsion force developed by intrauter-
ine pressure acting on the fetus, aided by the intra-abdomi-
nal pressure generated by the mother during her volitional
“bearing-­down” effort or “push.” The product of that pres-
sure, times the cross-sectional area of the fetal head, is the
maternal expulsion force acting to push the fetal head along
the birth canal and through the levator, and then urogenital,
hiatuses towards crowning. The progress of the fetal head
along the curve of Carus will depend on the resistance to
stretch of the maternal soft tissues and to a lesser extent on
the resistance to compression of the fetal head itself because
of its interaction with the maternal soft tissues. The fetal
head acts to dilate the maternal birth canal, but by Newton’s
J. A. Ashton-Miller and J. O. L. DeLancey
third law (for every action, there is an equal and opposite
reaction), the maternal birth canal resists stretch, acting so
as to compress the head, thereby molding it. If the maternal
birth canal tissues stretch a lot under little force, they pro-
vide little resistance to the head being advanced along the
birth canal. But if they stretch a little under the same force,
because they provide much resistance to stretch, then they
will also provide substantial resistance to the head being
advanced along the birth canal. Likewise, but to a lesser
extent, if the head molds easily, then this will aid progress
along the birth canal and vice versa. Since the force gener-
ated by uterine contractions and maternal efforts are not
unlimited, the difficulty of the task they must complete may
be decisive in the success or failure of vaginal birth. How
can we characterize this interaction between all the ele-
ments in the system in order to begin to understand the bio-
mechanics of what is happening during the second stage of
labor? We shall see later in this chapter that we can use
computational models to gain useful insights into these bio-
mechanical interactions.
12.2 Injury from Vaginal Birth
In one study of 160 primiparous women, we found that 32
(20%) exhibited visible damage to the levator ani muscles on
magnetic resonance (MR) scans [1]. None of the 80 nullipa-
rous women serving as controls had injuries, thereby identi-
fying birth as a cause of the type of levator ani muscle injury
seen in women with pelvic floor dysfunction. Twenty-nine of
these injuries occurred in the pubovisceral muscle; only
three injuries occurred in the iliococcygeal portion of the
muscle. This was a study originally designed to examine
stress urinary incontinence: equal numbers of women who
developed de novo stress incontinence and women who
remained continent after their first birth were recruited.
Because the stress incontinence group were twice as likely to
have defects as the continent group, the occurrence of these
defects in a group of primiparous women not oversampled
for stress incontinence would be somewhat lower than this
estimate. However, even if this estimate were halved, it
would still indicate that one in ten women delivering their
first infant will sustain levator damage. An association has
been demonstrated between MR-visible injury and de novo
stress urinary incontinence as well as pelvic organ prolapse.
In the case of the de novo stress urinary incontinence, the use
of forceps, anal sphincter laceration, and episiotomy
increased the odds ratio for levator muscle injury by 14.7-,
8.1-, and 3.1-fold, respectively. Women with levator injuries
were 3.5 years older and had a 78-min-longer second stage.
These morphological studies identify the role of vaginal
birth in the injury and indicate where some of the damage is
occurring but do not yield information about the mechanism(s)
of injury. In a more recent study, three-dimensional (3D)
12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery
ultrasound scans of women before and after vaginal birth
have confirmed that these types of injury occur during vagi-
nal delivery. There is great variation in the amount of injury,
from a few fibers on one side of the levator to the entire
pubovisceral muscle, both with and without distortion of sur-
rounding tissues.
12.3 Mechanisms of Levator Muscle Injury
There have been several suggestions for why the levator ani
muscles might be injured. Information from electrodiagnos-
tic studies has demonstrated that birth causes changes in
mean motor unit duration after vaginal birth [2], as well as
changes in pudendal nerve terminal motor latency. Abnormal
tests have also been found in women with prolapse or stress
incontinence. Although the pudendal nerve innervates the
voluntary urethral and anal sphincters, it does not innervate
the levator ani muscles, which receive their own nerve sup-
ply from the sacral plexus. It has not been clear whether the
visible levator defects are from neurological or stretch
injury.
Since it is difficult to make measurements of muscle
stretch during the second stage of labor, a simple geometric
mathematical model (Fig. 12.2) was developed that showed
some muscle damage during the second stage of labor may
come from overstretching because those parts of the muscle
that are stretched the most are those that are seen to be
injured on magnetic resonance (MR) scans [3]. The
­pubovisceral (also known as the pubococcygeal) muscle, the
shortest and most medial levator ani muscle, had the largest
tissue strain with a stretch ratio of 3.26, a figure subsequently
found to be consistent with measures made in MR images
during vaginal birth [4, 5]. Regions of the iliococcygeus,
pubococcygeus, and puborectalis muscles reached maximal
stretch ratios of 2.73, 2.50, and 2.28, respectively. These val-
ues considerably exceed the maximum stretch ratio of 1.5
tolerated by striated muscle in nonpregnant animal prepara-
tions. Tissue stretch ratios were found to be proportional to
fetal head size. For example, increasing fetal head diameter
by 9% increased medial pubovisceral stretch by the same
amount. This analysis revealed that the region of muscle
injured most often, the pubovisceral (pubococcygeal) por-
tion, was the portion of the muscle that underwent the great-
est degree of stretch, and the second area of observed injury,
the iliococcygeal muscle, was the muscle stretched second
most. Furthermore, when the portion of the muscle at risk
was identified in cross sections cut in the same orientation as
axial MR scans, the pattern of predicted injury matched the
injury seen in MR scans (Fig. 12.3). Finally, the maximum
stretch ratio was found at the end of the second stage of labor
when the fetal head crowned (Fig. 12.2). These theoretical
findings suggesting stretch-induced injury are supported by
studies showing increased insulin-like growth factor-1 splice
191
variants that indicate stretch and overload in women after
first vaginal birth.
We do not yet know whether, during a birth, injury occurs
to a pubovisceral muscle in its active or its passive state or
both. The best predictors of stretch injury in active muscle
are the strain or the product of force and strain1 (i.e., mechan-
ical work), with strain and work essentially equivalent in
their predictive value [6]. The best predictor of injury in pas-
sive muscle, as measured by the force deficit after 1 min, is
the negative work2 done stretching the muscle during the
stretch. When a passive muscle is stretched, its force depends
on two factors: the strain rate per unit time and the product of
the strain times the strain rate. An order-of-magnitude
increase in the strain rate can increase the peak force by
25%. Hence, a physician performing an instrumented deliv-
ery (vacuum or forceps instrumentation) is probably wise to
keep the rate of pelvic muscle stretch3 as low as possible by
delivering the fetal head as slowly as is reasonable. We rec-
ognize that injury can also occur when a shoulder is deliv-
ered or when the head is delivered occiput posterior, but the
mechanics of these injury mechanisms remain to be
investigated.
There have been many competing theories proposed to
explain the cause of birth-related pelvic floor injury includ-
ing muscle damage from compression or tearing and neu-
ropathy from compression or stretch. There is clear evidence
of alterations in neural function (e.g., [7]) and also evidence
from blood samples suggesting ischemia/reperfusion [8]
from compression. In addition, as outlined above, computa-
tional simulations of birth revealed remarkable elongation of
the levator ani muscles where portions of the muscle more
than tripled their lengths [3]. These observations, however,
do not indicate which of these proposed mechanisms is
responsible for the levator defect that is associated with pro-
lapse. Since efforts at prevention must be based on a proper
understanding of why the injury occurs, it is necessary to
decide between these hypotheses. For example, if compres-
sion is the proposed mechanism, lessening the duration of
time during which the tissues are compressed is logical. If
tearing of the muscle is the mechanism involved then, given
the viscoelastic nature of muscle and connective tissue,
allowing a slow and gradual delivery that may take some-
what longer time would be the right solution. Because the
Strain is defined as the increase in length divided by the original length
1 
of the structure of interest.
By convention a muscle is considered to do positive work when it
2 
shortens and negative work when it is lengthened. Lengthening contrac-
tions are widely used by the body in activities of daily living because
they can produce nearly twice the force than shortening contractions;
but the downside is that larger force is more likely to injure either the
muscle or its attachments to other structures. In fact, muscle can only be
injured during lengthening contractions, not when contracting isometri-
cally or shortening because the forces are lower.
The stretch ratio is defined as the current length divided by the original
3 
length.
192 J. A. Ashton-Miller and J. O. L. DeLancey

a 1.1 cm b 300

Muscle Length (mm)

PS 250 Initial Length
Final Length
200

150

100

S 50

0
1 2 5 10 15 20 24

2.9 cm PR PC IC

3.5

Stretch Ratio
2.5

1.5

4.7 cm
1
1 2 5 10 15 20 24

Muscle Band

3.5

PC 2
7.9 cm
3.0

IC 13
Stretch Ratio

IC 11
2.5 PC 3
IC 15
PR 1
IC 9
PC 5
2.0 PC 7
Extremity
9.9 cm
Muscle
Stretch
Limit
1.5 IC 20

IC 24
1.0
0 1.1 2.9 4.7 6.4 7.9 9.1 9.9
Descent (cm)

Fig. 12.2 (a) Simulated effect of fetal head descent on the levator ani
muscles in the second stage of labor. At top left, a left lateral view
shows the fetal head (as a sphere) located posteriorly and inferiorly to
the pubic symphysis (PS) in front of the sacrum (S). The sequence of
five images at left shows the fetal head as it descends 1.1, 2.9, 4.7, 7.9,
and 9.9 cm below the ischial spines, while the head passes along the
curve of Carus (indicated by the transparent, light blue, curved tube).
The sequence of five images at right are front-left, three-quarter views
corresponding to those shown at left. (b) The upper bar graph com-
pares, by muscle, initial and final muscle lengths corresponding to 1.1
and 9.9 cm model fetal head descent, respectively. The lower bar graph
shows the maximum corresponding stretch ratio found in each levator
ani muscle band (where each muscle’s stretch ratio is calculated from
the final length divided by the initial length). Note that the value of the
stretch ratio is not simply proportional to initial or final length. For both
graphs, muscles are arranged left to right, in ventral to dorsal order of
origin location. (c) The relationship between fetal head descent
(abscissa, icons at top) and the resulting muscle stretch ratios (ordinate)
in selected levator ani muscles. The labels at right identify the pubococ-
cygeus (PC), iliococcygeus (IC), and puborectalis (PR) muscle bands.
The largest stretch is induced in the medial-most pubovisceral (PC2)
muscle, the last muscle to be engaged by the fetal head. The shaded
region denotes the values of stretch tolerated by nongravid appendicular
striated muscle without injury. ©Biomechanics Research Lab,
University of Michigan, Ann Arbor 2003
12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery
a b
Fig. 12.3 (a) Normal anatomy in an axial mid-urethra proton density
magnetic resonance image that shows the normal pubovisceral muscle
(shown by the asterisks). (b) Woman who has lost a part of the left
pubovisceral muscle (displayed on the right side of the image, accord-
ing to standard medical imaging convention), with lateral displacement
of the vagina into the area normally occupied by the muscle. The arrow
points to the expected location of the missing muscle. (c) Axial, mid-­
urethral section through the arch of the pubic bone (see pubic symphy-
clinical actions suggested by these two theories are opposite,
knowing the specific mechanism of injury matters.
Fluid-sensitive MR scan techniques that document mus-
cle anatomy as well as tissue edema due to injury and evalu-
ate women at early and later time points during recovery
make it possible to test these hypotheses. Injuries that occur
due to muscle tearing would be evident immediately and
would not resolve. On the other hand, muscle injury due to
neurological injuries would develop over time. Compression
would cause edema that would involve both the internal
obturator muscle and the levator muscle since they are both
immediately adjacent and would be equally compressed
between the pubic bones and fetal head. Therefore, if muscle
compression is responsible for injury, the edema would be
expected to affect both internal obturator and pubovisceral
muscles where they lie between the fetal head and pelvic
bones.
Studies that imaged women with risk factors for pelvic
floor injuries both early (1–2 months) and late (7 months) in
the postpartum period have made it possible to study these
injury mechanisms [9]. Among 17 women in this mechanis-
tic study, 3 women had unilateral high-grade tears (more
than 50% of the muscle involved), 3 had unilateral low-grade
193
c
PS
sis (PS), top) and the model levator ani muscles corresponding to those
from the patient shown in (b). Intact muscles are shown in dark gray.
The location of simulated muscle atrophy is illustrated by the light gray
shading of the left-hand pubovisceral muscle. This location is shown to
correspond with the location of muscle atrophy demonstrated in (b). OI
obturator internus, PB pubic bone, R rectum, U urethra, V vagina.
©Biomechanics Research Lab, University of Michigan, Ann Arbor
2003
tears, and 1 had bilateral high- and low-grade tears of the
levator ani muscles (Fig. 12.4). All tears were located at the
pubic portion of the levator ani muscles. Regarding the com-
pression hypothesis, levator edema was present in all women,
but the internal obturator muscle was never involved. Edema
resolved at the later time point. None of the women showed
a pattern where an initially normal appearing muscle became
atrophic that would support atrophy due to neural injury. In a
larger subsequent group of women judged to be at high risk
for the levator injuries, injuries to the pubic bones were seen
as well [10]. There were 29% (17/59) who had subcortical
pubic bone fracture, and 66% (39/59) were found to have
pubic bone marrow edema attesting to the remarkable forces
placed on the bony pelvis during birth. Like the original
study, 90% (53/59) had LA muscle edema, and 41% (28/68)
had low-grade or greater LA tear 7 weeks’ postpartum. The
magnitude of LA muscle tear did not substantially change by
8 months postpartum, but LA muscle edema and bone inju-
ries showed total or near-total resolution at 8 months post-
partum (P  <  0.05). The magnitude of unresolved
musculoskeletal injuries correlated with magnitude of
reduced LA muscle force and posterior vaginal wall descent
(P < 0.05).
194
a b
c d
Fig. 12.4  Mid-urethral axial MR images in the region show the pubo-
coccygeal muscle normally seen lateral to the vagina. Panel a shows a
proton density scan where the solid arrow heads mark the pubococcy-
geal muscle and the open arrow heads show the obturator internus (OI).
Signal intensity is lower in the pubococcygeal (arrow head) than the
adjacent internal obturator (open arrow head). Panel b, a fluid-sensitive
Injury to the origin of the pubovisceral muscle will result
from a larger-than-normal tensile force on the muscle during
the second stage exceeding its ultimate tensile strength. The
appearance of the injured pubovisceral muscle in that region
or “injury zone” might appear as that shown in Fig.  12.5,
which illustrates what we have called “Type I” and “Type II”
injuries.
The normal histology of this zone seen in Fig.  12.6
shows the muscle taking origin directly from the perios-
teum over the pubic bone medially, from an apophysis
more centrally, and from the passive collagenous structure
known as the arcus tendineus levator ani more laterally. It
J. A. Ashton-Miller and J. O. L. DeLancey
scan, shows a more apparent difference. In panel c, a normal pubococ-
cygeal muscle (black arrow) is seen between the vagina (Vag) and inter-
nal obturator (black arrow) while it is absent on the left (L). This pattern
persists in the late scan (d). Panels c and d also show the “architectural
distortion” that involves the vaginal wall protruding laterally on the side
(subject’s left) of the injury right (R). ©DeLancey
is an open question where the injury actually starts at the
pubovisceral muscle origin. We recognize that the origin
of the pubovisceral muscle is not orthogonal to the pubic
bone but takes off caudally at an acute angle. It is known
that a tensile structure like a ligament that attaches to a
bone at an acute angle has an inherent mechanical stress4
Mechanical stress in a tissue is the force acting on a given portion of
4 
the tissue divided by the cross-sectional area of that portion. In the sim-
plest example, tissue stress might generally be tensile in a ligament
under tension but compressive in a sulcus of the fetal head during
molding.
12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery
Normal PVM Fiber Loss
“Type I”
a b
Fig. 12.5  Illustrations of the right inner pelvic sidewall showing the
fascial and levator arches originating from the pubic bone. (a) Two dif-
ferent types of the pubovisceral muscle (PVM) origin can be identified:
one being a direct aponeurotic attachment in the anteromedial portion
(open arrow) and the other being an indirect catenary attachment
through the levator arch (LArch) in posterolateral region (closed arrow).
Morphological and functional variation in these locations may account
for how injury might occur and progress. (b) Type I injury: PVM can
concentration on the side of the structure where the attach-
ment angle is acute, rather than where it is obtuse on the
other side of the ligament. Under high tensile loads, we
therefore anticipate that injury would be expected to start
in the vicinity of that stress concentration (see, e.g.,
Luetkemeyer et al. [11]).
12.4 E
 ffect of Pregnancy on Pelvic Floor
Tissue Properties
During pregnancy, hormones affect the biochemical com-
position of the solid matrix and hydration phases consti-
tuting each pelvic floor tissue. Remodeling mechanisms
lead to changes in the organization, orientation, and
diameter of the collagen fibers as well as the crimp struc-
ture of the collagen fibrils, reinforcing each tissue. Such
effects can significantly affect the short- and longer-term
viscoelastic properties of the vaginal wall, the pubovis-
ceral muscles, and the perineal body, for example. They
will largely determine (a) the extent and rate at which
these structures can be stretched by an expulsive force
acting cyclically on the fetal head and (b) the resistance
to stretch provided by those structures. The more a tissue
exhibits creep behavior, the further it will stretch under a
constant load. And the more it exhibits relaxation behav-
ior, the more the stress in a tissue will decrease over time
when held at a constant length, thereby helping to lower
195
PVM and L Arch
Detachment
“Type II”
c
locally be damaged, which then leads to PVM atrophy (semitransparent
closed arrow). (c) Type II injury: detachment of the LArch origin from
the pubic bone (semitransparent open arrow) observed in 32-year-old
patient with stress urinary incontinence and history of a traumatic birth
(third-degree laceration). Since there is only a single point of pubic ori-
gin at the LArch for the lateral margin of the PVM, detachment of that
point will result in complete offloading of that region of the PVM
(Reproduced from [11, 12] ©DeLancey)
the risk of soft tissue rupture in the next loading cycle.
Were a tissue to exhibit viscoplasticity, it would behave
like a solid below a critical level of stress, but above that
level, it would flow like a viscous liquid. There is evi-
dence that tensile failure in some soft tissues can be pre-
dicted by the product of the stress times the strain extant
in the tissue, so interventions that lower one or both these
variables will reduce the risk of rupture. Pregnancy is
known to significantly affect the stress-strain behavior of
vaginal tissues in rat [13] (Fig. 12.7). However, accurate
constitutive laws are lacking for pregnant human pelvic
floor tissues, and the effects of pregnancy on injury at
any human tissue level, and on structural failure, are as
yet largely unknown.
12.5 F
 inite Element Models
of Vaginal Birth
The finite element method is a mathematical technique
widely used by engineers for simulating how simple or
more complex structures that have known material prop-
erties will deform under given forces or pressures. For
example, for a given set of forces applied to the structure,
it allows one to calculate the mechanical stress, or force
per unit area, in different regions of interest in the struc-
ture along with the regional deformations. One finite ele-
ment model of the second stage of vaginal birth has
196
Fig. 12.6  Examples of intact medial, central, and lateral region histol-
ogy of the pubic origin of the PVM. Each row is from a different donor.
Histological images showing the pubic origin of the levator ani from
medial (column 1), central (column 2), and lateral (column 3) areas
with the orientation picture below. All samples shown are stained in
Masson’s trichrome, and the scale bars are 5  mm for each row of
images. Medial: the medial levator ani muscle fibers originate from
multiple slips attaching in an enthesis to the pubis; oblique interface
between the pubic bone (PB) and the levator ani muscle (LA) can also
be observed. The thickness of the LA is greater than in other areas. N/A
J. A. Ashton-Miller and J. O. L. DeLancey
denotes missing data due to a technical issue during harvesting process.
Central: the central portion originates from the PB in a single aponeu-
rotic attachment, which is noticeably thinner than medial portion. The
obturator internus muscle (OI) can be seen lateral to the LA. Lateral:
the levator arch (LArch) appears as dense blue connective tissue attach-
ing to the PB and forming the lateral margin of the pubic origin of the
LA.  Note that relative preponderance of the three portions varies by
individual (reproduced from [12]). The inset at the top shows the pos-
sible appearance of an avulsion of the left pubovisceral muscle from the
pubic bone seen from a left lateral view point. ©DeLancey
12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery
Fig. 12.7  Experimental data fro uniaxial failure tests on both pregnant
and control rat vaginal tissues. The specimens were stretched along the
circumferential direction at a stretch rate of 0.1 mm/s (Reproduced
from [13]
estimated the maximum levator muscle stretch to be 1.6
[14]. We believe this estimate was artificially low because
the geometric data for the model’s levator muscles were
taken from a cadaver. Because a cadaver naturally lacks
pelvic muscle tone and its pelvic floor is often stretched
during embalming, it normally exhibits an enlarged leva-
tor hiatus, and this will have reduced the calculated
stretch ratio. A more recent finite element model by Jing
et al. [15], based on the MR data of the levator muscles
from a living woman having levator muscle tone, demon-
strated a maximum stretch ratio of 3.5 (Fig. 12.6), thereby
corroborating the maximum stretch ratio predicted by
Lien [3, 15]. The maximum stretch ratio is expected to
depend on a number of factors, including the size of the
fetal head relative to that of the maternal pelvis, the
degree of molding of the fetal head, perineal descent, and
the subpubic arch angle. Hence, the maximum stretch
ratio is expected to range widely among individuals
(Figs. 12.2, 12.7 and 12.8).
The Jing finite element model of birth [15] demonstrates
which parts of the levator ani experience the greatest mechan-
ical stress and how the stretch ratio of the birth canal tissues
varies as the fetal head is pushed along the curve of Carus
(Fig.  12.9). The results corroborate and extend the simple
geometric model introduced earlier in this chapter but now
take into account how the material properties of levator ani-
like tissues resist fetal head movement.
197
12.6 O
 ther Approaches to Modeling
Vaginal Birth
Finite element models of the type employed by Jing et  al.
[15] take considerable computing power and time to run, so
they are cumbersome to employ when trying to predict what
will happen in many different birth scenarios. So instead we
asked our doctoral student, Paige Tracy, to use an alternative
approach that permitted us to more rapidly explore the out-
come of thousands of different birth scenarios in a relatively
short time. We started by simplifying the models of the leva-
tor muscles ([17], Fig. 12.10). Our earlier model simulations
had demonstrated that the most distal portion of the levator
that surrounds the urogenital hiatus experiences the largest
stretch ratio late in the second stage and is the most vulner-
able to injury, so we knew we had to include that portion of
the muscle in the simpler model. We also knew that another
distal portion of the levator ani, the puborectal muscle that
surrounds the levator hiatus, is rarely injured during vaginal
birth. So we wanted to include that muscle as a control in the
model to better understand why it is seldom injured while the
pubovisceral muscle is more susceptible to injury
(Fig. 12.11).
Next we wanted to include the effects of six factors
that we expected could have a bearing on the stretch ratio
experienced by the pubovisceral muscle [18]. These
included the size and molding of the fetal head, the loca-
tion of the origin of the pubovisceral muscle on the pubic
bone, the initial length and subsequent maximum normal
stretch of the pubovisceral muscle, and the subpubic arch
angle.
After finding values for these factors across the popula-
tion of women and fetuses, and after making simplifying
assumptions about how the two muscles of interest would
have to rotate downward during the second stage (Fig. 12.11),
we ran Monte Carlo simulations to determine how all the
different combinations of these six factors interact to geo-
metrically permit a population of women having different
pelvic sizes to give to birth to fetuses of different sizes
(Fig.  12.12). This type of analysis is called a capacity-­
demand ratio that is similar to an analysis, for example, of
how large a rigid ball can fit through a tube and is expressed
as the ratio (g) of capacity to demand. If capacity is larger
than demand, then g > 1, and if demand is larger than capac-
ity, g < 1. Thus, if the ball is 9 cm and the inner diameter of
the rigid tube is 10 cm, then g = 1.11, and there is adequate
capacity for the ball to pass. But, if the tube is 10 cm and the
ball is 11 cm, g = 0.91, and there is not adequate capacity for
the ball to pass.
198 J. A. Ashton-Miller and J. O. L. DeLancey

a d

229

Maximum
principal strain (%)

11.70

c
0.98

Maximum
principal stress (MPa)

Fig. 12.8  Finite element model results for a simulated single (120 N)
push delivery for a 31-year-old mother and fetus at 40 weeks gestation.
(a–c) An inferior three-quarter view of the pelvic floor viscohyperelas-
tic soft tissue deformations at three stages during the second stage of
labor: (a) Station +2, (b) a middle station, and (c) delivery of the fetal
head. The levator ani muscle (red), fetal head (gray), and public bone
(white) are shown. (d) The maximum predicted principal strain and (e)
stress distributions in the pelvic floor soft tissues at time of delivery.
The largest principal strain (d) reached 259% (3.59 stretch ratio). The
blue region nearest the pubic bone indicates the local region of highest
stress (e), corresponding to the location of muscle defects observed on
magnetic resonance scans. (Reproduced from [16])

There are points of clinical interest. Firstly, the results
suggest why the pubovisceral muscle is more commonly
injured than the puborectal muscle. This is because the
puborectal muscle swings down like a bucket handle pivot-
ing around the lower margin of the pubic bone, whereas
when the pubovisceral muscle swings down, it also has to
wrap around the pubic rami, thereby having to stretch more
to accommodate the passage of the fetal head through its
loop of soft tissue surrounding the urogenital hiatus.
Secondly, the results predicted that roughly 65% of women
12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery 199

Fig. 12.9 (a) Left lateral a I: 70 mm II: 122 mm III: 166 mm

view and (b) three-quarter
view of the simulated descent
of the fetal head at three fetal
head displacements along the
curve of Carus showing the
central pubic bones and
levator ani: (1) 70 mm, (2)
122 mm, and (3) 166 mm. (c)
The changes in perimetric
length and overall stretch ratio
of the levator hiatus during
the second stage of labor. b
(Reproduced from [15])

c
400 4
Perimetric length
Perimetric length of the

Overall stretch ratio of

3
levator hiatus (mm)

300 Stretch ratio

the levator hiatus

II
200 2
III

100 1
I

0 0
0 30 60 90 120 150 180
Fetal head displacement along the Curve of Carus (mm)

can give birth to fetal heads of any size (white cells in

Fig. 12.13); a smaller percentage, say 5%, could absolutely
not give birth because the fetal head was simply too large
(red cells); and the remaining 30% were borderline (pink
Uterus cells) where one could not predict for sure whether a suc-
cessful birth could happen [18]. It is interesting that the
puborectal muscle played little or no role (Fig. 12.14). This
computer model is essentially a geometric model of the fit of
Bladder the fetal head through the birth canal in a population of
um
na

ct women. If one could use ultrasound to measure the geomet-

Re
gi
Va

ric parameters used in the model prior to labor (i.e., the fetal
Public
head and urogenital hiatus diameters), one might be able to
Bone
predict which women need to be monitored closely in labor
PRM
because they may have difficulty just because of cephalole-
DeLancey

PV
M
vator disproportion. But a limitation of the model is that it
does not consider the known interindividual variability in the
viscoelastic behavior of the pelvic floor muscle tissues and
their attachments which we shall address next.
Fig. 12.10  Figure showing simplified geometry of the pubovisceral
muscle (PVM) and puborectal muscle (PRM) based on our published In order to address the lack of representation of soft tissue
measurements of their lines of action viscoelasticity in the Tracy (2016) model [18], we modified
200
Pre-labor
Ultimate
Crowning
PVM loop
Fig. 12.11  Upper left: left lateral view of 3D model of the pelvis (green),
showing the high origin location (arrow) of the pubovisceralis muscle
(PVM, orange) and the PVM insertion on the PB/AS (light blue). Upper
right: 3D model of the pelvis (green), showing the puborectalis muscle
(PRM) (dark purple, lower right of that image) originating from the PM
(white). In the upper two figures, A, P, L, R, and I denote anterior, poste-
rior, left, right, and inferior, respectively. Lower left: the pubic symphysis
is projected in the sagittal view seen in a view from the left showing a
downward rotation of the PVM loop. Note the wrapping of the PVM
that model to include values of tissue viscoelasticity deduced
from measurements of dilation of the urogenital hiatus by a
constant force performed by researchers at Baylor College of
Medicine during the first stage of labor in 28 healthy women
[19]. Engineering uses mathematical e­ quations to precisely
predict the behavior of specific structural elements such as
cables in a suspension bridge. These kinds of simulation
require additional equations, called constitutive equations, to
allow one to predict the element’s material behavior under
specific loading conditions. We described the viscoelastic
behavior of the soft tissues using a five-­parameter mathemat-
ical model (equation) of which three parameters described
the elastic response and two time constants, τ1 and τ2,
described the short-term and long-term time-dependent
response of the tissues to stretch. It turned out that parameter
that best described the difference in the ability of the distal
birth canal to dilate in these 28 women was the parameter
J. A. Ashton-Miller and J. O. L. DeLancey
Pre-labor
Ultimate
Crowning
PRM loop
around the inferior pubic ramus at point 2 at ultimate crowning. The por-
tion of the PVM between points 1 and 2 lying above the inferior pubic
ramus point, 2, is the “noncontact” length because it cannot contact and
encircle the fetal head due to the rigidity of the pubic bone. That part of the
PVM lying between points 2 and 3 lies below the pubic ramus at 2 so it can
contact and encircle the fetal head to allow it to pass inside the loop formed
by the PVM.  Lower right: this illustrates the downward rotation of the
PRM from the prelabor to the ultimate crowning position in the manner of
a hinged bucket handle. Note the absence of PRM wrapping. (From [18])
called τ2, the longer of the two time constants, which was
found to vary 20-fold above and below the mean value, as
can be seen in Figs. 12.15 and 12.16. This is a truly remark-
able difference in these healthy young women and presum-
ably reflects the degree to which hormones, as yet
unidentified, act to ripen these tissues in preparation for
childbirth. We then integrated these measures of soft tissue
viscoelastic behavior into the Tracy (2016) model to deter-
mine how much it would affect cephalolevator disproportion
for the PVM. The results may be seen in Fig. 12.15 which
shows that, with tissue viscoelastic behavior now included,
about 75% of women were predicted to be able to give birth
to any size of fetal head without cephalolevator dispropor-
tion [20]. The red cells in that figure would be those that one
would predict would have to have an instrumented delivery.
The pink cells are those that one would want to monitor care-
fully prior to and during labor to minimize the risk for injury.
12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery 201

Fig. 12.12 Graphic Original

illustration of the sensitivity
analyses in caudal view. Top:
nominal configuration.
Middle left: varying SL (thick
black band). Middle right:
varying soft tissue origin
placement on pelvis (black
arrow heads). Bottom left:
varying SPAA. Bottom right:
varying head size (gray
circle). The variation in soft
tissue length reduction in
downward rotation is not
shown. Factors were varied by
±10%. (From [18]) Varying Soft Tissue
Loop Length Varying Origin Placement

Varying Subpubic Arch Varying Head SIze

Angle

Fig. 12.13 Predicted
DEMAND (Fetal Head Circumference, in Percentile)
maternal capacity-to-fetal
head demand ratio, g, for the 2.3% 5% 10% 25% 50% 75% 90% 95% 97.7%
pubovisceral muscle (PVM) 2.3% 0.67 0.66 0.65 0.63 0.62 0.60 0.59 0.58 0.57
loop with wrapping. The
5% 0.78 0.77 0.76 0.74 0.72 0.70 0.69 0.68 0.67
Circumference, in Percentile)

intensity of the (red) shading

indicates the degree of 10% 0.90 0.89 0.87 0.85 0.83 0.81 0.79 0.78 0.77
CAPACITY (Maternal

cephalolevator disproportion
for the PVM. (From [18]) 15% 0.97 0.96 0.94 0.92 0.90 0.88 0.85 0.84 0.83
25% 1.08 1.06 1.05 1.02 0.99 0.97 0.95 0.93 0.92
50% 1.26 1.25 1.22 1.20 1.16 1.14 1.11 1.09 1.08
75% 1.44 1.42 1.39 1.36 1.32 1.29 1.26 1.24 1.23
90% 1.59 1.56 1.54 1.50 1.46 1.43 1.39 1.37 1.36
95% 1.67 1.65 1.62 1.58 1.54 1.50 1.47 1.45 1.43
97.7% 1.75 1.73 1.70 1.66 1.61 1.58 1.54 1.52 1.50
202 J. A. Ashton-Miller and J. O. L. DeLancey

Fig. 12.14 Predicted
DEMAND (Fetal Head Circumference, in Percentile)
maternal capacity-to-fetal
head demand ratio, g, for the 2.30% 5% 10% 25% 50% 75% 90% 95% 97.70%
puborectalis muscle (PRM) 2.30% 1.06 1.04 1.02 1.00 0.97 0.95 0.93 0.92 0.90
loop. The intensity of (red)
5% 1.13 1.12 1.10 1.07 1.04 1.02 0.99 0.98 0.97

Circumference, in Percentile)
shading indicates the degree
of cephalolevator 10% 1.22 1.20 1.18 1.15 1.12 1.09 1.07 1.05 1.04

CAPACITY (Maternal
disproportion for the
PRM. Note how much less 15% 1.27 1.25 1.23 1.20 1.17 1.14 1.11 1.10 1.19
disproportion is for the PRM 25% 1.36 1.34 1.31 1.28 1.25 1.22 1.19 1.17 1.16
in this figure than the
50% 1.51 1.49 1.46 1.42 1.39 1.36 1.32 1.30 1.29
pubovisceral muscle (PVM)
in the preceding figure. This 75% 1.66 1.64 1.61 1.57 1.53 1.49 1.45 1.44 1.42
helps explain the lower risk of
90% 1.80 1.78 1.74 1.70 1.66 1.62 1.58 1.56 1.54
PRM injury during childbirth.
(From [18]) 95% 1.89 1.86 1.83 1.78 1.74 1.70 1.65 1.63 1.61
97.7% 1.97 1.94 1.91 1.86 1.81 1.77 1.72 1.70 1.68

Values of τ2 over 1000  s predicted active second stages of
greater than 1 h for the 50th percentile maternal capacity and
50th percentile fetal head, demonstrating the potential of
such modeling in predicting difficult labors antenatally.
12.7 P
 udendal Nerve Stretch During
Vaginal Birth
Neurophysiologic studies have clearly associated change in
pudendal nerve function with pelvic floor disorders [21] and
also with vaginal birth [22]. Overstretching of the nerve is one
of the potential injury mechanisms, yet data concerning nerve
stretch were not available. To gain insight into this process, a
simple geometric model was used to predict the stretch ratios in
the nerves innervating the levator ani, urethra, and anal sphinc-
ter during the second stage of vaginal labor [23]. The results
showed that the inferior rectal branch exhibited the maximum
strain, 35%, and this strain varied by 15% from the scenario
with the least perineal descent to that with the most perineal
descent. The strain in the perineal nerve branch innervating the
anal sphincter reached 33%, whereas the branches innervating
the posterior labia and urethral sphincter reached values of
15% and 13%, respectively (Fig. 12.17). It was concluded that
during the second stage, (a) nerves innervating the anal sphinc-
ter are stretched beyond the 15% strain threshold known to
cause permanent damage in nonpregnant appendicular nerve,
so this is a risk factor for injury, and (b) the degree of perineal
descent was shown to influence pudendal nerve strain.
12.8 E
 ffect of Forceps on Cephalolevator
Disproportion
In small MRI studies of vaginal birth, it became clear that the
use of forceps increases the risk for levator injury up to
14-fold [1], and multivariable analysis on larger samples
show odds ratios of over 3 for levator injury [24]. Neither
study indicated an increased injury rate with vacuum deliv-
ery. It has been unclear whether these injuries are due to the
space-occupying nature of the forceps around the fetal head,
causing increased stretch of the levator ani, or whether the
risk of injury is increased by exerting too much traction force
too rapidly given the viscoelastic nature of the soft tissues.
Tracy [25] ran simulations to address the first question
and determined that the levator injury is not likely to be due
to the space-occupying nature of the forceps in the urogenital
hiatus (Fig. 12.18). One can then deduce that they must be
due to too large a traction force, a traction force that is
increased too rapidly, or a combination of the two. Balancing
that is the unknown ultimate tensile strength of the pubovis-
ceral muscles. One of our earlierstudies shows that the mean
(±SD) unilateral cross-sectional area of the PVM in healthy
young women is 1.25 ± 0.29 cm2 [26]. Knowing that a stri-
ated muscle can develop about 2.8 kgf/cm2 of muscle cross-
sectional area in the direction of the fibers, one can calculate
the average maximum isometric tension the pubovisceral
muscle can develop is about 3.5 kgf. During a lengthening
(eccentric) contraction, a striated muscle can double its ten-
sion, such that the left and right pubovisceral muscle can
each maximally develop a maximum of 7  kgf, such that
together they could maximally resist ~14 kgf without tear-
ing. (In the case of forceps, the traction force is actually
orthogonal to the pubovisceral muscle, and the loading of
that muscle will depend on many other factors including the
shape of the fetal head, the expulsion and traction forces, the
resistance to stretch of the muscle, etc.) But, in the average
woman, a force of 14 kgf or more is likely sufficient to avulse
one or both pubovisceral muscles from the pubic bone
because it exceeds their ultimate tensile strength under con-
ditions when they are being forcibly stretched.
There is, however, considerable variation in the cross-­
sectional area of the pubovisceral muscles across women.
For example, in 95% of women, the 2∗SD points would be
0.77–1.73  cm2. This means the maximum allowable dila-
tion force can vary from 8.6 to 19.4 kgf, a twofold variation
in healthy women. Hence, an average maximum permissi-
ble dilation force of 14 kgf would easily cause injury in the
12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery 203

DEMAND (Fetal Head Circumference, in Percentile)

2.3rd 5th 10th 20th 25th 30th 40th 50th 60th 70th 75th 80th 90th 95th 97.7th
2.3rd 2.2E+6 2.9E+6 2.3E+6 4.1E+6 2.9E+6 5.0E+6 4.5E+6 4.6E+6 5.3E+6 4.6E+6 6.1E+6 7.2E+6 *** *** ***
4.0E+6 3.7E+6 4.4E+6 3.8E+6 5.1E+6 4.4E+6 5.1E+6 5.0E+6 6.6E+6 7.5E+6
CAPACITY (Maternal Circumference, in Percentile)

5th 2.2E+6 2.5E+6 3.3E+6 3.2E+6 3.1E+6

10th 2.2E+6 1.7E+6 2.3E+6 2.1E+6 2.7E+6 3.1E+6 3.4E+6 3.1E+6 3.4E+6 3.6E+6 4.3E+6 4.4E+6 3.4E+6 3.3E+6 5.6E+6
15th 1.6E+6 1.3E+6 2.0E+6 2.5E+6 2.7E+6 1.7E+6 2.4E+6 2.7E+6 2.9E+6 2.8E+6 3.4E+6 3.8E+6 3.4E+6 2.9E+6 5.1E+6
20th 1.3E+6 1.6E+6 1.5E+6 2.0E+6 1.5E+6 1.8E+6 2.4E+6 2.8E+6 3.0E+6 1.8E+6 2.6E+6 3.0E+6 3.3E+6 3.8E+6 4.6E+6
25th 1.5E+6 1.7E+6 1.3E+6 1.8E+6 1.9E+6 1.7E+6 2.1E+6 1.6E+6 1.8E+6 2.5E+6 2.8E+6 3.1E+6 3.2E+6 3.3E+6 3.7E+6
30th 1.2E+6 1.4E+6 1.7E+6 1.9E+6 1.2E+6 1.4E+6 1.8E+6 2.1E+6 1.7E+6 2.3E+6 2.4E+6 1.8E+6 2.7E+6 3.4E+6 3.8E+6
40th 1.0E+6 1.2E+6 9.1E+5 1.3E+6 1.4E+6 1.6E+6 1.8E+6 2.0E+6 2.2E+6 2.2E+6 1.4E+6 1.7E+6 2.4E+6 2.3E+6 2.9E+6
50th 9.1E+5 6.7E+5 9.7E+5 1.2E+6 1.3E+6 1.3E+6 1.0E+6 1.2E+6 1.4E+6 1.7E+6 1.9E+6 2.0E+6 2.4E+6 2.6E+6 1.9E+6
60th 2.2E+5 8.1E+5 9.6E+5 1.1E+6 1.0E+6 8.3E+5 9.9E+5 1.3E+6 1.4E+6 1.6E+6 1.6E+6 1.5E+6 1.4E+6 1.9E+6 2.3E+6
70th 8.0E+5 8.5E+5 5.9E+5 7.8E+5 8.6E+5 9.5E+5 1.1E+6 1.2E+6 1.3E+6 1.3E+6 9.3E+5 1.1E+6 1.5E+6 1.8E+6 1.9E+6
75th 7.1E+5 8.0E+5 8.9E+5 8.9E+5 6.6E+5 6.4E+5 8.0E+5 9.6E+5 1.1E+6 1.2E+6 1.3E+6 1.4E+6 1.4E+6 1.3E+6 1.7E+6
80th 6.2E+5 7.1E+5 8.0E+5 9.2E+5 9.6E+5 1.0E+6 1.0E+6 7.2E+5 7.0E+5 9.1E+5 1.0E+6 1.1E+6 1.3E+6 1.5E+6 1.4E+6
85th 5.2E+5 5.9E+5 6.9E+5 8.1E+5 8.6E+5 9.0E+5 9.6E+5 1.0E+6 1.1E+6 1.1E+6 1.1E+6 7.9E+5 9.7E+5 1.2E+6 1.5E+6
90th 3.6E+5 4.4E+5 5.3E+5 6.5E+5 6.8E+5 7.4E+5 -2.5E+5 8.9E+5 9.6E+5 1.0E+6 1.1E+6 1.1E+6 1.3E+6 1.3E+6 9.2E+5
95th 2.5E+5 2.9E+5 3.4E+5 3.7E+5 4.3E+5 4.8E+5 5.4E+5 6.1E+5 6.8E+5 7.4E+5 8.0E+5 8.5E+5 9.8E+5 1.1E+6 1.3E+6
97.7th 3.0E+5 3.3E+5 3.7E+5 3.0E+5 3.2E+5 3.4E+5 3.7E+5 4.1E+5 4.4E+5 4.8E+5 5.3E+5 5.8E+5 7.1E+5 7.8E+5 9.3E+5

DEMAND (Fetal Head Circumference, in Percentile)

2.3rd 5th 10th 20th 25th 30th 40th 50th 60th 70th 75th 80th 90th 95th 97.7th
2.3rd 3.3E+6 3.9E+6 4.3E+6 4.3E+6 5.0E+6 5.1E+6 5.6E+6 6.0E+6 6.4E+6 6.8E+6 6.7E+6 7.5E+6 8.3E+6 8.5E+6 1.0E+6
5th 2.9E+6 3.0E+6 3.4E+6 3.6E+6 3.7E+6 4.0E+6 4.2E+6 4.5E+6 5.1E+6 4.9E+6 5.5E+6 5.2E+6 6.2E+6 7.0E+6 7.2E+6
CAPACITY (Maternal Circumference, in Percentile)

10th 2.0E+6 2.3E+6 2.7E+6 2.9E+6 2.8E+6 3.3E+6 3.1E+6 3.6E+6 3.8E+6 4.3E+6 4.4E+6 4.6E+6 4.7E+6 5.6E+6 5.8E+6
15th 1.8E+6 1.9E+6 2.2E+6 2.6E+6 2.5E+6 2.8E+6 3.0E+6 3.2E+6 3.4E+6 3.7E+6 3.6E+6 3.5E+6 4.4E+6 4.8E+6 5.3E+6
20th 1.8E+6 1.9E+6 2.1E+6 2.4E+6 2.3E+6 2.6E+6 2.7E+6 2.8E+6 2.7E+6 3.2E+6 3.3E+6 3.2E+6 3.9E+6 4.0E+6 4.6E+6
25th 1.4E+6 1.7E+6 1.9E+6 2.1E+6 2.0E+6 2.3E+6 2.3E+6 2.6E+6 2.7E+6 2.8E+6 3.1E+6 3.1E+6 3.6E+6 3.4E+6 4.2E+6
30th 1.4E+6 1.4E+6 1. 7E+6 1.9E+6 1.9E+6 2.1E+6 2.1E+6 2.5E+6 2.5E+6 2.4E+6 2.8E+6 2.9E+6 3.0E+6 3.4£+6 3.8E+6
40th 1.2E+6 1.3E+6 1.5E+6 1.6E+6 1.7E+6 1.8E+6 1.9E+6 2.1E+6 2.1E+6 2.3E+6 2.3E+6 2.5E+6 2.8E+6 3.0E+6 3.3E+6
50th 1.1E+6 1.1E+6 1.3E+6 1.4E+6 1.5E+6 1.6E+6 1.6E+6 1.8E+6 1.7E+6 2.0E+6 2.2E+6 2.0E+6 2.1E+6 2.7E+6 2.9E+6
60th 8.7E+5 1.0E+6 1.0E+6 1.3E+6 1.3E+6 1.3E+6 1.5E+6 1.6E+6 1.5E+6 1.8E+6 1.9E+6 1.8E+6 2.2E+6 2.3E+6 2.3E+6
70th 6.8E+5 8.4E+5 9.9E+5 1.0E+6 1.1E+6 1.2E+6 1.1E+6 1.3E+6 1.4E+6 1.6E+6 1.5E+6 1.6E+6 1.9E+6 2.0E+6 1.9E+6
75th 7.1E+5 8.1E+5 7.9E+5 9.9E+5 1.1E+6 1.1E+6 1.1E+6 1.2E+6 1.3E+6 1.2E+6 1.4£+6 1.5E+6 1.7E+6 1.8E+6 2.1E+6
80th 6.8E+5 6.6E+5 8.0E+5 9.4E+5 8.4E+5 9.2E+5 1.1E+6 1.2E+6 1.0E+6 1.2E+6 1.3E+6 1.4E+6 1.4E+6 1.7E+6 1.6E+6
85th 5.6E+5 6.5E+5 7.5E+5 7.6E+5 8.3E+5 9.0E+5 9.9E+5 9.3E+5 1.0E+6 1.2E+6 1.2E+6 1.3E+6 1.3E+6 1.6E+6 1.5E+6
90th 5.2E+5 5.9E+5 5.7E+5 7.1E+5 7.6E+5 8.1E+5 8.8E+5 8.2E+5 9.2E+5 1.0E+6 1.1E+6 1.1E+6 1.1E+6 1.4E+6 1.6E+6
95th 3. 7E+5 4.0E+5 4.9E+5 5.9E+5 6.1E+5 6.7E+5 7.2E+5 6.5E+5 7.2E+5 8.3E+5 8.9E+5 9.5E+5 1.1E+6 1.0E+6 1.2E+6
97.7th 3.3E+5 3.8E+5 4.4E+5 5.0E+5 4.6E+5 4.5E+5 5.2E+5 5.9E+5 6.5E+5 7.2E+5 7.6E+5 8.1E+5 8.0E+5 8.9E+5 1.0E+6

DEMAND (Fetal Head Circumference, in Percentile)

2.3rd 5th 10th 20th 25th 30th 40th 50th 60th 70th 75th 80th 90th 95th 97.7th
2.3rd 3.6E+6 3.9E+6 4.4E+6 4.9E+6 *** *** *** *** *** *** *** *** *** *** ***
CAPACITY (Maternal Circumference, in Percentile)

5th 2.9E+6 3.1E+6 3.5E+6 3.9E+6 4.1E+6 4.2E+6 4.5E+6 4.8E+6 5.1E+6 5.4E+6 5.7E+6 5.8E+6 *** *** ***
10th 2.3E+6 2.5E+6 2.7E+6 3.1E+6 3.2E+6 3.4E+6 3.5E+6 3.8E+6 4.0E+6 4.3E+6 4.5E+6 4.7E+6 5.2E+6 5.7E+6 6.2E+6
15th 2.0E+6 2.1E+6 2.4E+6 2.6E+6 2.8E+6 2.9E+6 3.1E+6 3.3E+6 3.5E+6 3.7E+6 3.9E+6 4.0E+6 4.4E+6 4.9E+6 5.3E+6
20th 1.8E+6 1.9E+6 2.1E+6 2.4E+6 2.5E+6 2.6E+6 2.8E+6 3.0E+6 3.1E+6 3.3E+6 3.5E+6 3.6E+6 4.0E+6 4.4E+6 4.7E+6
25th 1.6E+6 1.8E+6 1.9E+6 2.2E+6 2.3E+6 2.4E+6 2.5E+6 2.7E+6 2.8E+6 3.1E+6 3.2E+6 3.2E+6 3.7E+6 4.0E+6 4.4E+6
30th 1.5E+6 1.6E+6 1.8E+6 2.0E+6 2.1E+6 2.2E+6 2.3E+6 2.5E+6 2.6E+6 2.8E+6 2.9E+6 3.0E+6 3.3E+6 3.7E+6 4.0E+6
40th 1.3E+6 1.4E+6 1.5E+6 1.7E+6 1.8E+6 1.9E+6 2.0E+6 2.1E+6 2.2E+6 2.4E+6 2.5E+6 2.5E+6 2.9E+6 3.1E+6 3.4E+6
50th 1.1E+6 1.2E+6 1.3E+6 1.5E+6 1.6E+6 1.6E+6 1.7E+6 1.9E+6 2.0E+6 2.1E+6 2.2E+6 2.2E+6 2.5E+6 2.7E+6 3.0E+6
60th 9.5E+5 1.0E+6 1.2E+6 1.3E+6 1.4E+6 1.4E+6 1.5E+5 1.6E+5 1.7E+5 1.8E+6 1.9E+6 2.0E+6 2.2E+6 2.4E+6 2.6E+6
70th 8.2E+5 9.0E+5 1.0E+6 1.1E+6 1.2E+6 1.2E+6 1.3E+6 1.4E+6 1.5E+6 1.6E+6 1.7E+6 1.7E+6 1.9E+6 2.1E+6 2.3E+6
75th 7.5E+5 8.2E+5 9.2E+5 1.0E+6 1.1E+6 1.1E+6 1.2E+6 1.3E+6 1.4E+6 1.5E+6 1.5E+6 1.6E+6 1.8E+6 1.9E+6 2.1E+6
80th 6.9E+5 7.6E+5 8.4E+5 9.5E+5 9.8E+5 1.0E+6 1.1E+6 1.2E+6 1.3E+6 1.4E+6 1.4E+6 1.5E+6 1.6E+6 1.8E+6 2.0E+6
85th 6.2E+5 6.8E+5 7.6E+5 8.3E+5 9.0E+5 9.4E+5 1.0E+6 1.1E+6 1.1E+6 1.2E+6 1.3E+6 1.3E+6 1.5E+6 1.6E+6 1.8E+6
90th 5.3E+5 5.9E+5 6.6E+5 7.5E+5 7.9E+5 8.2E+5 8.8E+5 9.5E+5 1.0E+6 1.1E+6 1.1E+6 1.2E+6 1.3E+6 1.4E+6 1.6E+6
95th 4.3E+5 4.8E+5 5.4E+5 6.1E+5 6.4E+5 6.8E+5 7.1E+5 7.8E+5 8.3E+5 9.0E+5 9.3E+5 9.7E+5 1.1E+6 1.2E+6 1.3E+6
97.7th 3.5E+5 3.9E+5 4.4E+5 5.0E+5 5.3E+5 5.5E+5 6.1E+5 6.4E+5 6.9E+5 7.5E+5 7.8E+5 8.2E+5 9.0E+5 1.0E+6 1.1E+6

Fig. 12.15  Predicted pubovisceral muscle (PVM) state parameters
across the full range of pairings of maternal capacity-to-fetal head
demand are shown for τ2 values of 27  s (top panel), 550  s (middle
panel), and 11,000 s (bottom panel). The intensity of the (red) shading
indicates the extent by which the predicted injury threshold of 2.7 MPa
(PVM state parameter of 1) is exceeded. In the median table, the pre-
dicted PVM tear cutoffs for each of the other two tables are marked by
the dashed lines. Cells with ∗∗∗ denote labors predicted to exceed 24 h.
(For interpretation of the references to color in this figure legend, the
reader is referred to the web version of this article.) (From [20])

woman with the smallest pubovisceral muscle cross-­ the strength of the levator muscles, could be used to hyper-
sectional area, being 1.62 times too large, whereas it would trophy the pubovisceral muscle and its collagenous attach-
constitute only 72% of the maximum strength of those with ments such that they become more resistant to tensile
the largest muscles. This makes us wonder whether antena- failure during birth. For example, in one study we found a
tal pelvic floor exercise training, which is known to increase 10% hypertrophy in vastus type II fibers following 16 weeks
204 J. A. Ashton-Miller and J. O. L. DeLancey

Fig. 12.16 Sensitivity Distension curve sensitivity analysis: parameter Tau2

analysis showing the effect on 10
human dilation curves of a
1-decade decrease (green line)
and 1-decade increase (purple 9
line) for the τ2 constitutive
model parameter. The best fit
model is plotted in blue over 8
experimental human in vivo
distension data (gray). (From
7
[19])

Diameter (cm) 6

3
Device Distension

2 Model Maternal Capacity

.1 Tau2 Model Maternal Capacity

1 10 Tau2 Model Maternal Capacity

0
0 5 10 15 20 25 30 35 40 45
Time (min)

Fig. 12.17  The relationship 40

between fetal head descent
(abscissae, in cm) and the
resulting nerve strain
(ordinate, in percent) for the
four pudendal nerve branches.
IR denotes inferior rectal 30
nerve, per-AS perineal nerve
to the anal sphincter, per-L
perineal nerve to the levator
Nerve Strain (%)

ani, and per-US perineal

nerve to the urethral sphincter.
The nerves with the largest 20
predicted stretch during the
second stage of labor were the
first two. (From [23])

10

0
0 2 4 6 8 10
Fetal Head Descent (cm)

IR Per-AS Per-L Per-US

12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery 205

Soft
tissue loop

DEMAND (Fetal Head Circumference, in Percentile)

10 20 30 40 50 60 70 80 90
10 0.87 0.86 0.85 0.84 0.83 0.82 0.81 0.80 0.79
20 1.00 0.98 0.97 0.96 0.95 0.94 0.93 0.92 0.90
CAPACITY (Maternal

30 1.09 1.07 1.06 1.04 1.03 1.02 1.01 1.00 0.99

Circumference, in

Original (no
40
Percentile)

forceps) 1.16 1.14 1.13 1.11 1.10 1.09 1.08 1.07 1.05
50 1.23 1.21 1.19 1.18 1.17 1.15 1.14 1.13 1.11
60 1.29 1.27 1.25 1.24 1.23 1.22 1.20 1.19 1.17
70 1.36 1.33 1.32 1.30 1.29 1.28 1.27 1.25 1.23
80 1.44 1.41 1.39 1.38 1.37 1.35 1.34 1.32 1.30
90 1.54 1.51 1.49 1.48 1.46 1.45 1.43 1.42 1.39

DEMAND (Fetal Head Circumference, in Percentile)

10 20 30 40 50 60 70 80 90
10 0.86 0.84 0.83 0.82 0.82 0.81 0.80 0.79 0.78
20 0.98 0.97 0.95 0.94 0.93 0.93 0.92 0.90 0.89
CAPACITY (Maternal

Forceps (no 30 1.07 1.05 1.04 1.03 1.02 1.01 1.00 0.99 0.97
Circumference, in

indentation
Percentile)

of the fetal 40 1.14 1.12 1.11 1.10 1.09 1.08 1.06 1.05 1.03
head) 50 1.21 1.19 1.17 1.16 1.15 1.14 1.12 1.11 1.09
60 1.27 1.25 1.23 1.22 1.21 1.20 1.18 1.17 1.15
70 1.34 1.31 1.30 1.28 1.27 1.26 1.25 1.23 1.21
80 1.41 1.39 1.37 1.36 1.34 1.33 1.32 1.30 1.28
90 1.51 1.49 1.47 1.45 1.44 1.43 1.41 1.39 1.37

Fig. 12.18  The results of the simulation show that whether the forceps
indent the fetal head or not, the space-occupying nature of the forceps
within the urogenital hiatus has no meaningful effect on the risk for
cephalolevator disproportion. This suggests that forceps-related injuries
to the pubovisceral muscle (PVM) are instead likely associated with
either excessive traction force or traction force that is increased too rap-
idly for soft tissues to stretch without rupture. Given the demonstrated
viscoelastic nature of the PVM tissues, slowing the rate of application
of the traction force as much as is practical is advisable. (From [25])
206 J. A. Ashton-Miller and J. O. L. DeLancey

of progressive resistance training [27], and such training
could be expected to also hypertrophy the passive tissues in
series with the muscle.
12.9 E
 ffect of Maternal Pushing Styles
During the Second Stage
Many different variations of pushing styles are advocated by
clinicians during the second stage of labor. Some advocate
starting to push once the uterine pressure rises and sustaining
multiple pushes as long as the uterus is active, while others
suggest only pushing only when the mother feels the urge to
push, usually at the peak of the contraction. Because direct
experimental measurements are difficult to make in labor
without intrusive procedures, we used a mathematical model
to assess how they might compare from the point of view of
efficacy [28]. First, we modeled six different pushing styles,
whereby the mother generated increases in intra-abdominal
pressure at different points during the uterine contraction
(Fig. 12.19).
The results showed that while the triple-push pattern was
predicted to result in a 16% shorter second stage, with 59
volitional pushes, this came at the energetic expense of a
61% increase in the number of pushes required compared to
the peak push pattern, which only required 23 pushes
(Fig. 12.20). Since we know that the tensile stiffness of stri-
ated muscle increases about threefold when a muscle is
tensed, teaching the woman who is delivering without anes-
thesia not to contract her PVM during pushing would seem
to be important, because then the PVM are three times less
stiff and viscous; these are importat because minimizing
both attributes would make for considerably easier dilation
of the distal birth canal. In addition, a woman’s ability to
push with full force is limited by the onset of fatigue, so if
she becomes exhausted before the baby is born, then the
weakening of her efforts may necessitate assistance with for-
ceps or vacuum.

a b

20 20
Intraurethral pressure

Intraurethral pressure
(kPa)

(kPa)

0 0
0 1 2 3 0 1 2 3
c Time (min) d Time (min)

20 20
Intraurethral pressure

Intraurethral pressure
(kPa)

(kPa)

0 0
0 1 2 3 0 1 2 3

e Time (min) f Time (min)

20 20
Intraurethral pressure

Intraurethral pressure
(kPa)

(kPa)

0 0
0 1 2 3 0 1 2 3
Time (min) Time (min)

Fig. 12.19 (a–f) Illustration of the assumed time histories of the intrauterine pressure in the triple, peak, pre and peak, peak and post, pre and post
pushing patterns, respectively. (From [28]) ©Biomechanics Research Laboratory, University of Michigan
 12  Mechanisms of Pelvic Floor Trauma During Vaginal Delivery 207

80
Duration of labor (min)

60

40

20

0
Pre–and Peak and
Triple push Peak push Pre–push Post–push
peak push post–push
b

60
Numbers of voluntary pushes

40

20

0
Pre–and Peak and
Triple push Peak push Pre–push Post–push
peak push post–push

Fig. 12.20 (a) The predicted effect of the six different push patterns stage. (From [28], ©Biomechanics Research Laboratory, University of
(Fig. 12.18) on the duration of labor. (b) The estimated number of vol- Michigan)
untary pushes required for the different push patterns during the second

12.10 Conclusions
1. We have learned that simple models can yield powerful
insights to answer clinical questions and such models
are always our first choice before tackling a more com-
plicated model in order to address the effects of addi-
tional factors.
2. Based on our present understanding of the biomechanics
of the second stage of labor, the majority of women,
75%, can give birth to any fetal head size without risk
for cephalolevator disproportion and injury.
3. The minority of women, perhaps 5%, will need instru-
mented delivery, but this likely increases with advancing
age over 32 years. Why deserves further study.
4. The remaining 20% are in a gray zone in which obstetri-
cal and biomechanical factors interact to determine
whether the second stage will be successfully concluded
within a reasonable time and without a levator injury.
5. It is not yet possible to predict before labor which
women will sustain pubovisceral muscle injuries during
birth, but this is a fruitful area for future research. We
believe combining biomechanical models with ultra-
sound imaging input holds promise in this regard.
6. The tissues forming the distal birth canal are viscoelastic
in nature. That is to say that under a constant dilation
force, they stretch elastically at first and then continue to
dilate further at an initially rapid rate that decreases
exponentially with time. By the same token, they take
time to return to their original length, even after the
force is removed. There is a truly remarkable variation
in how rapidly these tissues dilate in healthy women.
The hormonal mechanisms underlying these changes
are poorly understood and deserve to be studied in the
future.
7. The biomechanical models of the second stage of labor
correctly describe when, where, and why injury is most
likely to occur: at the origin of the pubovisceral muscle
near the end of the second stage due to excessive stretch.
8. Clinicians intuitively know to slow the rate of delivery
as the fetal head crowns, and this intuition is supported
208
by biomechanical principles that the soft tissues, being
viscoelastic, are sensitive to strain rate.
9. The origin and architecture of the puborectal muscle
mean that it is almost never injured during birth, whereas
the more cranial origin of the pubovisceral muscle
means that it has to wrap around the pubic rami as the
perineum descends. This, along with its short starting
length of ~75 mm, means the pubovisceral muscle has to
stretch more than any other levator muscle for the fetal
head to pass through the urogenital hiatus.
10. The most common known injury zone is at or near the
origin of the pubovisceral muscle, as revealed by MR
and ultrasound imaging. There may be other tissues that
are susceptible to injury, but those tissues and their
mechanisms of injury remain to be elucidated.
11. Forceps do not cause levator ani injury due to space occu-
pying space in the urogenital hiatus. That leaves the alter-
native hypothesis to be tested that the maximal traction
force either leads to forces that exceeds the ultimate
strength of the tissues being stretched or is applied too rap-
idly leading to the ultimate strength being exceeded
because of the rate-sensitive nature of viscoelastic tissues.
12. The most efficient pushing pattern during the second
stage is for the mother to push for 10 s during the peak
uterine contraction. This results in delivery in the fewest
pushes.
13. There is presently a lack of biomechanical data on the
injury criterion for the soft tissues comprising the distal
birth canal.
14. Antenatal pelvic floor exercise training is known to
increase pubovisceral muscle strength, and much of this
could be due to better coordination. How much such
training is required to actually hypertrophy the muscle is
unknown.
15. We believe that taking into account biomechanical prin-
ciples is most helpful in attempting to understand why
levator muscle injuries occur during birth. Once we have
a better understanding, we can develop targeted inter-
ventions to better prevent them.
Take-Home Message
• Stretching the viscoelastic tissue of the distal birth
canal slowly will decrease the risk of injury because
of the phenomenon of stress relaxation. The corol-
lary is that stretching it rapidly will increase the risk
of injury, a caveat to those managing labor or using
forceps.
• Most, 75%, of women can give birth to any fetal
head size without risk of injury, but 20% will need
special attention to reduce the risk of injury. Better
methods are needed to identify these women with a
simple antenatal test.
J. A. Ashton-Miller and J. O. L. DeLancey
Acknowledgements We gratefully acknowledge the many talented
students and trainees whose work this chapter really represents and
funding from the National Institutes of Health grant P50 HD044406.
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delivery. Obstet Gynecol. 2004;104(2):327–35.
23. Lien KC, Morgan DM, Delancey JO, Ashton-Miller JA. Pudendal
nerve stretch during vaginal birth: a 3D computer simulation. Am J
Obstet Gynecol. 2005;192(5):1669–76.
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24. Shek KL, Dietz HP.  Intrapartum risk factors for levator trauma.
BJOG. 2010;117(12):1485–92.
25. Tracy PV.  On the prediction of pelvic floor muscle injury dur-
ing vaginal delivery in nullipara: anthropometric and viscoelas-
tic biomechanical analyses (PhD thesis). University of Michigan
Department of Biomedical Engineering, Ann Arbor, MI. 2017.
26. Masteling M, Ashton-Miller JA, DeLancey JOL. Technique devel-
opment and measurement of cross-sectional area of the pubovis-
ceral muscle on MRI scans of living women. Int Urogynecol J.
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27. Claflin DR, Larkin LM, Cederna PS, Horowitz JF, Alexander NB,
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 Posterior Compartment Trauma
and Management of Acute Obstetric
Anal Sphincter Injuries
Abdul H. Sultan and Ranee Thakar
Learning Points
• Obstetric anal sphincter injuries can have a devas-
tating effect on a woman’s quality of life.
• Endoanal ultrasound has highlighted that a significant
number of such injuries are being missed at the time of
delivery and therefore focused training of doctors and
midwives in digital rectal examination is mandatory.
• Appropriate classification of the injury and separate
repair of the disrupted internal and external anal
sphincter is important to achieve the best outcome.
13.1 Introduction
The posterior compartment consists of all the structures that
include the posterior vaginal wall and structures posterior to
it. During the process of vaginal delivery, fascia, muscles,
and nerves may be stretched or disrupted. While these
changes could be attributed to the physiological process of
childbirth, in some women they can lead to pathological
events with long-term consequences. Obstetric trauma to the
posterior compartment has been implicated in the develop-
ment of rectoceles, perineoceles, and fecal incontinence.
However, as many women who develop these conditions
tend to present many years after childbirth, either a direct
link to its causation is not considered or it is attributed to the
effects of aging or the menopause. As much of this is already
covered in the previous chapter, this chapter will concentrate
A. H. Sultan (*)
Urogynaecology and Pelvic Floor Reconstruction Unit
Croydon University Hospital, St George’s University of
London, London, UK
e-mail: asultan29@gmail.com
R. Thakar
Department of Obstetrics and Gynaecology, Croydon University
Hospital, Croydon, Surrey, UK
e-mail: raneethakar@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_13
13
on the pathological effects of childbirth on the posterior
compartment.
13.2 Rectoceles
The definition, etiology, and pathophysiology of rectoceles
are not fully understood. A rectocele is an out-pocketing of
the anterior rectal wall into the lumen of the vagina [1].
Although obstetric trauma and defecatory disorders have
been implicated, a rectocele can be identified in both asymp-
tomatic and nulliparous women [2]. Women may present
only when they become symptomatic, which could be many
years after childbirth.
A rectocele may be the result of over distensibility of an
intact rectovaginal septum, disruption of the perineal mem-
brane, and detachment from the perineal body (Fig. 13.1),
perineal hypermobility, or protrusion as a result of a defi-
cient perineum. Dietz and Steensma [3] conducted a pro-
spective study of 68 nulliparous pregnant women and
performed translabial ultrasound during pregnancy, repeat-
ing it between 2 and 6 months postpartum. A defect of the
rectovaginal septum was diagnosed if there was a disconti-
nuity in the anterior anorectal muscularis of ≥10  mm in
depth. Sonographic defects were identified in 2 of the 68
women before and in 8 of the 52 after childbirth. However,
4 of the 58 women were asymptomatic. The authors con-
cluded that childbirth does play a role, as there were some
de novo defects, while other defects enlarged after delivery.
This would suggest that vaginal delivery can cause disrup-
tion of the rectovaginal fascia. However, larger clinical stud-
ies are awaited that may identify obstetric risk factors such
as baby weight, episiotomy, instrumental delivery, etc. It
remains to be established whether modification of obstetric
practice, and in particular meticulous restoration of the peri-
neal and vaginal anatomy when repairing episiotomies and
genital lacerations, may minimize the development of recto-
celes. A deficient perineum or even a cloacal-like defect
may occur if the perineal muscles are not repaired ade-
211
212 A. H. Sultan and R. Thakar

a b c

Fig. 13.1  Diagrammatic representation (a) and photo (b) of a rectocele following disruption of the rectovaginal fascia and detachment from the
perineal body with widening of the genital hiatus and herniation of the rectum. (c) Photograph demonstrating a deficient perineum (arrow)

quately particularly if repair of the ruptured anal sphincter is Longitudinal Circular

also not repaired adequately. Surgical repair techniques are smooth muscle smooth
muscle
Rectum
described in Chap. 37.

13.3 O
 bstetric Anal Sphincter Injuries
(OASIS)

Obstetric anal sphincter injuries (OASIS) are reported to 3a

Internal
anal
occur in 2.9% (6.1% in primiparae) of woman in centers sphincter
3b
where mediolateral episiotomies are practiced [4], compared External
anal
to 12% [5] (19% in primiparae) [6] in centers practicing mid- 3c
sphincter

line episiotomy. However, rates as high as 7.5% have been 4

reported in centers practicing mediolateral episiotomy, sug- Anus

gesting increased awareness, training, and improvement in
recognition of OASIS [7, 8]. However, despite recognition
and primary repair of acute OASIS, 39% of those diagnosed
have symptoms of anal incontinence, and persistent anal
sphincter defects have been identified on ultrasound in
34–91% within 3 months of delivery [9].
Pudendal neuropathy following vaginal delivery has also
been implicated as a cause of incontinence, but prospective
studies have shown that the vast majority of women suffer
some degree of neuropraxia that recovers with time [10], or
reinnervation occurs [11].
In order to standardize the classification of perineal
trauma, Sultan [12] proposed the following classification
that has been adopted widely since 2002 including the Royal
College of Obstetricians and Gynaecologists [13], American
College of Obstetricians and Gynecologists [14], and inter-
national societies [15, 16] (Fig. 13.2).
Fig. 13.2  Diagrammatic representation of the anal sphincters demon-
strating the Sultan classification of major degrees of perineal tears (3a–
c and 4). Reproduced from [9], with permission
13.3.1 Applied Anatomy and Physiology
The anal canal measures about 3.5 cm in length, but in the
female is shorter in its anterior aspect by 0.5–1 cm. The exter-
nal anal sphincter (EAS) is made up of striated muscle that is
subdivided into subcutaneous, superficial, and deep and is
responsible for voluntary squeeze and reflex contraction pres-
sure (Fig. 13.2). It is innervated by the pudendal nerve, which
is a mixed sensory and motor nerve. The internal anal sphinc-
ter (IAS) is a thickened continuation of the circular smooth
13  Posterior Compartment Trauma and Management of Acute Obstetric Anal Sphincter Injuries
muscle of the bowel. It contributes about 70% of the resting
pressure and is under autonomic control. It is separated from
the EAS by the conjoint longitudinal muscle that is a continu-
ation of the longitudinal smooth muscle of the bowel. As
shown in Fig. 13.2, the subcutaneous EAS lies at a lower level
than the IAS, but during regional or general anesthesia, the
paralyzed EAS lies almost at the same level as the IAS.
Damage to the EAS results in fecal incontinence, which is
usually associated with urgency, and damage to the IAS is
usually associated with flatus incontinence and passive soil-
ing. However, damage to both sphincters can occur, giving
rise to mixed symptoms.
13.3.2 Diagnosis of OASIS
A careful vaginal and rectal examination must be performed in
all women who have undergone a vaginal delivery. In order to
do this, there must be adequate exposure, good lighting, and
analgesia [13, 15]. OASIS cannot be excluded without perform-
ing a proper rectal and vaginal examination (Fig. 13.3), as third-/
fourth-degree tears can occur despite an apparent intact
perineum [17]. The IAS is thinner and paler than the striated
EAS.  The appearance of the IAS can be described as being
analogous to the flesh of raw fish, as opposed to the red meat
appearance of the EAS. The EAS is demarcated laterally by the
perianal fat, an important landmark in identification of the EAS.
13.3.3 Repair of OASIS
In 1930, Royston described a commonly practiced technique
in which the ends of the torn sphincter were approximated by
Fig. 13.3  A partial tear along the length of the external anal sphincter
(EAS) (arrow) that could be missed without a rectal examination.
Reproduced from [9], with permission
213
inserting a deep catgut suture through the inner third of the
sphincter muscle and a second set through the outer third of
the sphincter [18]. In 1948, Kaltreider and Dixon described
their series of women since 1935 in whom one mattress or
figure-of-eight suture was used [19]. Fulsher and Fearl
described a technique in which sutures were inserted in the
fascial sheath or capsule of the anal sphincter, and no sutures
were allowed to pass through the sphincter muscle [20].
More specifically, Cunningham and Pilkington described
inserting four interrupted sutures in the capsule of the EAS at
the anterior, posterior, superior, and inferior points [21]. The
end-to-end approximation type of repair has been the stan-
dard and is still used widely. However, in 1999, Sultan et al.
[22] explored the overlap technique of primary repair of the
EAS (as described by Parks and McPartlin for secondary
sphincter repair [23]). In addition, Sultan et al. highlighted
the importance of recognition and separate repair of the
freshly torn IAS, which is largely responsible for maintain-
ing the resting tone of the anal sphincter, as persistent IAS
injury is associated with incontinence of flatus and passive
soiling [22].
The morbidity associated with perineal trauma depends
on the extent of perineal damage, technique and materials
used for suturing, and the skill of the operator. Practitioners
should therefore be adequately trained and adopt evidence-­
based techniques during perineal repair.
Repair should be conducted in the operating room where
there is access to good lighting, appropriate equipment, and
aseptic conditions. A specially prepared instrument tray con-
taining a Weitlander self-retaining retractor, four Allis tissue
forceps, McIndoe/Metzenbaum dissecting scissors, tooth
forceps, two artery forceps, stitch-cutting scissors, and a
needle holder is useful (www.perineum.net).
A general or regional (spinal, epidural, caudal) anes-
thetic will provide analgesia as well as muscle relaxation,
which is an important prerequisite to enable proper evalua-
tion of the full extent of the injury. As the EAS is a striated
muscle ring, under tonic contraction, the torn muscle ends
are prone to retract within its capsular sheath. Adequate
muscle relaxation allows the torn ends of the EAS to be
grasped and retrieved. This would enable repair of the torn
muscles without tension, especially if the intention is to
overlap the EAS [9].
Repair of OASIS should only be conducted by a doctor
who has been formally trained (or under supervision) in pri-
mary anal sphincter repair. In view of the observed subopti-
mal outcome associated with primary anal sphincter repair
when performed by obstetricians with varying degrees of
experience, it has been suggested that perhaps a repair per-
formed by colorectal surgeons may be associated with a bet-
ter outcome [24, 25]. Kairaluoma et  al. reported on 31
consecutive women who sustained OASIS (third and fourth
degree) [26]. All had an EAS overlap repair immediately
214
after delivery, performed by two colorectal surgeons. In
addition to end-to-end repair of the IAS, they also performed
a levatorplasty, to approximate the levator ani muscle in the
midline, with two sutures. At a median follow-up of 2 years,
23% complained of anal incontinence, 23% developed
wound infection, 27% complained of dyspareunia, and 1
developed a rectovaginal fistula. Thus, the outcome was no
better when the repair was conducted by colorectal sur-
geons. Furthermore, in a survey of colorectal practice in the
UK, only 6.7% of colorectal surgeons reported that they
performed more than 10 acute repairs per year; 60% had
never performed an acute sphincter repair; and 30% per-
formed less than five per year [27]. It is therefore not sur-
prising that only 19% of colorectal surgeons believed that
they should be involved in the acute management of OASIS
[27]. Therefore, the repair should be carried out by the most
experienced obstetrician on the labor ward, who encounters
this problem more frequently and is skilled in suturing the
extensive vaginal tears that can often accompany
OASIS. However, in a previous survey of candidates (mainly
obstetricians) attending a hands-on workshop on repair of
OASIS, only 13% were satisfied with their level of experi-
ence prior to performing their first unsupervised repair [28].
This highlighted the urgent need for structured and focused
training in this area.
13.3.4 Timing of Repair
Nordenstam et  al. conducted a randomized study in which
they found no difference in anal incontinence 12  months
after primary repair when women who had repair immedi-
ately after the tear were compared to those whose repair was
delayed for 8–12 h [7]. They concluded that there is no justi-
fication for delaying suturing. However, a delay in repair
may be justified in exceptional circumstances when an expe-
rienced obstetrician is not available.
13.3.5 Technique of Repair
In the presence of a fourth-degree tear, the torn anal epithe-
lium is repaired with interrupted sutures with the knots tied
in the anal lumen using Vicryl (polyglactin) or Vicryl Rapide
3-0 (Fig.  13.4). This technique has been widely described,
and proponents of the technique argue that by tying the knots
outside, the quantity of foreign material within the tissues
would be reduced and hence reduce the risk of infection.
However, this concern probably applies to the use of catgut
that dissolves by phagocytosis, as opposed to the newer syn-
thetic material such as Vicryl that dissolves by hydrolysis. A
subcuticular repair of the anal epithelium via the transvagi-
A. H. Sultan and R. Thakar
Fig. 13.4  Repair of the torn anal epithelium using a continuous Vicryl
3-0 suture (pig model)
nal approach has also been described and could be equally
effective provided the terminal knots are secure [9, 13, 29].
The IAS should be identified and, if torn, repaired sepa-
rately from the EAS [9, 13]. An end-to-end repair should be
performed with interrupted mattress sutures [9, 13]
(Fig. 13.5). An association between IAS defects and severe
symptoms of fecal incontinence 3  months after sustaining
OASIS has been demonstrated [30]. Furthermore, the size of
the IAS defect on ultrasound after primary repair of OASIS
appears to be related to the severity of symptoms [31].
However, during secondary sphincter repair, the ends of the
torn IAS are difficult to identify as they retract at the time of
injury and the gap is replaced by scar tissue. Consequently,
repair is invariably inadequate or impossible, highlighting
the importance of recognition and primary repair of the IAS
at the time of delivery.
When the EAS is only partially torn (grade 3a and some
3b), an end-to-end repair should be performed using two or
three mattress sutures instead of hemostatic “figure-of-eight”
sutures that can cause ischemia. If there is a full-thickness
EAS tear (some 3b, 3c, or fourth degree), either an overlap-
ping (Fig. 13.6) or end-to-end method can be used [13]. A
true overlap can only be performed if the two ends of the
EAS are completely torn along its full length and thickness
[32]; otherwise the residual fibers may need to be divided
before an overlap repair is performed, but this is not recom-
mended. A Cochrane review [33] including six randomized
studies showed that at 1-year follow-up, immediate primary
overlap repair of the external anal sphincter compared with
immediate primary end-to-end repair appeared to be associ-
ated with lower risks of developing fecal urgency and anal
incontinence symptoms. At the end of 36  months, there
appeared to be no difference in flatus or fecal incontinence
between the two techniques. However, since this evidence
13  Posterior Compartment Trauma and Management of Acute Obstetric Anal Sphincter Injuries 215

Fig. 13.5 (a) The torn ends of the internal sphincter being held by Allis forceps (E = external sphincter) and (b) repaired using mattress PDS 3-0
sutures. Reproduced from [9], with permission

length [36], and it has been shown that a shorter anal canal
length after primary repair is associated with a poorer out-
come [37]. After repair of the sphincter, the perineal muscles
should be sutured to reconstruct the perineal body, in order to
provide support to the repaired anal sphincter [9].

13.3.6 Repair of Rectal Buttonhole Tear

A rectal buttonhole tear is an acute tear between the vagina

and rectum that occurs during a vaginal delivery (similar to a
rectovaginal fistula that is diagnosed later) with intact anal
sphincters (Fig.  13.7). Isolated rectal buttonhole tears are
rare, and there is very little description in the literature
regarding it’s etiology, incidence, and repair. It is estimated
to occur in 1 in 8000 to 12,000 vaginal deliveries. The cause
Fig. 13.6  Overlap of the external anal sphincter (EAS, repair; AE anal
epithelium, IAS internal anal sphincter). Reproduced from [9], with
of buttonhole tears are not known but may be due to:
permission
(a) Ischemia of the vaginal/rectal mucosa due to impacted
head. This is not seen in the western world as this is a
was based on only two small trials, more research evidence result of obstructed labor for almost a day or more.
is needed in order to confirm or refute these findings. (b) Inadvertent incision of the rectum with scissors during
Two subsequent studies have reported excellent results an episiotomy.
using the overlap technique [34, 35], but long-term ­follow-­up (c) Injury during the forceps delivery.
is required. The single most important predictor of inconti- (d) No known explanation as it can also happen during a
nence following secondary repair is postoperative anal canal normal delivery.
216
Rectal
Buttonhole
tear
Intact
Anal
sphincter
Sultan©
Fig. 13.7  A rectal buttonhole tear with an intact external anal sphincter
demonstrated during a digital rectal examination
This is best repaired via the transvaginal approach. The
proximal and distal ends of the rectal mucosa must be
­identified, and the mucosa should be repaired using a con-
tinuous 3-0 Vicryl suture. To minimize the risk of the devel-
opment of a rectovaginal fistula, a second layer of tissue
should be interposed between the rectum and vagina by
approximating the rectovaginal fascia before suturing the
vaginal skin. A colostomy is rarely indicated unless there is
a large tear extending above the pelvic floor or there is gross
fecal contamination of the wound [9].
13.3.7 Suture Material
The anal epithelium is repaired using Vicryl 3-0. The sphinc-
ter muscles are repaired with either monofilament fine
sutures such as 3-0 PDS (polydioxanone) or modern braided
sutures such as 2-0 Vicryl (polyglactin), as these may cause
less irritation and discomfort with equivalent outcome.
Complete absorption of PDS takes longer than Vicryl, with
50% tensile strength lasting more than 3 months compared to
3  weeks, respectively [38]. To minimize suture migration,
care should be taken to cut the suture ends short and ensure
that they are covered by the overlying superficial perineal
muscles. Williams et al. [38] performed a factorial random-
ized controlled trial (n  =  112), in which women were ran-
domized into four groups: overlap with polyglactin (Vicryl;
Ethicon, Edinburgh, UK), end-to-end repair with Vicryl,
overlap repair with polydioxanone (PDS; Ethicon, Edinburgh,
UK), and end-to-end repair with PDS [34]. This trial was
A. H. Sultan and R. Thakar
specifically designed to test a hypothesis regarding suture-­
related morbidity (need for suture removal due to pain, suture
migration, or dyspareunia) using the two techniques. At
6 weeks there were no differences in suture-related morbid-
ity between the different groups.
13.3.8 Role of Antibiotics
In a prospective, randomized placebo controlled study of
patients who had sustained OASIS (n  =  147), it has been
shown that patients who received a single dose of intrave-
nous second-generation cephalosporin had a significantly
lower risk of perineal complications (8% compared to 24%)
compared to placebo by 2  weeks after the repair [39]. We
prescribe intravenous broad-spectrum antibiotics such as
cefuroxime 1.5 g and metronidazole 1 g intraoperatively and
continue this antibiotic regime orally for up to 3 days.
13.3.9 Stool Softeners
Constipation should be avoided, as passage of constipated
stool, or indeed fecal impaction requiring manual evacuation,
may disrupt the repair, and the majority consensus in the litera-
ture is that stool softeners should be prescribed [29]. Mahony
et al. performed a randomized trial (n = 105) of constipating
versus laxative regimens and found that the use of laxatives
was associated with a significantly earlier and less painful first
bowel motion, as well as earlier discharge from hospital [40].
Nineteen percent in the constipated regimen group experienced
troublesome constipation (two required hospital admission for
fecal impaction) compared to 5% in the laxative regimen group.
There were no significant differences in continence scores, anal
manometry, or endoanal scan findings.
A randomized study [41] has indicated that stool bulking
agents such as ispaghula husk (Fybogel) should be avoided,
as the authors found that incontinence occurred significantly
more often (33% vs. 18%) when lactulose and Fybogel were
consumed compared to lactulose only. We recommend lactu-
lose 15  ml twice a day for 10  days, but the dose could be
modified according to the stool consistency.
13.3.10  Postoperative Catheterization
Severe perineal discomfort, particularly following instru-
mental delivery, is a known cause of urinary retention, and
following regional anesthesia, it can take up to 12 h before
full bladder sensation returns. A Foley catheter should be
inserted for up to 24 h unless medical staff can ensure that
spontaneous voiding occurs at least every 3–4  h without
undue bladder overdistension.
13  Posterior Compartment Trauma and Management of Acute Obstetric Anal Sphincter Injuries 217

13.3.11  Postoperative Analgesia
The degree of pain following perineal trauma is related to the
extent of the injury, and OASIS are frequently associated
with other more extensive injuries such as paravaginal tears.
In a systematic review, Hedayati et al. found that rectal anal-
gesia such as diclofenac is effective in reducing pain from
perineal trauma within the first 24  h after birth [42]. In
women who had a repair of a fourth-degree tear, diclofenac
should be administered orally, as insertion of suppositories
may be uncomfortable, and there is a theoretical risk of poor
healing associated with local anti-inflammatory agents.
Codeine-based preparations are best avoided as they may
cause constipation leading to excessive straining and possi-
ble disruption of the repair.
13.3.12  Follow-Up
Ideally, these women should be under the care of a specialist
team, e.g., a perineal clinic, and follow-up should be about
8–12 weeks after delivery. The perineal clinic is viewed as a
supportive environment, and women feel confident about the
information provided by the team [43]. An information
booklet should be given to these women to ensure that they
understand the implications of sustaining OASIS and also to
provide information as to where and when to seek help if
symptoms of infection or incontinence develop. There is no
consensus of opinion on when pelvic floor and anal sphincter
exercises are best initiated, although it is recommended that
they should be commenced when the discomfort resolves
and the woman feels comfortable. Neels et al. found that the
intensity of pain during pelvic floor exercises is low (visual
analogue score = 2) and their results showed that fear of peri-
neal pain should not discourage women to start pelvic floor
muscle training shortly after childbirth [44]. Mathé et al. rec-
ommended early pelvic floor exercises to be commenced
within 30 days of delivery [45].
reported that only 9% of women have symptoms of anal
incontinence at 6  months follow-up [47]. Ramage et  al.
have shown that with recent repair techniques, favorable
outcomes can be achieved irrespective of the grade of
tear [48].
13.3.14  Management of Subsequent
Pregnancies
There are no randomized studies to determine the most
appropriate mode of delivery following a third-/fourth-­
degree tear. At the first postpartum visit, a careful vaginal
and rectal examination should be performed to check for
complete healing, scar tenderness, and sphincter tone. In
order to counsel women with previous third-/fourth-degree
tears appropriately, we find it useful to have a symptom ques-
tionnaire along with anal ultrasound (Fig. 13.7) and manom-
etry results. If vaginal delivery is contemplated, then these
tests should be performed during the current pregnancy.
Figure  13.8 presents a simple flow diagram demonstrating
the management of subsequent delivery after OASIS that we
follow in our unit [49]. One study has shown that if a large
sonographic defect (more than one quadrant) is present, or if
the squeeze pressure increment (above resting pressure) is
less than 20 mmHg, then the risk of impaired continence dra-
matically increases after a subsequent delivery [50]. We con-
ducted a prospective study over a 5-year period and found
that if there is no evidence of significant compromise of anal

13.3.13  Anal Incontinence Symptoms After

Primary Repair

Older studies with a variable follow-up have shown that

almost 40% of women who have a primary sphincter repair
have symptoms of persistent anal incontinence [9]. Women
who have asymptomatic anal sphincter defects following a
repair in the short term are at high risk of developing
symptoms of anal incontinence in the longer term [46].
More recent studies that have used the Sultan classification
of tears [12–16], with repair of the internal and external
Fig. 13.8  Endoanal scan image showing overlap (arrows) of the exter-
sphincter when indicated by trained doctors, have shown nal anal sphincter (E). I internal anal sphincter, A anal epithelium.
more favorable outcomes. Ramalingam and Monga Reproduced from [9], with permission
218 A. H. Sultan and R. Thakar

sphincter function, a subsequent vaginal delivery is not asso-
ciated with subsequent deterioration in function or symp-
toms [51]. We were therefore able to encourage asymptomatic
women who have minimal compromise of their anal sphinc-
ter function to have a vaginal delivery. Other studies have
found similar results, and based on these criteria, 70% of
women with previous OASIS go on to have a vaginal deliv-
ery [49, 52, 53] (Fig. 13.9).
These women should be counseled that they have an 88%
[6] (in centers practicing midline episiotomy) to 93% [4] (in
centers practicing mediolateral episiotomy) chance of not
sustaining recurrent OASIS. If an episiotomy is considered
necessary, e.g., because of a thick inelastic or scarred
perineum, a mediolateral episiotomy should be performed.
There is emerging evidence that routinely performed episi-
otomies prevent recurrence of OASIS [54]. The threshold at
which these women may be considered for a cesarean sec-
tion may be lowered if a traumatic delivery is anticipated,
e.g., in the presence of one or more additional relative risk
factors, such as a large baby, shoulder dystocia, prolonged
labor, or difficult instrumental delivery. However, in decid-
ing the mode of delivery, counseling (and its clear documen-
tation) is extremely important. Some of these women who
have sustained OASIS may be scarred both physically and

Management of pregancy after OASIS

Perineal clinic

Anorectal manometry
Endoanal ultrasound

Symptomatic Asymptomatic

Normal anal Abnormal (EAS Normal anal Abnormal (EAS

manometry and defect>1hr; Incremental manometry and defect>1hr; Incremental
endoanal ultrasound MSP <20mmHg) endoanal ultrasound MSP <20mmHg)

Vaginal delivery Conservative management

1. Dietary advice
2. Regulate bowel action Vaginal delivery
3. Constipating agents
- Codeine phosphate
- Loperamide
4. PFE & biofeedback

Severe Mild

Caesarian section
Family not complete Family complete

Vaginal delivery Secondary sphincter repair

Fig. 13.9  Flowchart of a suggested management of OASIS in a subsequent pregnancy [49]. EAS external anal sphincter, MSP maximal strength
pressure, PFE pelvic floor excercise
13  Posterior Compartment Trauma and Management of Acute Obstetric Anal Sphincter Injuries
emotionally and may find it difficult to cope with the thought
of another vaginal delivery. These women will require sym-
pathy, psychological support, and serious consideration of
their request for cesarean section.
Women who have minor degrees of incontinence (fecal
urgency or flatus incontinence) may be controlled with
dietary advice, constipating agents (loperamide or codeine
phosphate), physiotherapy, or biofeedback. These women
who have some degree of anal sphincter compromise
(Fig.  13.8) but whose symptoms are controlled should be
counseled and recommended a cesarean section.
Women who sustained a previous third-/fourth-degree
tear with subsequent severe incontinence and have failed
conservative management should be offered secondary
sphincter repair by a colorectal surgeon (or a urogynecolo-
gist with expertise in secondary sphincter repair), and all
subsequent deliveries should be by cesarean section. Some
women with fecal incontinence may choose to complete
their family before embarking on anal sphincter surgery. It
remains to be established whether these women should be
allowed a vaginal delivery, but it is likely that the damage
has already occurred and the risk of further damage is mini-
mal and possibly insignificant in terms of the outcome of
surgery. The benefit, if any, should be weighed against the
risks associated with cesarean section for all subsequent
pregnancies. Women who have had a previous successful
secondary sphincter repair for fecal incontinence should be
delivered by cesarean section [55]. Clearly there are going
to be women who do not entirely fit into any of the above
categories, e.g., those who have isolated internal sphincter
defects or those who have irritable bowel syndrome. The
management of these women should be individualized, and
a mutual decision should be made taking into account the
symptoms, examination findings, and results of the
investigations.
If there are no facilities for anal manometry and endo-
sonography, then the management will depend on symptoms
and clinical evaluation. In the absence of scientific evidence,
it would appear reasonable that asymptomatic women with-
out any clinical evidence of sphincter compromise as deter-
mined by assessment of anal tone could be allowed a vaginal
delivery. All women who are symptomatic should be referred
to a center with facilities for anorectal assessment and should
be counseled for cesarean section.
13.3.15  Training Issues
It has been shown that up to half of OASIS are not recog-
nized by the obstetrician or midwife [56, 57]. Inadequate
training of doctors and midwives in perineal and anal
sphincter anatomy [58] is believed to be a major contrib-
uting factor. In a survey of 75 doctors and 75 midwives in
219
the UK, Sultan et al. demonstrated inconsistencies in the
classification of perineal trauma, as one-third of doctors
were classifying third-degree tears as second-degree [58].
Most trainee doctors admitted that their training in recog-
nizing (84%) and repairing (94%) OASIS was poor.
Furthermore, in another older study, 64% of consultants
reported unsatisfactory or no training in the management
of OASIS [27]. OASIS that were previously believed to be
occult injuries [10] have now been proven to be undiag-
nosed injuries that could have been diagnosed clinically
by a trained clinician [56]. McLennan et  al. also raised
concern about training in the USA [59]. They surveyed
1177 4-year residents and found that the majority had
received no formal training in pelvic floor anatomy, episi-
otomy, or perineal repair and supervision during perineal
repair was limited. Similarly, Uppal et  al. demonstrated
that ob-gyn residents demonstrated substandard skill in
repairing anal sphincter laceration. Only 42.5% passed
their evaluation criteria, 42.5% suggesting a lack of ade-
quate training in repair [60].
A recent survey of candidates attending a hands-on train-
ing course using a latex model and fresh animal tissue has
shown that training in this fashion was useful in diagnosis
and repair of OASIS [28]. Siddighi et al. demonstrated that
residents in obstetrics and gynecology who underwent a
structured training workshop improved their surgical ability
with respect to managing OASIS [61]. As the occurrence of
OASIS is unpredictable and unplanned, and opportunities
for trainees to repair these injuries under authentic circum-
stances are few, a hands-on workshop in conjunction with
competency-based training appears to be the best way for-
ward (www.perineum.net).
13.4 Conclusions
Obstetric trauma to the posterior compartment can result in
pelvic floor denervation, disruption of the fascial supports,
and injury to the anal sphincter. Injuries to the anal sphinc-
ter can give rise to anal incontinence, and therefore accu-
rate detection and diagnosis of the full extent of the injury
are mandatory at delivery. Repair should be conducted by a
trained clinician, and the aim should be to restore the nor-
mal high-pressure zone of the anal canal represented by the
anal length. Failure to identify and repair the internal
sphincter at the time of the acute injury will increase the
risk of fecal incontinence and jeopardize the ability to
repair it at a later date. Attention needs to be focused on
training of doctors and midwives internationally in the
identification and repair of OASIS. Failure to recognize the
full extent of the injury and repair, it appropriately can have
devastating long-term consequences to the quality of life of
women [62, 63].
220
Take-Home Messages
• OASIS and rectal buttonhole tears cannot be
excluded without a rectal examination, and there-
fore every woman who undergoes a vaginal deliv-
ery must have a rectal examination.
• The injury should be classified as described above
to ensure that the full extent of the injury is
recognized.
• Repair should be conducted in a systematic
approach by a competent doctor.
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 Neurogenic Trauma During Delivery
Kimberly Kenton and Julia Geynisman-Tan
Learning Objectives
• There is a bimodal peak in pelvic floor disorders
following delivery and then again 15 years follow-
ing the event.
• Be able to describe the three types of peripheral
nerve injury and their respective recovery
timelines.
• Levator ani avulsion compounds the deleterious
effects of nerve injury on the pelvic floor.
14.1 Introduction
Several large, population-based studies report that a wom-
an’s lifetime risk of a pelvic floor disorder (urinary inconti-
nence, fecal incontinence, or pelvic organ prolapse) is 25%
[1, 2] and that her lifetime risk of surgery for a pelvic floor
disorder may be as high as 20% [3, 4]. Pregnancy and child-
birth are well-established risk factors for developing pelvic
floor disorders as evidenced by the fact that one third of
women report stress urinary incontinence within 1–5 years
of their first delivery.
A recent longitudinal cohort study enrolled 1528 women
5–10 years following their first delivery and followed them
annually for up to 9  years [5]. They reported the 15-year
cumulative incidence of pelvic floor disorders after first
delivery as: stress incontinence 34% (95% CI 30%–39%),
overactive bladder 22% (95% CI 18%–26%), anal inconti-
nence 31% (95% CI 26%–35%) and prolapse 30% (95% CI
25%–35%) [5]. Cesarean delivery was protective against
most pelvic floor disorders and was associated with a signifi-
K. Kenton (*) · J. Geynisman-Tan
Department of Obstetrics and Gynecology, Female Pelvic
Medicine and Reconstructive Surgery, Northwestern University
Feinberg School of Medicine, Chicago, IL, USA
e-mail: Kimberly.Kenton@nm.org
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_14
14
cantly lower hazard for stress incontinence (HR 0.46, 95%
CI 0.32–0.67), overactive bladder (HR 0.51, 95% CI 0.34–
0.76), and prolapse (HR 0.28 95% CI 0.19–0.42). Large
genital hiatus, likely the result of both neurogenic and ana-
tomic trauma to the levator ani muscles, was associated with
a higher risk of prolapse independent of route of delivery.
These authors also found that some pelvic floor disorders,
such as stress incontinence, have a high incidence in the first
few years after delivery where others, like prolapse, took
longer to develop. The 5-year cumulative incidence of stress
incontinence following vaginal delivery was 11% and pro-
lapse 1.6%, while the 15-year cumulative incidences were
34% and 30%, respectively. Operative vaginal delivery
increased the 15-year cumulative incidences for stress incon-
tinence, anal incontinence, and prolapse to 38%, 38%, and
45%, respectively.
Numerous translational studies going back as far as the
1980s support neurologic trauma to the pelvic floor and stri-
ated urethral sphincter muscles as at least one mechanism by
which pregnancy and delivery lead to pelvic floor disorders
[6–13]. There is also substantial evidence that anatomic
injury to the pelvic musculature plays a significant role in
postpartum pelvic floor disorders, including disruptions of
the anal sphincter muscles and detachment of the levator ani
from the pubic bones. The aim of this chapter is to explore
the role of neurogenic trauma during delivery and its impact
on pelvic floor function.
14.2 Neural Anatomy
A peripheral nerve is the structure used by efferent (motor)
and afferent (sensory) axons to transmit information in the
peripheral nervous system to and from the central nervous
system. Each nerve fiber, or axon, with its associated
Schwann cell, is embedded in the endoneurium, which is a
loose, collagenous matrix with large extracellular spaces.
Groups of nerve fibers are arranged into fascicles and sur-
rounded by the perineurium, a dense, mechanically strong
223
224 K. Kenton and J. Geynisman-Tan

connective tissue sheath that protects individual fibers from Table 14.1  Types of nerve injury seen in delivery
external trauma. Groups of fascicles are embedded in the Types of
epineurium, a loose connective tissue, which provides a nerve injury Neuropraxia Axonotmesis Neurotmesis
cushion of protection during stretching and compression. Description Transient Prolonged Complete
stretching or stretching or neural
Importantly, the epineurium also contains the vascular sup- compression that compression separation
ply, which crosses the perineurium to supply the nerve fiber results in leads to including
itself. This arrangement of nerve fibers into fascicles sur- short-term significant disruption of
rounded by loose connective tissue and the elasticity of the ischemia leading ischemia which the axon,
to a focal disrupts the Schwann cell,
perineurium have important implications for the protection conduction block axon, while and connective
and resilience of the peripheral nerves. They help to make across the affected preserving the tissue elements
peripheral nerves resistant to both compression and stretch portion of the Schwann cell
injury. nerve. There is no
disruption to the
axons or Schwann
cells
14.3 Pudendal Neuropathy Prevalence Common Frequent Rare
during
childbirth
The lumbosacral plexus is susceptible to compression and/or
Time to Days Weeks to Complete
stretch of peripheral nerves that innervate the pelvic floor resolution months recovery is
muscles and their vascular supply during childbirth. impossible
Compression and/or stretch may result in only a mild injury
to the myelin sheath, creating a local conduction block and
temporary loss of nerve function. This type of injury recov- mildest form of nerve injury. The nerve sustains stretching or
ers completely within hours to weeks. Unfortunately, a more compression that results in transient ischemia leading to a
severe injury occurs frequently, in which the axons them- focal conduction block across the affected portion of the
selves are injured, but the connective tissue framework is nerve. There is no disruption to the axons or Schwann cells,
intact. In these cases, the axon can regenerate over months. so the conduction block often resolves within a few minutes;
The pudendal nerve is the primary branch of the lumbosa- however, longer periods of compression or stretch may result
cral plexus thought to result in pelvic floor disorders associ- in edema or demyelination, which make take longer to
ated with vaginal delivery. The pudendal nerve arises from resolve. Neuropraxic injuries usually resolve within days to
the anterior roots of S2–4 to coalesce in the pelvis just proxi- weeks.
mal to the sacrospinous ligament. It leaves the pelvis through Prolonged or excessive compression or stretch to a nerve
the greater sciatic foramen only to reenter through the lesser can result in actual disruptions of the axons, while preserv-
sciatic foramen at which point it travels along the obturator ing the Schwann cell. This results in axonotmesis, and
internus fascia or Alcock’s canal. The pudendal nerve even- Wallerian degeneration begins within 24–36 h of the injury.
tually splits into its three terminal branches: dorsal nerve to It affects motor, sensory, and autonomic functions that may
the clitoris, which provides sensation to the clitoral area; the take weeks to months to resolve. Even though the axon is
perineal nerve, which innervates the striated urethral sphinc- disrupted, regeneration is usually complete, because the sup-
ter muscle and perineal skin; and the inferior hemorrhoidal porting Schwann cell remains intact. Axons grow at a rate of
nerve, which innervates the external anal sphincter and peri- 1–2 mm per day, so physicians can estimate the time to neu-
anal skin. romuscular recovery after childbirth.
The pudendal nerve is susceptible to compression and Neurotmesis is the most severe form of nerve injury
stretch injury during childbirth as it travels through the fixed resulting from complete neural separation including disrup-
point of Alcock’s canal in the pelvis. Studies have shown tion of the axon, Schwann cell, and connective tissue ele-
neurophysiologic evidence of pudendal nerve injury to the ments. This is not commonly associated with vaginal
external anal sphincter, levator ani, and striated urethral childbirth.
sphincter after vaginal childbirth [9, 11–13]. When a nerve injury does occur from compression, both
the amount of pressure and duration of compression have
important implications in nerve recovery. Locally applied
14.4 Mechanism of Nerve Injury pressure of 80 mmHg results in complete vascular obstruc-
tion and ischemia in the compressed nerve segment [14], and
The severity of nerve injury is related to the degree and dura- when the pressure or ischemia is sustained for 70  min, it
tion of ischemia from compression or stretch of the nerve results in irreversible nerve injury [15]. Compression at
(Table 14.1). Neuropraxia, or a local conduction block, is the lower pressures can also result in irreversible nerve injury
14  Neurogenic Trauma During Delivery
from both ischemia and mechanical deformation of the neu-
ral structure [16]. Pressure between the fetal head and vagina
during the second stage of labor can reach as high as
240  mmHg [17] and thereby easily lead to compression
neuropathy.
Similarly, if a nerve is stretched, the arrangement of nerve
fibers into fascicles embedded in the epineurium allows for
natural movement of fibers. However, when a nerve is
stretched beyond 15% of its length, the vascular supply to
the nerve fiber is compromised resulting in irreversible nerve
injury [18]. Theoretically, if the pudendal nerve is stretched
beyond 1.35 cm during the second stage of labor, irreversible
neuropathy will likely result. Using 3D computer modeling,
investigators demonstrated that nerves to the anal sphincter
stretch more than 15% during vaginal delivery [19]. The
inferior hemorrhoidal nerve sustained the greatest amount of
stretch (35%) in this model, although the perineal branches
to the anal sphincter (33%) and urethral sphincter (13%)
were also stretched to the point of possible vascular
disruption.
14.5 Measuring Nerve Injury
Electromyography is an electrodiagnostic technique that
plays an important role in differentiating neurogenic injury
from primary muscle pathology; localizing the site of nerve
injury; and providing information about the chronicity and
prognosis of the injury.
Needle electromyography has been used to confirm the
association between pelvic nerve injury and vaginal delivery,
stress incontinence, and fecal incontinence. Significant
changes in motor unit action potential morphology have
been reported after vaginal childbirth by multiple authors
[10–12, 20, 21]. Similarly, needle electromyography of the
striated urethral sphincter, levator ani, and external anal
sphincter muscles has shown electromyographic evidence of
denervation with subsequent reinnervation in women with
stress incontinence and pelvic organ prolapse [6, 22–25].
Neurogenic trauma to the pudendal nerve primarily
impacts three important pelvic floor structures: striated ure-
thral sphincter, external anal sphincter, and levator ani mus-
cles. The next sections of the chapter will focus on the role of
obstetric neurogenic trauma on these three muscles groups
and their effect on pelvic floor function.
14.6 Striated Urethral Sphincter
Vaginal delivery clearly impacts rates of stress urinary incon-
tinence in women. Two well-designed longitudinal cohort
studies followed women for 12–15 years after vaginal deliv-
ery and found stress incontinence rates of 34–42% [5, 26].
225
Cesarean delivery conferred a significantly lower risk of
stress incontinence than vaginal delivery [5]; however, other
delivery risks factors are not well established and vary in the
literature. While the precise mechanism of injury is unclear,
neurogenic injury to the pudendal nerve plays an important,
if not the most important, role.
Electrophysiologic and histologic studies demonstrated
that women with stress incontinence have decreased urethral
skeletal muscle volume and urethral neuromuscular changes
consistent with denervation injury [27, 28]. DeLancey et al.
compared urodynamic and clinical measures of urethral
function and support in a large cohort of women with stress
incontinence to women without urinary symptoms [29].
Urethral closure pressure alone predicted half of the occur-
rence of stress incontinence, while anatomic measures of
urethral support only predicted 16% of stress incontinence
cases. As urethral closure pressure is directly related to the
innervation (tone) of the urethral sphincter, these findings
emphasize the important role vaginal delivery has on neuro-
genic trauma to the pudendal nerve and the subsequent
development of stress incontinence.
Weider et  al. reported important differences in electro-
myographic parameters of the striated urethral sphincter in
nulligravid and primigravid women [20]. Women who under-
went one vaginal delivery showed significant electromyo-
graphic changes consistent with denervation-reinnervation
injury of the pudendal nerve compared with their nulligravid
controls. This is supported by multiple other studies which
show that women with stress incontinence have abnormali-
ties on electromyography and nerve conduction studies con-
sistent with pudendal nerve injury [6, 23, 30].
14.7 External Anal Sphincter
Anal incontinence affects up to 25–35% of women 6
months after delivery [31–33] and 31% 15  years after
delivery [5]. Using data from the Nurses’ Health Study,
investigators found that the odds of fecal incontinence to
liquid stools (remote from delivery) increased with each
pregnancy, suggesting an additive impact from each preg-
nancy [34].
Anal incontinence is more common after operative vagi-
nal delivery [5] and after obstetric anal sphincter injury [35]
suggesting an anatomic etiology in addition to a neurogenic
one. Sultan et  al. first reported high rates of occult anal
sphincter disruption on endoanal ultrasound (35%) in pri-
miparous women and associated these findings with anal
incontinence [36]. Other investigators continued to report
similarly high rates of occult anal sphincter injury on endo-
anal ultrasound ranging from 20 to 40% [37, 38]. With pri-
mary repair of obstetric anal sphincter injury, 60–80% of
women are asymptomatic 1 year after delivery [38].
226 K. Kenton and J. Geynisman-Tan

Gregory et  al. performed anal sphincter electromyogra- strong correlation between prolapse beyond the hymen (odd
phy on 28 nulliparous and 23 vaginally parous women ratio 2.7, 95% CI 1.3–5.7), symptoms of prolapse (odd ratio
12 weeks after delivery and found quantifiable evidence of 3.0, 95% CI 1.2–7.3), and levator ani avulsion. Other pelvic
pudendal neuropathy in the parous women [11]. Earlier floor disorders, such as stress incontinence, overactive blad-
investigators performed anal sphincter electromyography in der, and anal incontinence, were less impacted by levator ani
14 women immediately postpartum and 5  years after their avulsion, suggesting that these disorders may be more
first delivery and found continuous decline in the function of impacted by neurogenic trauma than anatomic disruptions of
the pudendal nerve over time [8]. These investigators also the levator ani.
reported that pudendal nerve injury to the external anal Anatomic disruptions to the levator ani seem to improve
sphincter was associated with both fecal incontinence and over time on imaging studies [42, 43]. One study reported
stress urinary incontinence. that 62% of levator ani avulsions diagnosed 3 months post-
partum resolved by 12  months [44]. However, unresolved
avulsions can lead to a persistently enlarged levator hiatus,
14.8 Levator Ani Musculature which is a risk factor for pelvic organ prolapse. A larger leva-
tor hiatus is associated with an increasing number of vaginal
Multiple authors have demonstrated electromyographic deliveries [45] and is more likely to remain enlarged after a
changes in the levator ani of women with stress incontinence vaginal delivery than an unlabored cesarean [46].
and prolapse [9, 22]. One study of 58 primiparous women
found that 24% and 29% had electromyographic evidence of
neuropathic injury to the levator ani 6 weeks and 6 months 14.9 Conclusions
after their first delivery [39]. Another study similarly showed
that one third of women demonstrated denervation-­ The relationship between childbirth, especially vaginal, and
reinnervation of the levator ani 6 weeks after delivery [40]. neurogenic trauma to the pelvic floor muscles is well estab-
However, in the case of the levator ani muscles, it is more lished. The anatomic position of the pudendal nerve makes it
difficult to separate the role of anatomic or mechanical particularly vulnerable to both compression and stretch injury
trauma from neurogenic trauma. Up to 30% of women sus- during pregnancy and childbirth. Electrophysiologic studies
tain an avulsion of their levator ani muscles with vaginal using needle electromyography consistently show evidence of
childbirth [21]. A recent study followed 453 women for denervation-reinnervation injury to the striated urethral sphinc-
6–17 years after their first delivery [41]. Fifteen percent of ter, external anal sphincter, and levator ani muscles in parous
women had an identifiable levator ani avulsion on ultrasound women. These neurogenic findings seem to be associated with
(Fig. 14.1). Not surprisingly, levator ani avulsion was more multiple pelvic floor disorders, including stress urinary incon-
common after forceps-assisted delivery. There was also a tinence, anal incontinence, and pelvic organ prolapse.

a b

Fig. 14.1 (a) The levator ani is intact bilaterally with attachment to the pubic symphysis. (b) the left levator ani is avulsed (arrow) and hanging at
a wider angle than its counterpart on the right
14  Neurogenic Trauma During Delivery
13. Weidner AC, Barber MD, Visco AG, Bump RC, Sanders DB. Pelvic
Take-Home Messages
• The 15-year cumulative incidence of pelvic floor
disorders after first delivery: stress incontinence
34%, overactive bladder 22%, anal incontinence
31%, and prolapse 30%.
• Vaginal delivery, and especially operative vaginal
delivery, leads to pelvic floor disorders by two
mechanisms: neuropathy and muscular avulsion.
These injuries can be identified by EMG and ultra-
sound and are not mutually exclusive.
• The pudendal nerve is susceptible to compression
and stretch injury during childbirth as it travels
through the fixed point of Alcock’s canal in the pel-
vis. Neurogenic trauma to the pudendal nerve pri-
marily impacts three important pelvic floor
structures: striated urethral sphincter, external anal
sphincter, and levator ani muscles.
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 Prevention of Perineal Trauma
Ranee Thakar and Abdul H. Sultan
Learning Objectives
• Highlight the importance of prevention of perineal
trauma.
• Explore the techniques which can be used in the antena-
tal period and during labor to minimize perineal tears.
• Inform readers about the care bundle which has
been developed with an aim to reduce obstetric anal
sphincter injuries.
15.1 Introduction
Perineal trauma may occur spontaneously during vaginal
birth or when a surgical incision (episiotomy) is intentionally
made to enlarge the diameter of the vaginal outlet. The clas-
sification of perineal trauma is described in Chap. 13 [1, 2].
Perineal repair after childbirth affects millions of women
worldwide. Approximately 85% of women sustain some form of
perineal trauma during vaginal delivery [3, 4]. The prevalence of
perineal trauma is dependent on variations in obstetric practice,
including rates and types of episiotomy, which vary not only
between countries but also between individual practitioners
within hospitals. The Euro-Peristat project which included 20
European countries showed a wide variation in the episiotomy
rates ranging from 3.7% in Denmark to 75% in Cyprus [5].
However, in recent years significant decreases in episiotomy
rates have been observed after attention was drawn to the nega-
tive outcomes associated with the routine use of episiotomy [6].
R. Thakar (*)
Department of Obstetrics and Gynecology,
Croydon University Hospital, Croydon, Surrey, UK
e-mail: raneethakar@gmail.com
A. H. Sultan
Urogynaecology and Pelvic Floor Reconstruction Unit
Croydon University Hospital, St George’s University of
London, London, UK
e-mail: asultan29@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_15
15
Majority of women experience some form of short-­term
discomfort or pain following perineal repair, and up to 20%
will continue to have long-term problems such as superficial
dyspareunia [7]. Short- and long-term morbidity associated
with perineal repair can lead to major physical, psychologi-
cal, and social problems affecting the woman’s ability to care
for her newborn baby and other members of the family [8].
Therefore, preventing perineal trauma in even a modest pro-
portion of childbearing women would benefit large numbers
of women. It would also reduce the cost of childbirth (with
fewer sutures and less suturing time required) and the need
for medical care. Identifying and modifying risk factors may
be one way of reducing perineal trauma. However, certain
antenatal risk factors such as maternal nutritional status,
body mass index, ethnicity, infant birth weight, race, length
of the perineal body, previous perineal trauma, and age can-
not be altered at the time of delivery, but awareness of these
factors might prompt modifications in the care pathway.
In this chapter we discuss interventions presented in the
order in which a decision is taken about whether an interven-
tion might have to be made in the course of patient care, i.e.,
starting in the antenatal period through to delivery of the
baby. The outcomes presented include perineal and anal
sphincter trauma.
15.2 Interventions in the Antenatal Period
15.2.1 Antepartum Perineal Massage
It has been proposed that perineal massage during the last
month of pregnancy may increase the flexibility of the peri-
neal muscles, leading to a reduction in muscular resistance.
This would allow the perineum to stretch at delivery without
tearing, thereby avoiding the need for an episiotomy. A
Cochrane review [9] showed that compared to controls, peri-
neal massage undertaken by the woman or her partner (as
little as once or twice a week from 35 weeks) was associated
with an overall 9% reduction in the incidence of perineal
229
230
Fig. 15.1  Diagram demonstrating the technique of perineal massage
trauma reduction requiring suturing (mainly episiotomies), in
women who had not previously given birth vaginally. When
comparing those who massage with controls, there was no
difference in the rates of first-, second-, third-, or fourth-
degree tears, instrumental deliveries, sexual satisfaction, or
urinary and anal incontinence. Furthermore, the authors
found that for every 15 women who practiced perineal mas-
sage in the antenatal period, one less woman would receive
perineal suturing following the birth. Women who massaged
up to an average of 1.5 times per week experienced a 16%
reduction, women who massaged an average of 1.5–3.4 times
per week experienced a 8% reduction, and women who mas-
saged more than 3.5 times per week did not experience a sta-
tistically significant reduction in the incidence of trauma
requiring suturing. Although perineal massage causes some
transient discomfort in the first few weeks, it is generally well
accepted by women. The majority (79%) report that they
would massage again, and 87% would recommend it to
another pregnant woman [10]. Therefore, women should be
informed about the benefits of antenatal perineal massage and
also provided with information on the technique (Fig. 15.1).
15.2.2 Pelvic Floor Muscle Training
Although evidence has shown that antenatal pelvic floor
muscle training can prevent and treat urinary incontinence
during pregnancy and in the immediate postpartum period
[11, 12], the effect on perineal trauma is not known. A large
cohort study (Norwegian mother and child cohort study)
conducted to estimate whether women doing pelvic floor
muscle training before and during pregnancy were at
increased risk of perineal lacerations [13], episiotomy,
instrumental delivery, or emergency cesarean section found
R. Thakar and A. H. Sultan
no association between regular pelvic floor muscle training
and any of the outcome measures.
The Epi-No (Tecsana GMBH, Muenchen, Germany) is a
device with an inflatable silicone balloon coupled to a hand
pump with a pressure display, developed as an antenatal birth
trainer and to assist pelvic floor muscle training. Its use in the
antenatal period was suggested, based on the assumption that
the pelvic floor muscle can undergo muscular extensibility by
increasing the muscle length mechanically through viscoelas-
tic and plastic deformation and through neuromuscular relax-
ation by intermittent muscle stretching. Unfortunately, in a
prospective, multicenter, randomized study, which included
660 nulliparous pregnant women from 37 weeks to labor, no
benefit was demonstrated for any grade of perineal tear [14].
15.3 Interventions During Labor and Birth
15.3.1 Water Birth
A Cochrane review of immersion in water in labor and dur-
ing delivery [15] was unable to draw conclusions on the out-
come of perineal trauma including OASI in these situations.
15.3.2 Position During Labor and Birth
It is controversial whether being upright or lying down has
advantages for women delivering their babies. Several physi-
ological advantages have been claimed for non-recumbent or
upright labor, such as the effects of gravity, lessened risk of
aortocaval compression, improved acid-base outcomes in the
newborns, stronger and more efficient uterine contractions,
improved alignment of the fetus for passage through the pel-
vis, and radiological evidence of larger pelvic outlet diameters
with an increase in the total outlet area in the squatting and
kneeling positions. The supine or semi-recumbent position for
birth is widely used in modern obstetrics due to the medical-
ization of childbirth. The main advantage cited is easy access
of the caregiver to the woman’s abdomen to monitor the fetal
heart rate. In addition, caregivers are comfortable with the dor-
sal position as it is the position in which they have usually
been trained to conduct deliveries and is the conventional ref-
erence position for textbook descriptions of the mechanisms
of vaginal delivery [16]. During labor and delivery, the woman
may be placed in the lithotomy, lateral recumbent, kneeling,
squatting, or standing position. A recent Cochrane review [16]
which included 30 trials showed that the use of any upright or
lateral position, compared with supine or lithotomy positions,
was associated with reduced duration of the second stage of
labor, a reduction in assisted deliveries and episiotomies, an
increase in second-degree perineal tears, and estimated blood
loss greater than 500 mL with fewer abnormal fetal heart rate
patterns. Due to the heterogenic nature of the trials included,
15  Prevention of Perineal Trauma
the authors concluded that women should be encouraged to
give birth in the position they find most comfortable. Further
research is needed in this area. A recent well-designed, multi-
center study in 41 UK units, aiming to determine whether
being upright in the second stage of labor in nulliparous
women with a low-dose epidural increases the chance of spon-
taneous delivery, showed that lying down in the second stage
of labor results in more spontaneous vaginal births in nullipa-
rous women with epidural analgesia, with no apparent disad-
vantages in relation to short- or longer-term outcomes for
mother or baby and this included OASI [17].
15.3.3 Application of Warm Perineal
Compresses in the Second Stage
of Labor
Perineal warm packs/compressors have not shave has been
advocated for many years in the belief that they reduce peri-
neal trauma and increase comfort during the late second stage
of labor. Physiological studies support the potential beneficial
effects of warm packs in dilating blood vessels, and increasing
blood flow, the transmission of blood by reducing the level of
nociceptive stimulation, and collagen extensibility [18]. A
Cochrane review showed that compared to women with no
warm compresses during the second stage of labor, approxi-
mately 50% fewer women in the warm-compress group expe-
rienced third- or fourth-degree tears; however the effect of
warm compresses on the incidence of other perineal trauma
and grades of perineal tears is uncertain [19].
Dahlen et al. questioned women and midwives about the
effects of warm packs on pain, perineal trauma, comfort, and
feeling of control, satisfaction, and intentions of views dur-
ing future pregnancies and found that warm packs were
highly acceptable as a means of relieving pain during the late
second stage of labor. Eighty per cent of women and mid-
wives felt that warm packs reduced perineal pain during
birth. The majority of women (86%) said they would like to
use perineal warm packs again for their next birth and would
recommend them to friends. Likewise, 91% of midwives
were positive about using warm packs, with 93% considered
using them in future as part of routine care in the second
stage of labor [20]. Based on this, the authors recommended
that this simple inexpensive practice should be incorporated
into second stage labor care. However there are concerns
regarding risks of infection and burns from hot water.
15.3.4 Manual Perineal Protection (MPP)
MPP continues to be a point of debate among maternity
healthcare professionals with some advocating “hands-on”
and others advocating “hands-off/poised” policies.
Bulchandani et al. [21] carried out a systematic review and
231
meta-analysis of both randomized controlled trials (RCTs)
and non-randomized studies (NRSs) to evaluate the effect
of manual perineal support on OASIS during vaginal deliv-
ery. The meta-analysis of RCTs did not demonstrate a pro-
tective effect (relative risk 1.03, 95% confidence interval
0.32–3.36). In the three RCTs included, the technique of
perineal support and delivery practice was not well
described. The method and duration of teaching, training,
and supervision to learn the intervention were unknown,
which makes it difficult to judge the quality. It is also
important to note that for most of the included RCTs, MPP
was used at the time of delivery of the head, and not neces-
sarily the shoulders. This is relevant because it is well
known that OASIS can occur as the shoulders deliver.
Furthermore, in the study by McCandlish et al. [22], lower
compliance with allocated management was noted in the
“hands-poised” group (70.1%) compared with the “hands-
on” group (95.3%). Another limitation was that implemen-
tation of the “hands-on” technique varied enormously
between studies. More importantly, OASI was not the pri-
mary outcome of the study.
Meta-analysis of NRSs showed that the OASIS rate was
reduced by more than 50% (from 4–5% to 2%) in a total
population of >75,000 deliveries and was not restricted to
low-risk births as in the RCTs. Among the three NRSs that
qualified for the meta-analysis, the two largest were from
Norway [23, 24]. In these studies the intervention period
lasted 6–14 weeks, and the training included compulsory
lectures, simulation training, and education of a group of
trainer-midwives who taught and supervised the entire staff
in the clinical setting before the intervention started. In
these studies the classical Finnish method of MPP was
used. In this technique, the delivery assistant presses the
baby’s head with the non-dominant hand to control the
speed of crowning through the vaginal introitus.
Simultaneously, using the thumb and index finger of the
dominant hand is used to support the perineum while the
flexed middle finger is used to take a grip on the baby’s
chin. When a good grip has been achieved, the woman is
asked to stop pushing, to breathe rapidly, while the midwife
slowly helps the baby’s head through the vaginal introitus.
When most of the head is out, the perineal ring is pushed
under the baby’s chin (Fig. 15.2).
The main focus of the intervention was on (1) good
communication between the accoucheur and woman
who was asked to do fast upper-costal breathing without
pushing just before delivery of the fetal head; (2) ade-
quate perineal support; (3) a delivery position that
allows visualization of the perineum; and (4) episiot-
omy only on indication [24]. The coordination of all
these components was stressed and MPP, was not car-
ried in isolation.
Randomized controlled trials are designed to measure the
efficacy of interventions and are considered to be the most
232
Fig. 15.2  The non-dominant hand is used to “cup” the fetal head and
control the speed and progress of the presenting part. The dominant
hand supports the perineum using the thumb and forefinger on the lower
part of the labia; firm pressure is used while flexing (curling in) the
remaining three fingers and pushing them against the perineum. As the
face becomes visible, use the middle finger of the perineal support hand
to assist with delivery of the chin over the introitus
rigorous form of research, allowing for a causal inference to
be made between treatments and outcomes. But the quality
of complex, multifaceted interventions may vary. A stepped
wedge cluster randomized trial is a novel research study
design that is increasingly being used in the evaluation of
service delivery-type interventions [25] and has therefore
been suggested. Such a health improvement project
­involving an “OASI care bundle” is currently underway in
the United Kingdom.
R. Thakar and A. H. Sultan
15.3.5 Second Stage Perineal Massage
A popular technique in the second stage is a stretching mas-
sage or “stripping” of the perineum to ease it back over the
head as it crowns. A Cochrane review addressing techniques
to reduce perineal trauma in the second stage demonstrated
that there were more women with an intact perineum in the
perineal massage group and fewer women with third- or
fourth-degree tears [19]. Massage did not appear to make a
difference to women with perineal trauma requiring sutur-
ing, first-degree tears, second-degree tears, or episiotomies.
However, data needs to be interpreted with caution due to the
medium to low quality of evidence. A small randomized
study, comparing the use of liquid wax (without additional
vitamins, i.e., jojoba oil) with purified formula of almond oil
with olive oil, rich with vitamins B1, B2, B6, and E and fatty
acid in the second stage of labor, did not demonstrate any
difference in perineal outcomes [26].
15.3.6 Episiotomy
Episiotomy is still performed routinely in many parts of the
world, in the belief that it protects the pelvic floor. It is
believed that enlarging the vaginal outlet by episiotomy
would reduce vaginal soft tissue stretching and tension dur-
ing childbirth, thereby preventing higher degrees of perineal
trauma and their subsequent complications. A systematic
review undertaken to compare rates of OASI among women
who had undergone mediolateral episiotomy versus those
who did not (most of whom were nulliparous) indicated that
mediolateral episiotomy has a beneficial effect in prevention
of OASI.  All studies included were non-randomized, and
data included women who had spontaneous vaginal and
instrumental deliveries [27]. However, evidence from RCTs
suggests that routine episiotomy does not prevent severe
perineal/vaginal tears. For women where an unassisted vagi-
nal birth is anticipated, a policy of selective episiotomy may
result in 30% fewer women experiencing severe perineal/
vaginal trauma [28].
There is evidence that episiotomies angled too close to the
midline are at higher risk of causing OASIs. In a quasi-­
randomized study of 407 nulliparous women, Coats et  al.
[29] demonstrated that OASIS occurred with 24% of midline
and 9% of mediolateral episiotomies. In this study, analysis
was not performed according to “intention to treat,” as sub-
jects not receiving their assigned treatment were excluded.
Despite randomization, fewer women had a midline episiot-
omy, suggesting that the OASIS rate could have been much
higher. Therefore, an episiotomy should only be performed
when clinically indicated, and a mediolateral episiotomy is
preferable to a midline episiotomy [28].
15  Prevention of Perineal Trauma
A mediolateral episiotomy is defined as one that is per-
formed between 40° and 60° from the midline. However, in
a prospective study of women having their first vaginal deliv-
ery, Andrews et al. [30] demonstrated that no midwives and
only 13 (22%) doctors performed a truly mediolateral episi-
otomy and that the majority of the incisions were in fact
directed closer to the midline indicating a need for improved
training in the art of performing an episiotomy. The inci-
dence of OASIS appears to be related to the angle of episi-
otomies as episiotomies angled closer to the midline were
associated with a higher incidence of OASIS [31]. Eogan
et al. [32] demonstrated that there was a 50% reduction in
OASIS for every 6° away from the midline. However, if the
episiotomy angle becomes nearly horizontal (90 degrees),
the pressure on the perineum is not relieved, and OASIs inci-
dence increases ninefold [33]. In a prospective study, an inci-
sion angle of mediolateral episiotomy of 60° resulted in a
low incidence of anal sphincter tearing, anal incontinence,
and perineal pain [34]. When episiotomy is indicated, the
mediolateral technique should be used on the distended
perineum, with careful attention to ensure that the angle is
60° away from the midline [1].
An episiotomy is defined by its length and depth.
Stedenfeldt [33] found episiotomies longer than 17 mm and
a depth > 16 mm were associated with a lower rate of OASIs.
Perineal pressure on the central posterior perineum may be
relieved only by episiotomies of a certain length and depth.
15.3.7 Instrumental Delivery
Mode of delivery has a huge influence on the risk of perineal
tears, with studies consistently demonstrating that women
a b
Fig. 15.3  Perineal trauma is more likely to occur with forceps delivery as the blades of the forceps applied around the fetus’s head occupy 12%
more of the pelvic outlet (a), while this does not occur with the vacuum extractor (b)
233
with instrumental deliveries have higher rates of anal sphinc-
ter tears [35–38]. The risk of having a severe perineal injury
has been reported to be 1.5–14.0 times higher with forceps,
and up to four times higher with a vacuum extractor, than
with spontaneous vaginal delivery [35, 39–42]. Perineal
trauma is more likely to occur with forceps delivery as unlike
the vacuum extractor; the blades of the forceps applied
around the baby’s head occupy an additional 12% of the pel-
vic outlet. Sequential instrumental use of vacuum and for-
ceps has been shown to increase the risk of OASI 1.8-fold
compared with single instrument use [43]. This highlights
the need to choose the most appropriate instrument at first
attempt and, in particular, the best type of cup for vacuum
deliveries. If the appropriately chosen instrument is applied
correctly and fails, cesarean section should be considered.
A study in England, United Kingdom, involving one mil-
lion primiparous women found that the use of forceps with-
out an episiotomy increased the odds of sustaining OASIS
sixfold compared with a vaginal delivery without an episi-
otomy [44]. In keeping with this, an observational study
from the Netherlands showed that mediolateral episiotomy
protected significantly for anal sphincter damage in both
vacuum extraction (OR 0.11, 95% CI 0.09–0.13) and forceps
delivery (OR 0.08, 95% CI 0.07–0.11). The number of
mediolateral episiotomies needed to prevent one sphincter
injury in vacuum extractions was 12, compared to 5 with for-
ceps deliveries [45].
One randomized trial of 200 women compared selective
episiotomy versus routine episiotomy in women where an
operative vaginal delivery was intended. No clear difference
was found between restrictive and routine use of episiotomy
in terms of severe perineal trauma; however the study was
underpowered for this outcome [46] (Fig. 15.3).
234
15.3.8 Epidural Analgesia
Epidural analgesia has become popular in modern obstetric
practice because of its excellent pain relief in labor. Albers
et  al. [47] found that epidural analgesia use in labor was
associated with a higher incidence of sutured perineal trauma
and this was attributed to factors such as nulliparity, a pro-
longed second stage, being non-Hispanic white, and having
an infant birth weight greater than 4000  g. Similarly,
Robinson et  al. demonstrated an association between epi-
dural use and increased OASIS because of more frequent use
of operative vaginal delivery and episiotomy [48]. Epidural
placement after engagement of the fetal head has been shown
to be associated with a lower incidence of malposition,
which in turn could reduce the need for instrumental delivery
and associated perineal trauma [49].
15.3.9 Interventions to Correct or Deliver
with an Occipito-Posterior Position
Persistent occipito-posterior (OP) positioning of the fetal
head is a risk factor for prolonged labor, instrumental deliv-
ery, and perineal trauma in primiparous and multiparous
women, probably due to the greater presenting cephalic
diameters [50]. In a case-control study, Fitzpatrick et al. [51]
compared 246 cases with persistent OP position in labor to
13,543 controls delivered with an occipito-anterior position
and found that anal sphincter trauma was significantly more
common in the OP group (7% vs. 1%), irrespective of parity.
Various methods of preventing an OP position during labor
and delivery have been proposed, including positioning the
laboring woman on hands and knees, oxytocin stimulation of
labor, and manual or instrumental rotation of the head to
occipito-anterior. A recent Cochrane review [52] comparing
the hands and knees maternal position in late pregnancy and
during labor when the fetus is in a lateral or posterior posi-
tion, to no intervention, did not suggest any benefit in the use
of this technique. None of the other proposed techniques
have been subjected to RCTs.
15.4 Conclusions
Obstetric perineal trauma can have a devastating effect on a
woman’s physical and social life, with associated psychologi-
cal sequelae. Consequently, every attempt should be made to
prevent such trauma leading to short-term effects such as pain
and dyspareunia or longer-term effects such as prolapse and
incontinence. This chapter has highlighted interventions that
may be used to minimize perineal trauma including new evi-
dence on the use of manual perineal protection [53]. However,
R. Thakar and A. H. Sultan
it is equally important to recognize and repair trauma appro-
priately, and therefore a focused and intensive training pro-
gram for doctors and midwives is essential. While cesarean
section may eradicate perineal trauma, it is associated with an
increased risk of mortality and morbidity and therefore should
only be offered selectively.
Take-Home Messages
• Obstetric perineal trauma can have a devastating
effect on a woman’s physical and social life, with
associated psychological sequelae.
• Proven strategies to minimize perineal trauma
include the practice of perineal massage in the ante-
natal period, the use of warm perineal compresses
in the second stage of labor, the restrictive use of
episiotomy, the preference of a correctly performed
mediolateral over a midline episiotomy, and the use
of a vacuum extractor instead of forceps for instru-
mental delivery.
• Rather than resorting to cesarean section to eradi-
cate perineal trauma, which is associated with an
increased risk of mortality and morbidity, and there-
fore every attempt should be made to make vaginal
delivery safer.
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 Part IV
Urinary Incontinence and Voiding Dysfunction
 Overview: Epidemiology and Etiology
of Urinary Incontinence and Voiding
Dysfunction
Ian Milsom and Maria Gyhagen
Learning Objectives
• Urinary incontinence (UI), overactive bladder
(OAB), and other lower urinary tract symptoms
(LUTS) as well as other forms of voiding dysfunc-
tion are common conditions encountered by many
different healthcare professionals. Medical special-
ists such as gynecologists, urologists, general prac-
titioners, and geriatricians are all involved in the
management as are nurses and physiotherapists.
This chapter provides these healthcare profession-
als with information regarding the epidemiology of
these common conditions. Knowledge regarding
the prevalence of a condition is important for estab-
lishing the distribution of the condition in the popu-
lation and for projecting the need for health and
medical services. Studies regarding potential risk
factors for these common urinary tract symptoms
provide important information regarding their etiol-
ogy. Knowledge regarding risk factors can be uti-
lized to create prevention programs in order to
reduce the burden of disease.
16.1 General Comments and Definitions
Urinary incontinence (UI), overactive bladder (OAB), and
other lower urinary tract symptoms (LUTS) are common
conditions with a significant influence on well-being and
quality of life as well as being of immense economic impor-
tance for the health service [1–5]. The annual cost of urinary
incontinence in Sweden, for example, has been reported to
account for approximately 2% of the total healthcare budget
I. Milsom (*) · M. Gyhagen
Department of Obstetrics & Gynaecology, Sahlgrenska Academy
at Gothenburg University, Gothenburg, Sweden
e-mail: ian.milsom@gu.se; maria.gyhagen@vgregion.se
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_16
16
[1]. Millions of women throughout the world are afflicted,
and there has been a growing interest in these symptoms in
recent years as a consequence of the increased awareness of
the human and social implications for the individual sufferer.
The WHO has acknowledged incontinence as a set of dis-
eases (ICD), and incontinence is also classified in the inter-
national classification of functionality (ICF) as it may be
extremely disabling.
Urinary incontinence has been defined in the joint report
from the International Urogynecological Association
(IUGA)/International Continence Society (ICS) as any invol-
untary leakage of urine [6]. However, some authors have
chosen to restrict prevalence figures according to the fre-
quency of involuntary urinary leakage—for example, based
only on daily, weekly, monthly, or annual urinary leakage.
Thus, for the reasons given above, it is difficult to compare
the results of different population studies.
OAB is a term to describe the clinical problem of urgency
and urge incontinence from a symptomatic rather than from
a urodynamic perspective. Previously various terms, such as
“irritable bladder” or “unstable bladder,” have been used.
According to the ICS, OAB is a symptom-defined condition
characterized by urinary urgency, with or without urgency
urinary incontinence, usually with increased daytime fre-
quency and nocturia [7, 8]. The ICS defines urinary urgency
as sudden compelling desire to pass urine, and the term OAB
is appropriate if there is no proven infection or other obvious
pathologies [7].
Nocturia has been defined by ICS as “the complaint that
the individual has to wake at night one or more times for
voiding”. Nocturnal polyuria refers to the production of an
abnormally large volume of urine during sleep. Nocturnal
enuresis, also called bedwetting, is involuntary urination
while asleep after the age at which bladder control usually
occurs.
This chapter describes the epidemiology of various types
of urinary tract dysfunction. Epidemiology is the scientific
study of the distribution and determinants of disease in peo-
ple. Descriptive epidemiology is the description of disease
239
240
prevalence and incidence by persons, place, and time, while
the term analytical epidemiology describes the search for
determinants of disease risk. Prevalence is defined as the
probability of experiencing a symptom or having a condition
or a disease within a defined population and at a defined time
point. The concept is important for establishing the distribu-
tion of the condition in the population and for projecting the
need for health and medical services. Incidence is defined as
the probability of developing the condition under study dur-
ing a defined time period. Incidence is usually reported for
1-, 2-, or 5-year time interval.
16.2 Prevalence of Urinary Incontinence
Population studies have demonstrated that urinary inconti-
nence is more common in women than in men and that
approximately 10% of all women suffer from urinary incon-
tinence [2, 3]. Prevalence figures increase with increasing
age, and in women aged ≥70 years, more than 40% of the
female population are affected. The reported prevalence of
urinary incontinence [4] and other forms of urinary tract dys-
function among women varies widely in different studies due
to the use of different definitions, the heterogenicity of dif-
ferent study populations, and population sampling proce-
dures. Thus, for the reasons given above, it is difficult to
compare the results of different population studies. However,
when reviewing the literature, there is considerable evidence
to support the theory that the prevalence of urinary inconti-
nence in women increases with age, but there are divergent
opinions regarding the pattern of this increase [3, 4, 9–41].
The prevalence of UI ranged from approximately 5% to
70% in published reviews [3, 4] based on population studies,
with most studies reporting a prevalence of any UI in the
range of 25–45%. For daily incontinence, prevalence esti-
mates typically range between 5% and 15% for middle-aged
and older women.
Thomas et  al. [9] performed a postal survey in order to
investigate the prevalence of urinary incontinence in two
London boroughs. The reported prevalence of urinary incon-
tinence increased from 5.1% in girls aged 5–14  years to
16.2% in 85-year-old women. There was, however, little or
no change in prevalence rates up to 35  years of age. The
prevalence rates then increased to approximately 10% in the
35–44 years age group. There was no significant increase at
the time of the menopause, but a further increase to approxi-
mately 16% occurred in women ≥75 years. In contrast, Iosif
and Bekassy [12] and Jolleys [17] reported a maximum prev-
alence of urinary incontinence at the time of the menopause
and in a large Norwegian study, Hannestad et al. [30] demon-
strated an increased prevalence during the perimenopausal
years, with prevalence rates being lower both before and
after the time of the menopause.
I. Milsom and M. Gyhagen
16
14
Samulesson et al
12
Simeonova et al.
10
% 8
6
4
2
0
20-29 30-39 40-49 50-59
Age, year
Fig. 16.1  Comparison of the prevalence of urinary incontinence in
women from two independant population-based studies [28, 29]
Two population-based studies from Sweden have
described the prevalence of UI in women of different ages. In
both studies, prevalence was restricted to women who had
urinary leakage at least once per week. Although the study
performed by Samuelsson and co-workers [28] was under-
taken in a rural area and that by Simeonova et al. [29] was
carried out in an inner city, there are strong similarities
between the results of the two studies, with a linear increase
in the prevalence of urinary incontinence which continues
over the perimenopausal years (Fig. 16.1).
Another Swedish population study [26] could not demon-
strate an increase in the prevalence of urinary incontinence
between women aged 46 and 56  years of age (prevalence
12% for both cohorts). The majority of 46-year-old women
were premenopausal, whereas the majority of 56-year-old
women were postmenopausal. There were no differences in
prevalence rates between pre- and postmenopausal women
within the respective birth cohorts. Thus, there was no evi-
dence to suggest that the prevalence of urinary incontinence
increased at the time of the last menstrual period. The sixth
International Consultation on Incontinence after an evalua-
tion of the available literature came to the conclusion that the
menopause per se did not influence the prevalence of UI [4].
However, this is not necessarily synonymous with the fact
that the reduction in circulating estrogens is not associated
with an increase in the prevalence of urinary incontinence in
women after the menopause.
The prevalence of urinary incontinence in women has
been compared with the prevalence in men of the same age
from the same urban population [26, 38]. There was a higher
prevalence of urinary incontinence in women than in men in
all the age groups studied. However in the oldest age studied,
the prevalence of UI in men was only marginally lower than
16  Overview: Epidemiology and Etiology of Urinary Incontinence and Voiding Dysfunction 241

30 The prevalence of UI in the same women (aged ≥20 years)

over time has been studied in order to assess possible pro-
25
gression or regression [39]. A self-administered postal ques-
Women
20 tionnaire with questions regarding urinary tract function was
Men
sent to a random sample of the total population of women in
% 15 1991. The same women who responded to the questionnaire
10
in 1991 and who were still alive and available in the popula-
tion register 16  years later were reassessed using a similar
5 self-administered postal questionnaire. The overall preva-
lence of UI increased from 15 to 28% (p < 0.001) from 1991
0
46 56 66 76 86 to 2007, and the incidence rate of UI was 21%, while the
Age, year corresponding remission rate was 34%.

Fig. 16.2  Comparison of the prevalence of urinary incontinence in

women and men of the same age from the same urban population [26,
38]
16.3 F
 actors Influencing the Prevalence
of Urinary Incontinence
in women (Fig. 16.2). In general, the prevalence of urinary Risk factors described in the literature [4] are shown in
incontinence was approximately three times more common Table  16.1. While many studies have reported associations
in women than in men. with incontinence, great caution is needed in assigning these
The majority of the population studies referred to in this as causal risk factors. A large majority of the studies are
chapter have been performed by means of postal question- cross-sectional in design and hence provide no evidence of
naires. In several of the studies, attempts have been made to causation, since the temporal association of the putative risk
determine the proportion of women suffering from the differ- factor and the onset of incontinence cannot be assessed.
ent types of urinary leakage, i.e., stress urinary leakage Even the highest quality observational studies may suffer
(SUI), urge urinary leakage (UUI), and mixed urinary leak-
age (MUI). Hannestad et  al. [30] demonstrated a fairly
­regular increase in prevalence of mixed incontinence with Table 16.1  Risk factors for urinary incontinence in women
increasing age and a decrease in prevalence of stress inconti-
Age
nence from the 40–49-year-old age group through the Ethnic variation
60–69-year-old group. In the literature, stress urinary leak- Obesity
age tends to dominate among younger women, while the Pregnancy
number of women with urge incontinence and mixed incon- Parity
tinence increases with age. Mode of delivery
There is no hard evidence for a difference in the preva- Collagen defect
Hormone replacement therapy
lence of UI between Western countries. However, comparing
Hysterectomy
prevalence between countries based on separate studies is Enuresis
difficult due to differences in methods and definitions, as Diet
well as language, cultural, and social differences. One of the Socioeconomic status
few studies to estimate the prevalence of UI in more than one Exercise
country found a similar prevalence of any UI (41–44%) in Comorbidities
three of the four countries examined (France, Germany, and  Diabetes mellitus
 Urinary tract infection
the UK) but a lower prevalence (23%) in the fourth country
 Cognitive impairment
(Spain) [31]. There was no apparent reason for the lower  Ischemic heart disease
prevalence in Spain.  Physical impairment
UI is, however, not static but dynamic, and many factors  Depression
may contribute to incidence, progression, or remission.  Chronic illness
There are only a few studies describing progression as well  Constipation
as remission, in the short term, of urinary incontinence in the  Stroke
 Parkinson
general population as well as in selected groups of the popu-
 Dementia
lation. The mean annual incidence of urinary incontinence  Chronic bronchitis, asthma
seems to range from 1% to 9%, while estimates of remission Medications
are more varying, 4–30% [39–41].  Diuretics
242
from residual or unmeasured confounding, further limiting
conclusions about causality.
The influence of various factors on the prevalence of uri-
nary incontinence was evaluated in women aged 46–86 years
resident in the city of Gothenburg, Sweden [26]. Age, parity,
and a history of hysterectomy were all correlated to the prev-
alence of urinary incontinence which increased in a linear
fashion from 12.1% in women 46 years of age to 24.6% in
women aged 86  years of age. The prevalence of urinary
incontinence was greater in parous women compared to nul-
liparous women, and prevalence increased with increasing
parity. Urinary incontinence was more prevalent in women
who had undergone a hysterectomy. There was no evidence
in this study to suggest that the prevalence of urinary incon-
tinence specifically increased at the time of the last menstrual
period.
Several studies suggest that the risk of urinary inconti-
nence “runs in the family” [4, 32, 42–44]. Family history
studies have found a two- to threefold greater prevalence of
stress UI among first-degree relatives of women with stress
UI compared to first-degree relatives of continent women. In
the EPINCONT study, daughters of mothers with urinary
incontinence had an increased risk of stress incontinence,
mixed incontinence, and urgency incontinence [29]. In gen-
eral the risk was somewhat higher for sisters of a woman
with UI than for daughters.
Studies from the Swedish twin register indicated that her-
itability contributes to the liability of developing urinary
incontinence. The authors presented evidence that for both
disorders genetic and non-shared environmental factors
equally contributed 40% of the variation in liability [43, 44].
Although study methodology and the magnitude of the risk
estimates vary, studies on familial transmission of inconti-
nence are in agreement [32, 43, 44] having a first-degree
female family member with stress urinary incontinence
increases the risk for an individual becoming afflicted by the
same disorder.
Many studies have assessed the influence of pregnancy
and in particular vaginal delivery on the risk of developing
UI. The prevalence of UI in nulliparous women of childbear-
ing age has been reported to be 10–25% [45–48]. UI preced-
ing pregnancy in nulliparous has been shown to be a strong
indicator for increased prevalence of UI 4–12 years postpar-
tum [49, 50]. Pregnancy in itself, independent of labor and
delivery practices, seems to be a risk factor for postpartum
UI [51, 52] especially if the incontinence started during the
first trimester [53]. During pregnancy the prevalence of UI
increases with gestational age [54] so that more than half of
all women report UI during the third trimester [55–57].
Stress UI and mixed UI increased the most during pregnancy
compared to before pregnancy, whereas urge UI did not
change during the same period [58]. During the first 3 months
I. Milsom and M. Gyhagen
postpartum, UI prevalence was 30% and most women had
stress UI [59]. In uncomplicated courses of pregnancy and
labor, UI usually declines rapidly during the first 3 months
following childbirth, indicating that most symptoms are part
of a normal pregnancy and delivery [51]. Several studies
have also demonstrated that postpartum UI is a risk factor for
UI after longer (7 months to 6 years) terms of follow-up [52,
60–62].
The first delivery is considered to increase the prevalence
of UI the most, and recent studies have demonstrated a fur-
ther increase for each delivery [26, 63–66]. Many cross-­
sectional and several longitudinal studies show a protective
effect of CS for UI [67–70].
BMI is considered to be an established risk factor for UI
[48, 65], whereas the association between UI and age is com-
plicated by confounders [71]. In a study of nulliparous
women, it was possible to assess the influence of BMI on the
prevalence of UI without the concomitant influence of child-
birth. The prevalence of UI increased with increasing BMI in
women of the same age (Fig. 16.3a, b).
16.4 OAB and Other LUTS
Several epidemiological studies [72–76] describing the
prevalence and the impact of OAB and other LUTS have
been published (Fig.  16.4). The reported prevalence of
OAB in females varied between 7.7% and 31.3%, and in
general, prevalence rates increased with age (Fig.  16.5)
[72–76]. The prevalence of OAB grouped according to
gender and nationality is described in Fig. 16.6. OAB has
been shown to be associated with other chronic debilitat-
ing illnesses such as depression, constipation, and diabe-
tes as well as neurological illnesses. OAB is commonly
associated with other LUTS (Fig.  16.4) which was well
illustrated by the cluster analysis performed by Coyne
et al. [77].
The prevalence of overactive bladder symptoms was
estimated in a large European study involving more than
16,000 individuals [72]. Data were collected using a
population-­based survey (conducted by telephone or face-
to-face interview) of men and women aged ≥40  years,
selected from the general population in France, Germany,
Italy, Spain, Sweden, and the UK using a random, strati-
fied approach. The main outcome measures were preva-
lence of urinary frequency (>8 micturitions/24 h); urgency
and urge incontinence; proportion of participants who had
sought medical advice for overactive bladder symptoms;
and current or previous therapy received for these
symptoms.
The progression or regression of OAB and other LUTS
was studied by Wennberg et  al. [39] in the same women
16  Overview: Epidemiology and Etiology of Urinary Incontinence and Voiding Dysfunction 243

Fig. 16.3 (a) Prevalence of a

urinary incontinence stratified
by age and body mass index
(BMI) [48]. (b) Leakage once
a week or more often grouped
according to age and BMI %
[48]
50
45
40
35
30 35-
25
20 30-34.9
15
25-29.9
10 BMI
5 <24.9
0
25-34 35-44 45-54 55-64
Age groups

35
30
25
20 35-

15 30-34,9
10 BMI
25-29,9
5
-24,9
0
25-34 35-44 45-54 55-64
Age groups

(aged ≥20 years) followed over a period of 16 years (from
1991 to 2007). The overall prevalence of OAB, nocturia, and
daytime micturition frequency of eight or more times per day
increased by 9%, 20% (p  <  0.001), and 3% (p  <  0.05),
respectively, from 1991 to 2007. The incidence of OAB was
20% and the corresponding remission rate was 43%. Women
with OAB symptoms were classified as OAB dry or wet
depending on the presence or absence of concomitant
UI. The prevalence of OAB dry did not differ between the
two assessment occasions (11% and 10%, respectively), but
the prevalence of OAB wet increased from 6% to 16%
(p < 0.001). Among women with no OAB in 1991, the preva-
lence in 2007 was 8% and 12% for OAB dry and wet, respec-
tively. There was a progression from OAB dry to wet in 28%.
Remission from OAB dry or wet to no OAB occurred in 50%
and 26%, respectively.
Nocturia is a very common symptom, the prevalence of
which increases with aging [4].
In the FINNO study [78], conducted in men and women
aged 18–79 years of age, approximately one out of eight men
and women reported at least two voids per night. In addition
one third reported one void per night. Young women reported
more nocturia than young men, prevalence of nocturia in
men and women equalized only in the sixth to seventh decade
of life, and in older age groups, men had more nocturia than
women.
16.5 P
 ublic Health Consequences of UI
and LUTS on a Global Scale
The economic consequences of UI and other LUTS have
been investigated [4], and there are now numerous reports to
support the statement that UI and LUTS have a huge bearing
on healthcare costs [1, 3, 4, 79–81]. Prevalence rates vary
throughout the world, but a recent review indicated that urge
244 I. Milsom and M. Gyhagen

60
54,2
%
48,5
50
Men
40 Women

30

20
12,8 14,2 13,4 12,2
12,6
10,8 9,8
8,4 7,1 8,8
10 6,7 7,3 5,5 6,3 6,7 5,5
3,9 3,1

0
ria cy cy ce cy am
g al et
e
io
n
in in
ct
u
ge
n
ue
n
ne
n
tte
n
tre ai
n e pl g rit e
rm bb
l
yi
n u bl
No Ur q ti ni s
St
r
Te om ct ib
Fr
e n er ow dr
i
nc pt i
dr
co t
Sl I
em -m
In In st
Po

Fig. 16.4  The prevalence of individual lower urinary tract symptoms in women and men based on data from the EPIC study [73]

Fig. 16.5  Prevalence of 40

overactive bladder by age.
Comparison of data from the 35 Men – 2001
SIFO study 1997 [72] and the Men – 2006
EPIC study 2005 [73] 30
Women – 2001
Prevalence, %

25 Women - 2006

20

15

10

0
18 -29 30 -34 35 -39 40 -44 45 -49 50 -54 55 -59 60 -64 65 -69 70+
Age, years

urinary incontinence rates were particularly high in the
Nordic countries [3] and in particular Sweden. The economic
consequences of urinary incontinence in Sweden were
assessed by Ekelund et al. [1]. The estimated annual cost for
urinary incontinence in Sweden at that time of the study was
1.8 billion Swedish crowns. The Swedish healthcare budget
at that time amounted to 93 billion Swedish crowns. Based
on the results of this evaluation, the annual costs of urinary
incontinence in Sweden accounted for approximately 2% of
the total healthcare costs. Ten years later, the annual esti-
mated costs had increased from 1.8 billion Swedish crowns
to 2.8–4.4 billion Swedish crowns [82].
Mean life expectancy in the industrialized world is
increasing, and in some countries 25% of all persons are at
present ≥65  years of age. Thus, the number of women
requiring treatment for urinary incontinence is expected to
increase in the future. Another important factor to consider,
apart from the numerical increase in the number of elderly
women, is the fact that many elderly women of today suffer
in silence, accepting these symptoms as a normal part of the
aging process. Women who are at present 30 and 40 years of
age have other demands on their physical condition and will
undoubtedly not accept what their older counterparts
accepted later in life.
16  Overview: Epidemiology and Etiology of Urinary Incontinence and Voiding Dysfunction
Fig. 16.6  Prevalence of 25
overactive bladder by gender
and country: EPIC study
results [73]
20
Prevalence, %
15
10
0
Germany
16.6 Voiding Dysfunction
Voiding dysfunction has been defined as abnormally slow
and/or incomplete micturition. The Standardization and
Terminology Committees [6] of the International Continence
Society (ICS) and the International Urogynecological
Association (IUGA) have included the following
subgroups:
• Hesitancy—The complaint of a delay in initiating
micturition.
• Slow stream—The complaint of a urinary stream per-
ceived as slower compared to previous performance or in
comparison with others.
• Intermittency—The complaint of urine flow that stops
and starts on one or more occasions during voiding.
• Straining to void—The complaint of the need to make an
intensive effort (by abdominal straining, valsalva, or
suprapubic pressure) to either initiate, maintain, or
improve the urinary stream.
• Spraying (splitting) of the urinary stream—The com-
plaint that urine passage is a spray or split rather than a
single stream.
• Feeling of incomplete (bladder) emptying—The com-
plaint that the bladder does not feel empty after
micturition.
• Need to immediately re-void—The complaint that further
micturition is necessary soon after passing urine.
• Post-micturition leakage—The complaint of a further
involuntary passage of urine following the completion of
micturition.
245
Men
Women
Italy Sweden United Canada
Kingdom
Country
• Post-dependent micturition—The complaint of having to
take specific positions to be able to micturate spontane-
ously or to improve bladder emptying, e.g., leaning for-
ward or backward on the toilet seat or voiding in the
semi-standing position.
• Dysuria—The complaint of burning or other discomforts
during micturition. Discomfort may be intrinsic to the
lower urinary tract or external (vulvar dysuria).
• Urinary retention—the complaint of the inability to pass
urine despite persistent effort.
There are only a limited number of studies describing the
prevalence of voiding dysfunction which is in sharp contrast
to the numerous studies describing the prevalence of urinary
incontinence and LUTS.  According to the available litera-
ture, the prevalence of voiding dysfunction ranges from 14%
to 40% [83–85]. Various potential risk factors have however
been investigated. A general progressive decline in urine
flow rates has been recorded in women with increasing
grades of genital prolapse [86]. Flow rates have also been
reported to decline in women post-hysterectomy, both after
vaginal and abdominal hysterectomy [86]. Drach et al. [87],
Fantl et al. [88], and Haylen et al. [89] found no significant
age dependence of urinary flow rates unlike the findings of
Barapatre [90]. Parity has not been shown to influence flow
rates [90]. Bladder neck obstruction in the female is
extremely rare [91]. However congenital malformations,
urethral diverticula, or urethral cysts may obstruct voiding as
can post-traumatic strictures or foreign bodies. In neurologi-
cal illnesses, poor detrusor contractility may be responsible
for a slow flow rate.
246
16.7 Overall Conclusion
The prevalence of urinary incontinence and lower urinary
tract symptoms (LUTS) such as frequency, urgency, nocturia,
and the condition known as overactive bladder has been well
described in large population-based studies. Urinary inconti-
nence is more common in women than in men, especially in
the younger age groups, and approximately 10% of all women
suffer from urinary incontinence. Prevalence figures increase
with increasing age, and in women aged ≥70  years, more
than 40% of the female population is affected. Numerous risk
factors for the development of urinary incontinence have
been identified. The prevalence of overactive bladder symp-
toms has been investigated in several multinational popula-
tion studies and has been reported to afflict 8–31% of the
adult female population. There are however only a limited
number of studies describing the prevalence of voiding dys-
function which is in sharp contrast to the numerous studies
describing the prevalence of urinary incontinence and
LUTS. According to the available literature, the prevalence of
voiding dysfunction ranges from 14% to 40%.
Take-Home Messages
• Urinary incontinence and other lower urinary tract
symptoms (LUTS) such as frequency, urgency, noc-
turia, and the condition known as overactive blad-
der are common in women of all ages. Population
studies have indicated an increase in prevalence
with age, and prevalence figures in excess of 50%
are not uncommon in studies performed in the
elderly. Thus incontinence is an important public
health issue both for the individual and society.
There is a need for more studies, in particular
population-­based studies, evaluating voiding
dysfunction.
• The prevalence of voiding dysfunction has been
reported to vary between 14% and 40% based on
the limited number of studies currently available.
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 Urinary Incontinence and Voiding
Dysfunction: Patient-Reported
Outcome Assessment
Eduardo Cortes and Linda Cardozo
Learning Objectives
• Understanding the principles and processes of
designing a PRO tool.
• How to choose the right PRO for the right purpose:
clinical or research.
• Understanding the different types of PROs.
• Update on PRO and voiding dysfunction.
17.1 Introduction
Clinical history has traditionally been used by clinicians as
the main clinical resource to collect and understand patients’
symptoms in relation to a health condition. However, clinical
history alone fails to assess the perception and impact that
their condition has in their daily activities and can be also
subject to clinician’s bias when interpreting the severity of
these symptoms. By providing a standardised method of data
collection, patient reported outcomes (PRO) provide clinic-
tians with a more objective rather than subjective clinical
review of patients’ experiences of their symptoms [1]. PROs
can be used both in the clinical setting for clinicians and for
patients making informed decisions and in the context of
clinical trials and research serving as primary or secondary
outcome measures while evaluating treatment impact [2].
A PRO is any clinical condition as described by the patient
without interference from a clinician’s interpretation [3].
Over 30 years, since the initial focus on QoL, a fruitful and
industrious period led to the development of a more multifac-
eted framework leading to a multiplicity of options when
selecting the right tool clinically or in a research setting.
E. Cortes (*)
Kingston Hospital, London, UK
e-mail: eduard@doctors.org.uk
L. Cardozo
King’s College Hospital, London, UK
e-mail: linda@lindacardozo.co.uk
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_17
17
The first International Consultation on Incontinence (ICI)
in 1998 recognised the multitude of tools available and thus
developed the ICI modular questionnaires (ICIQ) to meet the
need for universally applicable standards when selecting a
questionnaire for clinical practice and research [4, 5]. Since
then questionnaire development has expanded rapidly. The
different fields covered by multiple questionnaires has
evolved to a modular questionnaire format covering all
aspects of lower urinary tract, bowel, POP, and sexual dys-
function with many of the previous questionnaires being
included in the ICIQ modular format (all carrying Grade rec-
ommendation A).
Criteria for recommendation of questionnaires for LUTD at the fourth
consultation 2009
Grade of
recommendation Evidence required
Grade A Highly Published data indicating that it is valid,
recommended reliable and responsive to change on
psychometric testing with rigor in one data set
Grade B Published data indicating that it is valid and
Recommended reliable on psychometric testing with rigor in
several data sets
Grade C With Published data (including abstracts)
potential indicating that it is valid or reliable or
responsive on psychometric testing
Grade D Expert opinion/no data
Lower urinary tract dysfunction (LUTD) is a debilitating
health condition, and it encompasses a range of disease enti-
ties and symptom complexes, generally having a negative
impact on QoL [6]. The aetiology behind LUTD became more
complex than appreciated in the past involving both organ-
specific factors and systemic contributions. These complexi-
ties gave birth to the need for a more comprehensive assessment
strategy integrating both clinical markers and patient PROs
[1], leading to a major shift in the understanding and evalua-
tion of LUTD by giving more emphasis to patients’ self-
reported symptom severity and the subsequent impact on their
quality of life (QoL). In a series of reports from the International
Continence Society (ICS), Hays RD et al. [7] proposed gen-
eral guidelines to standardise well-defined outcome measures
249
250 E. Cortes and L. Cardozo

i. Hypothesize Conceptual Framework

• Outline hypothesized concepts and potential claims
• Determine intended population
• Determine intended application/characteristics (type of scores,
mode and frequency of administration)
• Performs literature/expert review
• Develop hypothesized conceptual framework
• Place PROS within preliminary and point model
• Document preliminary instrument development

ii. Adjust Conceptual

V. Modify Instrument
• Change wording of items,
Framework and Draft
populations, response options, recall Instrument
period, or mode/method of • Obtain patient input
administration/data collection • Generate new items
• Translate and culturally adapt to PRO • Select recall period, response
other languages options and format

´
• Evaluate modifications as Claim • Select mode/method or
appropriate administration/data collection
• Document all changes • Conduct patient cognitive
interviewing
• Pilot test draft instrument
• Document content validity
iV. Collect, Analyze, and
Interpret Data
• Prepare protocol and statistical analysis plan
(final endpoint model and responder iii. Confirm Conceptual Framework and
definition) Assess Other Measurement Properties
• Collect and analyze data • Confirm conceptual framework with scoring rule
• Evalute treatment response using • Assess score reliability, construct validity, and ability to
cumulative distribution and responder setect change
definition
• Finalize instrumen content, formats, scoring, procedures
• Document interpretation of treatment benefit and traning materials
in relation to claim • Document measurement development

Fig. 17.1  Patient reported Outcomes: The ICIQ and the state of the development FDA (2009). Guidance for industry-patient-reported out-
Art. Karin Coyne and Con Kelleher. Neurology and Urodynamics come measures: use in medical product development to support label-
29:645–651 (2010). The iterative process of patient reported outcome ling claims. Silver Spring FDA

and endpoints in clinical trials. Accurate assessment of
patient’s symptoms and perspective of their own symptoms
becomes paramount, and as such the means by which this is
measured must itself be precise.
• It is appropriate for the condition or populations being
investigated.
The five specific steps that are required for developing a
PRO are shown in Fig. 17.1.

17.2 Development of a PRO • Step I: Hypothesise conceptual framework

Development of a PRO questionnaire is a complex process
requiring concept and clinical coordination of cognitive psy-
chology, psychometric theory, and input generated by clini-
cians and patients to generate a statistically sound instrument.
For any data to be clinically useful, they must be obtained
using reliable instruments. The process is designed to satisfy
specific requirements:
• The PRO measures what it is intended to measure.
• It does it in a reliable reproducible context.
This involves the process of establishing a set of con-
cepts and potential claims to be investigated; defining the
target population, scores suggested and rigorous literature
review; and developing a conceptual framework.
• Step II: Adjust conceptual framework and draft
Patient input is required which will generate new items
or adjustments that better reflect the targeted population’s
perception of the condition. This involves focus groups
(usually 6–10 people) establishing a period of recall, con-
ducting semi-structured one-to-one interviews and pilot-
ing the drafted instrument [8].
17  Urinary Incontinence and Voiding Dysfunction: Patient-Reported Outcome Assessment
Cultural and language
adaptations
• Cultural adaptation
• Linguistic validation
• Psychometric validation
Modify instrument
• Concepts measured
• Population studied
• Instrumentation
• Application
• Administration
Assess
measurement properties
• Reliability
• Validity
• Ability to detect change
• Minimum important differences
Fig. 17.2 PRO development process. Developing guidance issues: the patient-reported outcome development process. Source: Food and Drug
Administration. Guidance for industry on patient-reported outcome measures: use in medical product development to support labeling claims. (FDA.
Federal Register 2009;74:65132–3)
Interviews can be exploratory (conducted to provide
insight into patient experience before instrument selec-
tion), developmental (explicitly capture patient
description of the proposed condition rather than using
clinical terminology, i.e. when assessing symptom
bother) or confirmatory (assessing whether an existing
instrument is appropriate for a specific purpose and
patient population) [9]. The results may lead to modifi-
cation of wording, response options or recall period in
order to improve the format of the instrument and facil-
itating administration. Saturation is defined when no
substantial adaptations are introduced following addi-
tional focus group interviews.
• Step III: Confirm conceptual framework and assess other
measurements properties
A final scoring rule confirms the conceptual frame-
work. The draft instrument is subjected to qualitative
assessment establishing content validity (the PRO reflects
the spectrum of symptoms intended to measure among
the population which is addressed to [10]), to score reli-
ability and ability to detect change. After content validity
has been established, psychometric evaluation should
confirm that the adapted instrument performs according
to its reliability, validity and responsiveness:
• Reliability, the ability of a measure to produce simi-
lar results when assessments are repeated [11, 12], is
critical to establish any changes related to treatment
or intervention. This is achieved by the patient com-
pleting the PRO more than once—7–14 days apart—
in the absence of change in symptoms (test-retest
reliability). Good reproducibility is demonstrated
with a Spearman’s correlation coefficient of at least
0.70.
251
Establish
conceptual framework
• Intended population
• Intended application
• Concepts and domains measured
• How concepts relate to other endpoints
Develop instrument
• Item generation
• Choice of response option
• Recall period
• Item reduction
• Scoring
• Relationship among concepts, items, domains,
• Instructions and format
• Respondent and administrative burden
Internal consistency reliability helps measure cor-
relation of internal items within the same domain.
Typically, a Cronbach’s alpha higher than 0.70 reflects
good internal consistency.
• Validity: the ability of an instrument to measure what was
intended [11, 13, 14]. Four aspects of validity process
need to be fulfilled to achieve full validation of a PRO:
–– Content validity: the instrument reflects the range
of concept intended to measure. Construct-­related
validity refers to evidence that an instrument
behaves in a way that is consistent with the theoreti-
cal implications associated with the constructs
being measured [14].
–– Convergent validity: the extent to which the mea-
sure correlates with similar instruments.
–– Discriminant validity: the extent to which it does
not correlate with other instruments designed to
assess dissimilar constructs or discriminates
between constructs that should be related.
–– Criterion validity: correlation between the proposed
construct and the gold standard, if available. When this
is possible, the desirable correlation should range
between 0.40 and 0.70. Any results close to 1.0 would
suggest redundancy of the proposed construct.
• Responsiveness should reflect whether the construct can
detect change in a patient’s response to treatment or
change of circumstances, making sure the measure is
equally sensitive to gains and losses in the concept [15].
It is also important not to assume that the responsiveness
of a PRO will apply to a different patient sample or sub-
group, so the clinician should not assume that that
responsiveness can be equally applied following medi-
cal and surgical treatment of the condition (Fig. 17.2).
252 E. Cortes and L. Cardozo

17.3 Linguistic and Cultural Validation
Most of the original work on PRO was and still is conducted
in the English language. However when using these tools
worldwide, one cannot assume that the psychometric proper-
ties are automatically transferable [16, 17], hence the need
to also establish a systematic and robust process of adapta-
tion to the different cultures and languages. For this purpose
the ICIQ regulates this process, and for a PRO to be recom-
mended by the ICIQ, the translated version must have under-
gone the following process:
• Two forward translations into the new language.
• A backward translation as quality control process.
Irregularities exposed at this stage may suggest the need
to redevelop the PRO as opposed to simply translate it.
• Adjudication of all translated versions.
• Expert panel discussion to ensure clarity.
• Testing the suggested instrument in bilingual participants.
vidual indicators, they may pose a statistical challenge if the
instrument selection is not as precise as required.
17.4 Types of PROs
PRO is any reported symptom coming directly from
patients, without interference from clinicians, about how
their symptoms are perceived by the patient and their
impact in their daily lives in relation to a disease or follow-
ing treatment [18].
Knowingly, urogynaecological symptoms as perceived by
the patient do not always provide a definitive diagnosis [15,
16]. The use of PRO in urogynaecological health helps pro-
vide a framework to agree treatments and goals as well as
inform decisions about treatment options and assess treat-
ment outcomes.
PROs are generally divided into two groups: generic and
condition specific.

As with all other constructs generated, a translated PRO • Generic questionnaires are multidimensional tools that
will also need to be psychometrically validated within the cover physical, social and emotional aspects of life and
target language for reliability, validity and responsiveness. can be used as population survey tools. One drawback of
Health-related quality of life (HRQL) PROs are multi-­ generic questionnaires is that they often lack sufficient
item questionnaires that usually collect information on vari- sensitivity to measure clinically relevant change in
ous aspects or “domains” relating to patient’s life or patients with LUTS.
condition. These domains may refer to different aspects of • Condition-specific HRQL questionnaires focus on the
our lives such as sleep, energy, emotions, social and work impact of specific conditions including items (groups in
life, sexuality, etc. but vary to some extent between the dif- domains) particular to both the condition and the popula-
ferent questionnaires. tions assessed. The type of PRO used in either a clinical
General principles that should guide selection of health or research setting will depend on the goals of the inter-
outcome measure (HOM) in order to optimise use of these vention and the specific research question to be addressed.
tools are as follows:
When using a PRO, it is important to differentiate between
• Psychometric robustness. The tool used measures the con- the concept being measured, the instrument chosen to assess the
cepts it claims to measure (validity) that the measure pro- condition and the “endpoint” or outcome of a clinical trial [8].
cess is consistent (reliability) and is able to depict change in Several patient outcome categories such as bother, frequency of
health status when change has indeed happened. symptoms, impact on activities of daily living (ADL), discom-
• Appropriateness. Is the selected tool applicable to the par- fort, productivity, quality adjusted life years (QALYs) and costs
ticular problem and the adequate population? which can often overlap. Health-related quality of life (HRQL)
• Acceptability. Any HOM selected should be pilot tested defined as “those attributes valued by patients including their
as lengthy or inappropriate questionnaires compromis- resultant comfort or sense of well-­being; the extent to which
ing its completion would jeopardise the integrity of any they are able to maintain ­reasonable physical, emotional, and
study. intellectual function which allows them to contribute positively
• Feasibility. Ease of administration (face-to-face, tele- to their families, workplace and in the community” has become
phone interview). a more inclusive conceptual outcome measure which encom-
• Precision. Does a yes/no response suffice to gather the passes most of the concepts described [19, 20].
item required?

Further to the above, one must consider the use of single
versus composite measures. Whereas a single measure may
facilitate an easier and more efficient administration, it may
however capture the multiple layers of a specific field exhib-
iting limitations on variability scores. In contrast composite
measures while providing a more holistic reflection of indi-
17.4.1 Symptom Frequency and Bother
Symptoms are defined by the ICS [21] as the “subjective
indicator of a disease or change in condition as perceived by
the patient, caregiver or partner and may lead him/her to seek
help from care professionals”. An example of questionnaire
17  Urinary Incontinence and Voiding Dysfunction: Patient-Reported Outcome Assessment
focusing on the area of specific bothersomeness of symptom
is Bristol female Lower Urinary Tract Symptoms (BFLUTS)
and its short form (SF) [22].
17.4.2 Discomfort and ADL
Discomfort is usually adapted from generic tools to specific
urogynaecology conditions, whereas pain is infrequently
assessed separately in urogynaecology as they are frequently
incorporated in into condition-specific HRQL measures.
17.4.3 Treatment Satisfaction
Patient satisfaction with treatment, is the individual evalua-
tion of several aspects of their care covering the different
dimensions of it such as access to resources, kindness, infor-
mation sharing, perceived competence of carers and satisfac-
tory change in symptoms. An example of patient satisfaction
outcome in Urogynaecology is the multi-item, multidomain
OAB-Satisfaction (OAB-S) measure [23].
17.4.4 Productivity
Work productivity is particularly relevant for conditions such
as OAB with a strong association with work absenteeism.
Although there are generic measures like the work produc-
tivity and activity impairment (WPAI) [24] for this particular
PRO, there is still no specific PRO adapted for the field of
urogynaecology. Some of the limitations for the develop-
ment of such tool are the impact that gender, cultural, work-
ing patterns and working age considerations can have in the
construct of such a tool.
17.4.5 QALY
Quality-adjusted life years (QALY) is a universal outcome
measure that combines gains and losses in both mortality and
morbidity, enabling cost-effectiveness across diseases and
programs, in order to allocate limited healthcare resources.
This economic evaluation allows to compare interventions in
terms of costs and benefits, and its use is widely spread and
recommended in current health economic models. In line
with this, algorithms have been developed to convert PROs
like the KHQ into QALYs [25].
17.4.6 Types for Urinary Problems
There are multiple PRO questionnaires available for the
assessment of pelvic floor disorders, and to a certain extent,
253
there will be inevitable areas of overlap among the different
tools available. When choosing a questionnaire either for
clinical practice or for research, care must be exercised to
choose from the most fitting options making sure that the
questionnaire content is understood and it is suited for the
chosen measure, avoiding questionnaire overload. If avail-
able, the clinician should always try to use a Grade A or
Grade A∗ questionnaire (where validity, reliability and
responsiveness have been established with rigor in several or
at least one data set).
As a general rule, when choosing a questionnaire, the cli-
nician should know:
• The questionnaire in depth
• Environmental boundaries of the responders
• The population targeted
• Previous reported studies using the proposed PRO
questionnaire
• Setting where the questionnaire will be completed
• If the questionnaire has been acknowledged by a regula-
tory body
The choice of the right PRO in urogynaecology must con-
sider simultaneously the interrelated pathologies contained
within the pelvic floor construct. Hence when assessing clin-
ically or as part of research, the clinician must routinely care-
fully depict the contribution to patient’s bothersome
symptoms arising from the different compartments, usually
requiring the combination of PROs that will include pelvic
organ prolapse, bladder, bowel and sexual function as well as
HRQL measures.
The following classification will briefly describe the com-
monest instruments used in pelvic floor pathology. All the
PROs highlighted in this section are broadly described sepa-
rately, and the reader is advised to visit the literature before
choosing the PRO most suitable for purpose.
17.4.7 Health-Related Quality of Life (HRQL)
PRO
HRQL PROs are multi-item questionnaires that often col-
lect data relating to patient’s life (domains) such as social
and work life, energy and sleep, emotional and sexual
problems, etc. Due to the multidomain nature of HRQL
questionnaires, they tend to be longer instruments and are
more limited when exploring in detail a specific problem.
A useful tool for consideration when assessing HRQL in
any research or clinical setting is the availability of the
minimal important difference (MID), as the value regarded
as a clinically meaningful difference to the participant.
MID values have been calculated for the King’s Health
Questionnaire (KHQ); Protection, Amount, Frequency,
Adjustment, Body Image Questionnaire (PRAFAB); and
254 E. Cortes and L. Cardozo

Overactive bladder questionnaire (OAB-q) [26, 27] There are currently two grade A evidence questionnaires
(Table 17.1). to assess symptom bother: the patient perception of bladder
condition (PPBC) [34] and the Urogenital Distress Inventory
(UDI-6) [35], Table  2. When assessing urgency, defined as
17.4.8 PROs for LUTS in Women: Symptom “the sudden compelling desire to pass urine which is difficult
Bother and Urgency to defer” [21], several tools have been developed with only
the Indevus Urgency Severity Scale (IUSS) [35] having a
These are short and relatively easy questionnaires which grade A evidence score available for both men and women
assess the impact of symptoms on patients and not merely and the patient perception of intensity of urgency scale
their presence only. They are frequently used in clinical tri- (PPIUS) [37]. The IUSS is a 4-point qualitative scale, devel-
als, and patients regard them as extremely helpful to repli- oped to reflect urgency severity at urination in a 7-day mictu-
cate the severity of their symptom bother. rition diary. It is structured in four distinct subjective degrees
of urgency linked to the level of impairment in relation to the
ability to complete activities. The PPIUS is a 5-point scale
Table 17.1  The most relevant HRQL PRO (Grade A) used in clinical questionnaire designed to rate the level of urinary urgency for
settings and research for the assessment of women with lower urinary each void during completion of a micturition diary. It has
tract dysfunction shown excellent content validity and test-retest reliability
Impact on Treatment Other [41]. Other grade B and C questionnaires available for men
PRO Q Symptoms HRQL outcome languages and women are shown on Table 17.2.
BFLUTS LUTS ✓ ✓ ✓
[22]
ICIQ-UI SF UI ✓ ✓ ✓
[28] 17.4.9 Screening Questionnaires
IIQ [29] UI/SUI ✓ ✓
KHQ [30] UI/SUI ✓ ✓ ✓
Completed patient screeners help urogynaecologists in the
OAB-q [31] OAB ✓ ✓ ✓
OAB-q SF OAB ✓ ✓ ✓ diagnosis and treatment of LUTs. Development of screeners
[31] must follow the same scientifically robust process as
PRAFAB UI ✓ ✓ ✓ described above from conceptual design, psychometric and
[32] linguistic validation. Screeners also have additional criteria
UISS [33] UI ✓ ✓ ✓ such as sensitivity and specificity they must fulfil to be con-
LUTS lower urinary tract symptoms, UI urinary incontinence, SUI sidered sound measures.
stress urinary incontinence, OAB overactive bladder
BFLUTS Bristol Female Lower Urinary Tract Symptoms questionnaire,
Types of LUTS screeners
ICIQ-UI SF International Consultation on Incontinence Modular
Questionnaire—Short Form, IIQ Incontinence Impact questionnaire, 1. LUTS screeners: these groups of questionnaires improve
KHQ King’s Health Questionnaire (ICIQ-LUTSqol), OAB-q Overactive detection of urinary symptoms including urinary inconti-
bladder questionnaire (ICIQ-OABqol), PRAFAB Protection, Amount,
Frequency, Adjustment, Body Image, UISS Urinary incontinence sever-
nence, OAB and other LUTS.  The International
ity score Consultation on Incontinence has evaluated several LUTS

Table 17.2  Summary of PRO. PRO Q Symptoms Bother Treatment Other

Measures: symptom bother and
urgency. Grade A evidence Bother outcome languages
questionnaires appear coloured PPBC [34] LUTS   
in grey IUSS Indevus urgency UDI-6 [29] UI   
severity, PPBC Patient perception
of bladder condition, PRO Q Symptoms Urinary Treatment Other
UPS Urgency perception score, Urgency Urgency outcome languages
UPS∗ Urgency perception scale, IUSS [36] UI  
UU Scale Urinary urgency scale
PPIUS [37] UI 
UDI [29] UI/SUI  
UPS [38] UI 
U PS* [39] UI  
UU Scale [40] UI  
17  Urinary Incontinence and Voiding Dysfunction: Patient-Reported Outcome Assessment 255

screeners that are available on their website www.iciq.net on symptoms and quality of life assessment tools in urinary
[42]. One of the limitations of many screeners is the chal- incontinence and make grades of recommendation according
lenge to reflect the mixed nature of urinary incontinence to their degree of validation in the published literature.
in most patients, therefore failing to detect more than one Inclusion criteria were determined by the highest scrutiny on
symptom complex. With that premise as a starting point, the level of validation, i.e. the robustness of their psychomet-
the Bladder Control Self-Assessment Questionnaire ric standards of validity, reliability and sensitivity to change.
(B-SAQ) was developed by a European panel of experts Ultimately, the aim of this complex and laborious exer-
encompassing both OAB and stress urinary symptoms cise was to provide the wider clinical and research commu-
with bothersome scales [43]. nity with high-quality questionnaires and disseminate a
2. OAB awareness tool/OAB-V8 is an adaptation from the standardised assessment of pelvic floor dysfunction.
OAB-questionnaire (OAB-q) consisting of 33 items The result of this joint effort delivered 14 ICIQ modules
assessing HRQL and bothersomeness in relation to OAB with further modules in development. To facilitate clinicians
[31]. OAB-V8 is an 8-item screening questionnaire grad- and researchers tailoring questionnaires to achieve a com-
ing answers on a Likert scale. Patients scoring 8 and plete evaluation, the ICIQ divided these modules into three
above are advised to seek medical expertise. categories:
3. Interstitial cystitis index (ICSI)/pelvic pain and urgency/
frequency (PUF): The ICSI has been validated as painful (a) Core modules: provide evaluation of core problems for
bladder syndrome tool showing good test-retest reliabil- urinary, vagina and bowel symptoms and urinary
ity, internal consistency, construct validity and sensitive incontinence
to change [44]. It is a 4-item questionnaire measuring the (b) Specific patient groups: provide evaluation of specific
severity of day-night frequency, urgency and bladder symptom complexes such as nocturia, OAB, neurogenic
pain. However, the ICSI lacks specificity as a diagnostic bladder, long-term catheter users
tool and the reliability of a 1-month recall period has not (c) Add-on modules on QoL: recommended in addition to
yet been tested. one of the above
The PUF [45] questionnaire is an eight-question
screening tool for IC/PBS which shows good sensitivity In order to include all relevant clinical aspects of the indi-
but also limited specificity. When correlated with clinical vidual with pelvic floor dysfunction/LUTS and be aware that
findings on hydrodistention cystoscopy (under GA), it symptom relief does not always correlate with QoL improve-
failed to predict positive findings. Reproducibility and ment post treatment [48, 49], the ICIQ recommends the use
lack of patient input in their design have further question of a core- or symptom-specific module and an add-on quality
its validity as a symptom-based diagnostic tool. of life measure which can include a questionnaire on sexual
4. MESA (Medical, Epidemiological and Social aspects of matters, intimately related to outcomes following pelvic floor
Aging questionnaire) [46] was designed to test urinary dysfunction treatments and a post-treatment evaluation.
incontinence and urinary symptoms in non-­ Recommended modules by the ICIQ:
institutionalised elderly women; the MESA is a 15-item
screening questionnaire divided into two subscales scor- • Core modules for women LUTS: ICIQ-FLUTS
ing for stress and urgency urinary incontinence as well as • Specific patient groups for OAB, ICIQ-OAB, and noctu-
other urinary symptoms. Based on the MESA, the ria, ICIQ-N
Continent Index (CI) was further developed as a screen- • Add-on QoL and sexual matters: ICIQ-LUTSqol and
ing questionnaire in the elderly to identify older women ICIQ-FLUTsex
most at risk of UI in order to apply targeted prevention
strategies in those women most likely to benefit [47]. The use of the ICIQ modules is a currently widespread
practice in clinical and research practice. As a result users are
reassured that outcomes follow high-quality and robust psy-
chometric validation data sensitive to change, aiding clini-
17.5 International Consultation cians and researchers in comparing the impact of treatments
on Incontinence Modular and their outcomes in a more holistic way.
Questionnaire (ICIQ)

In the first ICI (1998), worldwide experts were set up in sub-­
committees to provide evidence-based recommendations
regarding all areas of incontinence care and research.
One of those sub-committees was convened to review of
the relevant literature regarding the questionnaires available
17.6 Voiding Dysfunction
Female voiding dysfunction (VD) is a complex urinary
condition, poorly understood, and challenging to manage.
The International Urogynaecological Association and the
256
International Continence Society define female voiding dys-
function (VD) as “abnormally slow and/or incomplete mic-
turition (voiding) based on symptoms and urodynamic
investigations”. Voiding dysfunction can be due to neuro-
genic nerve dysfunction, non-relaxing pelvic floor muscles
or both. Voiding dysfunction is also classified as being
caused by either underactivity of the bladder (detrusor) or
outflow obstruction (urethra). Evaluation by a clinician may
include tests, such as uroflowmetry, post-void residual and
pressure flow studies. Treatment is individualised, depend-
ing on specific aetiology [50].
The use of PRO specifically designed to assess VD is
scarce, and in the absence of a neurogenic cause, most stud-
ies to date have relied on the tools generally available and
previously described. Numerous studies have explored the
effect of bladder/bowel dysfunction and specific bladder/
bowel interventions on QoL in the neurologically intact pop-
ulation. Although several tools have been designed for this
purpose in the non-neurogenic group, similar studies are
lacking in the neurogenic group with multiple sclerosis
(MS), spinal cord injury (SCI), Parkinson’s disease (PD),
cerebral vascular accident (CVA) and spina bifida (SB).
These patients often suffer similar urinary and bowel diffi-
culties which significantly affect their QoL including recur-
rent UTIs and faecal impaction, interpersonal and
socialisation limitations, persistent incontinence episodes
and catheterisation difficulties [51, 52].
Although most of interventions in patients with VD are
addressed to improve their QoL, it is still not routine practice
the use of PRO as a primary outcome measure in the neuro-
genic patient, hence the small numbers of tools available.
When assessing QoL in VD in the neurogenic patient, there
is still a variation in tools used which include both general
validated questionnaires for UI and specific ones for
VD. Selecting a QoL measure when the objective is to mea-
sure symptom burden would be inappropriate given that
some patients may have significant symptoms, but despite
this they still perceive their QoL to be good. This distinction
is particularly important amongst individuals with neuro-
genic bladder dysfunction.
In a systematic review conducted by Patel et  al. [53],
looking at tools used in patients with VD neurogenic blad-
der and bowel problems, out of a total of 51 articles, differ-
ent questionnaires were used for different purposes. The
most common tools used for urinary dysfunction were the
Medical Outcomes Study Short Form 36-Item and 12-Item
Health Survey or SF-36 and SF-12 [54, 55]. These ques-
tionnaires assess general, physical, and emotional health as
well as limitations on activities of daily living and sociali-
sation. They do not include any specific domains regarding
E. Cortes and L. Cardozo
urinary and bowel dysfunction, therefore overlooking spe-
cific PRO and satisfaction with urinary and bowel manage-
ment strategies. Other less frequently used but more specific
tools for neurogenic patients included were the Neurogenic
Bladder Symptom Score (NBSS) [56], Qualiveen
Questionnaire [57] and the Incontinence Impact
Questionnaire SF. However, one of the main limitations of
these questionnaires is not having been validated in larger,
heterogeneous populations, and the correlation of results
with existing overall and disease-specific QoL question-
naires is unclear.
Urinary-specific QoL tools, such as the I-QOL, KHQ,
IIQ7, and ICIQ-OAB, have also been used frequently in the
assessment of urinary dysfunction in patients with neuro-
logical conditions. These tools have a high validity and reli-
ability for neurologically intact patients affected by
overactive bladder or stress urinary incontinence but may not
have adequate sensitivity and specificity to assess subtle
effects on QoL following urinary interventions in those with
neurologic conditions [58–60].
The use of instruments devoted to the assessment of
impairment and disability such as the Craig Handicap
Assessment and Reporting Technique (CHART) [61],
Satisfaction with Life Scale (SWLS) [62], SF-36 and SF-12
have on some occasions demonstrated inconsistency with
previous reports of best practice [51]. In a study by Akkoc
et al. [63], when looking at QoL in patients with suprapubic
catheter (SCI) and bladder management, patients with inter-
mittent catheterization performed by attendant (IC-A) had
worst QoL outcomes in areas of physical limitations, emo-
tions and social limitations using the KHQ when compared
with those self-managing. Interestingly, they also showed
better or similar scores in incontinence impact, physical lim-
itations and emotions when compared with indwelling cath-
eter users, in contrast to previous reports. In another study by
Cameron et al., using the CHART and SWLS questionnaires,
they demonstrated no significant difference in physical inde-
pendence, mobility, occupation and social integration when
comparing IDC, CC and CIC despite an increase in hospital
admissions and pressure ulcers in the IDC group. PRO has
also been used to measure the impact in QoL of different
interventions in neurogenic patients with VD including con-
servative measures [64], neuromodulation [65], intravesical
botulinum toxin A [66] and reconstructive surgery [67].
Although three urinary- or bowel-specific questionnaires
exist for SCI and MS patients (Qualiveen, FICQoL and
QoL-BM), these tools have not been validated in larger, rep-
resentative populations. Most previous studies have relied on
non-validated QoL tools or tools originally validated for
another disease entity to assess QoL and PRO.
17  Urinary Incontinence and Voiding Dysfunction: Patient-Reported Outcome Assessment 257

Table 17.3  International consultation on Incontinence Modular Questionnaire (ICIQ) modular structure
Recommended add on modules
Recommended Generic
Condition modules Optional modules QoL QoL Sexual matters Post-treatment
(A) Core modules
Urinary symptoms Males: Males: ICIC-­ ICIQ-LUTSqol SF-12 Males: ICIQ-­
ICIQ-MLUTS MLUTS LF ICIQ-MLUTSsex satisfactiona
Females: Females: ICIQ-­ Females:
ICIQ-FLUTS FLUTS LF ICIQ-FLUTSsex
Vaginal symptoms and ICIQ-VS ICIQ-VSqola SF-12
sexual matters
Bowel symptoms ICIQ-B ICIQ-Bsqola SF-12
Urinary incontinence (UI) ICIQ-UI short form ICIQ-UI LP ICIQ-LUTSqol SF-12 Males:
ICIQ-MLUTSsex
Females:
ICIQ-FLUTSsex
(B) Specific patient groups
Nocturia ICIQ-N ICIQ-Nqol SF-12 Males:
ICIQ-MLUTSsex
Females:
ICIQ-FLUTSsex
Overactive bladder (OAB) ICIQ-OAB ICIQ-OABqol SF-12 Males:
ICIQ-MLUTSsex
Females:
ICIQ-FLUTSsex
Neurogenic ICIQ-spinal cord SF-12
diseasea
Long-term catheter users ICIQ-LICa
Children ICIQ-CLUTS∗ ICIQ-­
CLUTSqola
Textbook of female urology and urogynaecology. Editors Linda Cardozo—David Staskin. Chapter 17 (Table 17.1) (page 139). CLUTS children
lower urinary tract symptoms, FLUTS female lower urinary tract symptoms, MLUTS male lower urinary tract symptoms, QoL quality of life
a
In development

Other PROMs (Table 17.3) are not specifically designed
to assess bladder related QOL or neurogenic bladder symp-
toms. However, they contain a bladder domain or have been
used unvalidated [68]:
• Spinal Cord Injury Secondary Conditions Scale (SCI-­
SCS): a 16-item QOL scale examining secondary condi-
tions associated with SCI [69].
• Spinal Cord Injury Quality of Life (SCI-QOL): a multidi-
mensional, computer adaptive PROM with a total of 19
item banks, which include a 15-question item bank related
to bladder management difficulties [70].
• Spinal Cord Injury Functional Index (SCI-FI): a scale
containing 90 items on self-care which provides a com-
prehensive assessment of functional abilities of individu-
als with SCI [71].
• Multiple Sclerosis Quality of Life 54-item scale
(MSQOL-­54): a 52-item scale distributed across 12 sub-
scales with 2 additional items assessing multiple dimen-
sions of QoL associated with MS [72].
• Multiple Sclerosis Impact Scale 29-item (MSIS-29): a
39-item scale examining the physical and psychologi-
cal impact of MS acceptable for patient-level assess-
ment [73].
• Functional Assessment of Multiple Sclerosis (FAMS): a
59-item scale which broadly examines personal and social
QOL domains for individuals with MS [74].
• Hamburg Quality of Life Questionnaire in MS
(HAQUAMS): a 38-item questionnaire for QOL assess-
ment across individuals with varying level of disease
severity associated with MS [75].
• Multiple Sclerosis Quality of Life Inventory (MSQLI): an
inventory containing ten scales including a bladder con-
trol scale for comprehensive assessment of many domains
of QOL affected by MS [76].
• Quality of Life in Spina Bifida (QOLSB) scale: two
indexes designed to assess QoL, one for completion by
parents and by the child with spina bifida. The scales con-
tain 44 and 47 items [77].
258
17.7 Limitations of PRO
The initial psychometric development of these tools is tai-
lored to a very specific indication and patient population, and
if applied outside the intended parameters, the data gathered
may be invalid in particular if used in research [78].
A relevant limitation stems from the difficulty with fully
understanding the patient’s and clinician’s description of
symptoms. In a study by Rodriguez et al. [79], patients com-
pleted the UDI-6 and so did their treating physician after an
interview, demonstrating that physicians underestimated the
degree of bother reported by the patient at least 25–37% of
the time. There is often weak relationship between PRO and
clinically objective definitions.
Another setback seen was the discordance between out-
comes reported by patients and outcomes measured by
objective clinical parameters. This lack of correlation
between laboratory measures and questionnaires is due to
these measurement approaches measuring different aspects
of LUTD (emotional bother vs. volumes leaked or number of
incontinence episodes). One cannot supplant the other and
they must be used in conjunction.
Taken by themselves out of clinical context, question-
naires cannot discriminate between related conditions. Two
individual patients with very different symptom complexes
may generate similar scores in the presence of different
pathophysiologies; responses to medical and surgical treat-
ments will vary, hence the need for patient characterisation
before implementing the different treatment modalities.
Further work is needed to improve the ability of current PRO
to provide symptom discrimination for the multiple of aeti-
ologies causing LUTD [80].
17.8 Future of PRO
Novel approaches are needed to better categorise different
LUTD complexes and identify their underlying cause, as
well as their proportional contribution to overlapping symp-
tom profiles seen in numerous urological conditions. PROs
are invaluable for both research and clinical assessments of
LUTS, but there is need to improve current questionnaires to
better discriminate among various pathophysiologies of
these symptoms.
Due to the broad and numerous symptoms comprised
within LUTD, It is probably unwise, if not impossible, to try
to identify a preferred health outcome for LUTD.  At the
ICI-RS meeting in 2011, Bristol, a group of experts sug-
gested a new concept aimed at standardising the scope of
assessment while providing guidance to develop a minimum
outcome dataset for the treatment evaluation of LUTS.  In
E. Cortes and L. Cardozo
order to overcome the challenges posed by the symptom
complexity within LUTS, it was advised the use of at least
one condition-specific tool that better would represent the
area to be studied, a choice left to the discretion of the inves-
tigator/clinician. This would also enable research engines to
establish a set of compartmentalised data, more analysis and
evidence-based friendly. With this premise established, a
new toolkit with the acronym of MOST (Minimum Outcome
Set for Testing) was designed [81]. It was agreed that such
tool should encompass five minimum categories Fig.  17.3
for LUT evaluation: global measure, satisfaction (patient’s
perception of improvement), HRQoL, symptoms (to an
extent interlinked with the HRQoL category) and adverse
events (currently there is no tool for this purpose). Additional
categories suggested included signs (objective measures like
the pad test), psychosocial impact (indicative of improve-
ment when an additional burden such as depression becomes
more manageable), health economics (cost-benefit ratio of
any intervention) and goal setting (highly specific to each
individual).
Due to the heterogeneity of symptoms in LUTD as well as
the availability of multiple psychometrically validated exist-
ing PROMs, clinicians routinely find challenging trying to
obtain a comprehensive picture of the patient outcomes. The
limitations seen with bladder diaries as primary endpoints
such as an intrinsic placebo effect [81], bladder retraining
effect [82] or lack of compliance [83, 84] has led to calls for
the development of a new multidimensional PROM that
could replace bladder diaries as the primary endpoint.
Supporting this initiative stands the significant positive cor-
relations seen between bladder diary endpoints and widely
used PROM [85–87] in conjunction with the recommenda-
tions of the ICI-RS 2011. Acknowledging the limitations
faced by most of the existing PROs having been developed
prior to guidelines issued by different international regula-
tory bodies, namely, the European Medicines Agency and
US Food and Drug Administration [88–90], Chapple et  al.
[91] have suggested the development of a new multidimen-
sional PROM that would incorporate:
1. A well-stablished PROM such as the OABSS which dem-
onstrated good correlations with bladder diary
2. Evaluation of HRQoL and satisfaction that could reduce
the placebo effect
3. Extension of the recall period reducing the training effect
In line with this more holistic approach to PRO, a new
instrument, the overactive bladder assessment tool (BAT)
[92], has been recently developed to provide a superior tool
rather than the use of bladder diary and other PROs for OAB
patients in clinical practice and research trials.
17  Urinary Incontinence and Voiding Dysfunction: Patient-Reported Outcome Assessment 259

Global Health Adverse

Satisfaction related Symptoms
measure events
quality of
life

One condition/symptom-specific tool

Optional categories:
Signs
Psychosocial
Health economics
Goal setting

Achieve the ‘MOST’ out of health

outcome evaluation for LUTD

Fig. 17.3  What are the best outcome measures when assessing treatments for lower urinary tract dysfunction (LUTD)? Achieving the MOST out
of outcome evaluation; ICI-RS 2012. With permission from [81]
260
17.9 Conclusion
Existing PROs which have been adequately evaluated have
the potential to provide sensitive and specific assessment of
patients and within clinical trials, increasing the efficiency of
treatment alternatives and research to measure minimal
meaningful treatment benefits. New challenges highlighted
by the Food and Drug Administration have pushed the indus-
try and experts to identify existing instruments and develop
new ones for the evaluation of treatment outcomes in a more
defined population.
Take Home Messages
• Patient-reported outcomes (PROs) are an essen-
tial tool for the assessment of patient’s clinical
symptoms in urogynaecology without interfer-
ence of the attending clinician. The use of PRO is
recommended in both clinical and research
settings.
• It is important to understand a patient’s perspec-
tive of her medical condition to allow us to treat
her more effectively as well as being able to dif-
ferentiate between the types of questionnaires
which are available in order to target an individ-
ual with the most appropriate tool for her
condition.
• Development of a PRO is a rigorous psychometric
exercise structured through different steps that
result in its validity as a diagnostic tool. It enables
us to assess a patient’s desire for treatment as well
as the treatment outcomes.
• The rise worldwide of multiple tools available led
to the International Consultation on Incontinence
(ICI) setting up an international convention of the
expert scientific community to develop a consensus
of the tools more representative clinically: the ICI
modular questionnaires (ICIQ).
• The use of PRO in voiding dysfunction needs fur-
ther development and currently is mostly
approached using both generic urinary PROs and
disease-specific questionnaires with LUTD
domains.
• PROs are an evolving science, and the community
of experts continue developing new constructs that
better amalgamate symptoms and objective
measures.
E. Cortes and L. Cardozo
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 Urodynamics Techniques
and Clinical Applications
Michel Wyndaele and Paul Abrams
Learning Objectives
• To understand the place, role and goal of urody-
namics in lower urinary tract symptom assessment
in women with pelvic floor dysfunction
• To develop insight in the available urodynamic
tests, the evaluated parameters and the normal find-
ings of a urodynamic evaluation
• To learn which urodynamic tests can provide insight
in the underlying pathophysiology of specific lower
urinary tract dysfunctions, as well as the limitations
therein
18.1 Introduction
The bladder, urethra and urethral sphincter compose the
lower urinary tract (LUT) which has two functions: it stores
the urine produced by the upper urinary tract (UUT) at low
pressure, and it intermittently expels the urine under volun-
tary control at a socially appropriate time and place.
Disturbances in one or both of these functions lead to LUT
symptoms (LUTS) which can therefore be classified into
storage, voiding and postmicturition LUTS [1].
The first line of LUTS treatment is conservative and con-
sists of lifestyle advice, behavioural and physical therapies,
as well as pharmacological treatment, or treatment of an
underlying condition (urinary tract infection, cardiac failure,
etc.). It is accepted that urodynamics (UDS) are not required
prior to starting these noninvasive empiric or conservative
treatments in a patient with LUTS.  However, a first-line
M. Wyndaele (*)
Division of Urology, UMC Utrecht, Utrecht, The Netherlands
P. Abrams
Bristol Urological Institute, Southmead Hospital, Bristol, UK
e-mail: paul_abrams@bui.ac.uk
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_18
18
diagnostic evaluation consisting of a thorough medical his-
tory and physical examination, completion of a validated
symptom score questionnaire including quality of life and/or
bother assessment (e.g. ICIQ), and completion of a 3-day
bladder diary (e.g. ICIQ), is imperative. Urine analysis and
ultrasound measurement of post-void residual (PVR) are
also essential in the first-line diagnostic workup [2, 3].
When further (invasive) treatment for a patient’s LUTS is
being considered, the clinician should decide if there is a
good indication to perform urodynamic tests and whether the
findings can and will be used to further guide treatment.
UDS are defined as the tests and measurements that can be
used collectively or individually to interactively and dynami-
cally study and understand the two functions of the LUT
(storage and evacuation of urine). UDS should always be
performed and reported according to the 2016 International
Continence Society (ICS) Good Urodynamic Practices and
Terms [4, 5] and using the 2002 ICS terminology [1].
Recently, several guidelines have been published to assist the
clinician in making the decision whether UDS is indicated
and in designing the urodynamic test to provide the clinician
with all the information required to plan and discuss further
treatment options: the American Urological Association
(AUA)/Society of UDS, Female Pelvic Medicine and
Urogenital Reconstruction (SUFU) Urodynamic Guideline
[6], and the EAU guidelines on treatment of male non-­
neurogenic LUTS [2], on urinary incontinence (UI) [3] and
on neuro-urology [7].
In this book chapter, we describe the available urody-
namic tests, the normal findings, and the evidence and future
perspectives for the role of urodynamics in different types of
LUT dysfunction.
18.2 Urodynamic Techniques
UDS are performed prior to (planning) second- or third-line
treatment when noninvasive empiric or conservative treat-
ments have failed to improve a patient’s LUTS. The goal of
263
264 M. Wyndaele and P. Abrams

the urodynamic evaluation is to reproduce the patient’s 18.2.1 Free Uroflowmetry and Measurement
symptoms and to identify the underlying pathophysiological of Post-void Residual Volume
mechanisms. The general role of UDS in clinical practice is
presented in Table 18.1 [8]. Free uroflowmetry is a first-line noninvasive screening test
The information from the first-line diagnostic evaluation for patients with LUTS that measures the flow rate of the
(i.e. medical history, physical examination, questionnaire, external urinary stream (the micturition volume emitted per
bladder diary, urine analysis and measurement of PVR) is unit of time) and is expressed in mL/s [5]. It is a relatively
crucial in deciding which questions need answering during cheap test and can easily be repeated.
the test, in designing the evaluation to obtain these answers The parameters evaluated in uroflowmetry are presented
and in interpreting the urodynamic test results [9]. To assist in Table 18.3 and these should only be interpreted by account-
in designing the urodynamic evaluation, LUT (dys)func- ing for possible test artefacts (e.g. unsuitable environment,
tion can be classified according to the affected LUT func- psychological factors, etc.). A schematic representation of
tion (storage or voiding) and the anatomical components uroflowmetry is presented in Fig. 18.1.
(bladder or outlet) of the LUT (Table 18.2 [10]). Each of In healthy adult women, Qmax should be above 18 mL/s
the urodynamic techniques studies at least one of these fac- under the age of 45, above 15 mL/s between 46 and 65 years
tors. However, urodynamic evaluation of a patient usually of age and above 10 mL/s above 65 [11]. The flow curve pat-
consists of a series of tests over the course of one appoint- tern should be bell-shaped, but the interpretation thereof is
ment, as one of the roles of UDS is to obtain information on
other, asymptomatic aspects of LUT function or dysfunc-
Table 18.3  Parameters of uroflowmetry
tion (Table  18.1 [8]). As an example, in a patient with a
Parameter Unit Definition
storage dysfunction such as urinary incontinence (UI),
VV Voided volume mL Total amount of urine voided
voiding function should also be evaluated in the UDS to
Qmax Maximum flow mL/s Highest flow rate for a given curve
allow prediction of possible postoperative voiding rate
difficulties. TQ Flow time s Time of urine flow
TQmax Time to s Time until the maximum flow rate
Table 18.1  General role for urodynamics in clinical practice [8] maximum flow is achieved
PVR Post void mL Remaining intravesical urine
1. To identify all factors contributing to LUTD and/or the origin of residual volume after completion of
the symptoms and assess their relative importance voiding
2. To obtain information on all other (symptomatic and non-­
symptomatic) factors of LUT function: bladder and outlet
function both during bladder filling and during voiding (see
mL
Table 18.2)
3. To predict the possible consequences of LUTD on the UUT: V
identifying the “unsafe” bladder o
4. To allow prediction of the outcome (including undesirable side l
effects) of a treatment for LUTD u
m Qmax (Maximum flow rate – mL/s)
5. To confirm the effects of, or the mode of action of a (new or
experimental) treatment for LUTD e
6. To understand the reason of failure of previous treatments of
LUTD
LUT lower urinary tract, LUTD lower urinary tract dysfunction, UUT
upper urinary tract

VV (Voided volume – mL)

Table 18.2  Classification of normal and abnormal lower urinary tract
function [10]
Storage (dys)function Voiding (dys)function
Bladder Normal (relaxed—low Normal (contracting)
pressure) Underactive
Overactive Acontractile s
Urethra Normal (maintains Normal (relaxed) TQmax (Time to Qmax – s) Time
contraction) Overactivity of sphincter and/or
Incompetent under stress pelvic floor
TQ (Flow time – s)
Inappropriate relaxation Mechanical obstruction
Combined (dys)function Fig. 18.1  Schematic representation of uroflowmetry parameters
 18  Urodynamics Techniques and Clinical Applications
95th
60
50
Maximum urine flow rate (mL/s)
40
30
20
10
0 (pabd) pressures are measured. The detrusor pressure, which
0 100 200 300 400
Voided volume (mL)
Fig. 18.2  Liverpool nomogram for uroflowmetry in women
subjective as no objective tools to assist in curve pattern
evaluation have been validated (yet). To assist in the interpre-
tation of uroflowmetry, nomograms, such as the Liverpool
nomogram for women (Fig. 18.2) [12], have been validated.
PVR is the remaining intravesical urine volume deter-
mined immediately after completion of voiding [5].
PVR can measured by using an “in-and-out” catheter, but
true PVR may thereby be underestimated as residual urine
may not be removed entirely [13]. Ultrasound (or bladder
scan) allows noninvasive estimation of PVR [4]. Ultrasound
has a sensitivity of 66.7% and a specificity of 96.5% in
detecting PVR ≥ 100 mL in women [13]. Therefore, multi-
ple measurements of PVR using ultrasound are recom-
mended [3, 6].
Uroflowmetry and measurement of PVR can indicate a
voiding dysfunction but to distinguish between possible
underlying mechanisms such as bladder outlet obstruction
(BOO) or detrusor underactivity (DU), a pressure-flow study
(PFS) is required.
18.2.2 Evaluation of Storage Function: Filling
Cystometry
Filling cystometry is a minimally invasive evaluation of LUT
storage function in which the pressure/volume relationship
of the bladder (detrusor) is measured during bladder filling
[1]. This investigation aims to reproduce the patient’s storage
LUTS and to relate them to any concomitant urodynamic
observation, thereby also defining detrusor and urethral
function during filling.
265
90th Prior to a filling cystometry, the patient is cleanly cathe-
terised (transurethrally, suprapubically or through a
75th Mitrofanoff channel), and a second, fully liquid-filled open
or punctured balloon catheter is placed rectally (or vaginally
50th or through an abdominal stoma if a rectal catheter is not pos-
sible). Catheterising the patient may induce the following
morbidity: temporary dysuria (<50%), mild macroscopic
25th haematuria (6%), bacteriuria (8%) or symptomatic infection
(<5%) [14]. However, the routine use of prophylactic antibi-
10th
5th otics is not recommended [8]. An electromyography (EMG)
of the pelvic floor may simultaneously be performed using
surface electrodes placed on the perineum or needle elec-
trodes inserted in the external anal sphincter. During the test,
the bladder is continuously filled with liquid (saline or con-
trast fluid), while the intravesical (pves) and abdominal
500 600 represents the detrusor smooth muscle activity, is calculated
by subtracting pabd from pves (pdet = pves − pabd) [4].
Provocation tests may be necessary to elicit a patient’s
LUTS and should be annotated on the trace. Examples are:
asking the patient to cough or perform a Valsalva manoeuvre,
a running tap, changing the infusion rate or temperature of
infused fluid, etc. A schematic representation of a normal
filling cystometry (and pressure-flow study) trace is provided
in Fig. 18.3.
Cough tests are repeated every 100  mL of filling (and
after voiding).
The following bladder characteristics are evaluated dur-
ing a filling cystometry:
• Bladder sensation: evaluation of the volumes required to
elicit patient-reported sensations of bladder filling [15]:
–– first sensation of filling (normally at 40% of strong
desire to void)
–– first desire to void (normally at 65% of strong desire to
void)
–– strong desire to void
–– abnormal sensations such as urgency or pain
–– nonspecific sensations such as chills, hypotension,
malaise, sensation of abdominal fullness or tension
• Maximum cystometric capacity: around 570 mL in women
[16]. This marks the end of the filling cystometry and is
generally reached when the patient reports a strong desire
to void while taking into consideration the maximum VV
previously recorded on the completed bladder diary [1]
• Detrusor function: the detrusor should be relaxed, however,
spontaneous or provoked, involuntary detrusor contrac-
tions (DO) may be seen [17], which are only clinically sig-
nificant if it replicates the patient’s symptoms of urgency.
• Bladder compliance: is calculated as ΔVolume/Δpdet and
is expressed in mL/cmH2O. A normal bladder can accom-
modate to a large volume change with only a small increase
266 M. Wyndaele and P. Abrams

Fig. 18.3 Schematic Filling cystometry Pressure-flow study

overview of a normal filling
cystometry and pressure-flow F mL/s
study trace. pabd = abdominal l
pressure, pdet = detrusor o
pressure, pves = vesical w
Q
pressure, Q = flow rate

p
r 20 Pves
e
s
s
u
r
e 20 Pabd
s

0 Pdet = Pves - Pabd

cmH2O
Cystometric capacity
Cough tests
s
Time

in pressure because of its viscoelastic properties and
because of the beta 3 adrenoreceptors which induce relax-
ation of the detrusor muscle. “Normal” values or cut-­offs
for compliance have been difficult to identify, but less than
40 mL/cmH2O rise in detrusor pressure can be regarded as
normal and prohibits secondary pressure transfer from the
bladder to the kidneys, thereby providing protection from
upper tract damage and renal impairment.
• Continence: normal bladder filling is characterised by
the absence of urine flow. If urinary incontinence
occurs, it should be related to bladder sensation [e.g.
urgency UI (UUI) secondary to DO] or to stress tests
which increase abdominal pressure [urodynamic stress
UI (SUI) due to cough or Valsalva], or to both [mixed
UI (MUI)]
18.2.3 Evaluation of Voiding Function:
Pressure-Flow Studies or Voiding
Cystometry
PFS are performed as a continuation of the filling cystom-
etry and start from the moment the “permission to void” has
been given, once the maximum cystometric capacity has been
reached. A schematic representation of a normal pressure-­flow
study (and filling cystometry) trace is provided in Fig. 18.4.
Normal voiding is characterised by a voluntarily initiated
sustained urethral relaxation and a maximal detrusor con-
traction (without abdominal contraction) and, resulting in a
continuous flow and complete emptying of the bladder
within a normal time span and in the absence of obstruction
[17]. However, it is important to note that many women void
successfully by urethral relaxation alone, without much of a
rise in pdet [18], because their outlet resistance is low.
PFS also allow evaluation of the bladder outlet, as pdet
during voiding is a function of outlet resistance: the greater
the outlet resistance during voiding, the higher pdet will be
in a patient with normal detrusor contractility, still allowing
complete bladder emptying in a healthy bladder with BOO
[19]. Therefore, the urinary flow rate is a product of detrusor
contractility, and abdominal pressure, working “against”
bladder neck and urethral resistance.

PFS is a minimally invasive evaluation of voiding function in

which the pressure/volume relationship of the bladder is
measured alongside the urine flow (uroflowmetry) during
bladder emptying [1]. This investigation aims to reproduce
the patient’s voiding LUTS and to relate them to any syn-
chronous urodynamic observation, thereby also defining
detrusor and urethral function during bladder emptying.
18.2.4 Video-Urodynamics
In video-UDS, filling cystometry and PFS are combined with
radiographic (or sonographic) imaging of the LUT. The blad-
der is filled with radio-opaque contrast fluid (instead of saline),
allowing the synchronous evaluation of lower urinary tract
18  Urodynamics Techniques and Clinical Applications 267

Fig. 18.4 Pressure-flow Pre-micturition Opening

study during normal voiding pressure pressure Pressure at maximum flow
showing vesical pressure
(pves, light blue), abdominal
Maximum
pressure (pabd, red), detrusor
Pabd abdominal
pressure (pdet, violet) and
pressure
urine flow rate (Q, yellow).
tQmax = time to max flow
rate; tQ = flow time
Maximum
intravesical
pressure
Pves

Maximum
detrusor
Pdet pressure

Maximum
Q flow rate

t Qmax Time
Opening tQ
time

Table 18.4  Video-urodynamic findings in relation to anatomical site Video-UDS are the gold standard for the evaluation of
Anatomical site Video-urodynamic finding neurogenic LUT dysfunction [6, 7]. Figure  18.5 illustrates
Ureters and renal Vesico-ureteral reflux + grade (in relation to the finding of detrusor-sphincter dyssynergia (often found in
pelvis bladder function) patients with multiple sclerosis) on a video-urodynamic
Bladder Trabeculation trace. In non-neurogenic women, video-UDS are helpful to
Diverticula
distinguish dysfunctional voiding (functional BOO) from
Christmas tree appearance
Post-void residual (+ quantification)
anatomical BOO (see Sect. 18.3.4) [6, 20]. Furthermore,
Vesico-vaginal fistula some anatomical abnormalities may influence the interpreta-
Filling defect (e.g. prostate median lobe, bladder tion of the urodynamic evaluation. Identification of vesico-­
tumour, bladder stone) ureteric reflux (VUR), or of bladder diverticula, for example,
Bladder base Cystocoele + grade (at rest, during stress testing has to be taken into account when interpreting bladder com-
and during voiding)
pliance as they can accommodate a pop-off for the bladder
Bladder neck Filling: Bladder neck incompetence (during
stress testing) pressure, leading to overestimation of bladder compliance,
Filling: Bladder neck opening during detrusor when bladder compliance appears more normal than it is, as
overactivity contractions bladder pressure is reduced (pressure-sink effect). The indi-
Voiding: Bladder neck dysfunction or cations for video-UDS are displayed in Table 18.5 [21].
dyssynergia
Voiding: Bladder neck fibrosis
Urethra Urinary incontinence
Urethral stricture 18.2.5 Ambulatory Urodynamics
Urethral diverticula
Urethro-vaginal fistula Ambulatory UDS are defined as any functional test of the
(Neurogenic) detrusor—(external urethral) LUT predominantly utilising natural filling of the LUT and
sphincter dyssynergia reproducing the subject’s normal activity (including activity
Dysfunctional voiding due to pelvic floor
overactivity
by which the symptoms are provoked) [22]. “Ambulatory”
refers to the patient being freely mobile, and the test being
conducted outside the UDS suite.
(LUT) function and anatomy in complicated patients with The lack of data on the reproducibility of ambulatory
bladder and/or urethral dysfunction with a high chance of a UDS, and the dependence on the investigator for the post-­
coexisting anatomical abnormality. Table 18.4 lists the possi- test analysis are big limitations [8]. Further standardisation is
ble video-urodynamic findings in relation to anatomical site. needed to improve applicability.
268
Fig. 18.5 Video-urodynamic trace displaying detrusor-external
sphincter dyssynergia—type 3. Bladder volume (Vinfus), green; detru-
sor pressure (pdet), violet; vesical pressure (pves), light blue; abdomi-
Table 18.5  Indications for video-urodynamics in women
1. Neurological findings or a history of neurologic disease
2. Diagnosis of type and site (mechanical or functional) of BOO
3. Idiopathic urinary retention
4. History of congenital genitourinary anomaly (e.g. ectopic ureter,
posterior urethral valves, prune-belly syndrome, vesico-ureteral
reflux, etc.)
5. Prior radical pelvic surgery or radiation therapy
6. History of pelvic reconstructive surgery, including SUI surgery,
urethral stricture repair, POP reconstruction and urethral
diverticulectomy
7. Pre- or post-renal transplant evaluation of bladder function
8. Suspicion of vesico-vaginal or urethro-vaginal fistula
9. Suspicion of urethral diverticulum
BOO bladder outlet obstruction, POP pelvic organ prolapse, SUI stress
urinary incontinence
18.2.6 Urethral Pressure Profilometry
Urethral pressure profilometry (UPP) is a graph indicating
the intraluminal pressure along the length of the urethra [1],
thereby evaluating not only the intrinsic function of the ure-
thral sphincter, but also the functionality of external urethral
support which is determined by the anatomical integrity of
M. Wyndaele and P. Abrams
nal pressure (pabd), red; electromyography (EMG), white; voided
volume (Vura), blue; urethra flow rate (Qura), yellow
the pubo-urethral and urethra-pelvic ligaments and the pubo-­
coccygeal muscle. The aim of the test is to evaluate the abil-
ity of the urethra and its surrounding structures to keep the
bladder outlet closed during bladder filling, thereby main-
taining continence.
UPPs are performed in supine position, typically prior to
filling cystometry and PFS. Two separate transurethral cathe-
ters are usually inserted, and pves is measured simultaneously
to exclude a detrusor contraction as the cause of an observed
pressure rise on the trace [17]. Pves is subtracted from the ure-
thral pressure while the measuring catheter is withdrawn along
the urethra at a slow constant rate, to calculate the urethral
closure profile. The maximum urethral closure pressure
(MUCP), the maximum difference between the urethral pres-
sure and pves [1, 17], is the most important parameter, and
normally lies between 40 and 60 cmH2O. Figure 18.6 provides
a schematic illustration of UPP and its parameters. It needs to
be noted that the technique is not used by many urologists as
the clinical relevance of UPP remains controversial [23].
Diverse studies have shown the poor test-retest reliability of
UPP, and the significant overlap between normal and patho-
logical values, explaining the poor specificity and sensitivity
of the test [24].
18  Urodynamics Techniques and Clinical Applications
Fig. 18.6 Schematic cmH2O
illustration of urethral
pressure profilometry and its
parameters
Intraurethral pressure Maximum
urethral
closure
pressure
Functional profile length
Bladder
pressure
In women the UPP is usually a bell-shaped curve, which
begins to rise from the bladder neck and reaches the maxi-
mum pressure at the mid-urethral point, due to the activity of
the intraurethral striated musculature. The pressure then
decreases and has negative values at the level of the external
meatus. The functional profile length indicates the urethral
length across which a positive pressure (above bladder pres-
sure) is measured and is thereby indicative of the urethral
area assisting in preserving continence.
18.3 Clinical Applications
The goal of UDS is to reproduce the patient’s symptoms and
to identify the underlying pathophysiological mechanisms.
Once the patient’s LUTS have been classified (Table  18.2,
[10]), the questions which need answering can be identified,
and the test can be designed to allow the urodynamic ques-
tions to be answered and interpreted.
18.3.1 Overactive Bladder
Overactive bladder (OAB) syndrome (OAB-S) is defined as
urinary urgency (the complaint of a sudden, compelling
desire to pass urine which is difficult to defer [1]), usually
accompanied by increased daytime micturition frequency
and nocturia, with or without UUI, in the absence of urinary
269
Maximum
urethral
pressure
Total profile length
cm
Distance
tract infection (UTI) or other obvious pathology (e.g. bladder
tumour, distal ureteral or bladder stones, or a foreign body)
[17]. It is classified as a bladder storage dysfunction
(Table 18.2, [10]).
18.3.1.1 F  ree Uroflowmetry and Measurement
of Post-void Residual Volume
The first test to be performed in women with OAB-S, is free
uroflowmetry and measurement of PVR. Uroflowmetry can
indicate a voiding dysfunction, which may be worsened by
treatment with antimuscarinics [3, 6]. Furthermore, incom-
plete bladder emptying, identified by measuring PVR, can
lead to quicker refilling of the bladder to full capacity, and
can hence induce an increase in micturition frequency and
nocturia. Suspicion for an increased PVR in women with
OAB-S should arise when they are/have [25]:
• aged above 55 years
• had prior incontinence surgery
• a history of multiple sclerosis
• a vaginal prolapse stage 2
18.3.1.2 Filling Cystometry
The urodynamic observations which can be found in women
with OAB are DO (see section on “Detrusor Overactivity”)
and reduced bladder compliance (see section on “Reduced
Bladder Compliance”).
270
Detrusor Overactivity
DO is the objective urodynamic observation of an involun-
tary detrusor contraction during bladder filling, which may
be spontaneous or provoked and which may be phasic (dur-
ing filling) or terminal (near cystometric capacity, which
often leads to involuntary initiation of micturition) [1]. It
needs to be clearly distinguished from urgency, which is the
key symptom of OAB and which is defined as a sensation
(and therefore subjective) [1]. DO can be classified into neu-
rogenic DO, if a clear underlying neurologic disease is pres-
ent, or idiopathic DO if no clear underlying cause can be
identified [1]. Finally, DO can directly lead to UI during uro-
dynamics, which is referred to as DO incontinence [1].
Figure 18.7 illustrates the presence of detrusor overactivity
on a urodynamic trace.
The correlation between OAB-S (a sensation, subjective)
and the presence of DO (an observation, objective) is mod-
est in women [26, 27]. Furthermore, DO can also be test-­
induced, and can be found in healthy asymptomatic
volunteers who are unaware of its presence, or describe it as
a normal desire to void [6, 15]. On the other hand, an
increased sensation of bladder filling may be the sole under-
lying cause of OAB, although the absence of DO during fill-
Fig. 18.7  Illustration of
detrusor overactivity on a
urodynamic trace. Abdominal
pressure (pabd), dark green;
vesical pressure (pves), blue;
detrusor pressure (pdet), light
green; flow rate (Flow), red;
voided volume, black;
electromyography (EMG),
dark green
M. Wyndaele and P. Abrams
ing cystometry does not rule out its existence. Induction of
DO can be attempted by using provocative measures such as
coughing, moving to a more vertical position or running a
tap [24]. It is therefore very important to correlate a patient’s
symptoms with the objective urodynamic observations in
OAB-S [26].
Reduced Bladder Compliance
Reduced bladder compliance is diagnosed when pressure
rises significantly (true cut-offs have been difficult to define)
with increasing volume in the absence of a detrusor contrac-
tion [1], as illustrated in Fig. 18.8. When a reduction in blad-
der compliance is observed during UDS, filling should be
stopped for at least 2  min, as a too high filling rate may
induce a bladder pressure rise. If the pressure declines again,
filling can be restarted at a much lower rate.
Reduced bladder compliance is usually caused by struc-
tural bladder changes and can therefore be found in neuro-
genic bladders (spina bifida, spinal cord injury), when detrusor
hypertrophy occurs as a result of increased outlet resistance
(detrusor-sphincter dyssynergia), or after bladder wall scar-
ring due to tuberculosis or pelvic radiotherapy. It always
warrants intervention (e.g. bladder relaxants, botulinum
18  Urodynamics Techniques and Clinical Applications
Fig. 18.8  Urodynamic trace displaying reduced bladder compliance. Abdominal pressure (pabd), dark green; vesical pressure (pves), blue; detru-
sor pressure (pdet), light green; flow rate (Flow), red; voided volume, black; electromyography (EMG), pink
toxin injections in the detrusor, or augmentation cysto-
plasty) due to its possible negative long-term effects on
renal function.
The indications for video-UDS when reduced bladder
compliance is suspected have been discussed in Sect. 18.2.4.
An important observation in patients with reduced blad-
der compliance is the detrusor leak point pressure (DLPP)
which is defined as the lowest pdet at which urine leakage
occurs in the absence of either a detrusor contraction or
increased pabd [1]. It is an indication of outlet resistance and
a measure of the urethral pop-off mechanism in patients with
reduced bladder compliance. An absolute cut-off of less than
40 cmH2O DLPP is considered safe. A DLPP of greater than
40 cmH2O with or without VUR often leads to hydronephro-
sis and subsequent upper tract deterioration and possibly
renal impairment [28].
18.3.2 Stress Urinary Incontinence
SUI, is classified as a urethral storage dysfunction
(Table 18.2, [10]), and is defined as the complaint of invol-
untary leakage on effort or exertion, or on sneezing or
coughing [1]. It occurs when a sudden rise in intra-abdom-
inal pressure is not followed by a sufficiently strong
271
increase in urethral pressure [due to urethral hypermobility
or intrinsic sphincter deficiency (ISD)], leading to leakage
of urine.
Two recent well-designed randomized controlled trials
[29, 30] showed that UDS do not affect treatment outcome in
women with “uncomplicated SUI”. However, the majority of
women present with non-typical or complicated SUI, which
is SUI with concomitant OAB symptoms with or without
UUI, concomitant bladder emptying problems, prior SUI
surgery, an uncertain clinical diagnosis or failure to demon-
strate SUI on physical examination, a history of pelvic radia-
tion, neurologic disease, or very severe symptoms [31]. It is
recommended that urodynamic evaluation is performed prior
to proceeding to invasive, potentially morbid or irreversible
treatments in these patients [8, 32].
18.3.2.1 F  ree Uroflowmetry and Measurement
of Post-void Residual Volume
The first test to be performed in women with SUI is free
uroflowmetry and measurement of PVR. Uroflowmetry can
indicate a voiding dysfunction, which should prompt addi-
tional urodynamic testing as this may worsen after invasive
treatment for SUI [3, 6]. Furthermore, concomitant pelvic
organ prolapse (POP) may lead to an increased PVR in
women with SUI [33].
272
18.3.2.2 Assessment of Urethral Function
Several tests (UPP and measurement of abdominal leak point
pressure or ALPP) have been proposed to identify
ISD. Urethral hypermobility on the other hand is a clinical
diagnosis (physical examination) and should always be
assessed. Urethral hypermobility and ISD can coexist, but
when no urethral hypermobility is found in a patient with
SUI, then it must be caused by ISD, regardless of urody-
namic testing.
Urethral Pressure Profilometry
In women with SUI and no urethral hypermobility, a MUCP
of 20  cmH2O or less has been used as a definition of ISD
[34]. However, UPP does not diagnose SUI, it cannot dis-
criminate urethral incompetence from other disorders, it can-
not estimate the severity of UI, and it does not provide an
indicator for success after surgery [3, 23].
Abdominal Leak Point Pressure
ALPP is defined as the lowest value of the intentionally
increased pves that provokes urinary leakage in the absence
of a detrusor contraction [17], and is an assessment of the
Fig. 18.9  Urodynamic trace displaying stress urinary incontinence
and Valsalva testing to determine Valsalva leak point pressure. Multiple
estimates of the ALPP at a fixed bladder volume (200–300 mL) are rec-
M. Wyndaele and P. Abrams
ability of the urethral sphincter to resist a rise in pabd during
filling cystometry. As urine leakage is required to measure
ALPP, it can only be measured in patients with SUI, and
hence there are no normal cut-off values. If leakage cannot
be provoked in a patient with SUI symptoms, the urethral
catheter(s) should be removed, to unmask the SUI [6], and
hence allow ALPP assessment [35]. The rise in pabd can be
induced by a cough (CLPP) or Valsalva (VLPP—Fig. 18.9):
in general, it is easier to define the ALPP during Valsalva.
ALPP < 60 cmH2O indicates ISD and ALPP > 90 cmH2O
indicates little or no ISD, while values in between are con-
sidered equivocal for ISD [36]. However, the association
between ALPP, the patient’s perception of bother, and the
amount of UI is weak [24]. Furthermore, ALPP parameters
are not a helpful predictor of success of surgery in women
with SUI [8]. Nevertheless, ALPP (and/or MUCP) may
affect the type of surgery chosen by the clinician [6].
18.3.2.3 Pelvic Organ Prolapse
In women with high grade POP, it is recommended to per-
form stress testing during physical examination and/or dur-
ing filling cystometry with prolapse reduction with a pessary,
ommended [17]. Vesical pressure (pves), blue; abdominal pressure
(pabd), red; detrusor pressure (pdet), green; flow rate (Flow), black
18  Urodynamics Techniques and Clinical Applications
ring forceps or vaginal pack [6], as (surgical) POP reduction
may lead to occult SUI or latent SUI [17], and therefore has
implications for management or planning [37]. Furthermore,
POP may also be associated with BOO or with detrusor
underactivity (DU), and hence PFS may help in predicting
postoperative bladder function.
18.3.3 Underactive Bladder and Detrusor
Underactivity
The clinical presentation of the underactive bladder (UAB) is
fairly atypical, making it difficult to define [38, 39], as it
often combines storage LUTS, voiding LUTS and postmic-
turition LUTS [40]. UAB is classified as a voiding dysfunc-
tion of the bladder (Table  18.2, [10]), as opposed as BOO
(voiding dysfunction of the urethra), but clinical distinction
is difficult due to its non-diagnostic clinical presentation.
18.3.3.1 F  ree Uroflowmetry and Measurement
of Post-void Residual Volume
Free uroflowmetry and measurement of PVR can be used in
women with voiding LUTS and suspected incomplete blad-
der emptying, but they do not allow identification of the
underlying pathophysiology [40]. A Qmax < 12 mL/s (with
>100 mL VV and with or without PVR >150 mL) could dis-
tinguish women with voiding difficulties from women who
void normally [41], but does not allow distinction between
UAB and BOO.
18.3.3.2 Pressure-Flow Studies
UAB has a urodynamic correlate: detrusor underactivity
(DU), which is defined by the ICS as a contraction of reduced
strength and/or duration, resulting in prolonged bladder
emptying and/or a failure to achieve complete bladder emp-
tying within a normal time span [1]. Diagnosis requires PFS,
as it requires measurement of pdet and flow rate, which are
both low in DU (as opposed to BOO which is characterised
by high pdet and low flow rate).
Various methods have been proposed to evaluate the
strength of the detrusor contraction in women [39]. For exam-
ple, a pdetQmax (detrusor pressure at maximum flow rate) of
less than 30, 20 and 10 cmH2O combined with a respective
Qmax of less than 10, 15 and 12 mL/s have been proposed as
criteria for DU [40, 42]. Bladder voiding efficiency (BVE),
defined as VV divided by VV  +  PVR (measured after uro-
flowmetry or PFS), has also been proposed as a distinctive
measure between DU and BOO.  A cut-off of 90% allowed
differentiation between DU and BOO [42]. Furthermore, this
measure was shown to correlate well with the above men-
tioned pdetQmax criteria [40]. However, none of the described
methods include evaluation of prolonged emptying, which is
an important part of the definition by ICS [39, 42].
273
A distinctive finding is an acontractile detrusor [1] when
no detrusor contraction can be detected and voiding is only
by straining, which is defined as neurogenic acontractile
detrusor when the cause is neurologic [17].
18.3.4 Bladder Outlet Obstruction
BOO is classified as voiding dysfunction of the urethra
(Table 18.2, [10]) and is relatively rare and more difficult to
grasp in women (compared to men). It is characterised by a
high pdet and low flow (in contrast to DU, see Sect. 18.3.3),
and hence requires PFS to be diagnosed (Fig. 18.10) [6]. Two
types of BOO can be distinguished in women: anatomical
BOO (e.g. post-SUI surgery, urinary stone, bladder tumour,
urethral stricture, POP, etc.) and functional BOO (e.g. idio-
pathic urinary retention (Fowler’s syndrome) or dysfunc-
tional voiding). This makes standardisation of measurements,
creation of nomograms and identification of cut-offs diffi-
cult. The urodynamic criteria used in men to diagnose BOO
(e.g. BOO Index) cannot be used in women due to a different
pressure-flow relation.
Three methods of diagnosing BOO in women have been
evaluated [43]:
• pdetQmax and Qmax cut-off points [44]
• video-UDS, to identify the site of obstruction between the
bladder neck and distal urethra in the presence of a sus-
tained detrusor contraction (Fig. 18.5) [45]
• a nomogram to identify and classify BOO in
women [46]
A correlation between these findings and clinical history
(such as LUTS, incomplete bladder emptying, recurrent
UTI, history of POP or SUI surgery) is recommended to
accurately diagnose BOO in women [6].
18.4 Future Perspectives
The following topics are or should be the subject of further
investigation:
• The role of UDS in female SUI.
Many urodynamicists insist on doing UDS prior to
SUI surgery pointing out that few women have “simple”
or pure SUI symptoms. It has not been feasible to con-
duct a RCT in unselected women with SUI, to determine
whether or not UDS lead to a better outcome. This is
largely due to the lack of equipment of many functional
urologists and urogynaecologists. There is also some evi-
dence that women, after discussion, prefer to have preop-
erative UDS.
274
Fig. 18.10  Pressure-flow study in bladder outlet obstruction as indicated by high pressure—low flow. Vesical pressure (Pves), blue; abdominal
pressure (Pabd), red; detrusor pressure (Pdet), green; flow rate (Flow), black
• The role of UDS in female voiding difficulty.
As noninvasive testing such as uroflowmetry cannot
distinguish between BOO and DU in women with poor
flow, and/or poor bladder emptying, UDS are required for
definitive diagnosis prior to interventions such as sacral
neuromodulation. Academic work continues in an attempt
to develop a reliable standard for measuring DU in
women. Existing methods and indices are restricted by:
complexity (e.g. Watts factor, only studied in experimen-
tal settings), impracticality or patient discomfort (e.g.,
occlusion testing to assess detrusor contractility), relative
lack of applicability in women (e.g., BOO index as
described in men), or lack of consensus on normal values
(e.g., pdetQmax and Qmax, BVE) [38].
Similarly the diagnosis of BOO in women remains diffi-
cult as BOO is only seen in about 5% of women coming for
UDS, the causes of female BOO are diverse and there is no
single reliable curative treatment, as there is in men with
prostatic obstruction. Hence it will remain difficult to create
a BOO index for women.
18.5 Conclusions
When empiric and conservative treatment does not provide
sufficient symptom improvement, further assessment with
urodynamics is indicated. The urodynamic evaluation should
M. Wyndaele and P. Abrams
be designed to allow reproduction of a patient’s lower uri-
nary tract symptoms and identification of underlying patho-
physiological mechanisms.
In patients with a suspected storage dysfunction, filling
cystometry allows identification of detrusor overactivity or
reduced bladder compliance as possible underlying causa-
tion of overactive bladder. Most women with stress inconti-
nence have other storage and/or voiding symptoms and
urodynamics should always be performed prior to invasive
treatment. In the minority with “pure stress urinary inconti-
nence”, urodynamic observations can guide the type of sur-
gery chosen, but this has not yet been shown to change
treatment outcome.
Voiding dysfunction in women has recently received more
research attention and various urodynamic parameters are
being evaluated on their ability to distinguish detrusor underac-
tivity from bladder outlet obstruction in pressure-­flow studies.
Video-urodynamics can provide a useful addition when
anatomical information is needed in complex patients (e.g.
prior surgery or neurogenic patients). Ambulatory urody-
namics can be used when symptoms cannot be reproduced or
explained by conventional urodynamics.
Whichever urodynamic tests are chosen for the individual
patient, the quality of the testing is paramount and that means
that urodynamic staff must be properly trained to carry out the
test in an excellent technical fashion. They must also be able to
adapt the test during the investigation and to be expert in the
evaluation of the urodynamic test and its clinical significance.
18  Urodynamics Techniques and Clinical Applications
14. Porru D, Madeddu G, Campus G, Montisci I, Scarpa RM, Usai
Take Home Messages
Urodynamics provide important diagnostic confirma-
tion of lower urinary tract dysfunction in pelvic floor
disorders after empiric and/or conservative treatment
for symptoms. Correct methodology and interpretation
of the urodynamic evaluation allows identification of
underlying pathophysiological mechanisms prior to
advancing to invasive treatment.
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 Ultrasonographic Techniques
and Clinical Applications
Andrzej P. Wieczorek, Magdalena Maria Woźniak,
and Aleksandra Stankiewicz
Learning Objectives
• To learn about available ultrasonographic tech-
niques in pelvic floor ultrasound applied for patients
with urinary incontinence and voiding
dysfunctions
• To familiarize with equipment advantages and
limitations
• To review clinical usefulness in respect to the litera-
ture concerning ultrasound assessment in the diag-
nostics and monitoring of treatment of urinary
incontinence and voiding dysfunctions with refer-
ence to two-dimensional (2D) and 3D TPUS tech-
niques, as well as 2D and 3D EVUS
19.1 Introduction
Female urinary incontinence and voiding dysfunctions are
reported in the literature to range from 6% to 37.7% of the
general population; however the prevalence has varied con-
siderably in different studies and in various populations [1,
2]. There is no consensus for a single unified definition and
classification for female voiding dysfunctions [3].
The International Continence Society (ICS) defines uri-
nary incontinence as “the complaint of any involuntary leak-
age of urine” [4], whereas voiding dysfunction as “abnormally
slow and/or incomplete micturition diagnosed by symptoms
and urodynamic investigations” [5], but it must be under-
A. P. Wieczorek (*) · M. M. Woźniak
Department of Pediatric Radiology, Medical University of Lublin,
Children’s University Hospital, Lublin, Poland
e-mail: wieczornyp@interia.pl
A. Stankiewicz
Department of Radiology, University Hospital of North Midlands,
Stoke-on-Trent, UK
e-mail: Ola.Stankiewicz@uhnm.nhs.uk
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_19
19
lined that urinary incontinence and voiding dysfunctions are
a wide group of lower urinary tract symptoms. The symp-
toms have been divided by the ICS into three groups: stor-
age, voiding, and post-micturition. These abnormalities have
various background, which can be neurological, functional,
anatomical, or idiopathic.
In the past some definitions and grading systems of void-
ing dysfunctions, e.g., stress urinary incontinence, have been
based on the X-ray fluoroscopic images of the position of
vesical neck and intrinsic sphincteric mechanism at rest and
with straining [6]. These diagnostic methods were embar-
rassing for patients and thus often unaccepted. Since that
time many authors have described ultrasound imaging tech-
niques which with time have been more often introduced
into the diagnostics.
Ultrasound is a synonymous of many different modalities
and approaches. Technical aspects such as frequency, shape
of transducer, and philosophy of beam formation (2D, 3D,
4D) can provide a variety of information about all pelvic
floor structures in order to evaluate anatomical background
of UI and VD.
The role of US is the assessment of location of urinary
bladder and urethra during rest and dynamic assessment of
their mobility in relation to symphysis pubis, evaluation of
hyper-rotation, prolapse, post-void volume, and relations
among organs belonging to various compartments (urethra,
vagina, anal canal). In patients with prolapse of anterior and
posterior compartments, US should be helpful in defining
cystocele, rectocele, and enterocele.
Another purpose of performing ultrasound is the attempt
to answer the question if there are any anatomical abnormali-
ties which could cause voiding dysfunction and are not diag-
nosed by clinical examination. Several anatomical disorders
can give the symptoms of UI or voiding dysfunctions such as
improper (ectopic) subtrigonal ureteral insertion, uretero-
cele, bladder and urethral diverticulas, urachal abnormali-
ties, trigonal and urethral tumors, and neoplasmatic
infiltration of bladder trigone or vaginal wall.
277
278
Moreover in women after deliveries, US can assess not
only abnormal location but also the degree and extent of
defect of various pelvic floor structures, for example,
levator ani muscle which could be causative factors of UI
and VD.
Ultrasound is also a very useful technique in postoperative
assessment as it allows for the precise visualization of the
location/position of tapes and meshes and also in follow-­up
postsurgical complications such as fistulas, hematomas, and
other.
Summarizing, ultrasound can provide anatomical infor-
mation which cannot be obtained in clinical examination
allowing for categorization of patients for various types of
treatment.
In recent guidelines for urinary incontinence and voiding
dysfunctions issued by various societies, ultrasound is not
the first-line diagnostic tool and is not recommended;
­however it can be a very valuable add-on to clinical examina-
tion particularly in case of complex inborn or postdelivery
disorders [7]. Dynamic character of the examination can give
a huge dose of functional information. A number of publica-
tions describe how to quantify the mobility of pelvic floor
structures. The advantage of US is its wide availability for
Fig. 19.1  Asymmetry of the
urinary bladder (below
horizontal line) in patient with
voiding dysfunction.
Transabdominal ultrasound
with abdominal transducer
type AB2-7D, General
Electric. B bladder
A. P. Wieczorek et al.
various specialties, low cost, high reproducibility, and rela-
tive simplicity of the method.
19.2 External Ultrasound
Transabdominal ultrasonography (TAUS) has limited use-
fulness in the assessment of urinary incontinence and void-
ing dysfunction. Due to the wide distance between the
transducer and the examined organs and to the low frequen-
cies used, this modality provides low-resolution images of
the urethra and pelvic floor structures [8]. Its role is reserved
for the evaluation of bladder shape and bladder wall thick-
ness, calculation of post-voiding bladder volume, and
assessment of the upper urinary tract. Asymmetry of the
urinary bladder, particularly its lower wall, can help in
selecting the patients with lateral defect and prolapse
(Fig.  19.1). Transabdominal US is also used for defining
upper and lower urinary tract abnormalities, e.g., duplica-
tions of collecting systems, ectopic ureters, urachal abnor-
malities (Fig. 19.2), and other.
Transperineal ultrasound (TPUS) is the general term used
for the ultrasound performed with the transducer placed on
19  Ultrasonographic Techniques and Clinical Applications
Fig. 19.2  Urachal cyst
(arrow). Transabdominal
ultrasound with abdominal
transducer type AB2-7D,
General Electric. B bladder
the perineum (Fig. 19.3). This encompasses translabial ultra-
sound (TLUS), where transducer is positioned on the right or
left labia, introital ultrasound when the transducer is placed
between the labia, and true TPUS when transducer is placed
on the perineum between the vaginal orifice and the anal
margin.
The amount of anatomical and functional information
obtained is similar in each of these techniques, as all pelvic
structures (bladder, urethra, vaginal walls, anal canal, and
rectum) located between the dorsal/posterior surface of the
symphysis pubis and the ventral/anterior part of the sacral
bone could be visualized. Moreover, all techniques enable to
obtain sagittal, coronal, and oblique sections, although the
most commonly used is the midsagittal plane, which allows
overall assessment.
Currently, no guidelines exist on which transperineal
approach to use; however we know from our experience that
translabial approach is the most appropriate in patients with
associated pelvic organ prolapse, as the probe placed on the
labia allows prolapse to fully develop.
279
19.2.1 Examination Technique
No patient preparation or micturition is required before the
examination, and no rectal or vaginal contrast is used.
Patients are recommended to feel comfortable with the
amount of the urine in their bladder. Standardization of
bladder filling is not possible in patients with urinary incon-
tinence as most are not able to hold urine. However, the
amount of the urine in the bladder can influence the results
of measurements, with a full bladder resulting in a reduced
mobility of the urethra [9]. The patient is placed in a supine
position but, if necessary, can be asked to stand during the
examination.
Different types of probe can be used: convex transducers
are normally reserved for abdominal or obstetric examina-
tions, at a frequency of 4–6 MHz, and end-fire transducers
are routinely used for gynecological or urological purposes,
at higher frequencies (7–12  MHz), but with a smaller
insonation angle resulting in a smaller field of view. Both
types of probe allow the application of color Doppler for
280 A. P. Wieczorek et al.

a b

c d

Fig. 19.3  Scheme of transducer placement on the perineum for perineal/transperineal (a), translabial (b), and introital (c) approach. The field of
view depends on the placement of the transducer and may focus on either the anterior compartment (d) or the posterior compartment (e)
19  Ultrasonographic Techniques and Clinical Applications
evaluation of urethral vascularity [10, 11], urethral funnel-
ing, and assessment of the passage of urine [12].
Two-dimensional (2D) TPUS is the simplest US tech-
nique, and it is set as default technique on the US scanner. It
can be performed with almost every ultrasound scanner,
which makes this method broadly accessible. It enables
imaging in coronal, sagittal, and oblique sections, providing
a flat image of the visualized anatomy. A limitation of this
modality is represented by the low frequencies used and rela-
tively poor resolution.
2D TPUS enables measurements of the pelvic structures
in the midsagittal plane at rest or during functional tests
(coughing, Valsalva maneuver, maximal pelvic floor con-
traction). These are as follows:
• Bladder wall thickness (BWT) normal value up to 5 mm;
abnormal over 5 mm [13].
• Post-voiding residual bladder volume: for the assessment
of bladder outlet or obstruction; post-voiding residual
bladder volume should not exceed 50 mL [14–16].
• Bladder–symphysis distance (BSD): the distance between
the bladder neck and the lower margin of the symphysis
a b
Fig. 19.4  Assessment of pelvic organs with 2D transperineal ultrasound,
(a) at rest and (b) during Valsalva maneuver. Bladder–symphysis distance
is the distance (vertical line) between the bladder neck and the lower mar-
281
pubis. The value of BSD should be equal to approxi-
mately two-thirds of the length of the urethra, and differs
individually, normally ranging between 20 and 30  mm
(Fig.  19.4). The BSD value enables assessment of the
position and mobility of the urethra and the bladder neck
with good interobserver reliability at rest and excellent
during Valsalva maneuver [17]. There is no definition of
“normal” for bladder neck descent, although a cut-off of
20  mm has been proposed to define hypermobility [12]
and reported to be strongly correlated with stress urinary
incontinence [18].
• Urethral length (taken as the distance from the bladder
neck to the visible end of the external urethral orifice) and
width. Normal values vary individually, ranging between
30 and 45 mm.
• γ angle: i.e., angle between the inferior edge of the sym-
physis pubis and the urethrovesical junction, at rest
(Fig. 19.5) and on Valsalva [5].
• Urethral rotation: i.e., rotation of the proximal urethra on
Valsalva [5].
• Retrovesical angle (RVA): i.e., angle between proximal
urethra and trigonal surface of the bladder (Fig. 19.5) [5].
gin of the symphysis pubis. The horizontal line indicates the lower margin
of the symphysis pubis and is a reference point for the measurements of
bladder neck movement. B bladder, SP symphysis pubis, U urethra
282 A. P. Wieczorek et al.

a b

UVJ

RVA

SP

c d

Fig. 19.5  Scheme of the ultrasound parameters in transperineal ultra- (a). 2D transperineal ultrasound at rest; γ angle (b). Retrovesical angle
sound: γ angle, between the inferior edge of the symphysis pubis (SP) (c). A anal canal. Transperineal ultrasound during Valsalva maneuver
and the urethrovesical junction (UVJ). Retrovesical angle (RVA), showing (d) cystocele and (e) enlarged gamma angle. B-mode image
between proximal urethra (U) and trigonal surface of the bladder (B) with transducer type 9C2, BK Medical
19  Ultrasonographic Techniques and Clinical Applications
The following reference lines have been proposed for the
assessment of pelvic organ descent by transperineal
ultrasound:
• A horizontal reference line touching the inferior edge of
the symphysis pubis drawn parallel to the border of the
screen proposed by Dietz and Wilson (H-line) [19]
• A central reference line drawn through the longitudinal
axis of the interpubic disk of the symphysis pubis (the
central pubic line) proposed by Schaer et al. [20]
• A reference line between two hyperechoic contours of the
symphysis pubis proposed by Hennemann et al. [21]
In the study by Hennemann et al. comparing three above-
mentioned reference lines for the assessment of pelvic organ
descent by TPUS, the authors concluded that the central
pubic line [21] was shown to be inferior owing to poor visi-
bility in volumes, whereas the reference line between two
hyperechoic contours of the symphysis pubis obtained
repeatability parameters comparable to the horizontal line of
Dietz and Wilson [19].
Recently 2D TPUS can be also performed with ultrasound
elastography options which can show elastic properties of
pelvic floor organs, for example, perineal body or superficial
perineal muscles [22].
Two-dimensional TPUS can be enriched by adding a third
dimension (depth) or fourth dimension (time) to it, which is
known as 3D and 4D TPUS, respectively.
The main advantage of 3D/4D TPUS, compared to 2D
mode, is the possibility of obtaining reconstructed sections
to precisely visualize the relevant pelvic floor structures
along their proper planes and to measure their volume. The
reconstructed axial plane allows evaluation of the levator ani
muscle (LAM) and its attachments to the pubic rami and
measurement of the diameter, area, and volume of the uro-
genital hiatus [23–26]. Another advantage of the 3D tech-
nique is the possibility of recording data for subsequent
off-line assessment.
Recently a new display technique called tomographic
ultrasound imaging (TUI) has been introduced to 3D
TPUS.  Tomographic ultrasound imaging (TUI) allows the
examiner to obtain a volume dataset that simultaneously dis-
plays multiple images at specific distances (Fig. 19.6). Dietz
et al. established minimal sonographic criteria for the diag-
nosis of avulsion with the use of TUI when complete avul-
sion of the puborectalis muscle is best diagnosed by requiring
all three central slices to be abnormal [27]. These findings
were subsequently confirmed by Shek et al. who described
3D/4D ultrasound technique for the assessment of levator
avulsion via evaluation of TUI as a gold standard method
used by dozens of research groups around the world. Levator
283
avulsion is diagnosed if the muscle insertion is clearly abnor-
mal in slices at the plane of minimal hiatal dimensions and at
2.5 and 5 mm cranial to this [28].
Four-dimensional ultrasound gives live action images of
the pelvic floor anatomy. This technique is particularly
helpful in recording functional tests of the pelvic floor
(coughing, Valsalva maneuver, maximal pelvic floor con-
traction) [29, 30]. It is a simple technique assessing sym-
metry or asymmetry of pelvic floor structures indicating
potential defect.
19.3 Endoluminal Ultrasound
Endoluminal US includes endovaginal (EVUS), endoanal/
endorectal (EAUS/ERUS), and historical method being
transurethral (TUUS) ultrasound (see [31, 32]).
Endovaginal US can be performed with the following
transducers (see [31]): (1) end-fire transducer, commonly
used in gynecological and urological practice; this type of
probe gives sector 2D images and allows visualization of
sagittal and transverse sections of the urethra and surround-
ing tissues; (2) electronic biplane transducer, with linear and
transverse arrays (type 8848, BK Medical, Herlev, Denmark)
and perpendicular beam formation (type 8838 and its recent
version X14L4, BK Medical, Herlev, Denmark); and (3)
360° rotational probe, with multifrequencies (6–16  MHz)
and axial ultrasound beam formation (type 2052, and its
recent version 20R3, BK Medical, Herlev, Denmark). An
advantage of high-frequency EVUS is the detailed evalua-
tion of pelvic floor morphology, due to the close distance
between the transducer and examined organs. There are also
other vendors offering similar solutions such as Hitachi
(Tokyo, Japan).
The presence of the transducer in the vagina, however, has
the limitation that in patients with pelvic organ prolapse it
can prevent the descent during functional assessment.
Recently EVUS can be performed additionally with the
use of ultrasound shear wave elastography (SWE) which is a
noninvasive real-time technique used to estimate tissue
stiffness.
Endoanal US (EAUS) is commonly performed with the
rotational probes (see [32]). Although EAUS provides
images of the urethra that are comparable to those obtained
by EVUS, its usefulness in clinical practice is limited. The
main reasons for this are artifacts due to bowel movements
and the presence of feces or air in the small bowel or rec-
tum; a large distance of the transducer from the area of
interest that reduces the resolution [25]; and low accep-
tance by patients due to embarrassment and discomfort
during scanning.
284
Fig. 19.6 (a) Three-dimensional transperineal ultrasound showing unilateral defect of levator ani (arrow), (b) the same examination presented
with the use of tomographic ultrasound imaging (TUI) option
In the past also transurethral US (TUUS), including a
dynamic 3D US, was performed by using a 10 MHz trans-
ducer, diameter 23 F, allowing 360-degree transverse images
of the urethra and surrounding tissues (type 1850, BK
Medical, Herlev, Denmark) [33–35]. The main advantage of
TUUS was the lack of a compression effect and the absence
of urethral displacement [25]. Direct contact of the trans-
ducer (endoluminal character) also gave a precise image of
A. P. Wieczorek et al.
urethral morphology. In another study, Schaer et al. [35] cor-
related TUUS findings with histology. Structures that are
well visible with TUUS were the striated and smooth ure-
thral sphincter muscles, vagina, and blood vessels with
diameters exceeding 0.2 mm. The longitudinal smooth mus-
cle layer appeared as a w ­ ell-­defined internal hypoechoic
ring. The outer circular smooth muscle layers and the striated
muscle layers were a more irregular and hyperechoic zone.
19  Ultrasonographic Techniques and Clinical Applications
The circular smooth muscle layers and the striated sphincter
muscle layers could not always be differentiated easily.
The limitation of the endourethral approach was its inva-
siveness. It was also very embarrassing for the patient, and
often not accepted by examined women. Additionally, it car-
ries the risk of transmitting urinary tract infection. Due to
these limitations, together with the introduction of high-­
frequency EVUS, the role of TUUS has been largely limited
and rather no longer used in clinical practice.
19.3.1 Examination Technique
Technical aspects of EVUS have been reported in [31]. The
use of the rotational probe and 3D reconstruction provides an
overall view of the pelvic structures in the axial/sagittal and
coronal sections. This modality allows assessment of the
relationship between the urethral complex and the structures
located between the posterior surface of the symphysis pubis
(SP) and the internal margin of the LAM.  The following
qualitative and quantitative assessments can be obtained [36]
(see [31]):
• Evaluation of the symmetry between the urethra and the
anal canal, in the axial plane
• Evaluation of the symmetry between the left and right
branches of the pubovisceral muscle and visualization of
the attachment or detachment of the muscle to the pubic
rami in the axial plane [37]
• Anatomy of the levator ani muscle and its subdivisions
[38]
• Measurements of biometric indices of the levator hiatus
(anterior–posterior and transverse diameters and levator
hiatus area), in the axial plane
• Identification of the superficial transverse perinei, bulbo-
spongiosus, and ischiocavernosus muscles and assess-
ment of the urogenital hiatus, in the axial plane
• Urethral position in the coronal plane
• Urethral length and width and bladder–symphysis dis-
tance, in the midsagittal plane
• Evaluation of the bladder neck and bladder trigone, in the
midsagittal plane
• Evaluation of the perineal body [39]
The use of a high-frequency (5–12 MHz) biplane trans-
ducer in EVUS provides a more detailed evaluation of the
urethral complex (see [31]) [40]. Compared to the rotational
probe, it allows a dynamic assessment of the anterior com-
partment and analyses of urethral vascularity. The following
qualitative and quantitative assessments can be obtained [40]
(see [31]):
285
• Measurement of urethral length, depth, width, and vol-
ume, in the axial and midsagittal planes
• Measurement of BSD at rest and during Valsalva maneu-
ver, in the midsagittal plane
• Measurement of rhabdosphincter muscle length, depth,
width, and volume, in the axial and mid sagittal planes
• Evaluation of the integrity of the perineal body
• Functional dynamic assessment of bladder and urethral
mobility
• Evaluation of urethral vascularity [41–43]
Three-dimensional endovaginal ultrasound (3D EVUS)
can be also used to determine the prevalence of levator ani
(LA) muscle subdivision defects in patients with SUI [44].
Excellent agreement between raters assessing levator ani
muscle deficiency using 3D endovaginal ultrasound has been
demonstrated [45]. Moreover, endovaginal 3D US is compa-
rable to MRI in its ability to identify both normal and abnor-
mal LAM anatomy [46].
The vascular pattern of the urethra may be obtained using
color Doppler. To allow further off-line assessment, the data
should be registered and stored as video files. We recom-
mend performing two video acquisitions: one in the longitu-
dinal plane at the level of the urethral lumen and the second
in the axial plane at the level of the midurethra. Quantitative
assessment of the urethral blood perfusion may be performed
with PixelFlux software (Chameleon Software, Freiburg,
Germany) [41, 42] (Figs. 9.10, 9.11, 9.12, and 9.13)
(see [47]).
Obtained automatically three-dimensional data can be
further post-processed using the BK Medical 3D Viewer (BK
Medical, Herlev, Denmark) in order to perform vascular ren-
der mode and maximum intensity projection (MIP). Volume
render mode (VRM) is a technique for analysis of the infor-
mation inside a 3D volume by digitally enhancing individual
voxels. It is currently one of the most advanced and com-
puter-intensive rendering algorithms available [48]. Vascular
render mode refers to the application of render mode to 3D
data volume with color Doppler acquisition to provide visu-
alization of the spatial distribution of the vascular networks.
Maximum intensity projection is a 3D visualization modality
involving a large amount of computation. It can be defined as
the aggregate exposure at each point, which tries to find the
brightest or most significant color or intensity along an ultra-
sound beam. The application of MIP in a 3D color mode
reduces the intensity of the grayscale voxels so that they
appear as a light fog over color information, which is there-
fore highlighted. In a color volume, the colors are mapped to
a given value in the volume. We recommend performing
VRM and MIP to analyze the 3D data volume with color
Doppler acquisition (Figs. 9.4 and 19.7).
286
a c
Fig. 19.7  Endovaginal ultrasound with transducer type 8848, (BK
Medical). Vascular render mode reconstruction of a 3D color Doppler
dataset shows the spatial distribution of the vessels in the female ure-
thra. 1 intramural, 2 midurethra, 3 distal urethra. Scans obtained in two
19.4 Discussion
Transabdominal ultrasound is a reliable method for assess-
ment of the urinary bladder to determine bladder wall thick-
ness (BWT) and bladder neck wall mass, in patients with
voiding dysfunctions and outflow obstruction [49]. It allows
measurement of post-voiding residual urine volume and can
help to determine whether additional tests are needed. The
efficiency and safety of bladder US makes its use beneficial
in a wide variety of populations, including hospitalized
patients, children, and the elderly. Transabdominal US can
also be used for suprapubic aspiration of fluid collections
and evaluation of intravesical masses. Its role in the evalua-
tion of urinary incontinence is limited. Sugaya et al. [8] used
this modality to assess the bladder neck morphology in
women with urethral syndrome or stress urinary inconti-
nence (SUI), in order to determine the ultrasonographic find-
ings of these conditions. They reported that transabdominal
US provides useful information and should be carried out as
a routine examination in female patients with micturition
disorders. However, recent multicenter study of the
Collaborative Group of the Bladder Ultrasound Study (BUS)
reported limited usefulness of the transabdominal measure-
ment of BWT in patients with detrusor overactivity.
According to results of this study, BWT could not substitute
of the urodynamics in patients with overactive bladder [50].
The usefulness of TPUS in the assessment of urinary
incontinence and voiding dysfunction has been widely
A. P. Wieczorek et al.
different patients show a poor (a) and rich (b) network of vessels. (c)
Transperineal ultrasound with power Doppler shows the spatial distri-
bution of the vessels in the female urethra. B bladder, SP symphysis
pubis
reported in the literature. Bai et al. [51] performed TPUS to
evaluate the differences between patients with or without
urethrovesical junction hypermobility associated with
SUI. They found the two groups differed in the bladder neck
descent. Hypermobility of the bladder neck in nulliparous
patients is not often seen. Harris et al. [52] reported a bladder
neck mobility of 31° in nulliparous patients versus 38° in
parous patients. Volloyhaug et al. studied changes of recto-
vesical angle, BND, and urethral rotation between rest and
Valsalva in patients from their pregnancy to 4 years postpar-
tum. They have found increase in values of all these param-
eters irrespective the mode of delivery. The higher values
were associated with LAM avulsion [53].
In patients with stress incontinence, but also in asymp-
tomatic women [54], urethral funneling may be observed on
Valsalva maneuver and sometimes also at rest (Fig. 19.8). Its
morphologic basis is unknown, and its incidence is reported
to range from 18.6% to 97.4%. Funneling is often associated
with leakage, and occasionally weak grayscale echoes may
be observed in the proximal urethra, suggesting urine flow
and therefore incontinence during straining. However, fun-
neling may also be observed in urge incontinence. Marked
funneling has been shown to be associated with poor urethral
closure pressures [12, 55]. Tunn et al. [56] performed introi-
tal US in patients with SUI, to distinguish those with and
without urethral funneling. The two groups were compared
for clinical history, urodynamic results, and MRI findings.
The results of this study, however, could not elucidate the
19  Ultrasonographic Techniques and Clinical Applications
Fig. 19.8  2D transperineal ultrasound. Urethral funneling (arrow). A
anal canal, B bladder
pathogenesis of urethral funneling. Schaer et al. [54] evalu-
ated the bladder neck in continent and stress-incontinent
women, by TPUS with the help of US contrast medium
(galactose suspension-Echovist-300). This method allowed
quantification of the depth and diameter of bladder neck dila-
tion, showing that both incontinent and continent women
may have bladder neck dilation and that urinary continence
can be established at different locations along the urethra.
Parity seemed to be a main prerequisite for a proximal ure-
thral defect with bladder neck dilation.
Dietz et al. [57] reported that bladder neck mobility and
maximum urethral closure pressure are strong predictors of
the diagnosis of SUI, provided that major confounders such
as previous incontinence or prolapse surgery, pelvic radio-
therapy, or urethral kinking on ultrasound are excluded.
Bladder neck descent explains 29% and urethral closure
pressure 12% of overall variability. Bladder neck mobility
appears to be the strongest predictor. Hall et  al. [58] per-
formed a comparison of periurethral blood flow resistive
indices and maximum urethral closure pressure in women
with SUI and concluded that TLUS and Doppler spectral
waveform can confidently be included in the assessment of
morphology and urethral resistive indices.
Chen et  al. in their study using quasistatic elastography
for quantitative evaluation of the elastic modulus of the peri-
neal body provided a first in vivo estimation of the nullipa-
rous perineal body modulus. Their results provide a baseline
for future studies aimed at addressing relevant clinical ques-
tions such as how much late stage pregnancy affects perineal
body modulus and whether, for example, it is affected by
perineal massage [22].
287
Assessment of the urethral sphincter using a 3D US scan
predicts the outcome of continence surgery [59]. By per-
forming 3D TPUS with the use of a sector endovaginal
probe, Digesu et al. [59] found that the rhabdosphincter vol-
ume was a predictive factor for surgical outcome. They
reported that women whose continence surgery failed had
significantly smaller preoperative urethral sphincter volumes
(mean value 1.09 cm3) than those who had an objective cure
(3.79 cm3) (p < 0.001).
Ultrasonography plays a very important role as a fol-
low-­up examination after pelvic reconstructive surgeries.
It enables evaluation of the position of tapes and meshes,
as improper positioning or erosion can cause unsuccessful
surgery. Two-dimensional and 3D-TPUS were performed
by Dietz et  al. [60] to assess the effectiveness of various
suburethral slings (tension-free vaginal tape, TVT; supra-
pubic arch sling, SPARC; and intravaginal sling, IVS). All
three tapes could be visualized by ultrasound and showed
comparable short-term clinical and anatomical outcomes.
TVT and SPARC were highly echogenic, with SPARC
being generally flatter and of wider weave. The IVS
seemed narrower and less echogenic [60]. Three-
dimensional ultrasound was also used by Ng et  al. [61],
who found that the midurethral position of the TVT may
not be essential in restoring continence and that the TVT,
once inserted, may not always remain in the midurethral
position. Bogusiewicz et al. described the utility of EVUS
in the assessment of the position of tapes. The position of
the tapes was determined at the sagittal plane by 3D trans-
vaginal ultrasound using a linear transducer. The authors
reported that most of the patients with suburethral sling
failure have tapes located outside the high-pressure zone
of the urethra [62]. Another predictor of failure may be
improper C-shape of the tape suggesting its improper ten-
sion [63] (Fig. 19.9).
A key role in the diagnosis of urinary incontinence and
voiding dysfunctions is assessment of the morphology and
function of three pelvic floor structures, which are the endo-
pelvic fascia, the levator ani muscle (LAM), and the perineal
membrane (Fig.  19.10). These structures provide support
holding the pelvic organs in place and contribute to main-
taining urinary continence [64]. The feasibility of visualizing
the endopelvic fascia by US was reported by Reisinger et al.
[65], who, not surprisingly, found 3D EVUS to be superior
than 3D EAUS in the visualization of this fine structure. Both
3D EVUS (with use of rotational or biplane transducers) and
3D TPUS provide an accurate evaluation of the LAM mor-
phology and its attachment to the pubic rami and allow mea-
surement of the biometric indices of the levator hiatus.
Shobeiri et  al. identified subdivisions of LAM using 3D
EVUS in his study on cadaveric pelvis [38]. In the presence
288
a b
Fig. 19.9  Endovaginal ultrasound with biplane transducer (type 8848,
BK Medical). Visualization of folded tape (arrows) being a cause of
unsuccessful surgery in B mode (a) and volume render mode (b). (c) In
of LAM damage, this modality gives precise information
about the location of the defect and can be used for monitor-
ing its natural history. Van Delft et  al. performed both 3D
EVUS and 3D TPUS in pregnant patients at 36 weeks of ges-
tation and 4 days and 3 months delivery, and they found that
in 24% of patients hematomas were present at the puborecta-
lis insertion to the pubic rami immediately after delivery,
with no avulsions reported antenatally [37]. Moreover, they
have found that 62% of LAM avulsions were no longer vis-
ible at 1 year postpartum, suggesting that partial avulsion has
tendency to improve over time [66, 67]. This studies are in
agreement with study of Grob et  al., who analyzed mean
A. P. Wieczorek et al.
the sagittal section, postsurgical complications are visualized: an
inserted tape into the urethra (yellow arrow) and abnormal C-shape of
the tape (white arrow) suggesting its improper tension
echogenicity area of the puborectalis muscle in patients dur-
ing and after pregnancy. They found higher values of mean
echogenicity area of puborectalis muscle during pregnancy
and just after delivery, as compared to the scan at 6 months
postpartum [30]. Additionally, the perineal membrane, a tri-
angular fibrous layer that attaches the perineal body to the
pubis, can be visualized.
Endovaginal US also has a relevant role in detecting pel-
vic organ prolapse (POP) coexisting with urinary inconti-
nence (see Chap. 49).
By performing 3D EVUS with the use of a biplane trans-
ducer, we determined the rhabdosphincter volume that,
19  Ultrasonographic Techniques and Clinical Applications
a b
Fig. 19.10 (a) Three-dimensional endovaginal ultrasound in patient
with urinary incontinence with transducer type 8838, BK Medical.
Bilateral levator ani defect (arrows) and subsequent enlargement of hia-
tal area. (b) Three-dimensional EVUS with transducer type X14L4, BK
according to Digesu et al. [59], represents a predictive factor
for surgical outcome. Our results (mean value 1.2 mL) were
comparable to those obtained with 3D EAUS by Athanasiou
et al. [68] and with the measurements performed with mag-
netic resonance imaging (MRI) by Tan et al. [69]. In patients
with advanced degenerative changes of connective tissue
(aging), appearing on ultrasound as inhomogeneity of the
urethral complex muscles, a worse therapeutic effect might
be expected compared to patients with normal-appearing
rhabdosphincter and smooth muscles.
One of the advantages of the high-frequency EVUS is the
opportunity to assess the urethral vascularity. The lumen of
the urethra is surrounded by a prominent vascular plexus that
is believed to contribute to continence [70]. The spatial dis-
tribution of urethral vessels with the different blood supply,
their density and localization, and the intensity of perfusion
of the blood flow play an important role in urethral function.
It is possible that urinary incontinence and pelvic organ dys-
function may result in a change in urethral vasculature, pos-
sibly before the appearance of clinical signs [70]. Analyses
of urethral vasculature could become a predictive parameter,
which would allow implementation of prophylaxis or early
treatment for patients before their symptoms become severe.
In our study [41], performed in a group of 18 nulliparous
females, we demonstrated that the urethral vasculature is dif-
ferent along its entire length. With the use of PixelFlux soft-
289
Medical. Asymmetry of pelvic floor structures caused by levator ani
defect. Enlargement of hiatal area. A anus, B bladder. SP symphysis
pubis, U urethra, V vagina
ware, we found that the three regions of interest (ROI)
defined in the longitudinal plane presented significant differ-
ences in the intensity of perfusion. The midurethra, which
includes the rhabdosphincter muscle, showed the greatest
intensity of perfusion (mean value 0.014  cm/s, p  <  0.05),
compared to the intramural part of the urethra (0.007 cm/s,
p  <  0.05) and to the distal urethra (0.005  cm/s, p  <  0.05).
However, the perfusion between the intramural and distal
urethra was similar (0.57 cm/s, p < 0.05). No significant dif-
ferences were found in the intensity of perfusion in the two
ROIs defined in the axial section at the level of the midure-
thra. The parameters of perfusion appeared similar (0.76,
p < 0.05) in the outer layer (rhabdosphincter) and inner layer
of the urethra (circular smooth muscle, longitudinal smooth
muscle, and submucosa) [41]. Lone et  al. performed color
Doppler EVUS in incontinent patients and at 1  year from
baseline. Out of 67 recruited patients, 50 patients opted for
conservative management and 17 underwent surgery. The
vascularity of the urethra was assessed in the midurethra.
Follow-up scan did not show statistically significant differ-
ences in vascular parameters within the groups or between
the groups at comparison to baseline [43]. This was however
a pilot study, and further investigation in larger cohort should
be carried out.
Historically performed transurethral US also allowed for
an accurate assessment of urethral morphology. Test–retest
290
Fig. 19.11  3D endovaginal ultrasound with rotational transducer (type
2050, BK Medical). Visualization in the coronal section of rotated tape
(TVT) resulting in unsuccessful surgery (arrows)
reliability of TUUS in measuring female urethral sphincter
indices was performed by Heit [33]. The results showed
that the urethral longitudinal smooth muscle layer was the
only structure that could be measured reliably using
US. Measurements of the rhabdosphincter were not reliable
because the outer portion of that structure lies outside the
depth of penetration of a 12.5 MHz transducer [33]. Dynamic
TUUS and 3D reconstruction of the rhabdosphincter and
urethra in continent and incontinent women was performed
by Mitterberger et al. [34]. Partial or complete loss of rhab-
dosphincter function was detected in patients with stress
incontinence. The ultrasonographic findings were found to
have a good correlation with the grade of incontinence.
Furthermore, under contraction of the rhabdosphincter, an
increase of the urethral length was observed. In incontinent
patients, the urethral length did not increase significantly,
due to reduced contractility of this muscle. Normal contrac-
tion of the rhabdosphincter resulted in an elongation of the
urethra [34]. These findings from TUUS appeared important
clinically and are still relevant despite the fact that the
method itself is no longer in clinical practice.
As already reported for TPUS, endocavitary US is par-
ticularly useful in choosing appropriate management and in
postoperative follow-up. Endovaginal US may help to define
A. P. Wieczorek et al.
Fig. 19.12  Endovaginal ultrasound with biplane transducer (type
8848, BK Medical). Asymmetric distribution of color Doppler signal in
patient with inflammatory complication after transobturator tape (TOT)
insertion. SP symphysis pubis, U urethra
the causes of unsuccessful surgery resulting from improper
positioning of tapes and meshes [71], their elongation, too
tight placement, folding, or asymmetry, most often seen in
case of transobturator tapes (TOT) (Figs.  19.9 and 19.11).
The study of Bogusiewicz et al. has found that the highest
failure rate of the “outside-in” transobturator tapes is associ-
ated with the position of the tape in the proximal third ure-
thra, as assessed on the EVUS [72]. The ultrasound
assessment of the position of suburethral slings shows
­excellent and good repeatability and reproducibility (ranged
from 0.67 to 0.99), which confirms validity of US and its
usefulness in clinical and academic practice [73].
Endocavitary US is also very useful in the diagnosis of
postoperative complications such as hematomas, fistulas,
and small fluid collections, not visualized with transabdom-
inal ultrasound or TPUS. In case of inflammatory processes
following insertion of tapes or meshes, color Doppler mode
may confirm the presence of inflammation and locate the
changes (Fig. 19.12). Defreitas et al. [24] used endocavitary
3D US to examine the distribution of periurethral collagen
and to incorporate this technology into a practical treatment
decision algorithm for women with stress urinary inconti-
nence requiring collagen injection. They found that ultraso-
nographic evaluation of collagen volume and periurethral
19  Ultrasonographic Techniques and Clinical Applications
Fig. 19.13  Bulking agent in
the area of vesical neck in
patient operated for voiding
dysfunction. Endovaginal
ultrasound with transducer
type 8838, BK Medical. B
bladder
location was an affordable, noninvasive, and objective tech-
nique to predict improvement after periurethral collagen
injection [24] (Fig. 19.13). Similar conclusions were drawn
from the study of Yune et  al., who used 3D EVUS in the
assessment of the location and distribution of transurethral
bulking agents. They found that the bulking agents are eas-
ily identified on ultrasound and were most often found at
3- and 9-o’clock positions as intended, however at variable
distance from urethrovesical junction. In 41% it did not
form a typical sphere [74]. In another study, Bacsu et  al.
used 3D EVUS to assess durability of collagen bulking
agents in treatment of SUI. They found that collagen injec-
tion is relatively stable over the time, with a mean period of
43 months free of symptoms [75].
High-resolution multiplanar US allows comprehensive
evaluation of abnormalities of the female urethra such as
urethral diverticula, abscesses [71], tumors [76], and other
urethral and paraurethral lesions [77, 78] (Figs.  19.14,
19.15, and 19.16). A number of diverticula and the loca-
tion, size, configuration, and possible contents of the sac
may be demonstrated (Fig.  19.17). Most important, the
291
position of the neck of the diverticulum may be precisely
identified for surgical purposes [79]. The EVUS allows
visualization of coexisting anatomical disturbances con-
tributing to voiding dysfunctions, such as inborn abnormal-
ities, as well as acquired conditions—most commonly
changes connected to aging, post-inflammatory changes, or
pelvic organ prolapse.
Khullar et al. [80] described a technique of measuring
bladder wall thickness using EVUS.  Ultrasonographic
measurements showed a good intra- and interobserver
reproducibility. Women with urinary symptoms and detru-
sor instability were found to have significantly thicker
bladder walls than women with urodynamically diagnosed
stress incontinence (Fig.  19.18). This result was con-
firmed in another study by the same authors, who reported
that a mean bladder wall thickness greater than 5 mm at
EVUS is a sensitive screening method for diagnosing
detrusor instability in symptomatic women without out-
flow obstruction [81]. However, recent multicenter study
of the Collaborative Group of the Bladder Ultrasound
Study (BUS) reported limited usefulness of the transab-
292 A. P. Wieczorek et al.

a b

Fig. 19.14  Endovaginal ultrasound with biplane transducer (type bilateral ureteroceles (yellow arrows) and (c) in the sagittal section a
8848, BK Medical). The images visualize (a) in the axial section a cal- dystopic ureter as solitary abnormality (white arrow). B bladder, DU
cified dystopic insertion of the ureter to the urethra (U) (b) in the axial dystopic ureter
section a dystopic insertion of the ureter (white arrow) with coexisting
19  Ultrasonographic Techniques and Clinical Applications 293

a b

c d

Fig. 19.15  Soft tissue tumors in the area of vesical neck causing void-
ing dysfunction (a) transabdominal B-mode image with transducer type
C1-5D, BK Medical; (b) endovaginal ultrasound with transducer type
8838, BK Medical, color Doppler image showing relatively rich net-
work of vessels within the tumor in the sagittal section. (c) 3D endo-
vaginal ultrasound with transducer type 8848, BK Medical; (d)
endovaginal ultrasound with transducer type 8838, BK Medical, power
Doppler image showing relatively rich network of vessels within the
small vesical neck tumor in the sagittal section. B bladder, SP symphy-
sis pubis, U urethra
294 A. P. Wieczorek et al.

a b

Fig. 19.16 Calcifications (C) in the urethral complex (U). (a) Axial section. Calcifications localized within the rhabdosphincter and
Endovaginal ultrasound with transducer type 2050 (T), (BK Medical). externally to the rhabdosphincter (RS). (c) Endovaginal ultrasound with
Axial section. Intraurethral localization of calcifications (arrows). (b) end-­fire with transducer type IC5-9D, (General Electric). Ureterocele
Endovaginal ultrasound with transducer type 8848, (BK Medical). with calcification (stone) inside (arrow). B bladder, UR enlarged ureter
19  Ultrasonographic Techniques and Clinical Applications
a overactivity. According to the results of this study, BWT
b urogynecology was described by Rahmanou et  al. [83].
Fig. 19.17 (a) Endovaginal ultrasound with transducer type 8848 BK
Medical. Diverticula of urethra are visualized in the sagittal section. (b)
Endovaginal ultrasound with transducer type X14L4, BK Medical.
Diverticula of the urethra are visualized in the sagittal section (white
arrows) coexisting with improperly positioned tape (yellow arrow). B
bladder, SP symphysis pubis, U urethra
295
dominal measurement of BWT in patients with detrusor
could not substitute of the urodynamics in patients with
overactive bladder [50]. Aljuraifani et al. investigated the
function of the striated urogenital sphincter (SUS) with
ultrasound shear wave elastography (SWE). The authors
found the method challenging because it is difficult to
access and requires invasive measures. They concluded
that stiffness increases within the anatomical region of the
SUS during voluntary pelvic floor muscle ­contractions
with predictable response to changes in contraction inten-
sity [82] (Fig. 19.19).
The role of all types of US modalities (transabdominal,
endovaginal, endorectal, transperineal, and intraurethral) in
They suggested that transabdominal US is a useful tech-
nique to measure the bladder volume and to investigate
bladder diverticula. Endorectal US has a role in visualiza-
tion of the lower urinary tract in women with neurologi-
cally impaired anal sensation, while both TPUS and TUUS
appear not to be clinically relevant for assessing the pelvic
floor [83]. Interestingly, no specific use of EVUS was iden-
tified. Tunn et  al. [84], in updated recommendations on
ultrasonography in urogynecology, concluded that ultraso-
nography is a supplementary, indispensable diagnostic pro-
cedure and that TPUS and EAUS are the most useful
techniques. In patients undergoing diagnostic workup for
urge incontinence, US occasionally demonstrates urethral
diverticula, leiomyomas, and cysts in the vaginal wall as
well as bladder abnormalities, such as diverticula, foreign
bodies, or bullous edema. These findings lead to further
diagnostic assessment. Moreover, recent review performed
by Salsi et al. highlights an important role of 3D/4D TPUS
in urogynecology [85]. Albrich et  al. found a significant
correlation of subjective digital assessment of pelvic floor
muscle strength with 2D and 3D ultrasound parameters as
an objective diagnostic tool [86]. Lone et  al. in the study
performed using 2D TPUS and high-frequency 2D/3D
EVUS reported pelvic floor ultrasound as helpful in provid-
ing additional information, however, not changing the ini-
tial management of the patient, and therefore the authors
concluded that pelvic floor ultrasound should not replace
clinical assessment [87].
296 A. P. Wieczorek et al.

Fig. 19.18  Hypertrophy of

vesical neck in patient with
voiding dysfunction (white
arrow). Additionally visible
small clinically irrelevant
urethral calcification (yellow
arrow). Endovaginal
ultrasound with transducer
type X14L4, BK Medical. B
bladder, SP symphysis pubis

a b

Fig. 19.19  Ultrasound elastography showing elastic properties of pelvic floor organs. (a) TPUS shear wave elastography (SWE) of the perineal
body, superficial and deep parts (arrows). (b) EVUS strain elastography of the urethra during contraction

19.5 Conclusions Take-Home Messages

In conclusion, although TPUS is recognized as a very good
technique in the diagnosis of urinary incontinence and
voiding dysfunctions, high-frequency EVUS offers a sig-
nificant amount of additional information. This modality
provides a detailed assessment of the morphology, vascu-
larity, and functionality of the urethral complex and appears
to play a relevant role in the management of these patho-
logical conditions [88].
• Pelvic floor ultrasound used in urinary incontinence
and voiding dysfunctions includes many different
modalities and approaches which can provide a
variety of information about all pelvic floor struc-
tures in order to evaluate anatomical background of
UI and VD.
• Each ultrasonographic technique and anatomical
access has different imaging opportunities, and the
19  Ultrasonographic Techniques and Clinical Applications
13. Sturm RM, Cheng EY.  Bladder wall thickness in the assessment
knowledge of their possibilities and limitations is
essential.
• Transperineal ultrasound (TPUS) is recognized as a
very good technique in the diagnosis of urinary
incontinence and voiding dysfunctions enabling
reliable assessment of relations of pelvic floor
organs and performing dynamic studies.
• High-frequency endovaginal ultrasound (EVUS)
offers a significant amount of additional informa-
tion providing a detailed assessment of the mor-
phology, vascularity, and functionality of the
urethral complex and appears to play a relevant role
in the management UI and VD.
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 Biofeedback
Kari Bø and Paolo Di Benedetto
Learning Objectives
By reading this chapter, the reader will be able to
understand:
• The difference between feedback and biofeedback
• That biofeedback is not a treatment by itself, but an
adjunct to, e.g., exercise
• That EMG and manometry cannot be used to teach
a correct PFM contraction, as these methods cannot
separate between correct and incorrect contraction
• The evidence for pelvic floor muscle training with
and without biofeedback for stress and urgency uri-
nary incontinence
• That some patients may be motivated by use of bio-
feedback and that biofeedback as an adjunct to pel-
vic floor muscle training can be very important
20.1 Introduction
Shumway-Cook and Wollacott [1] have described feedback
as all the sensory information that is available as the result of
a movement that a person has produced. Feedback can be
intrinsic (coming from the person herself/himself) or extrin-
sic (coming from the outside, e.g., from a therapist telling
how the person performs a given task). It can be given during
a movement/maneuver such as during a pelvic floor muscle
(PFM) contraction or be expressed or explained after the
K. Bø (*)
Department of Sports Medicine, Norwegian School of Sport
Sciences, Oslo, Norway
e-mail: kari.bo@nih.no
P. Di Benedetto
Department of Rehabilitation Medicine, Institute of Physical
Medicine and Rehabilitation, University of Udine, Udine, Italy
e-mail: mrsart@libero.it
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_20
20
action, e.g., the therapist explains a record of PFM contrac-
tions to the patient. Figures  20.1 and 20.2 show the first
attempt to contract the PFM in young nullipara women with-
out and with SUI, respectively. In pelvic floor rehabilitation,
verbal feedback is usually given to all patients during instruc-
tion to make a contraction, using vaginal palpation or visual
observation of movement of the perineum.
Biofeedback, on the other hand, has been defined as “a
group of experimental procedures where an external sensor
is used to give an indication on bodily processes, usually
with the purpose of changing the measured quality” [2].
Biofeedback equipment was developed within the area of
psychology, mainly for measurement of sweating, heart rate,
and blood pressure during different forms of stress. In the
western world, Kegel [3] was the first to report results of
pelvic floor muscle training (PFMT) on urinary incontinence
(UI) and pelvic organ prolapse. He based his training proto-
col on thorough instruction of correct contraction, using
vaginal palpation and clinical observation for direct feed-
back of ability to perform a correct contraction. In addition,
he used a manometer to measure vaginal squeeze pressure as
biofeedback of strength of the contraction during the training
program. Today, a variety of biofeedback apparatus is com-
monly used in clinical practice to assist with PFMT, and the
biofeedback can be visual, auditory, or both.
20.2 Purpose of Using Biofeedback
In many textbooks, the term “biofeedback” is often used to
classify a method that is different from PFMT. However, bio-
feedback is not a treatment by itself. It is an adjunct to train-
ing, measuring the response from a single PFM contraction.
Hence the correct terminology should be PFMT with or
without biofeedback.
In the area of PFMT, both vaginal and anal surface elec-
tromyography (EMG) and urethral and vaginal squeeze pres-
sure measurements have been utilized with the purpose of
making the patients more aware of muscle function and to
301
302 K. Bø and P. Di Benedetto

rect contraction, and manometers, dynamometers, or surface

c c cc c c Holding Endurance EMG cannot distinguish between correct and incorrect con-
tractions. To date, vaginal palpation and ultrasound/MRI are
the most valid methods for feedback/biofeedback of correct
Highest:22 contraction and relaxation of the PFM.
Given that the patients are able to perform a correct PFM
contraction, the different biofeedback apparatuses can mea-
Fig. 20.1  Recordings of vaginal squeeze pressure measured by fiber-­
sure the following:
optic microtup transducer connected to an air-filled balloon (Camtech
AS, Sandvika, Norway); first attempts of pelvic floor muscle (PFM) con-
traction of a 19-year-old female student with no pelvic floor symptoms. • Maximal voluntary contraction (MVC)
C, PFM contraction (highest 22 cm H2O from resting pressure to peak). • Length of the contraction (local muscular endurance)
The woman attempts to hold, but she is not able to do so for a long time,
• Coordination of the contraction
which is very common at the first attempts to do a PFM contraction. She
is, however, able to do several repetitions of coordinated contractions • Ability to repeat contractions (local muscle endurance)
• Ability to relax after voluntary contraction

Holding Hence, the indications for use of PFMT with and without
ccc cc c Endurance biofeedback are UI, fecal incontinence, pelvic organ pro-
lapse, sexual disorders, voiding difficulties, constipation,
and pain.
Highest:14

Fig. 20.2  Recordings of vaginal squeeze pressure measured by fiber-­
optic microtup transducer connected to an air-filled balloon (Camtech
AS, Sandvika, Norway). First attempts of pelvic floor muscle contrac-
tion of an 18-year-old female student with proven stress incontinence
with urodynamic assessment and 43  g of leakage on ambulatory pad
test. She can contract correctly, assessed by vaginal palpation, but her
voluntary contractions are weak and uncoordinated and she fatigues
rapidly. She cannot hold and she is not able to repeat contractions
enhance and motivate patients’ effort during training [4, 5].
Today ultrasound and magnetic resonance imaging (MRI)
can also be used as biofeedback during a PFM contraction.
These methods have the advantage of being able to show
both the lift (sagittal plane) and the squeeze (constriction of
the hiatus in the axial plane) [6, 7].
As several research groups have found that more than
30% of women may not be able to perform a correct PFM
contraction at their first consultation [8–11], some authors
have suggested that biofeedback can be used to teach a cor-
rect contraction. A correct PFM contraction is described as a
squeeze around the urethra, vagina, and rectum, with an
inward and forward lift of the perineum [8, 12]. The most
common error during attempts to contract the PFM is to use
outer pelvic muscles (e.g., the hip adductors, abdominal and
gluteal muscles) [9]. In addition, Bump et al. [11] found that
as many as 25% were straining/pressing down instead of lift-
ing inward. This is important, as straining/Valsalva opens the
levator hiatus, and such maneuvers may weaken the muscles.
It is imperative to be aware that erroneous attempts at PFM
contractions (e.g., straining) may be registered by both
manometers and dynamometers [13, 14] and contractions of
muscles other than the PFM may affect surface EMG activity
[15]. It takes a person to explain and instruct how to do a cor-
20.3 Effect of Biofeedback Training
Since Kegel first presented his results on PFMT [3], several
randomized controlled trials (RCTs) have shown that PFMT
without biofeedback is more effective for stress urinary
incontinence (SUI) than no treatment [16]. A Cochrane
review found that 24 trials involving 1583 women compared
PFMT with and without biofeedback with 17 trials contribut-
ing data to the analysis for one of the selected primary out-
comes. All trials contributed data to one or more of the
secondary outcomes. Women who received biofeedback were
significantly more likely to report that UI was cured or
improved compared to those who received PFMT alone (risk
ratio 0.75, 95% confidence interval 0.66–0.86). However,
women in the biofeedback arms usually had more contact
with the health professional than those in the non-­biofeedback
arms. Many trials were at moderate to high risk of bias, and
the regimens proposed for adding feedback or biofeedback to
PFMT alone varied considerably [17]. The 2017 International
Consultation on Incontinence (ICI) report concluded that
with regard to clinic-based biofeedback, new evidence (two
studies) reported no statistically significant differences
between BF-assisted and non-biofeedback groups for self-
reported cure, improvement, or frequency of leakage episodes
(Level of Evidence: 1). Furthermore, there were no statisti-
cally significant differences between home biofeedback and
non-biofeedback groups for self-reported cure, improvement,
frequency of leakage episodes, and pad test measures in
women with SUI (Level of Evidence: 2) [5, 18–32].
The published biofeedback studies differ in the probes
used, the type of feedback/biofeedback provided (EMG, pres-
sure, ultrasound), and whether biofeedback was undertaken at
20 Biofeedback
home or in the clinic. Treatment duration varied from 4 weeks
to 6 months, and the total number of participants ranged from
12 [20] to 135 [22]. When participants were randomized,
some of the groups became very small. Although Berghmans
et  al. [23] demonstrated faster progress in the biofeedback
group, there is no convincing evidence that PFMT with bio-
feedback adds any additional benefit to PFMT alone. Four
studies found a significant increase in PFM function in the
PFMT + biofeedback group compared to PFMT alone, mea-
sured with either EMG [22, 32] or vaginal pressure transduc-
ers [30, 31]. Wong et al. [26] found a significant subjective
improvement in PFMT alone over PFMT  +  biofeedback in
one study, and the opposite in another trial [29]. No statisti-
cally significant differences were found in objective measures
of UI in any of the studies.
Unfortunately, most of the trials are flawed, with different
training dosages in the two arms of the studies. The study of
Glavind et al. [24] was confounded by a difference in train-
ing frequency, and the effect might be due to a double train-
ing dosage in the biofeedback group, the use of biofeedback,
or both. Pages et al. [30] compared 60 min of group training
5 days a week with 15 min of individual biofeedback training
5 days a week and found that the individualized biofeedback
training protocol was more effective as assessed by women’s
report and measurement of PFM strength.
Also, the adherence to training with and without bio-
feedback differed [32]. When the two groups under com-
parison receive different dosage of training in addition to
biofeedback, it is impossible to conclude what is causing a
possible effect.
Other factors may also bias the results of studies compar-
ing PFMT with and without biofeedback. Since PFMT is
effective without biofeedback, a large sample size may be
needed to show any additional effect over PFMT alone. In
most of the published studies comparing PFMT with PFMT
combined with biofeedback, the sample sizes are small, and
type II error may have been the reason for not finding an
additional effect [5]. However, in the three largest RCTs, no
significant additional effect on UI of adding biofeedback was
demonstrated [22, 27, 28].
Only one RCT was found evaluating the effect of PFMT
with and without biofeedback for overactive bladder (OAB).
Wang et  al. [33] randomized 120 women, mean age
52.7 years (standard deviation (SD) 13.7 years), with symp-
toms of OAB to 12  weeks of PFMT, PFMT with biofeed-
back, or electrical stimulation.
The results showed that the groups receiving PFMT with
and without biofeedback were better than the electrical stim-
ulation group, but there were no statistically significant dif-
ferences between training with and without biofeedback.
The use of home-based biofeedback requires patients to
undress, go to a private room, and insert a vaginal or rectal
device in order to exercise, and many patients may not like
this [34]. On the other hand, some may find it motivating to
303
use biofeedback to control and enhance the strength of the
contractions when training.
Some of the new apparatus has built in registration of adher-
ence to the training program. Any factor that may stimulate
high adherence and intensive training should be recommended
for the purpose of enhancing the effect of a training program.
Hence, when available and the patient is motivated to use it,
biofeedback can be suggested as an option for home training.
At office follow-ups, in order to record improvement, detect
non-improvement at an early stage, and motivate the patient,
the physiotherapist should use a responsive, reliable, and valid
assessment tool to measure the response to training [14].
20.4 C
 linical Recommendations for the Use
of Biofeedback
1. Instruct in correct PFM contraction using vaginal palpa-
tion, visual observation, ultrasound, or MRI to give feed-
back of the contraction.
2. If a home biofeedback tool is available at an acceptable
cost, ask if the woman is motivated to use it in her training
program.
3. If the patient is cooperative and motivated, give thorough
instruction on how to use and clean the apparatus.
4. Follow general strength training recommendations with
three sets of 8–12 close-to-maximum contractions per day.
The sets can be done separately or put together at one time-
point, fitting into the individual patient’s time schedule. As
the use of biofeedback requires the patient to undress, we
suggest that the training is done in one session.
5. Follow-up visits with the physiotherapist at least weekly
or bi-weekly are recommended, to follow up improve-
ment/non-improvement.
20.5 Conclusion
There is no evidence that use of biofeedback is more effec-
tive than pelvic floor muscle training alone to treat urinary or
fecal incontinence.
Take-Home Message
Biofeedback can be used as a motivational tool for
those who are interested in using this technique.
Correct contraction of the PFM must be assured by
either observation, palpation, or ultrasound/MRI
before use of sEMG or manometry/dynamometry as
biofeedback.
304 K. Bø and P. Di Benedetto

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 Selection of Midurethral Slings
for Women with Stress Urinary 21
Incontinence

Joseph K.-S. Lee and Peter L. Dwyer

lier work with Petros, developed the tension-free midurethral

Learning Objectives sling [2]. Early results confirmed its ease of use as an ambu-
• To understand the various modifications to midure- latory procedure [2], and subsequent long-term follow-up of
thral tapes up to 11  years has confirmed its long-term durability and
• To understand comparative data between these relative safety [3].
tapes in regard to efficacy and complications Tension-free vaginal tape (TVT®; Gynecare, Somerville,
• To understand key factors in prediction of tape failures NJ, USA) and the other midurethral slings have rapidly
gained worldwide acceptance due to low morbidity,
decreased hospitalization and equivalent success when com-
pared to more traditional operations. Ward and Hilton
reported the first randomized controlled trial (RCT) compar-
21.1 Introduction ing 175 women having a TVT and 169 women having a
Burch colposuspension [4]. Similar objective cure rates
There had been a significant shift in the focus of modern (defined as negative 1-h pad test) were reported at 2 years [5]
surgery for female stress urinary incontinence (SUI), from (63% and 51%, respectively, assuming those lost to follow-
the proximal urethra and bladder neck to providing addi- ­up were failures; 78% and 68%, respectively, carrying the
tional support at the midurethra without tension or signifi- last observed result forward), confirming the initial 6-month
cant compression, in order to improve continence without results. The equivalence of objective cure rates between TVT
“fixing” the bladder neck. Petros and Ulmsten [1] based their and Burch colposuspension was again confirmed at the
proposed “integral theory” and sling position on Robert 5-year follow-up [6] (33% and 26%, respectively, assuming
Zacharin’s anatomical studies, which demonstrated the women lost to follow-up were failures; 75% and 69%,
insertion of the pubourethral ligaments at the junction of the respectively, carrying the last observed result forward).
middle two-thirds and upper one-third of the anterior vaginal Trends in surgical activity from the National Health
wall. Their sling placement used multifilament tapes which Service (NHS) in the United Kingdom (UK) [7] and Australia
created a fibrotic reaction and were removed a few months [8] saw a rapid uptake of midurethral slings (MUSs) from
later. However, because of the remodelling process, the 1998 and a corresponding decline in colposuspension. The
“neo”-ligaments were absorbed and failed to provide long-­ phenomenal success and popularity of TVT has perhaps
term success and support. Ulmsten et al., based on their ear- itself led to the introduction of “clones” or “look-alike”
slings with multiple modifications purported to appeal to a
Electronic Supplementary Material The online version of this wide range of pelvic surgeons. However, the choice of sur-
chapter (https://doi.org/10.1007/978-3-030-40862-6_21) contains gery will vary according to the clinical situation, and no one
supplementary material, which is available to authorized users. operation will suit all patients. For example, if infection is
present, synthetic slings would be best avoided; or women
J. K.-S. Lee (*) having abdominal surgery for another indication may be bet-
St Vincents Clinic University of NSW, Sydney, NSW, Australia ter suited to a colposuspension or fascial sling. Midurethral
e-mail: urogynae@gmail.com synthetic slings have accounted for over 80% of all stress
P. L. Dwyer operations performed over the last 20 years with their popu-
Department of Urogynaecology, Mercy Hospital for Women, larity among gynaecologists and urologists varying little
Melbourne, VIC, Australia
over time, confirming their success in our patients.
e-mail: peter@pldwyer.com

© Springer Nature Switzerland AG 2021 305

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_21
306
Fig. 21.1  Retropubic sling [9]
However synthetic MUS along with synthetic mesh for POP
is under legal and media attack which has had serious com-
mercial consequences to the availability and development of
MUS for women (Fig. 21.1).
21.2 Other Types of Retropubic
Midurethral Slings
21.2.1 Top-Down Systems
The suprapubic arch sling (SPARC®, American Medical
Systems, Minnetonka, MN, USA) comes with a type 1
monofilament polypropylene mesh attached to a trocar
designed to be inserted top-down from abdominal wall,
directing out towards a vaginal incision. SPARC’s thinner
trocar needle is to be passed under finger guidance top down,
theoretically allowing the surgeon some control over the path
of the needle, compared to the larger TVT trocars, which are
passed from the vagina up to the suprapubic area, using the
positioning of the instrument’s handle for guidance. SPARC
is now no longer commercially available. Other top-down
systems include Lynx® (Boston Scientific, Natick, MA,
USA), Supris® (Coloplast, Minneapolis, MN, USA) and
Desara® (Caldera, Agoura Hills, CA, USA).
Comparative studies between SPARC and TVT have
yielded conflicting cure rates, although these appear to be
lower in SPARC procedures [10–12] compared to TVT. Of
the four reported RCTs [13–16], although two [14, 16] did
not demonstrate a difference in bladder perforation rate,
Tseng et al. [15] and Lim et al. [13] reported 4/31 and 4/61
perforations within the SPARC group compared to none and
1/61, respectively, in the TVT group. Lord et al. [16] reported
J. K.-S. Lee and P. L. Dwyer
the largest SPARC vs. TVT RCT, albeit with a short follow-
­up of 6–8 weeks, demonstrating higher incidence of urinary
retention within the SPARC group, with more patients
requiring a second operation to loosen the tape (6.5% vs.
none). Meta-analysis confirmed that TVT outperforms
SPARC in subjective cure rate (odds ratio (OR) 0.56 (95%
confidence interval (CI) 0.35, 0.92); p = 0.02) and objective
cure rate (OR 0.53 (95% CI 0.34, 0.82) p = 0.005) assessed
by negative cough test and negative pad test [12]. The most
recent Cochrane review [17] reach a similar conclusion, con-
firming the bottom-up route was more effective for subjec-
tive cure (RR 1.1; 95% CI 1.01, 1.19), incurring less voiding
dysfunction, fewer bladder perforations and vaginal mesh
exposure.
21.2.2 Intravaginal Slingplasty (IVS)
Although designed as a bottom-up approach akin to TVT, the
intravaginal slingplasty (IVS®, Tyco Healthcare, Mansfield,
MA, USA) trocar comes with a blunt disposable tip and,
more importantly, a multifilament polypropylene mesh with
smaller pores of 55–65 μm and denser texture, consequently
making it more stiff.
Meschia et al. [18] reported the largest of the three RCTs
[13, 18, 19] comparing TVT to IVS, totalling 190 patients
with a 2-year follow-up. Regardless of the definition of
objective cure rates (any definition of continence, negative
stress test, combining all three RCTs), TVT appears to have
a higher rate of cure (OR  =  0.51 (95% CI 0.3, 0.83);
p = 0.007). A recent Danish report noted significant vaginal
mesh exposure with the IVS tape, at a rate of 11.8% com-
pared to none in a TVT group at 5-year follow-up. This com-
parative cohort study also demonstrated a significant decline
in IVS cure rate compared to TVT over 5 years [20].
21.2.3 Self-Made Slings
Several investigators [21, 22] have explored cutting and tai-
loring a piece of pre-packaged off-the-shelf mesh and using
it to perform a MUS while adhering to the primary objective
of achieving tension-free midurethral placement, sometimes
using a Stamey needle carrier to facilitate sling placement.
Such self-made suburethral slings have a financial advantage
(reportedly only US $15) over more costly commercially
packaged sling kits. A group from the University of California
Los Angeles (UCLA) subsequently reported 5-year data
from their cohort of 69 patients, confirming a reasonable
subjective cure rate of 72%, with a further 16.4% who
reported improvement [23]. Although some groups have
reported good perioperative outcomes, including no bladder
21  Selection of Midurethral Slings for Women with Stress Urinary Incontinence 307

perforations or mesh exposure [22, 25], other groups have

reported significant incidence of voiding difficulties (18%
[26]; 23% [24]) and mesh exposure (3% [24]). A
Shanghainese group [27] reported their comparative trial of
a self-made sling against commercial kit using same surgical
route, showing no significant differences in clinical out-
comes, at only 1-month follow-up. While further RCTs are
needed to add maturity to the available data, these self-made
slings can be made at low costs and therefore have an impor-
tant place in the treatment of female SUI in developing
countries.

21.2.4 Overview

Many other slings have been introduced, often faster than

research could evaluate every modification. Slings may well
lookalike, though they do have significant differences in
design of trocars, mesh attachments and mesh characteris-
tics, and often come encumbered with a different learning
curve. For polypropylene slings, differences in mesh varia-
tions include pore size, fibre size, tensile strength and
whether the material is bonded or knitted. An excess of vagi-
nal mesh exposure and extrusions seen in the IVS tape, a
multifilament microporous tape, has been described earlier.
An excess of vaginal exposure/extrusions is also seen in
Obtape (Obtape®, Mentor, Santa Barbara, CA, USA) [28,
29], a microporous unwoven thermally bonded tape.
The high risk of rejection or infection with the IVS and
Obtape slings has shown that all slings are not equal. Careful
evaluation of new slings or devices for safety and efficacy is
needed before general introduction, as poor performance
could be to the detriment of thousands of women.
21.3 O
 ther Approaches for Sling
Placement
21.3.1 The Transobturator Route
In an effort to decrease complications associated with pas-
sage of trocars through the retropubic space, the transobtura-
tor approach (TO) via the obturator foramina to deploy
midurethral slings was developed in 2001 by Delorme [30].
In contrast to Delorme’s outside-in approach, de Leval
described an inside-out approach in 2003 [31]. Theoretically,
these two approaches could reduce potential injury to the
bladder, bowel and other major vessels, compared to the ret-
ropubic approach (RP). Further, a wider vector of urethral
support with a broad-based hammock could, in theory, mini-
mize de novo urgency or postoperative voiding dysfunction
(Fig. 21.2).
Fig. 21.2  Transobturator sling [9]
21.3.2 Outside-In Versus Inside-Out
Although the outside-in technique requires more periurethral
dissection, anatomical studies [32–35] suggest that the
inside-out technique is associated with a more variable tra-
jectory [34] and closer proximity to the deep external puden-
dal vasculature and the obturator canal [32, 35], though the
two methods share similar distances from the dorsal clitoral
nerve [32].
Non-randomized cohort studies of at least 100 women
comparing these two techniques have reported equivalence in
efficacy rates at 12-month follow-up [36, 37] (82–92%),
including a recent study of 5 years follow-up from Hong Kong
[38]. Three RCTs comparing both techniques reported similar
efficacy at 3-month [39], 6-month [40] and 12-month follow-
up [41]. Abdel-Fatah et  al. presented the 6-month results of
their evaluation of transobturator tape (E-TOT) study compar-
ing 160 TVT-obturator (TVTO®, Gynecare, Somerville, NJ,
USA) and 157 outside-in ARIS (ARIS®, Coloplast,
Humlebaek, Denmark) procedures, demonstrating similar
efficacy at 6 months (urodynamic stress incontinence (USI),
87.6% vs. 83.2%, p = 0.28) [40]. There appears to be more
vaginal perforation within the outside-in group, of 5% versus
0% [39]. The same group reported their 1-year [42], 3-year
[43] and 9-year [44] results which continue to show similar
clinical efficacy between outside-in and inside-­out, albeit with
a decline in overall success, 74.7% to 73.8% to 64.6%, respec-
tively. Cochrane review did confirm similar (RR 1.06; 95% CI
308 J. K.-S. Lee and P. L. Dwyer

0.91, 1.23) subjective cure rates between inside-out and out- 2.4%), de novo urgency rate (8.1–8.3%) but have an excess
side-in, although voiding dysfunction was more frequent in of groin pain (20.8% vs. 4.5%) within the transobturator
inside-out group (RR 1.74, 95% CI 1.06, 2.88) [17]. group, compared with retropubic route.
Data from a large Austrian transobturator tape (TOT) reg- Systematic reviews of pooled RCT of small patient num-
istry [45] reported an intraoperative bladder/urethral injury bers, varied quality and relative short follow-up have many
rate of 1%, the majority of which was in the outside-in group.limitations. Looking at large databases (e.g. national) with
Although the incidence of groin pain is reportedly up to 16% long follow-up may provide more accurate information on
[46] for the inside-out technique, the RCT conducted by efficiency and relative risks. Foss Hansen et al. [80] used the
Liapsis et  al. [41] reported no difference in postoperative Danish National Patient Registry to identify women who
groin pain; however, But and Faganeli’s RCT reported that had surgery for urinary incontinence from 1998 through
the inside-out technique is more painful [39]. Systematic 2007, and the outcome was a reoperation within 5 years. A
reviews [17, 47] of RCTs report higher vaginal perforation total of 8671 women (mean age, 56.1  years; range, 6.7–
rate from outside-in route; however, a recent report from 93.7 years) underwent surgical treatment for urinary incon-
Austria [48] on 10-year outcome of inside-out route reports tinence. Among these women, 5820 (67%) received a
a cumulative 7% mesh extrusion rate. synthetic midurethral sling at baseline. The cumulative inci-
The jury remains out on whether the outside-in is better dence of reoperation after any surgical treatment for urinary
than inside-out technique. incontinence was 10%. The lowest rate of reoperation was
observed among women having pubovaginal slings (6%),
retropubic midurethral tape (6%) and Burch colposuspen-
21.3.3 Retropubic Versus Obturator sion (6%) followed by transobturator tape (9%) and urethral
injection therapy (44%). The transobturator tape carried a
Comparison between the retropubic and transobturator twofold higher risk of reoperation (HR, 2.1; 95% CI, 1.5–
approaches was evaluated in three meta-analyses [12, 49, 2.9), and urethral injection therapy carried a 12-fold higher
50], four updated RCTs [51–54] and nine further RCTs [55– risk (HR, 11.5; 95% CI, 9.3–14.3) compared with retropu-
63], though there are considerable variations in methodolo- bic midurethral tape.
gies and outcome measures between these studies. RCTs are In a recent large retrospective multivariate analysis of
often powered for non-inferiority with a short- to medium-­ 1136 patients who underwent MUS [81], bladder perfora-
term follow-up. Nevertheless, meta-analyses and subsequent tions appear to be confined to inexperienced surgeons (<50
RCTs [55–57, 59–63], with the exception of one [58], slings). Other risk factors for bladder perforation include a
showed no significant difference in subjective and objective history of previous caesarean section, colposuspension, body
cure rates for SUI between the RP or TO approaches [64– mass index (BMI) < 30 kg/m2, use of local anaesthesia and
77]. The most recent Cochrane review [17] confirmed no sta- presence of a rectocele. Combination of these risk factors
tistically significant difference in subjective cure rates gave good prediction (area under the curve (AUC) of
between these two routes irrespective if follow-up was less 0.85 ± 0.06 from the receiver operator curve). Despite rela-
than 12 m or 1–5 years or more than 5 years. Despite such tively low rates of bladder or urethral injuries [78], it remains
equivalence, more RCTs have short-term follow-up and are prudent to confirm the integrity of the lower urinary tract by
often not powered to examine important subgroups, such as routine cystourethroscopy following any midurethral sling
patients with intrinsic sphincteric deficiency (ISD) who have procedures. The presence of intravesical mesh in the long
the most severe form of SUI. However, a more recent sys- term can cause bladder pain, irritative urinary symptoms,
tematic review [47] reached a different conclusion. It found recurrent urinary tract infections and stone formation.
transobturator route has poorer objective (OR 0.82; 95% CI Recognition of bladder perforation with trocar replacement
0.70, 0.96) and subjective (OR 0.83; 95% CI 0.70, 0.98) cure appears to have no long-term sequelae.
rates compared with the retropubic route.
Analysis of randomized data comparing the RP and TO
approaches confirmed that the TO approach comes with 21.4 Predictors of Failure
lower odds of bladder perforations (odds ratio (OR) 0.13
(95% CI 0.06, 0.27) [50]), pelvic haematoma (OR 0.25 (95% Despite impressive cure rates for SUI, failure can occur, with
CI 0.05, 0.82) [78]) and symptoms of voiding dysfunction reoperation rates ranging from 1.2% to 7% [50, 82]. It is
(OR 0.55 (95% CI 0.31, 0.98) [79]). Nevertheless the TO unclear whether there are clinical factors that place a patient
approach comes with a higher odds of vaginal perforations at higher risk for objective or subjective failure, since most
(OR 2.08 (95% CI 0.89, 4.95) [79]) and groin ache (OR 9.34 RCTs are not powered for subgroup analyses. Combining
(95% CI 3.02, 28.9) [79]). The 2016 Cochrane review [17] data from heterogenous RCTs would also limit precision,
confirmed their similar vaginal mesh exposure rate (2.1– reflecting inherent limitations of meta-analysis [83].
21  Selection of Midurethral Slings for Women with Stress Urinary Incontinence
Nevertheless, it remains a clinical priority to ascertain clinical
risk factors that could accurately predict surgical failures.
Identification of risk factors could facilitate preoperative
counselling and potentially allow modification of the surgi-
cal approach to optimize patient outcomes.
Factors known to influence treatment success after sur-
gery for SUI include ageing, medical comorbidities, inconti-
nence severity, previous anti-incontinence surgery, recurrent
SUI, concurrent prolapse procedure, urethral mobility and
function and the presence or absence of concurrent urgency
urinary incontinence (UUI) [84]. Retrospective analysis,
using multiple logistic regression analysis, of over 1100
women who underwent MUS at our department has indi-
cated that BMI  >  25  kg/m2, mixed urinary incontinence
(MUI), previous continence surgery (ISD) and diabetes mel-
litus are independent risk factors for subjective failure, with
concomitant prolapse operation conferring a protective effect
[85]. While there may be significant inconsistency in the lit-
erature in this regard, with most studies being retrospective,
poorly designed and underpowered, and failing to control for
confounding variables or lacking consistency in evaluation
or follow-up [84, 86], data regarding some of these areas are
emerging from randomized trials.
21.4.1 Intrinsic Sphincter Deficiency
Patients with significant urethral sphincteric impairment are
recognized as a challenging population to treat, as they suffer
from the severest form of SUI. Traditionally, ISD is defined
as having Valsalva leak point pressure (VLPP) of less than
60  cm  H2O and/or maximum urethral closure pressure
(MUCP) of less than 20  cm  H2O.  Observational series of
TVT [87] or TVTO [88] that stratified patients to
VLPP < 60 cm H2O or VLPP > 60 cm H2O have shown lower
cure rates (82% vs. 93.1%, p  =  0.013) and higher risk of
failure (OR 12.8 (95% CI 2.5, 60.8)).
In a non-randomized study comparing 97 and 39 patients
who underwent SPARC and Monarc procedures, respec-
tively, Rapp et al. [89] reported no differences in outcome,
suggesting low VLPP < 60 cm H2O may not be predictive of
outcome. Data from three recent RCTs [53, 59, 71, 82, 90]
designed to compare RP vs. TO showed that VLPP was not
predictive of outcome, although the total number of patients
with low VLPP was only 50 [53, 71, 90], 30 [71, 82] and 32
[59]. Rechberger’s [63] recent RCT reported a subanalysis of
85 patients with low VLPP  <  60  cm  H2O (45 RP, 40 TO).
More patients had failure after a TO approach compared to a
RP approach (10/45 vs. 5/45). Concerns regarding the effi-
cacy of TO MUS are also reflected in Abdel-Fatah’s E-TOT
RCT [40], with a subanalysis within their RCT of 43 patients
with MUCP < 30 cm H2O. Irrespective of the route of TOT,
women with low MUCP < 30 cm H2O have a lower conti-
309
nence rate by urodynamic definition at 6 months compared
to women with higher MUCP (58% vs. 90%, p < 0.01). The
largest RCT to date examining the effectiveness of RP vs.
TO specifically in ISD patients (VLPP < 60 cm H2O and/or
MUCP < 20 cm H2O) studied at least 164 patients [58]. This
RCT demonstrated a clear superiority in efficacy for the RP
route in the treatment of female SUI with ISD, compared to
the TO approach, as 1 in 16 women requested repeat surgery
in the RP group compared to 1 in 6 within the TO group, with
the risk ratio of repeat surgery being 2.6 (95% CI 0.9, 9.3).
The importance of urethral closure pressure was further
highlighted in non-randomized studies that use a combina-
tion of VLPP and MUCP [91, 92]. These studies have shown
higher failure rate (postoperative USI risk ratio (RR) 5.89;
95% CI 1.02–33.90) [85] and lower success (54.5% vs.
95.8%, p  =  0.006) [92] when VLPP  <  60  cm  H2O and
MUCP < 42 cm H2O were present in women undergoing the
TO approach.
In a further analysis of the Cochrane review [17], focus-
ing only on those with intrinsic sphincter deficiency, retropu-
bic route confers greater objective, subjective cure rates
compared with transobturator route, resulting in a higher risk
of repeat continence surgery in those who had prior transob-
turator sling (RR 14.4; 95% CI 2.0–106).
21.4.2 Effect of MUS on Lower Urinary Tract
Function
Mixed urinary incontinence is common, with an estimated
prevalence of 30% of all women with urinary incontinence,
and is more bothersome than pure SUI [93]. Although MUS
procedures are generally very effective in treating SUI, there
is a concern these procedures might aggravate the urgency
component or lead to de novo UUI and consequent patient
dissatisfaction.
Nevertheless, the effect of MUS on detrusor overactivity
(DO) and MUI is emerging with favourable results.
Rezapour and Ulmsten reported a subjective cure of 85% in
women with MUI 4 years after TVT, although they excluded
women with DO [94]. There are similar reports of substan-
tial MUI resolution after TVT, although cure rates are typi-
cally lower than for pure SUI [95–98]. In a retrospective
multivariate analysis [99] of over 700 patients over
50  months, patients who had mixed incontinence that
underwent a transobturator sling have lower odds of having
persistence in urinary urgency (OR 0.61; 95% CI 0.39–
0.94). Systematic reviews [17, 47] of RCTs comparing ret-
ropubic against transobturator do not show a statistically
significant difference in storage lower urinary tract symp-
toms or de novo urgency rates. However, the retropubic
approach comes with a higher rate of voiding dysfunction
(9.2% vs. 5.7%, OR 1.66; 95% CI 1.2–2.3).
310 J. K.-S. Lee and P. L. Dwyer

21.4.3 The Elderly dure with a mean follow-up of 50 months [110] demonstrat-
ing an overall subjective cure rate of 85% (elderly 81%,
Ageing causes functional and anatomical changes in the younger 85%, p = 0.32), with no significant difference in cure
lower urinary tract. The ageing lower urinary tract has a rate between the retropubic and transobturator sling in the
higher rate of detrusor overactivity, urgency incontinence elderly group (82% vs. 79.3%, p = 0.75). The bladder perfo-
and ISD. Older women are also more likely to have had prior ration rate was similar between the two groups (3%). The
procedures for urinary incontinence and therefore may have hospitalization time was significantly longer in the elderly
higher rates of urethral fixation. Severe vaginal atrophy (1.6 ± 1.7 days vs. 0.7 ± 1.1 days, p < 0.001). It is our practice
related to long-standing lack of oestrogen support of the vag- to routinely keep women over 80 years in hospital overnight,
inal tissues in the older woman could potentially pose a as opposed to using day surgery for MUS in younger women.
greater risk of poor healing and erosion after vaginal incon- Major perioperative complications were uncommon (1%). Of
tinence surgery. It should come as no surprise that older age the patients who had an isolated sling procedure, 37% of the
is associated with greater risks of post-sling surgery compli- elderly and 9% of the young patients failed their first trial
cations [100] and postoperative morbidity and mortality, voiding (p < 0.001). However, the long-­term rate of voiding
with their higher incidence of medical comorbidities when difficulty was similar between the two groups (elderly 8% vs.
subjected to more major open abdominal and vaginal surgi- young 6%, p = 0.21). The rate of de novo urge incontinence
cal procedures in the past [101, 102]. was similar between the two groups (7%).
Concerns regarding worse outcomes might have contrib- Midurethral slings are effective in alleviating the burden
uted to under-treatment of elderly woman in the past, with of urinary incontinence in elderly woman. There are differ-
literature demonstrating underrepresentation of women aged ences in reported cure rates following TVT in the elderly
over 70 years in SUI surgical trials [103], and elderly woman woman with SUI, with less data for TVTO or Monarc slings.
not receiving SUI surgery as often as younger woman [104]. Older women undergoing midurethral sling surgery can
A recent RCT demonstrated that at 6  months post-­ expect continence rates that compare favourably to those of
randomization, a group of elderly women over age of 70 who younger women.
underwent immediate TVT surgery had significantly
improved quality of life and patient satisfaction and fewer
urinary problems compared to a control group waiting for 21.4.4 The Obese
the same surgery [105]. The rates of intraoperative and post-
operative complications were similar to those observed in Women who are significantly overweight are more likely to
younger groups of women. Despite an age-related higher have stress and urge urinary incontinence and failed stress
risk from surgery, invasive treatment of SUI in elderly incontinence surgery [111].
women is better than no treatment. Two observational studies with short follow-up of
Divergence in cure rates has been reported in comparative 6 months [112, 113] have not identified BMI as a predictor of
studies involving elderly woman who underwent TVT for surgical failure following TVT.  In contrast, a study of 760
SUI [106]. Cure rates ranged from 45% to 93% for elderly women, with 5-year follow-up after TVT, has demonstrated
woman versus 73–95% for younger woman. Contributors to a higher overall cure rate in women of normal weight com-
such differing results include considerable differences pared to those with BMI  >  35  kg/m2 (81.2% vs. 52.1%,
between the studies in length of follow-up, definition of cure, p = 0.0005) [114]. In a multivariate analysis of 138 women
methodologies and cut-offs, for ages ranging from 65 to following TVT 5 years later [115], lower cure rates were also
76 years. In an analysis of risk factors for failure, following reported in women with BMI > 25 kg/m2 (68.3% vs. 83.3%,
a TVTO procedure involving 54 women with a mean follow- p  =  0.044). In our multivariate analysis of 1225 women,
­up of 9 months [107], age and previous incontinence surgery BMI > 25 kg/m2 was again found to be an independent risk
were identified as risk factors for surgical failure on univari- factor for surgical failure, confirming earlier reports, although
ate analysis, although their significance was lost following there is no difference in failure rate between the type of
multivariate analysis. Studies analysing failure following slings for obese women [85].
TVT [108], or TVT and Monarc [82], have identified age as
a risk factor for surgical failure. Larger studies with longer
follow-up have not demonstrated age to be a risk factor fol- 21.5 Biological Slings and Exitless Slings
lowing multiple logistic regressions [109].
A recent large retrospective study from our hospital Suburethral autologous pubovaginal slings have been used
reported outcomes involving 1225 women (96 are more than since first described by Aldridge in 1942. The increasing
80 years of age) who underwent a midurethral sling proce- popularity of minimally invasive midurethral slings has also
21  Selection of Midurethral Slings for Women with Stress Urinary Incontinence
led to the use of biological products in sling techniques. The
purported advantages of using non-autologous xenografts
include avoidance of harvesting, minimal dissection with
lower perioperative morbidity as well as possible lower rates
of infection and erosion. Although reports are sparse, ero-
sions do occur [116, 117].
Observational studies suggest Pelvicol (Pelvicol®, Bard
CR, Covington, GA, USA) is inferior when compared with
autologous fascial pubovaginal slings or TVT in the treat-
ment of women with SUI.  A comparative study reported
3-year outcomes of 48 women who underwent Pelvicol or
autologous rectus fascial sling procedures, confirming an
inferior cure rate (54% vs. 80.4%, p = 0.009) [118]. Women
who underwent either autologous fascia pubovaginal sling or
TVT reported lower scores for symptom severity, in a cross-­
sectional questionnaire survey of 173 women (81 autologous
slings, 60 Pelvicol, 32 TVT) compared to those who had a
Pelvicol pubovaginal sling [119].
The only RCT comparing retropubic Pelvicol to TVT
studied 132 women (74 Pelvicol, 68 TVT) with 3-year fol-
low-­up using a non-validated questionnaire. Assuming lost
to follow-up data as failures (4 Pelvicol, 7 TVT), comparable
cure rates were observed for Pelvicol (77.8%) and for TVT
(79.1%) [120]. Similarly, there was no statistically signifi-
cant difference in the rates of frequency, nocturia, de novo
urgency or dyspareunia between the two groups. A similar
RCT comparing transobturator porcine dermis to transobtu-
rator synthetic polypropylene reported its 2-year outcomes
(75 porcine dermis, 76 synthetic) in an abstract in 2008
[121]. Favourable results seen at 12  months (89.5% vs.
90.8%) were not replicated at 24 months, with the biological
group reporting a higher failure rate 21.3% vs. 10.5%.
Another recent RCT comparing TVT, Pelvicol and autol-
ogous fascial slings reported its interim results at the
International Continence Society (ICS) meeting in 2008.
Powered to have at least 76 women in each arm, using vali-
dated questionnaires, the authors reported a significant
reduction in recruitment, possibly due to increasing popular-
ity of TVT. In their interim analysis of 115 patients (30 TVT,
35 Pelvicol, 50 autologous), there was no detectable differ-
ence in clinical outcome (dry rate, improvement rate, reop-
eration rate and self-catheterization rate) between TVT and
autologous slings, although TVT utilized less operating time
and postoperative in-hospital length of stay [122]. Pelvicol
slings, however, had significantly lower improved and dry
rates at 12 months (61% and 22%), compared to TVT (93%
and 55%) or autologous slings (90% and 48%) (p < 0.0015).
Not surprisingly, Pelvicol also had a significantly higher
reoperation rate of 20% compared to 0% for TVT or autolo-
gous slings.
311
Reported data on the efficacy of Pelvicol slings for the
treatment of female SUI, apart from one RCT, showed infe-
riority over existing suburethral slings. Data on other bio-
logical slings are too few to make a definitive clinical
conclusion. The updated National Institute for Health and
Clinical Excellence (NICE) Interventional Procedures
Programme contains an overview of biological slings [123],
echoing similar concerns about the long-term efficacy of the
newer biological slings.
21.5.1 Exitless Mini-Sling
The drive towards minimally invasive MUS has led to the
development of “exitless mini-slings”, the most popular of
these being TVT-Secur (TVT-Secur®, Gynecare,
Somerville, NJ, USA) [124] and MiniArc (MiniArc®,
American Medical Systems, Minnetonka, MN, USA). The
advantages claimed for these mini-slings over traditional
RP or TO MUSs mainly relate to avoiding the retropubic
space, limiting the passage of materials through spaces
containing known vessels, nerves and viscera. Early studies
of TVT-Secur and MiniArc reported short-term cure rates
of 70.4–93.5% [125–127] and 75.7–90.2%, respectively
[127, 128]. Despite being all classified as single incision or
mini-slings, TVT-Secur®, MiniArc® (AMS, Minnetonka,
MN, USA), Solyx® (Boston Scientific, Natick MA, USA),
Ajust® (Bard, New Providence NJ, USA), Altis® (Coloplast,
Minneapolis, MN, USA), Ophira® (Promedon, Cordoba,
Argentina) and TFS (TFS, South Australia) have macro-
scopically very different anchorage systems. In a system-
atic comparative analysis [129] of mini-slings against
standard midurethral slings, mini-slings were shown to
have inferior efficacy. TVT-Secur has the largest sample in
this analysis and possibly has the least “secure” anchorage
mechanism. When TVT-Secur was excluded, efficacy of
mini-slings was comparable to standard MUS.  A 3-year
Dutch RCT [130] comparing Monarc with MiniArc showed
similar objective and subjective cure rates. A similar
Australian RCT [131] with 5-year follow-up was recently
reported, demonstrating similar efficacy between Monarc
and MiniArc, with minimal complications. Nevertheless,
mini-slings do come with likely higher learning curve and
at best only have similar efficacy against transobturator
sling and most likely might have lower cure rates against
those with higher risks for failure, including ISD, obesity
and previous failed surgery. Quite a few of these mini-
slings were either deregistered, withdrawn or no longer
supplied with Solyx, Ophira and Altis available at the time
of writing (Fig. 21.3).
312
Fig. 21.3  Exitless mini-sling [9]
21.6 Surgeon-Related Factors
Practice variations are often driven by surgical training,
individual surgeon preferences, local norms and potentially
covert or overt manufacturers’ influence. Despite a paucity
of data with regard to surgeon-related factors and MUS
selection, data is accumulating on learning curve. Studies
[132] suggest that duration of surgery was shortened after
15 cases and higher rates of complications occur in first
4  months of training [133], with first 50 cases attracting
higher rates of bladder injuries or urinary retention, whereas
a Dutch study [134] reports better objective/subjective rates
after 20 cases. Large retrospective analysis has shown, not
surprisingly, that surgeon experience has a direct influence
on the rate of bladder perforation when using retropubic
slings [81]. We suspect that this is true for other complica-
tions, e.g. pelvic haematomas, and probably also for success
rates. Learning curve for midurethral sling is likely to be
variable from one surgeon to another and longer than
expected with confounders to include prior experience, dif-
ficulty of procedure, level and quality of the proctor. The
relationship between ongoing caseload and midurethral
sling complications was also examined in a population-
based study [135] from Canada. After 10  years, patients
from low-­volume surgeons have 37% more (absolute risk
reduction 0.63; 95% CI 0.36–0.92) mesh removal or revi-
sion than those from a higher volume surgeon (75th centile,
18  cases/year). Surgeons who had adequate prior training
and adequate ongoing caseload are likely to continue to
have good results.
J. K.-S. Lee and P. L. Dwyer
21.7 Summary
Midurethral sling procedures have become a routine urogyn-
aecological procedure and the cornerstone of anti-­
incontinence surgery, mainly because these procedures have
proved to be durable, reproducible, safe and effective. Not all
slings have the same mesh or route of application. Slings uti-
lizing macroporous monofilament polypropylene mesh have
the most favourable safety and efficacy data to date. There
are concerns regarding long-term efficacy with the use of
biological slings. Systematic reviews and meta-analyses of
RCTs comparing the retropubic or transobturator approach
to midurethral slings have so far demonstrated equivalence
in short- to medium-term efficacy. Longer-term studies using
large databases suggest that the retropubic midurethral sling
may offer the best results and lowest stress incontinence
reoperation rates. The retropubic approach attracts a greater
risk of bladder injury, though if recognized and treated
appropriately, this generally has no long-term consequences.
The transobturator approach is associated with more vaginal
perforations and groin pain, though less pelvic haematoma
and voiding difficulty and possibly fewer overactive bladder
symptoms.
Emerging data that showed the transobturator route
has less efficacy in women with intrinsic sphincter defi-
ciency (VLPP < 60 cm H2O, MUCP < 20 cm H2O) com-
pared to the retropubic route. The efficacy and safety of
TVT are not compromised in the elderly or obese [107],
based on observational data. There is less data available
for the transobturator route for these subgroups and
greater paucity of data for direct comparison between
these slings. Retropubic slings may be preferable in
young, physically active patients, the obese or those with
ISD, as they have greater efficacy and their use is associ-
ated with less groin pain. A case could be made for using
the transobturator sling in patients with previous retropu-
bic operations or mixed urinary incontinence and, in
elderly patients, to reduce the risk or difficulty of needle
passage, as long as ISD is excluded. However, these
patients may be found eventually to have improved cure
rates with the retropubic MUS.
21.8 Conclusions
Women that respond best to midurethral sling surgery are
those who have simple SUI, no ISD/MUI, no previous SUI
or prolapse operations and a mobile urethra. The retropubic
MUS at present seems to give the best long-term results.
The skill, experience and ongoing caseload of the sur-
geon, not only in performing the operation but in case selec-
tion, are an important factor in patient outcome.
21  Selection of Midurethral Slings for Women with Stress Urinary Incontinence 313

13. Lim YN, Muller R, Corstiaans A, et al. Suburethral slingplasty eval-

Take-Home Messages uation study in North Queensland, Australia: the SUSPEND trial.
Aust N Z J Obstet Gynaecol. 2005;45:52–9.
• MUS have become the most commonly performed 1 4.
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SI operation worldwide because of its proven suc- clinical trial comparing suprapubic arch sling (SPARC) and
cess and day surgery simplicity. tension-free vaginal tape (TVT): one year results. Eur Urol.
2005;47:537–41.
• Both the retropubic and transobturator slings are 15. Tseng L, Wang A, Lin Y, et  al. Randomized comparison of the
popular with the retropubic sling being more effec- suprapubic arc sling procedure vs tension-free vaginal taping for
tive long term especially in recurrent SI or ISD SI. stress incontinent women. Int Urogynecol J Pelvic Floor Dysfunct.
• Complications occur following all surgeries and are 2005;16:230–5.
16. Lord HE, Taylor JD, Finn JC, et al. A randomized controlled equiva-
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effectively to avoid medicolegal sequelae. incontinence. BJU Int. 2006;98:367–76.
• Clear discussion with patients regarding benefits 1
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pubovaginal sling versus tension-free vaginal tape for treatment of
J. K.-S. Lee and P. L. Dwyer
urodynamic stress incontinence: a prospective randomised 3-year
follow-up study. Eur Urol. 2004;46:629–35.
121. Riva D, Baccichet R, Paparella L, et al. Synthetic versus biologi-
cal trans-obturator sling for stress urinary incontinence: a random-
ized study. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(suppl
1):S1.
122. Guerrero K, Emery S, Wareham K, et  al. A randomised control
trial comparing TVT, pelvicol and autologous fascial slings for
the management of stress urinary incontinence in women. BJOG.
2010;117(2):1493–502.
123. National Institute for Health and Clinical Excellence.
Interventional Procedures Programme. Insertion of biological
slings for stress urinary incontinence in women. London: National
Institute for Health and Clinical Excellence; 2005.
124. Debodinance P, Lagrange E, Amblard J, et al. TVT-Secur: more
and more minimally invasive. Preliminary prospective study of
110 cases. J Gynecol Obstet Biol Reprod. 2008;37:229–36.
125. Neuman M.  Perioperative complications and early follow up
with 100 TVT-Secur procedures. J Minim Invasive Gynecol.
2008;15:480–4.
126. Meschia M, Barbacini P, Ambrogi V, et  al. TVT-Secur: a mini-
mally invasive procedure for the treatment of primary stress
incontinence. One year data from a multicentre prospective trial.
Int Urogynecol J Pelvic Floor Dysfunct. 2009;20:313–7.
127. Jiminez Calvo J, Hualde Alfaro A, Raigoso Ortega O, et al. Our
experience with mini tapes (TVT Secur and MiniArc) in the sur-
gery for stress incontinence. Actas Urol Esp. 2008;32:1013–8.
128. Debodinance P, Delporte P.  MiniArc. Preliminary prospec-
tive study on 72 cases. J Gynecol Obstet Biol Reprod (Paris).
2009;38:144–8.
129. Mostafa A, Lim CP, Hopper L, Madhuvrata P, Abdel-Fattah
M. Single-incision mini-slings versus standard midurethral slings
in surgical management of female stress urinary incontinence: an
updated systematic review and meta-analysis of effectiveness and
complications. Eur Urol. 2014;65(2):402–27.
130. Schellart RP, Zwolsman SE, Lucot J-P, et al. A randomized, non-
blinded extension study of single-incision versus transobturator
midurethral sling in women with stress urinary incontinence. Int
Urogyneol J. 2018;29:37–44.
131. Lee J, Rosamilia A, Lim YN, Thomas E, Murray CJ, Leitch A,
Dwyer P. MiniArc and Monarc suburethral sling in women with
stress urinary incontinence - a randomised controlled trial – 60m
follow up. Int Urogynecol J. 2017;28(Suppl 1):S80–1.
132. Ito H, Yamanaka H, Hagiwara M, Furuuchi T, Matsumoto K,
Kanai K, Kodaira K, Ninomiya A, Nakamura S.  Efficacy of
tension-­free vaginal tape compared with transobturator tape in
the treatment of stress urinary incontinence in women: analysis of
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Urol. 2011;11:13.
133. Maguire T, Mayne CJ, Terry T, Tincello DG. Analysis of the surgi-
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Neurourol Urodyn. 2013;32(7):964–7.
134. Koops SE, Bisseling TM, van Brummen HJ, Heintz AP, Vervest
HA.  What determines a successful tension-free vaginal tape? A
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Surg. 2015;150:1167–75.
 Tape Positioning: Does It Matter?
22
Aparna Hegde and G. Willy Davila

that followed in 2001 retained the midurethral location while

Learning Objectives
• To understand the importance of sling location in
ensuring success following sling surgery and to
examine the evidence regarding the same.
• To delineate the corollary factors that modify the
influence of sling location on success following
sling surgery, including:
–– The various parameters that form a part of
dynamic sling function
–– The impact of performing sling surgery and ante-
rior wall prolapse repair through the same incision
–– The impact of suture fixation of the sling
changing the direction of placement from retropubic to tran-
sobturator [4]. Most subsequent commercial mesh kits using
a polypropylene mesh have adopted the midurethral princi-
ple, including the new minislings [5] differing only in the
anatomical path traversed by the tape, either retropubic or
transobturator.
But is the location of the sling an integral determinant of
outcomes? The evidence is conflicting. While some studies
are equivocal regarding the importance of sling location [6–
8], others have showed that the outcomes are better when the
sling is located midurethrally [9, 10]. Fortunately, modern
synthetic tapes are highly echogenic and easily visualized on
ultrasound [11]. Imaging studies have provided valuable
information regarding the contribution of sling location to
the outcomes following sling surgery ([9]; Figs. 22.1, 22.2,

22.1 Introduction

The reassuring outcomes, acceptable complication rates, and

the short learning curve of midurethral sling surgery have
underlined their almost universal acceptance in the treatment
algorithm of a patient with SUI.  The “integral theory” of
Petros which championed the criticality of the midurethral
support provided by the pubourethral ligament in urinary
continence [1, 2] formed the basis for the development of the
minimally invasive procedure of the retropubic transvaginal
tape by Ulmstem in 1996 [3]. The tape was designed to lie at
the site of attachment of the pubourethral ligaments, thus
replicating their supporting role. The transobturator sling

A. Hegde (*)
Tata Center for Urogynecology and Pelvic Health, Mumbai and the
Center for Urogynecology and Pelvic Health, New Delhi, India
e-mail: aparnag.hegde@gmail.com
G. W. Davila
Section of Urogynecology and Reconstructive Pelvic Surgery, Fig. 22.1  Transperineal ultrasound. Midsagittal plane view. The tran-
Department of Gynecology, Cleveland Clinic Florida, sobturator sling can be seen as a slightly curved echodense structure
Weston, FL, USA lying beneath the midurethra. AC anal canal, B bladder, LA levator ani
e-mail: davilag@ccf.org S sling, SP symphysis pubis, T transducer, U urethra, V vagina

© Springer Nature Switzerland AG 2021 317

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_22
318
Fig. 22.2  Transperineal ultrasound. Coronal view. The transobturator
sling can be seen hugging the urethra in a U-shaped manner. B bladder,
S sling, SP symphysis pubis, T transducer, U urethra
Fig. 22.3  Endovaginal ultrasound. Midsagittal plane anterior pelvic
compartment view. The transobturator sling is seen to lie midurethrally
casting a shadow across the urethra. B bladder, EUM external urethral
meatus, P pubic symphysis, S sling, U urethra, UVJ urethrovesical
junction
22.3, and 22.4). In this chapter, we will analyze the evidence
regarding the role played by location in the outcomes follow-
ing sling surgery and discuss the important corollary param-
eters influencing the interaction between sling location and
tape action.
22.2 T
 he Theoretical Basis for Midurethral
Sling Placement
The theoretical basis for the midurethral sling is provided by
two basic pathophysiological concepts: the integral theory
[1] and the hammock hypothesis [12]. Though urethral
A. Hegde and G. W. Davila
Fig. 22.4  Endovaginal 360-degree ultrasound. Axial plane view. The
TVT sling can be seen hugging the urethra in a U-shaped manner. AC
anal canal, U urethra
sphincter competence and the “seal” provided by the urothe-
lium and the submucosal vascular plexus have also been pro-
posed as important determinants of continence [13], the
integral theory and the hammock hypothesis have fundamen-
tally shaped the surgical treatments designed for stress uri-
nary incontinence in the last two decades.
The integral theory of Petros and Ulmstem proposed that
increased intra-abdominal pressure in continent women
results in forward stretching of the distal vagina by the pubo-
coccygeus muscle and backward stretching of the proximal
urethra around a competent pubourethral ligament, enabling
urethral closure [14]. This so-called high-pressure zone of
the urethra, considered crucial for continence mechanism,
was postulated to extend between the point of maximal pres-
sure and the urethral knee [15].
The hammock hypothesis of DeLancey states that the
anterior vaginal wall and endopelvic fascia, attached later-
ally to the arcus tendineus fascia pelvis and levator ani mus-
cle, form a hammock-like supportive layer on which the
urethra and the vesical neck rest [12]. During straining, the
pressure from above compresses the urethra against the ham-
mock, causing closure.
Thus damage to the pubourethral ligaments or laxity of
the vaginal wall resulting from its damaged connections to
the arcus tendineus fascia pelvis and the levator ani muscle
can potentially lead to stress urinary incontinence [1, 12].
The midurethral sling has been designed as a permanent non-­
absorbable reinforcement of the urethral support provided by
22  Tape Positioning: Does It Matter?
the pubourethral ligaments. It could potentially also supplant
the suburethral hammock support.
Various articles describing the procedure therefore
emphasized the importance of placing the tape midurethrally
without fixation or elevation of the urethra/bladder neck
complex and not near the bladder neck or at the proximal
urethra [6, 16].
22.3 P
 roposed Mechanism of Action
of the Midurethral Tape
Given the central role of the midurethral sling in the treat-
ment of SUI, it is surprising that its mechanism of action is
not entirely understood. This is owed significantly to the
fact that the underlying theories described above are still
hypotheses—largely unproven. It has been described that
­midurethral positioning allows the tape to act as a fulcrum
to produce dynamic kinking of the urethra [17, 18] or act as
a mechanical device to enhance the increase in intraurethral
pressure [19, 20] with stress [9]. The dynamic kinking and
formation of a “knee angle” has been shown to be present in
approximately 90% of cured patients following TVT sling
surgery [14, 21–26] but in only 24–50% of patients who are
continent following the transobturator procedure [14, 19,
26, 27]. According to Yang et al. [20], the main anti-inconti-
nence mechanism of TOT is urethral encroachment by the
tape which they described on ultrasound as a protrusion of
the tape into the posterior wall of the urethra, with a tran-
sient narrowing of its lumen [20, 24]. It has also been
described that during Valsalva maneuver, the TVT tape
rotates toward the symphysis pubis, compressing the urethra
and the surrounding tissues [21, 23, 28]. These different
descriptions by various authors cohere around the centrality
of “dynamic compression” of the urethra in the continence
mechanism of the tape.
Placement of the tape does not change the mobility of
the proximal urethra in either TVT or TOT tape [19, 20,
29]. Several studies do, however, indicate a transient
effect on bladder neck mobility in both the TVT [23, 24,
29–37] and TOT tapes [19, 20, 29]. It may be speculated
that this short-­lived restriction of the bladder mobility
shortly after surgery results from the effect of healing or
from less effective Valsalva maneuver due to pain or anxi-
ety over “spoiling” the effect of the cure [38]. If placed
correctly, the TVT tape lies close to the high-pressure
zone of the urethra [2]; hence in a majority of cured
patients, a positive pressure transmission in the middle
portion of the urethra is observed during urethral pressure
profilometry [24]. The maximal urethral closure pressure
and the urethral closure area appear to increase after a
TVT procedure [26]. No effect of TVT-O insertion on ure-
thral pressure profilometry has been observed [26, 38].
319
22.3.1 The Controversy Regarding Sling
Location and the Evidence on the
Importance of Sling Location
Though midurethral location is theoretically important, well-­
designed studies that conclusively establish the relevance of
sling location are lacking. The available studies differ in the
ultrasound imaging techniques employed and point of refer-
ence used to measure sling location. These variations impact
the results of the studies, and hence it is imperative that we
read the fine details of each study before drawing any
inference.
For example, in a prospective observational study of 142
women whose outcomes were evaluated 5 weeks to 2.1 years
following TVT sling surgery, Dietz et al. concluded that the
position and mobility of the TVT vary markedly [7]. Using
transperineal ultrasound, the tape position in their study was
found to vary from 30 mm above to 12.7 mm below the sym-
physis pubis at rest and between 15 mm above and 18.7 mm
below the symphysis pubis on Valsalva [7]. They hypothe-
sized that the varying degrees of dissection, the localization
of incision, and the preoperative degree of anterior vaginal
wall prolapse may be responsible for the same. They also
found that variations in placement seemed to have little
effect on symptom resolution and patient satisfaction. The
key differentiator in this study is the fact that they have used
the symphysis pubis as the reference point for determining
sling location, largely because they contend that midurethral
slings work by “dynamic compression,” i.e., kinking or com-
pression of the urethra against the posteroinferior contour of
the pubic symphysis whenever intra-abdominal pressure is
raised [6]. Therefore in their reckoning, it should not matter
much for success as to whether the urethra is compressed
proximally or distally. A criticism that can be levied at this
paper is that while dynamic compression of the urethra may
be an important component of the continence mechanism,
the role of the symphysis pubis as the focal point for mea-
surement of dynamic effect has not been proven. In the sce-
nario that it does act as the focal point against which the
compression occurs, is the distance of the sling from the
symphysis pubis an accurate indicator for all the dynamic
components involved in such a compression mechanism?
It must be mentioned that the results of this paper are sup-
ported by two smaller studies: In a study of 31 patients who
underwent TVT sling surgery, all enrolled women were con-
tinent though the sling was located midurethrally in only 21
women [8]. Another study used metal clips and an X-ray-­
proof string to mark the TVT sling location intraoperatively
and found that all the 20 women were continent postopera-
tively though the sling was located under the proximal ure-
thra in only 11 patients [6]. Lo et al. [11] observed urethral
kinking in five out of ten women with tapes implanted under
the proximal urethra [25]. It is probable that if the tape is
320 A. Hegde and G. W. Davila

situated relatively close to the midurethra, it may still work

as a fulcrum [11]. This explanation is supported by the fact
that the pubourethral ligaments were discovered along the
area between the 20th and 60th percentiles of the urethral
length [34].

22.3.2 Evidence in Favor of Primacy

of Location in the Continence
Mechanism of Midurethral Slings

Urethral pressure profile measurements and lateral urethro-

cystography provide support for the theory that the urethral
zone between the point of maximal urethral closure pressure Fig. 22.5  Endovaginal ultrasound. Midsagittal plane anterior pelvic
and the urethral knee is crucial for continence mechanism compartment view. The transobturator sling is seen to lie midurethrally
[3]. This zone, termed as the high-pressure zone of the casting a shadow across the urethra. B bladder, PS pubic symphysis, S
­urethra, has been calculated to lie between 53% and 72% of sling, U urethra
the functional urethral length, in other words, at the approxi-
mate site of attachment of the pubourethral ligaments [3].
We have used 2D and 3D multicompartment imaging of the
pelvic floor (BK ProFocus UltraView, Peabody, MA) to per-
form a series of studies on sling location and function at
Cleveland Clinic Florida. In an unmatched case-control
study of 100 patients who underwent Monarc transobturator
sling surgery, we analyzed the association of static and
dynamic sling location (as determined on three-dimensional
endovaginal ultrasound of the anterior pelvic compartment)
with outcomes 1–2 years following surgery [35]. The study
divided the patients into two groups based on outcomes:
Group A (50 patients) had successful outcomes, and Group
B (50 patients) had suboptimal outcomes. A composite mea-
sure of failure was used for outcome assessment: presence of
urine leakage on a standardized cough stress test at 250 mL
Fig. 22.6  Endovaginal ultrasound. Midsagittal plane anterior pelvic
and a “yes” answer to question 3 of the UDI-6 validated compartment view. The transobturator sling (S) is seen to lie beneath
questionnaire. The sling location was found to be signifi- proximal urethra (U) just distal to the urethrovesical junction (UVJ). B
cantly more proximal in those who had failed sling surgery bladder, P pubic symphysis
when compared with those who had succeeded (Figs. 22.5
and 22.6). In Group A, 90% of the patients had the sling
located either beneath the “high pressure zone” of midure-
thra or at the junction of the proximal urethra and midurethra
(Fig. 22.7).
In a study of 72 women [17], Kociszewski found using
transperineal ultrasound that a TVT tape located between
50% and 80% of the urethral length was associated with
a success rate of 91%. The other tape positions however
failed in 36% of the patients (p  =  0.0085). In another
study of 61 patients who underwent three-dimensional
endovaginal ultrasound following poor outcomes after
either retropubic or transobturator sling surgery, only
21.3% had the sling positioned between 50% and 75% of
the urethral length. The tape was below 50% of the func-
tional urethral length in 73.8% of the patients examined
Fig. 22.7  Endovaginal ultrasound. Midsagittal plane anterior pelvic
and above 75% of functional length in 4.9% of the
compartment view. The transobturator sling (S) is seen to lie beneath
patients [36]. As in the case of TVT, the position of a the bladder proximal to the urethrovesical junction (UVJ). B bladder,
TVT-O has also been found to influence the cure rate. PS pubic symphysis, U urethra
22  Tape Positioning: Does It Matter?
According to Yang et al. [20], location of a tape under the
proximal half of the urethra, a resting angle between the
tape arms of less than 165°, absent urethral encroachment
at rest, and persistent bladder neck funneling are inde-
pendent risk factors for failure (Chap. 17).
22.3.3 The Benefits of Determining
the Location of a Failed Sling
Even supposing that the hypothesis that sling location is
an essential determinant of its success is true, are there
any real clinical benefits of determining the location of a
sling that has failed? There are several potential advan-
tages. Ascertaining the location of the failed sling may
help to elucidate the reasons for failure of the surgery
[11]. Confirming the location of the sling may be useful
preoperatively if sling takedown surgery is planned [11]
or to even decide whether sling takedown is necessary if
the sling surgery has failed. For example, if the sling is
located proximally and is seen on dynamic assessment to
be pulling apart the bladder neck on stress (cough/
Valsalva) leading to incontinence, it may be prudent to
perform sling takedown. However, if the sling is located
distally and is not causing any distortion of the urethral
anatomy or that of surrounding structures resulting in a
negative impact on continence or future treatment, then it
may be prudent to leave the sling in place.
It also serves as a useful guide about the best course of
treatment in the future. In a patient in whom the previous
failed sling is located proximal to the urethrovesical junc-
tion, it is akin to starting anew in a treatment-naïve patient
because the sling is incorrectly located and thus has no
impact on continence in the patient. However, if continence
is slightly improved, if not completely achieved, and the
sling is found to be located beneath proximal urethra, there
is a possibility that bulking agent injection could be benefi-
cial. Also if a repeat sling surgery is planned, determining
the location of the previous sling can potentially guide us in
identifying the optimal location of insertion of the new
sling. It will also give us invaluable clues as to whether we
need to remove the previous failed sling. In patients in
whom the previous sling is located beneath the proximal
urethra, the sling is sometimes seen to pull open the bladder
neck on cough/Valsalva and contribute to further worsening
of the incontinence. In such patients, it may be prudent to
remove the previous sling before a new sling is inserted.
Lastly, if the previous sling location is not accurately
known, one may insert the new sling on top of the previous
sling as seen in Fig. 22.8, thereby interfering with the con-
tinence mechanism of the new sling.
321
Fig. 22.8  Transperineal ultrasound. Midsagittal view. A curved TVT
sling (S) can be seen inserted over a flat transobturator sling. B bladder,
SP symphysis pubis, U urethra
22.4 D
 oes the Position of the Sling Change
After Implantation?
It is important to determine whether the change in position is
a natural progression, and if so, does this lead to temporally
worsening results? Studies have revealed that the position of
TVT sling does not change much over time [25, 32]. A grad-
ual caudal displacement of the TVT with respect to the sym-
physis pubis has been described, by about 1.8 mm a year [32]
and 1.7  mm over 3  years [25]. But the sling movement is
concordant with the distal movement of the surrounding tis-
sues, particularly in women who have undergone concomi-
tant anterior repair [11]. It therefore may reflect recurrence
or progression of prolapse rather than natural tape movement
[37]. The tape has not been found to change its position with
respect to the bladder neck, either at rest or on Valsalva [25,
29]. TOT tape has also been shown to remain in the same
position over 2 years from the time of surgery [29].
The change in position may be iatrogenic: the sling may
have been placed proximally at the time of surgery.
Preoperative introital ultrasonography was performed in a
study of 102 women who underwent TVT sling surgery, and
urethral length was measured [39]. The vaginal incision for
sling insertion was initiated at one-third of the sonographi-
cally measured urethral length [39]. The TVT sling was
found in the target range of 50–70% of the urethral length in
88.2% of patients. 91.1% of the patients were cured and
6.9% of the patients showed improved continence. Thus if
322
the sling is placed precisely at the midurethral location, it is
more likely to remain in the desired position with respect to
the urethral length.
Another iatrogenic reason for the displacement of the
sling may potentially be the placement of the sling through
the same incision as that used for anterior vaginal wall repair
in women undergoing concomitant anterior vaginal wall
repair and sling surgery. In a prospective cohort study of 100
women who underwent TOT sling surgery at Cleveland
Clinic Florida [34], we found, using 3D endovaginal ultra-
sound, that 50% of patients who had undergone concomitant
anterior vaginal wall repair (Group A) had the sling located
proximally as opposed to only 23.8% of patients in whom
only sling surgery was performed (Group B; p  <  0.05).
Nineteen percent of the patients in Group A had the sling
located proximal to the urethrovesical junction as opposed to
4.8% of patients in Group B (p < 0.05). All the patients who
had the sling located proximal to the urethrovesical junction
had suboptimal treatment outcomes following surgery. Thus
patients who undergo transobturator sling surgery, with con-
comitant anterior vaginal wall repair performed through the
same incision, are more likely to have the sling located more
proximally when compared with patients who undergo tran-
sobturator sling surgery alone.
22.5 I f Location of the Sling Is Important,
Does Suture Fixation of the Sling 22.6 W
upon Implantation Help?
In a study of 463 patients randomly allocated to either stan-
dard TOT sling procedure (232 patients) or a TOT sling pro-
cedure bolstered by a 2-point tape fixation with absorbable
sutures (231 patients), both the subjective cure rate (85.15%
vs. 75.77%) and the objective cure rate (85.37% vs. 75.59%)
were significantly more in the tape-fixation group [27].
Among patients with intrinsic sphincter deficiency, the out-
comes were significantly better in the tape-fixation group
when compared with the control group (95.1% vs. 73.8%
cured or improved; p = 0.0011).
However, even if the suture fixation leads to improved
outcomes, it is prudent to assess whether that is because the
sling has remained in the desired location a year after sur-
gery. We conducted an unmatched case-control study of 80
patients returning to our center for the 1-year follow-up visit
following sling surgery for SUI [40]. The patients belonged
to two groups: Group A (40 patients) had undergone TOT
sling surgery in which the sling was not suture-secured to the
urethra, and Group B (40 patients) had undergone a pubo-
vaginal sling procedure during which the tape was suture-­
fixated to the proximal urethra. On 3D endovaginal
ultrasound performed 1  year following sling surgery, the
odds of the sling being located at the desired position was
A. Hegde and G. W. Davila
found to be significantly more in Group B when compared
with Group A (OR, 2.21; 95% CI, 1.027–4.77, p = 0.04).
In order to understand whether the transobturator route of
the surgery was a potential confounder to the study results,
we expanded the study to include 40 patients who had under-
gone TVT sling surgery in a third group (unpublished data,
[11]). In the TVT group also, only 14 (35%) patients had the
sling in the desired midurethral location when compared to
31 (77.5%) in the pubovaginal sling group. When we looked
at tape percentile (the distance of the midpoint of the sling
from the urethrovesical junction divided by the urethral
length), the tape location in the patients who had undergone
TOT sling surgery was found to be more proximal than that
in patients who had undergone TVT sling surgery; however,
it was not statistically significant (p = 0.254). There may be
other confounders that we have not accounted for, including
the difference in elasticity and flexibility of the slings; how-
ever, the study results do suggest that suture-fixating the tape
in place during implantation is associated with desired sling
location a year following surgery [11]. The ideal next step in
conclusively solving this piece of the puzzle may be a trial in
which patients are randomized into a study group where
suture fixation is done and control group without suture fixa-
tion followed by determination of sling location using ultra-
sound a year after sling surgery.
 hat Explains Successful Outcomes
Following Sling Surgery in Patients
in Whom the Sling Is Not Located
Midurethrally? Dynamic Functional
Assessment of Slings and Its
Correlation with Outcome
A question that thus arises is whether it is primarily the loca-
tion of the sling at rest or the location during dynamic activ-
ity that results in a successful outcome? Also, are we missing
the larger picture when we focus only on sling location?
What other ancillary factors interact with the sling location
variable to ensure continence during stress?
In some patients continence is restored even when a TVT
is located proximally and the urethra does not angulate dur-
ing straining [25]. In these cases the tape is likely to work as
a traditional pubovaginal sling by suspending the bladder
neck and proximal urethra [38]. However, this may be just
one among many alternative explanations. Dynamic func-
tional assessment of in vivo sling behavior may prove crucial
to help understand the mechanism of action of the midure-
thral sling and help delineate reasons for failure [9].
We conducted an unmatched case control study of 100
patients returning for their 1–2-year follow-up visit follow-
ing TOT sling surgery: Group A (n = 50) patients had suc-
cessful outcomes and Group B (n  =  50) patients had
22  Tape Positioning: Does It Matter? 323

suboptimal outcomes [9]. The deformability of the sling on
Valsalva, the concordance of urethral movement with the
sling, and the location of the sling were noted in each patient
at 1-year follow-up point with the help of 2D and 3D trans-
perineal ultrasound. Two-dimensional dynamic assessment
of sling function was performed during cough, Valsalva, and
squeeze maneuvers. Three-dimensional cubes of the anterior
pelvic compartment were obtained in each patient, over 6 s
across the midsagittal plane in maximal Valsalva and over
30 s at rest.
Concordance of urethral movement with the sling during
maximal Valsalva (Figs. 22.11 and  22.12)  The 3D cube
obtained over 30 s at rest was analyzed to determine the loca-
tion of the sling relative to the urethral length at rest. The
sling location at rest was compared to that on maximal
Valsalva. If the sling location on maximal Valsalva relative to
the urethral length was identical to that at rest, the urethra
was considered to move concordant with the sling [9]. If the
sling location on maximal Valsalva relative to the urethral

Deformability of the sling  The dynamic change in shape of

the tape in the 2D cineloop film was used to categorize three
types of sling deformability:

1. Parallel to the urethral lumen at rest (flat or slightly curved

in shape along its width at rest) and deforms to a c-shape
on maximal Valsalva
2. Parallel to the urethral lumen, both at rest and during
maximal Valsalva: the tape remains flat or slightly curved
in shape along its width and does not deform to a c-shape
on maximal Valsalva (Fig. 22.9)
3. C-shaped at rest and during maximal Valsalva: the tape
remains c-shaped along its width both at rest and during
maximal Valsalva (Fig. 22.10)

Location of the sling on maximal Valsalva  The 3D cube

obtained over 6 s during maximal Valsalva across the mid-
sagittal plane was analyzed to determine location of the sling
on maximal Valsalva.
Fig. 22.10  Transperineal ultrasound. Midsagittal view. TVT sling (S),
located beneath the proximal urethra (U), curved both at rest and on
cough/Valsalva. B bladder, SP symphysis pubis, T transducer

Fig. 22.9  Transperineal ultrasound. Midsagittal view. TVT sling (S) Fig. 22.11  Transperineal ultrasound. Midsagittal view. Transobturator
flat at both rest and on cough/Valsalva. B bladder, SP symphysis pubis, sling (S), located midurethrally at rest. B bladder, SP symphysis pubis,
T transducer, U urethra T transducer, U urethra
324
Fig. 22.12  Transperineal ultrasound. Midsagittal view. Urethra (U)
moves in a discordant manner with the sling (S) resulting in the sling
being located proximal to urethrovesical junction (UVJ) on cough/
Valsalva. SP symphysis pubis
length differed from that at rest, the urethral movement in
relation to the sling was considered discordant [9].
The deformability of the sling on Valsalva, concordance
of urethral movement with the sling, and location of the sling
were compared between the two groups. When compared
with Group B, Group A had a significantly greater number of
patients in whom the sling deformed on Valsalva (flat at rest
and curved into a c-shape on Valsalva), the urethral move-
ment was concordant with the sling, and the sling was located
beneath midurethra (p < 0.0001). The urethrovesical junction
moved distal to the sling in eight (26.7%) patients in Group
B who had discordant movement of the urethra relative to the
sling. In the three patients in Group B in whom the sling
deformed on Valsalva and the urethra moved in a concordant
manner with the sling, the sling was located beneath proxi-
mal urethra at maximal Valsalva. In all the 17 (56.6%)
patients in Group B in whom the urethra moved in a concor-
dant manner with the sling, the sling did not deform on
dynamic assessment and was located beneath the proximal
urethra. In all the 31 (48.4%) patients in Group A in whom
the sling remained either flat or curved, the urethra moved
concordant with the sling, and the sling was located beneath
midurethra.
Therefore the data suggests that on 2D and 3D transperi-
neal ultrasound, the best outcomes following midurethral
transobturator sling surgery are found to be associated with
concordance of urethral movement with the sling and
midurethral location at maximal Valsalva followed by
A. Hegde and G. W. Davila
deformability of the sling on dynamic assessment [9].
However, the three parameters often work together to com-
pensate for the failure of an individual parameter to ensure
successful outcome [9]. A patient in whom the sling does not
deform on Valsalva (i.e., does not curve into a c-shape from
flat at rest along its width) may still have a successful out-
come if the sling is located in the correct location (midure-
thral) at rest and the urethra moves in a concordant manner
with the sling [9]. Conversely, a patient, in whom the sling
deforms on Valsalva, may still have a poor outcome if the
urethra moves in a discordant manner with the sling and/or
the sling is not located beneath the midurethra [9].
When the urethra does not move in a concordant fashion
with the sling, i.e., the urethra moves independent of the
sling, it indicates that the sling has not fixated itself to the
suburethral connective tissue or the sling has been inserted
too loosely, and, therefore, even though the sling has scarred
in following surgery, the urethra and surrounding tissue
move independent of it [9]. Therefore even if the midurethral
or bladder neck sling is confirmed on static 2D and 3D ultra-
sound to be placed in the correct location, dynamic assess-
ment is critical, as it may show that the urethra moves
independent of the sling. As seen in our study, in some
patients with failed slings, the urethrovesical junction may
even move distal to the sling on dynamic assessment.
Therefore the sling does not have the desired functional
effect and may fail [9].
We followed up the previous study with a second study in
which we correlated the dynamic assessment of sling func-
tion on transperineal ultrasound with outcomes 1  year fol-
lowing surgery in 94 patients who had undergone retropubic
midurethral sling surgery (TVT, Ethicon, Bridgewater, NJ)
[41]. Our hypothesis was that, due to its retropubic location,
the TVT sling procedure may be associated with increased
tape tension and urethral compression, which may compen-
sate for any inappropriate sling location while still maintain-
ing continence [41]. We found that even in the case of
retropubic midurethral slings, the best outcomes following
surgery are found to be associated with concordance of ure-
thral movement with the sling and midurethral location at
maximal Valsalva followed by deformability of the sling on
dynamic assessment.
Kociszewski et  al. correlated the dynamic changes in
TVT sling shape seen on transperineal ultrasound with out-
comes following TVT sling surgery in 72 women [10]. They
found that 98% of patients, in whom the tape was flat at rest
along its width in the midsagittal plane and curved into a
c-shape during straining, were continent after surgery. There
was improvement in one case (2%), and none of these
patients was classified as failure. In the 11% of patients in
whom the tape position was flat along its width at rest and
during straining (i.e., too far away from the urethra), the fail-
ure rate was highest at 25%. In the 28% of patients in whom
22  Tape Positioning: Does It Matter?
the sling was c-shaped along its width at rest and on strain-
ing, the failure rate was 10%.
Kociszewski et al. hypothesized that a sling that remains
c-shaped both at rest and on straining is likely to have been
placed too tightly [10]. While it is conceivable that for proper
functioning the tape should remain at a certain distance from
the urethral lumen, there is no clear understanding of what
that optimal distance is. The risk of failure has been found to
be increased fivefold if this distance is greater than 5 mm,
and when it is shorter than 3 mm, the risk of developing post-
operative voiding dysfunctions or overactive bladder
­symptoms due to bladder outlet obstruction is significantly
increased [38].
22.7 T
 ape Position and Postoperative
Complications
A subset of patients will develop voiding dysfunction or de
novo overactive bladder symptoms following midurethral
sling procedures [38]. Hypothetically, the risk of these com-
plications is higher when the tape is positioned too close to
the bladder neck, but it remains controversial if this really
plays a critical role [38]. Ducarme et al. [42] showed that the
tape was located closer to the bladder neck in patients with
postoperative voiding dysfunction. However, they found that
in patients who developed de novo urgency incontinence, the
tape was located closer to the external urethral meatus [42].
These observations have been disputed by others [7, 29]. It is
much more likely that the risk of voiding dysfunction and de
novo urgency increases when the tape is inserted too tightly.
In the study by Dietz et al. [7], the incidence of these compli-
cations correlated with more cranial positioning of the tape.
Kociszewski et  al. [10] only observed complications in
patients with a distance of less than 3 mm between the tape
and the urethral lumen. Furthermore, as described above,
they contend that if the tape has a c-shaped appearance, it
indicates that it was not placed in a tension-free manner.
They found that it was associated with sixfold higher risk of
postoperative complications [10]. Similarly, after a TVT-O
procedure, signs of tight tape placement, such as urethral
encroachment at rest and a distance at rest of less than 12 mm
between the tape and the symphysis pubis, were found to be
associated with development of voiding dysfunction [20].
Postoperative complications after TVT-O may also be
related to inadequate repositioning of the tape arms. If, on
Valsalva maneuver, the arms are too close to each other (too
narrow of a suburethral angulation), the risk of voiding dys-
function substantially increases. Closer angulation at retain-
ing is associated with de novo urge incontinence [43].
It is also apparent that voiding dysfunction may develop
in cases of intraoperatively unrecognized urinary tract perfo-
ration or urethral erosion by the tape [44, 45].
325
Is sling location at rest correlated with de novo and persis-
tent overactive bladder symptoms following sling surgery?
We conducted a prospective cohort study in 104 patients
with urodynamic stress or mixed incontinence who under-
went sling surgery: 64 patients underwent transobturator
sling surgery, and 40 patients underwent retropubic midure-
thral sling surgery [46]. All patients answered the UDI-6 and
the OAB-sf validated questionnaires at 1-year follow-up
visit. The location of the sling (as determined on 3D endo-
vaginal ultrasound) was not found to be associated with
development of de novo urgency incontinence, persistence,
or resolution of urgency symptoms in patients who under-
went transobturator sling surgery. However, in the patients
who underwent retropublic sling surgery, though the location
of the sling had no association with the development of de
novo urgency incontinence, persistence of urgency symp-
toms was significantly more in those patients in whom the
sling was not placed midurethrally (p  =  0.005). Similarly,
resolution of urgency symptoms in patients who underwent
retropubic sling surgery was significantly more in those
patients in whom the sling was placed midurethrally as
opposed to altered locations (p  =  0.034). The transformed
symptom severity score and the transformed HRQL subscale
scores of OAB-sf were not associated with development of
de novo urgency incontinence, persistence, or resolution of
urgency symptoms in patients who underwent transobturator
sling surgery (p  >  0.05). However, in patients who under-
went retropubic sling surgery, the transformed symptom
severity score was significantly lower, and the quality of life
subscales were significantly better when the sling was placed
midurethrally (p < 0.05).
22.8 Future Directions
There is increasing evidence being generated regarding
sling function and the influence of tape positioning on surgi-
cal outcomes. However, the need of the hour is standardiza-
tion of terminology and technique of sonographic assessment
that forms the backbone of much of the evidence. The evi-
dence is also quite fragmented, and the quality of the studies
is debatable. There is, hence, a need to conduct if not ran-
domized controlled trials, then prospective cohort studies, at
least, to conclusively prove the impact of sling location on
outcomes following sling surgery. Multicenter trials are
necessary. More robust studies are also necessary to conclu-
sively understand dynamic sling behavior and whether it
may prove useful to suture-fixate the sling. The influence of
retropubic direction of sling placement on sling location
when compared with the more horizontal transobturator
sling placement needs to be better delineated in the future.
Clinicians managing patients with stress incontinence
should familiarize themselves with the value of sonographic
326
assessment of sling behavior. Standardized training courses
in ultrasound assessment need to be more readily available.
22.9 Conclusion
Accurate tape positioning critically influences outcomes fol-
lowing sling surgery. Passive and dynamic sonographic
assessment of sling location and behavior with exertion can
be very helpful in explaining the mechanism of action of
suburethral slings and help elucidate reasons for failure ­and/
or complications. With perineal and 2D and 3D ultrasound
imaging, various sling factors can be assessed including
location along the length of the urethra, distance from ure-
thral lumen (as a measure of degree of tightness), appropriate
location of sling arms, and sling behavior with exertion such
as Valsalva and coughing. These variables can have signifi-
cant value in the management of patients with suboptimal
outcomes following sling procedures. In addition, recent
sonographic evidence strongly suggests that sling fixation
(or the lack of) upon implantation may be important in
achieving desired continence.
References
Take-Home Messages
• Recent advances in sonographic 2D and 3D assess-
ment of the pelvic floor, both transperineal and endo-
vaginal, have enabled better understanding of the
impact of tape positioning on surgical outcomes.
• While there is still some controversy regarding the
same, there is compelling evidence in favor of the
primacy of location in the continence mechanism of
slings.
• Sling location is, however, only one component of
the three parameters that underlie dynamic sling
function: best outcomes following sling surgery are
found to be associated with concordance of urethral
movement with the sling and midurethral location
at maximal Valsalva followed by deformability of
the sling on dynamic assessment. However, the
three parameters often work together to compensate
for the failure of an individual parameter to ensure
successful outcome.
• Inappropriate positioning of the tape may increase
the risk of postoperative complications. Development
of voiding dysfunction or de novo urgency is more
common if the tape is placed too tightly.
• Patients who undergo transobturator sling surgery
along with concomitant anterior vaginal wall repair
performed through the same incision are more
likely to have the sling located more proximally
A. Hegde and G. W. Davila
when compared with patients who undergo transob-
turator sling surgery alone.
• Suture-fixating the tape in place during implanta-
tion may be associated with desired sling location.
However, more robust prospective studies are
needed to conclusively prove the same.
• Midurethral location of the retropubic sling, as
opposed to transobturator sling, is associated with
reduced persistence of urgency symptoms, higher
rates of resolution of urgency symptoms, lower
severity of urgency symptoms, and better quality of
life.
• Lastly determination of the location of a failed sling
is an essential step in both deciding the future
course of treatment and delineating the reasons for
sling failure.
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 Colposuspension and Fascial Sling
Fiona Reid
Learning Objectives
• To understand the historical context of both colpo-
suspension and fascial sling
• To recognize the subtle variation in surgical tech-
nique which may influence outcome
• To appreciate the need for high-quality, large multi-
centre randomized controlled trials to compare sur-
gical outcomes for stress incontinence
• To understand the limitations of our current knowl-
edge about options of surgery for individual patients
23.1 Introduction
The goal of any incontinence surgery is to restore function
and to achieve continence, with minimal transient surgical
morbidity and without immediate or long-term
complications.
In modern practice women choosing to have surgery to
treat stress urinary incontinence (SUI) have a choice of sev-
eral procedures. These include a variety of fascial slings,
open or laparoscopic colposuspension, mid-urethral poly-
propylene tapes placed using a retropubic, trans-obturator or
single incision approach or several bulking agents and artifi-
cial sphincters. It is the clinician’s role to advise and counsel
them about their individualized options.
Electronic Supplementary Material The online version of this
chapter (https://doi.org/10.1007/978-3-030-40862-6_23) contains
supplementary material, which is available to authorized users.
F. Reid (*)
The Warrell Unit, Manchester University Hospitals NHS
Foundation Trust, Manchester, UK
e-mail: Fiona.Reid@mft.nhs.uk
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_23
23
23.2 Colposuspension
23.2.1 Historical Background
Colposuspension is the surgical approach of lifting the tis-
sues near the bladder neck and proximal urethra in the area
of the pelvis behind the pubic rami, the retropubic space.
(Also called the Cave of Retzius, named after the Swedish
anatomist Anders Retzius 1796–1860.)
In 1927, Dr. Thomas Hepburn (father of the actress
Katharine Hepburn) first described a technique to elevate the
prolapsed female urethra and fix it to the posterior aspect of
the periosteum of the symphysis pubis [1]. However it was in
1949 that Marshall, Marchetti and Krantz published the pro-
cedure (MMK) as a colposuspension treatment for female
incontinence [2]. In the MMK procedure sutures are placed
in the vagina, close to the urethra and along its length and
then to the periosteum. MMK recommended taking a double
bite rather than a single bite in to the vagina (Fig. 23.1).
Surgery is frequently an evolutionary process and in 1961
Burch described how he modified the MMK technique, in
response to a technical difficulty he had experienced.
One day while we were doing an MMK operation, the sutures in
the periosteum continued to pull out and it was necessary to look
for another point of attachment [3].
Hence Burch described suturing to the iliopectineal liga-
ment, which is also called Cooper’s ligament. (This structure
is named after Astley Cooper an English surgeon and anato-
mist who first described it in 1804.)
The MMK technique is no longer recommended because
the long-term results do not appear as effective as the Burch
colposuspension. The MMK can also cause voiding difficul-
ties due to compression of the urethra and cases of osteitis
pubis from suturing to the periosteum rather than Cooper’s
ligament [4] (Fig. 23.2).
Tanagho added further modifications in 1976, emphasiz-
ing the need to avoid midline dissection, to place the suspen-
sion sutures laterally and to avoid compression of the urethra
329
330
Fig. 23.1  Original MMK midline sutures to periosteum. •  =  Suture
placement, V = Vagina, U = Urethra, + = additional sutures. (Simple
Vesicourethral suspension Marchetti et al. AJOG 1957; 74(1) 57–63)
Fig. 23.2  Original Burch suture to iliopectineal line with no bow
stringing
F. Reid
[5]. The next advance came in 1991 when Vancaillie
described the laparoscopic colposuspension [6].
23.2.2 Mechanism Action
Originally it was proposed that the mechanism by which a
colposuspension restored continence was elevation of the
bladder neck back to a level above the pelvic diaphragm,
within the intra-abdominal cavity [7]. This facilitated the
transmission of raised intra-abdominal pressure to the upper
urethra maintaining its closure. Later in 1994, DeLancey
also proposed the Hammock Theory [8]; this proposes a
dynamic mechanism in which during episodes of raised
intra-abdominal pressure, the upper urethra is rotated and
compressed against the elevated bridge of vagina which has
been lifted and sutured to the iliopectineal ligament.
23.2.3 Surgical Technique of the Modern
Colposuspension
Colposuspension can be performed either by a laparoscopic
approach or through a small low Pfannenstiel incision.
Proponents of the open technique may perform the proce-
dure through a “three-finger incision”; this is probably about
5–7 cm wide, however more commonly the incision is over
10 cm. The laparoscopic approach can be either trans-perito-
neal or extra-peritoneal. (See Video 23.1.)
No matter which route of access is chosen, the principles
of the dissection to the white line (arcus tendineus fascia pel-
vis) and Cooper’s ligament (iliopectineal ligament) and the
suturing are the same. Dissection in the midline is usually
avoided. Using the laparoscopic approach, structures are
magnified which improves visualization and result in less
blood loss. If bleeding is encountered, it can be controlled
initially with cephalad elevation of the surgeon’s finger in the
vagina, combined with the insertion of a figure of eight
suture under running and tied down on to the bleeding point.
The number of sutures and type of suture material used
for the elevation sutures is controversial. Tanagho uses heavy
absorbable sutures no. 1 Maxon TM (a monofilament polyg-
lyconate, a copolymer of glycolic acid and a trimethylene
carbonate) or Vicryl TM (braided polyglycolic acid suture
PGA) [9]. However, many surgeons still prefer to use a per-
manent suture such as Ethibond TM (a braided polyester).
However, use of permanent sutures can lead to delayed per-
foration of the sutures into the bladder. This can occur many
years after the index operation and may present as recurrent
urinary tract infections, haematuria and/or pain due to stone
formation (Fig. 23.3a, b).
Some surgeons take a single suture “bite” through the
partial thickness of the vagina, others prefer a “double
23  Colposuspension and Fascial Sling 331

a b

Fig. 23.3 (a) Delayed perforation of bladder by ethibond suture over 10 years after colposuspension. (b) Ethibond sutures removed from bladder
after delayed perforation

Fig. 23.4  Anatomy of

Cooper’s ligament
retropubic space and
placement of sutures marked
with x. (Reference: M Paraiso Arcus tendineus
Laparoscopic Surgery for levator ani
Stress Urinary Incontinence
and Pelvic Organ Prolapse
Chapter 17 Plastic surgery Arcus tendineus
key) fasciae pelvis

Obturator internus
muscle and fascia

Obturator
canal

bite”. Most surgeons insert two sutures either side of the
urethra, hence four in total; however some only insert one
suture on each side and others up to three or four each
side. There is no evidence to support or refute these varia-
tions in practice.
Some surgeons prefer to fill the bladder with approxi-
mately 200 mL of diluted methylene blue to aid identifica-
tion of its lateral margins and demonstrate any inadvertent
cystotomy. Some surgeons advocate cystoscopy following
the insertion of the sutures to exclude sutures in the bladder
or ureteric injury. The incidence of which is unknown but
probably rare.
Tanagho recommends placing the suspension sutures as
far lateral as possible in the vagina, with two sutures on each
side. The first suture is placed at the level of the mid-urethra
and the second at the urethra-vesical junction, identified by
palpating the catheter balloon whilst applying gentle down-
ward traction on the urethral catheter. At this level the sutures
are placed as far lateral as possible in the vagina (Fig. 23.4).
The sutures are then passed laterally through Cooper’s
ligament (iliopectineal ligament). However, care should be
taken not to extend the lateral dissection too far due to risk of
injury to the obturator bundle.
The vagina should be elevated to “just enough” to support
the bladder neck. It is important not to over elevate the
vagina. Usually there is some bow stringing of the sutures
between the vagina and Cooper’s ligament, which is a con-
siderable difference between the modern colposuspension
and that described by Burch (Fig. 23.5a, b).
The variation in the type, number and the placement of
sutures and degree of elevation may account for variation in
outcome between surgeons performing colposuspension.
332 F. Reid

a b

Fig. 23.5 (a) Normal position colposuspension sutures with bow stringing. (b) Space of Retzius: Colposuspension sutures lateral to previous TVT

Table 23.1 Videourodynamic classification of SUI (Blaivas JG,

23.2.4 Indications Olsson CA. J Urol. 1988; 139: 727–731)
Leakage
The primary indication for a colposuspension is stress uri- Type UDS Appear on videourodynamics
nary incontinence. 0 No Flat bladder base above symphysis pubis
It may be the preferable procedure if a concomitant open 1 Yes At rest the bladder base is flat and above symphysis
abdominal hysterectomy is required. It may be the preferable pubis and UVJ is closed at rest
procedure if there is coexisting anterior compartment pro- On cough/strain there is less than 2 cm descent of
the bladder base
lapse. However an anterior repair and MUS or fascial sling
2a Yes At rest the bladder base is flat and above symphysis
on a string would also suffice. pubis and UVJ is closed at rest
On cough/strain there is greater than 2 cm rotational
descent of the bladder base
23.2.5 Contraindications 2b Yes At rest the bladder base is below symphysis pubis
and UVJ is closed at rest
On cough/strain there is greater than 2 cm rotational
It is traditionally taught that intrinsic sphincter deficiency descent of the bladder base
(ISD) is a contraindication to colposuspension. However the 3 Yes The urethrovesical junction (UVJ)—“bladder neck”
definition of ISD remains controversial. is open at rest
A fixed urethra is also thought to be a contraindication.
The method by which fixation is defined can be simple visual
inspection, a Q-tip test, trans-perineal ultrasound or compared to other continence procedures [11], and this may
videourodynamics. occur in up to 32% of cases [12].
If videourodynamics are used, then the Blaivas categories It can also be associated with “colpo-pain syndrome”,
(Table 23.1) [10] are used to quantify types of incontinence dyspareunia, and voiding difficulty especially if the anterior
based on the position of the bladder base in relation to the wall is over elevated.
symphysis pubis and the status of the urethra-vesical junc-
tion at rest (also called the bladder neck). Traditionally col-
posuspension would not be used for type 1 cases. 23.3 Fascial Sling

23.3.1 Historical Background

23.2.6 Complications
Giordano described the first sling procedure, in 1907.
Colposuspension appears to be associated with a greater risk Gracilis muscle was dissected and wrapped around the ure-
of development of vaginal posterior compartment prolapse thra. Other surgeons subsequently suggested supporting the
23  Colposuspension and Fascial Sling
urethra with pyramidalis muscle [13], the round ligament,
bulbocavernosus muscle, levator ani and fat. The use of the
Martius fat pad continues to be used to support urethral
repairs.
Initially these slings were designed to compress the ure-
thra and cause obstruction. The “modern” fascial sling is
designed to support but not elevate or compress the urethra-­
vesical junction, commonly known as the “bladder neck”.
Aldridge first described it in 1942. However, Aldridge also
included an anterior colporrhaphy which is no longer a stan-
dard part of a sling procedure.
Aldridge did not use a formal open dissection of the space
of Retzius.
Since that time surgeons have strived to reduce the mor-
bidity associated with harvesting the autologous sling.
McGuire and Lytton in 1978 revised the Aldridge fascial
sling and advocated its use in cases of intrinsic sphincter
deficiency. Then in 1991, Blaivas and Jacobs developed an
unattached fascial sling on a string. Since then there have
been a variety of detached slings of variable lengths
described. Also slings have been made from rectus sheath,
fascia lata and vaginal fascia. Surgeons tried to reduce mor-
bidity further by removing the need to harvest the sling,
using of allografts such as cadaveric fascia lata or dura mater.
Xenografts including porcine and bovine dermis or animal
small intestine submucosa (SIS) have been used. There is
evidence that xenografts are not as effective as autologous or
polypropylene slings [14].
Slings have been made from a variety of synthetic materi-
als too: Gore-Tex (Polytetrafluoroethylene W. L. Gore Inc.,
Flagstaff, Arizona, USA), Mersilene (polyethylene Ethicon,
Edinburgh, UK), Silastic (Silicone) and Marlex
(Polypropylene CR Bard, Cranston, Richmond, USA). These
however were all associated with exposure and infections
and are no longer used.
The most recent development in the evolution of the
autologous fascial sling is the placement of a short sling on a
string at the mid urethra and the blind passage of the sling
through the Space of Retzius using a curved needle device
similar to those used to perform retropubic tapes [14, 15].
23.3.2 Mechanism of Action
In Aldridge’s original description, the proposed mecha-
nism of the sling was active; the end of the sling was
attached to the abdominal aponeurosis and therefore
moved with the abdominal wall. During a cough or sneeze,
the abdominal wall moves upwards and the sling is drawn
upwards, effectively increasing intra-urethral pressure
(Fig. 23.6).
333
a
R
A A R
b R2
P
A
R1
Fig. 23.6  Aldridge sling mechanism action. R  =  rectus abdominis
muscles, U = urethra, A = strips of rectus fascia. R1 = relaxed position
of rectus muscles R2  =  tightening of contracted rectus muscles.
(Aldridge AH Transplantation of fascia for relief of Urinary Stress
Incontinence. AJOG. 1942;(44):398–411)
23.3.3 Variation in Surgical Technique
of the Autologous Fascial Sling
23.3.3.1 The Original Aldridge Sling
A low modified lithotomy position is used to allow access to
both vaginal and abdominal surgery. Through a low Pfannenstiel
skin incision, about two fingers breadth (3–4  cm) above the
symphysis pubis, strips of rectus sheath are dissected from the
underlying rectus muscles. The strips can be marked with a pen
or diathermy to guide excision. The strips are about 1.5  cm
wide and about 6 cm long. The rectus sheath is left attached at
the level of the symphysis pubis (Fig. 23.7).
For simple primary cases, Aldridge describes dissecting
from the vagina upwards in a plane of loose areolar avascular
tissue. The attached sling is passed down attached to curved
forceps.
Some surgeons prefer to perform a formal dissection of the
retropubic space prior to passing the fascial sling. The method
of dissection used is the same for an open colposuspension.
The gap between the two bellies of the rectus muscles is
opened to the level of the peritoneum. In primary cases the
peritoneum can be gently reflected from the pelvic sidewall
with posterior pressure applied to the peritoneum, in a medial
to lateral sweeping motion of the index fingers, until the leva-
tor ani and the arcus tendinous levator ani (also known as the
white line) are visible. Dissection of the midline over the ure-
thra should be avoided, and care should be taken at the lateral
margin to avoid the obturator bundle (see Fig. 23.4). This dis-
section is more difficult in obese patients, post-radiotherapy,
and following previous surgery to the retropubic space.
334
Fig. 23.7  Insertion of Aldridge sling. (Aldridge AH Transplantation of
fascia for relief of Urinary Stress Incontinence. AJOG.
1942;(44):398–411)
In complex cases sharp dissection may be necessary,
instilling 200 mL of methyl blue into the bladder may clarify
its margins, but this will also restrict access in the space of
Retzius. If very dense adhesions are present, a high cystot-
omy may help to facilitate safe dissection of the bladder.
The second part of the operation requires either an
inverted U-shaped incision, or a linear longitudinal incision
is made in the anterior vaginal wall. The urethra-vesical
junction, commonly called the bladder neck, is identified by
the gentle traction on the urethral catheter balloon. Sharp lat-
eral dissection is performed under the symphysis pubis
toward the endopelvic fascia. A finger is then used to push up
into the cave of Retzius. Roberts clamp or similar curved
forceps is passed into this space and used to penetrate the
F. Reid
endopelvic fascia and then to pick up the fascial strips which
are then passed either side of the bladder down to the vagina.
The strips are united in the midline, using an overlap
suturing technique. The vaginal and abdominal incisions are
then closed.
The original description by Aldridge also included an
anterior repair which is no longer performed unless there is
concomitant prolapse. Aldridge also described using fascia
lata harvested from the thigh.
Clancey, Lorouche and Cundiff have produced an excel-
lent short film demonstrating harvesting of fascia lata which
can be seen via the link www.mdedge.com/authors/
and-geoffrey-w-cundiff-md.
Since 1942, other variations to the original technique
have been described. The most significant, by Blaivas in the
1990s, was the detachment of the sling and subsequently the
use of a shorter section of rectus sheath (6  cm  ×  1.5  cm)
sutured to two lengths of heavy absorbable suture, to create a
sling on a string [16].
More recently further development has been described in
which a much smaller 3  cm suprapubic incision is made,
through which a strip of rectus abdominis fascia, at least
6 cm in length and 1 cm in width, is harvested. No suprapu-
bic dissection is made in the space of Retzius. Each end of
this strip of fascia is tied to a heavy non-absorbable suture
[14, 15]. A longitudinal incision is made in the anterior vagi-
nal wall, and a limited periurethral dissection is carried out in
a similar manner to a retropubic mid-urethral polypropylene
tape insertion. Using a specially adapted retropubic needle
with an eye in it, the harvested rectus fascia is then passed
through the retropubic space in the same manner as a
TVT. Hence the autologous fascial sling is placed at the level
of the mid-urethra rather than at the bladder neck (Video by
Guerrero et al. [14]).
Some surgeons recommend that the centre of the sling is
sutured to the mid-urethra in order to prevent migration. The
two ends of suture are loosely tied together over the rectus
fascia so that the sling is placed in a tension-free manner
without any suspension of the mid-urethra.
23.3.4 Indications for a Fascial Sling
The traditional indication for a fascial sling was failed previ-
ous continence surgery especially in the presence of a fixed
urethra, intrinsic sphincter deficiency, previous radiotherapy,
congenital short urethra, epispadias or neuropathic urethral
dysfunction. However, the evidence on which this traditional
belief is based is weak.
The fascial sling is used with or without a Martius graft
for those who have had a polypropylene mid-urethral sling
removed from the urethra or a urethral diverticulum excised.
23  Colposuspension and Fascial Sling
The development of the shorter sling on a string placed in
a similar manner to a TVT has lead more clinicians to offer
women a fascial sling as a primary procedure.
23.3.5 Contraindications
A patient who has a high risk of retropubic bowel adhesions
should probably not be considered for a fascial sling expect
a patient who has a high risk of bowel adhesions in the retro-
pubic space.
If the woman has had extensive previous abdominal sur-
gery or a previous abdominal hernia, this will make it techni-
cally difficult to harvest a sling from the abdominal wall, and
fascia lata may be more appropriate.
Obesity will make the surgery more challenging and may
increase the risk of haemorrhage and hernia.
23.4 Outcomes of Colposuspension
and Fascial Sling
Assessing the outcome of surgery for stress urinary inconti-
nence is complex.
Most commonly, researchers report cure as “the dry rate”,
the resolution leakage from SUI. The “dry” rate for a proce-
dure does not reflect the potential impact that other compli-
cations can have such as voiding difficulties and overactive
bladder. A patient global impression score is useful; however
this can probably be influenced by other factors such as pre-
operative counseling.
The best evidence available is from multicentre RCTs with
long-term follow-up using multiple outcome measures. Long-
term outcomes, over 5 years, are required as surgical success
of some procedures is known to decline with time [17, 18].
The NICE guidance (2013) for Urinary Incontinence in
Women contains a comprehensive summary of both random-
ized trials, cohort and case series of all continence surgery
including fascial slings, in Appendix H (https://www.nice.org.
uk/guidance/cg171/evidence/appendix-h-pdf-191581167).
23.5 I s Laparoscopic Colposuspension
as Effective as Open?
Up to 2 years after surgery, high-quality RCT evidence has
shown that the subjective and objective outcome laparo-
scopic colposuspension is comparable to open colposuspen-
sion [19, 20].
Burch, himself, was the ultimate pragmatist and said “the
present operation, like all operations, will probably not go
too smoothly on the first few attempts but, once learn it goes
much better”. It is important when reviewing trials to ensure
335
that in both arms of the intervention, the surgeons are trained
and have completed enough cases to ensure their learning
curve is complete.
Also both arms of the study should use the same number
and type of sutures.
An economic review from three RCTs found that tension-­
free vaginal tape (TVT) may be more cost-effective than
laparoscopic colposuspension which in turn may be more
cost-effective than open retropubic colposuspension [21].
23.6 D
 o the Sutures Used
for a Colposuspension Affect
Outcome?
There is only one study comparing different numbers of sus-
pension sutures, one each side compared to two [22]. The
study found subjective cure rates of 89% women randomized
to two sutures compared with only 65% in those randomize
to one suture. There are no trials comparing the type of
sutures, whether absorbable sutures are as effective as
non-absorbable.
23.7 I s Colposuspension as Effective
as an Autologous Fascial Sling?
The most recent Cochrane review of colposuspension in 2017
included 55 trials involving a total of 5417 women [23].
A subgroup analysis of studies comparing “traditional
slings” and open colposuspension showed better effectiveness
with traditional slings, than open colposuspension, in the
medium and long term (RR 1.35; 95% CI 1.11–1.64 from 1 to
5 years follow-up, RR 1.19; 95% CI 1.03–1.37). Voiding diffi-
culties were more common following a sling procedure; how-
ever the incidence of posterior compartment prolapse was
greater following colposuspension. The term “traditional fas-
cial sling” covers a significant group of procedures. In the
recent Cochrane review, trials using autologous slings placed at
the mid-urethra and those placed at bladder neck were included
in a common analysis. They also included allograft, xenograft
and synthetic slings. From this heterogenous collection of pro-
cedures, it is difficult to draw useful clinical conclusions.
The most recent International Consultation on
Incontinence (ICI), in 2017, concluded that the autologous
fascial sling (AFS) is the most widely evaluated biological
sling and is an effective and durable treatment for SUI (Level
1 Evidence). They added the caveat that there was some evi-
dence (Level 2) that autologous slings may be superior to
other biological materials [24].
The ICI stated that AFS is more effective than colposus-
pension at mid-long term (EL = 1/2) however AFS is associ-
ated with a higher rate of early postoperative voiding
336
dysfunction. Very limited data suggest that the overall rates
of late surgical complications are similar after sling and col-
posuspension; however, the pattern of complications may
vary.
AFS were found to be as effective as polypropylene MUS
in the short term (Level 1); however the operating time and
length of stay was significantly short for the MUS [24].
The SISTEr trial was a large high-quality multicentre
RCT of Burch and Sling on a String; 655 women were ran-
domized, 326 to a sling and 329 to a colposuspension.
Success rates were higher for women who underwent the
sling procedure than for those who had a colposuspension
(66% vs. 49%, p  <  0.001). However, more women who
underwent the sling procedure had urinary tract infections,
difficulty voiding and postoperative urge incontinence [25].
23.8 I s the Sling on a String as Effective
as the Traditional Aldridge Sling?
Since the millennium most “traditional slings” reports in the
literature are for detached slings made from autologous rec-
tus sheath. There are no randomized trials comparing an
attached sling (Aldridge) to the detached (Blaivas) version.
Hence it is not possible to determine if cure, incisional her-
nia, pain, detrusor overactivity or voiding dysfunction are
affected by either technique. However the attached (Aldridge)
sling requires greater dissection of rectus sheath and may
theoretically have a greater risk of incisional hernia but pro-
ponents suggest it has a lower incidence of voiding
difficulties.
23.9 I s a Shorter Sling on a String
as Effective as a Full Length
Detached Sling?
There is one RCT which compared two detached autologous
rectus sheath fascias, a long sling (20  cm  ×  1.5  cm) to a
shorter sling on a string (8–10 cm × 1.5 cm). The study ran-
domized 165 women, 81 to the long sling and 84 to the short
sling on a string. Long-term follow-up, between 61 and
89  months (average 6  years), was achieved in 56/81 and
69/84 for the long and shorter sling, respectively [26].
Women were followed up at five regular time intervals.
At the last recorded long-term follow-up, there was still a
trend towards baseline for the IIQ-7 and UDI-6 scores.
However there was no difference between the two groups
(Table 23.2).
One woman in the 20 cm sling and four in shorter sling
group had the sling surgically released. At long-term follow-
­up, three women from each group performed regular self-­
catheterization. There were no reported incisional hernias.
F. Reid
Table 23.2  Different lengths of fascial sling
Cure rates
Long detached fascial Short sling on fascial
sling string
6 months 76–82% 77–83%
Over 29–62% 44–57%
5 years
23.10 I s an Autologous Sling Better at the
Mid-Urethra or the Bladder Neck?
There has been a move to use a modified TVT introducer to
insert an autologous sling on a string at the level of the mid-­
urethra rather than the bladder neck. This also avoids the
need to perform the formal retropubic dissection of the Cave
of Retzius [14, 15].
There are no trials comparing AFS at UVJ versus mid-­
urethra; however there is one trial which demonstrates that
AFS at the mid-urethral which some are calling aTVT
(autologous TVT) is as effective as synthetic polypropylene
TVT. The multicentre study recruited 79 women to undergo
the “autologus TVT” and 72 to polypropylene TVT. At 1
year there was no statistically significant difference in sub-
jective cure rates between the “autologus TVT” (90%) and
polypropyleneTVT (93%) [14].
23.11 I s Fascia Lata as Effective as Rectus
Sheath Fascia?
Fascia lata can be harvested from the lateral thigh. There are
no randomized trials or cohort studies comparing fascia lata
to rectus fascia slings.
23.12 A
 re Allografts as Effective
as Autologous Slings?
There are no RCT data to compare cadaveric slings to autol-
ogous slings.
23.13 A
 re Xenograft Slings as Effective
as Autologous Slings?
There is a multicentre RCT which at 1 year found that the
subjective success of TVT, AFS and Pelvicol® were 93%,
90% and 61% respectively. The trial stopped the recruitment
to Pelvicol due to poor outcomes. One in seven patients in
the Pelvicol group underwent repeat sling surgery for early
failures. At a median follow-up of 10 (range 6.6–12.6) years,
subjective success rates for TVT and AFS were 73% and
75% respectively [17].
23  Colposuspension and Fascial Sling
However another single site RCT of a Pelvicol® (n = 68)
and TVT (n = 60) found no difference in outcome, 82% and
88% dry, respectively [27].
23.14 Conclusion
When comparing fascial sling to colposuspension, there are
several variables within each of these procedures which
should be clearly specified. Hence great care must be taken
when considering the results of meta-analysis of surgical tri-
als. The success of some surgical procedures can be very
operator dependent; hence studies should be multicentred to
ensure the results are generalizable.
Although randomized trials are important, they are not the
only hallmark of good research. As Burch highlighted the
learning curve for some procedures can be quite long:
the present operation, like all operations, will probably not go
too smoothly on the first few attempts but, once learned it goes
much better
It is important not to include cases from the learning curve
in an RCT.
Research should also be powered to detect at least a mini-
mally important clinical difference in outcome rather than an
arbitrary statistical change in score.
One should also remember that rare complications may not
be apparent in RCT and surgeons should be encouraged to par-
ticipate in submission of outcome data to national databases.
There are subgroups of patients, for example, the elderly,
the obese, those with significant comorbidities such as
benign joint hypermobility syndrome or diabetes or smokers,
who perhaps may respond better to one type of treatment
than another. However, our current level of knowledge does
not allow for such individualized care.
Take-Home Messages
• There are considerable variations in the techniques
used by surgeons performing colposuspensions and
fascial slings. These should be clearly documented
and controlled in surgical trials.
• Fascial sling on a string appears to have greater lon-
gevity than colposuspension, but fascial sling also
appears to be associated with more severe voiding
difficulties, at least in the short term.
• There is inadequate data to guide the choice of
operation for subgroups such as the elderly, obese,
or those with other co morbidities.
• Despite the inadequate quality of outcome data
available, it is important to offer women choice of
operations for SUI.
337
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incontinent women. Acta Chir Scand. 1961;276(suppl):1–68.
8. DeLancey JO.  Structural support of the urethra as it relates to
stress urinary incontinence: the hammock hypothesis. Am J Obstet
Gynecol. 1994;170:1713–23.
9. Tanagho E.  Colpocystourethropexy. In: Raz S, Rodriguez L, edi-
tors. Female urology. Philadelphia, PA: Saunders Elsevier; 2008.
p. 385–90.
10. Blaivas JG, Olsson CA. Stress-incontinence - classification and sur-
gical approach. J Urol. 1988;139(4):727–31.
11. Ward KL, Hilton P, U.K.I.T.T. Grp. Tension-free vaginal tape ver-
sus colposuspension for primary urodynamic stress incontinence:
5-year follow up. BJOG. 2008;115(2):226–33.
12. Auwad W, et  al. The development of pelvic organ prolapse after
colposuspension: a prospective, long-term follow-up study
on the prevalence and predisposing factors. Int Urogynecol J.
2006;17(4):389–94.
13.
Goebell R.  Zur operativen Beseitigung der angeborenen
Incontinentia vesicae. Ztschr F Gynakol Urol. 1910;2:187–91.
14. Guerrero KL, et  al. A randomised controlled trial compar-
ing TVTTM, PelvicolTM and autologous fascial slings for
the treatment of stress urinary incontinence in women. BJOG.
2010;117(12):1493–503.
15. Malde S, Moore JA. Autologous mid-urethral sling for stress uri-
nary incontinence: preliminary results and description of a contem-
porary technique. J Clin Urol. 2016;9(1):40–7.
16. Chaikin DC, Rosenthal J, Blaivas JG. Pubovaginal fascial sling for
all types of stress urinary incontinence: long-term analysis. J Urol.
1998;160(4):1312–6.
17. Khan ZA, et al. Long-term follow-up of a multicentre randomised
controlled trial comparing tension-free vaginal tape, xenograft and
autologous fascial slings for the treatment of stress urinary inconti-
nence in women. BJU Int. 2015;115(6):968–77.
18. Brubaker L, et al. 5-Year continence rates, satisfaction and adverse
events of burch urethropexy and fascial sling surgery for urinary
incontinence. J Urol. 2012;187(4):1324–30.
19. Kitchener HC, et  al. Laparoscopic versus open colposuspen-
sion - results of a prospective randomised controlled trial. BJOG.
2006;113(9):1007–13.
20. Carey MP, et al. Laparoscopic versus open Burch colposuspension:
a randomised controlled trial. BJOG. 2006;113(9):999–1006.
21. Dean N, et  al. Laparoscopic colposuspension for urinary incon-
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2017;(7):CD002239.
22. Persson J, Bossmar T, Wolner-Hanssen P.  Laparoscopic col-
posuspension: a short term urodynamic follow-up and a
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2000;79(5):414–20.
338 F. Reid

23. Lapitan MCM, Cody JD, Mashayekhi A.  Open retropubic colpo- nary incontinence in women: short, medium and long-term follow-
suspension for urinary incontinence in women. Cochrane Database ­up. Int Urogynecol J. 2007;18(11):1263–70.
Syst Rev. 2017;(7):CD002912. 27.
Abdel-Fattah M, Barrington JW, Arunkalaivanan
24. Rovner E.  Surgery for urinary incontinence in women. In:
AS.  Pelvicol((TM)) pubovaginal sling versus tension-free vagi-
Incontinence. 2017, ICUD ICS. Bristol: ICS. p. 1741–855. nal tape for treatment of urodynamic stress incontinence: a
25. Albo ME, et al. Burch colposuspension versus fascial sling to reduce prospective randomized three-­ year follow-up study. Eur Urol.
urinary stress incontinence. N Engl J Med. 2007;356(21):2143–55. 2004;46(5):629–35.
26. Guerrero K, et  al. A randomised controlled trial comparing two
autologous fascial sling techniques for the treatment of stress uri-
 Injectable Biomaterials
Tomi S. Mikkola
Learning Objectives
• Understand the history of various injectable
biomaterials
• Classification of bulking agents that are currently
used
• Safety and efficacy of modern bulking agents
• Role of modern bulking agents in the treatment of
stress urinary incontinence
24.1 Introduction
Stress urinary incontinence (SUI) affects millions of women
worldwide, and many are surgically treated with a lifetime
risk of SUI surgery being approximately 15% [1]. The cur-
rent gold standard treatment of SUI is either retropubic or
transobturator midurethral sling. However, midurethral
slings have recently become under scrutiny due to mesh
complications including erosion, pain, and voiding difficul-
ties [2]. These concerns have increased the interest in inject-
able biomaterials as urethral bulking agents (UBAs) that
increase the central filler volume and thereby the power of
the urethral sphincter [3]. Although UBAs are considered to
be particularly helpful in women with a low urethral closing
pressure (intrinsic sphincter deficiency), bulking is equally
effective in both urethral hypermobility and intrinsic sphinc-
ter deficiency [3, 4], likely since often both are present to
some extent in SUI patients. Various injectable biomaterials
Electronic Supplementary Material The online version of this
chapter (https://doi.org/10.1007/978-3-030-40862-6_24) contains
supplementary material, which is available to authorized users.
T. S. Mikkola (*)
Department of Obstetrics and Gynecology, Helsinki University
Central Hospital, Helsinki, Finland
e-mail: tomi.mikkola@hus.fi
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_24
24
as UBAs have been used in the past 100  years, which
included, e.g., autologous fat, porcine dermis, paraffin, car-
bon beads, polytetrafluoroethylene, ethylene vinyl alcohol,
calcium hydroxyapatite, Teflon, silicone, and dextran poly-
mer [5]. Many of them were withdrawn due to safety con-
cerns such as hypersensitivity, secondary to migration of the
product and adverse effects like abscess formation. The more
recent UBA substances introduced into clinical practice
appear safe; however, the long-term outcomes remain to be
determined [6, 7]. The aim of this chapter is to outline the
current knowledge of the safety, efficacy, and future of UBAs
in SUI treatment.
24.2 Safety of Urethral Bulking Agents
An ideal UBA should be biocompatible, hypoallergenic,
nonmigratory, and durable. Currently it is difficult to get an
overview of the safety of the different products. Systematic
reviews are based on low numbers of randomized controlled
trials (RCTs) that are moreover of moderate quality. A recent
extensive review show that UBAs have an overall complica-
tion rate of 32%; however, majority of these are non-severe
and transient [8]. Despite this, more severe complications
such as periurethral abscesses and granulomas are seen. This
appears to be strongly associated to the injectable biomate-
rial, mostly related to mini-particles suspended in a carrier
gel such as dextranomer hyaluronic acid [9] but also to sili-
con elastomer such as cross-linked vinyl dimethyl
polydimethylsiloxane [8]. The mini-particles are not bio-
compatible and may elicit a chronic inflammatory response
that results in tissue hardness and in some patients leads to
calcification, erosion, and migration of the particles. In con-
trast, non-particulate gels including cross-linked collagen
(bovine collagen) and homogenous hydrogel (polyacryl-
amide hydrogel, PAGH) are biocompatible and not associ-
ated with chronic inflammation. Since bovine collagen
(Contigen) has been withdrawn from the market, at present
339
340
PAGH is the only non-particulate gel with very good safety
data [10–12].
The safety of UBA depends on the product itself, as well
as on the physician skills on performing the procedure. The
latter could be best managed by appropriate training and
standardized methods. However, there are no standardized
injection techniques that could be generalized to all UBAs.
When comparing paraurethral and transurethral injection
routes, lower complication rate and a trend towards better
subjective and objective outcomes favor transurethral injec-
tion [13, 14]. Furthermore, transurethral injections, such as
PAGH, may be performed under visual control in order to
more accurately place the bolus of the material and confirm
the urethral coaptation. This also allows to determine the
used technique more precisely, and ideally the injection tech-
nique could be standardized and visually verified for studies
as well as for clinical training. The current technique for
PAGH is to inject under visual control approximately 1.5 cm
from bladder neck four cushions that meet at midline (see
Video 24.1). Also after training it is important that surgeons
carry out a sufficient case load to maintain their skills and
recommended annual number is at least 20 cases [15].
Although these numbers come mainly from SUI sling sur-
gery, they likely apply also for bulking procedures.
24.3 Efficacy of Urethral Bulking Agents
The Cochrane review from 2012 [13] on urethral injection
therapy for SUI concluded that the review of 14 trials, which
included 2004 women, found some limited evidence that
UBA therapy can relieve SUI in women. However, before
UBA therapy can be recommended as a standard first-line
treatment for temporary or partial relief of symptomatic SUI,
further comparative RCTs are required [13]. Since 2012 new
studies have been conducted, particularly with more modern
and safe UBA, such as PAGH [12]. In a randomized, pro-
spective, multicenter study, 345 women with SUI were
treated with either PAGH or collagen gel [12]. At 12 months
47.2% of patients with PAGH and 50% with collagen gel
were cured, and 77.1% and 70%, respectively, considered
themselves cured or improved. These 1  year results with
PAGH are similar as in previous studies [16, 17]. With simi-
lar results in reviews assessing efficacy of different UBAs
and particularly polydimethylsiloxane and PAGH [6, 7],
66–89% subjective success rates at 12 months were detected.
In contrast, the objective success rates were less well docu-
mented ranging from 25% to 73% [7]. Furthermore, the
long-term efficacy of UBA treatments is not well determined,
T. S. Mikkola
and thus, the literature lacks information about repeated
injections or about the cost-effectiveness aspects of both first
and repeated treatments.
When choosing the treatment of SUI, also patient’s goals
and expectations should be considered. It has been demon-
strated that women tend to be pragmatic in their overall
expectations regarding treatment outcome [18]. Furthermore,
when asked about attitudes and expectations with different
treatments, 57% of women preferred minor procedure with
low risk of complications and are prepared to accept lower
success rate [18]. For this reason, the effectiveness of a pro-
cedure should be balanced with its invasiveness.
24.4 Future Directions
Majority of currently available UBA treatments appear safe;
however, the long-term efficacy particularly as primary treat-
ment remains to be determined. Since the current gold stan-
dard treatment of SUI is either retropubic or transobturator
midurethral sling, UBAs should be compared to these treat-
ments in the typical SUI population. This is particularly
important due to the recent concern about the mesh complica-
tions affecting also midurethral slings. Currently one RCT
comparing PAGH and TVT sling is conducted (www.clinical-
trials.gov). A total of 224 women with primary SUI were ran-
domized for TVT (n = 111) or PAHG (n = 113) treatment [19].
Primary outcomes were patient satisfaction, effectiveness, and
complications at 1-year follow-up. Data were analyzed with
an intention-to-treat basis. At 1-year follow-up, the median
(IQR 25–75 percentile) satisfaction score (0–100) for TVT
was 99 and for PAHG 85 (p < 0.001), and thus, PAHG did not
meet the non-inferiority criteria. Similarly as with objective
cure rates, the cough stress test was negative in 95% of TVT
patients versus 66% of PAHG patients (p < 0.001). However,
most perioperative complications (hematoma, bladder perfo-
ration, or urinary retention) and all reoperations due to compli-
cations were associated with TVT.  Furthermore, at 1-year
erosions, pelvic/implantation site pain and difficulty to empty
bladder were associated only with TVT.
This trial will help to determine also the subjective and
objective long-term efficacy and if PAGH treatment could
have potential to become a more prominent first-line treat-
ment for SUI. In addition, more studies comparing the differ-
ent UBA treatments, particularly with new products, are
needed. Lastly, given the likely decline in efficacy of UBAs
over time, follow-up periods in all future studies should be
2–5 years to describe long-term outcomes and the need for
repeated injections.
24  Injectable Biomaterials
24.5 Conclusions
Bulking agents represent a minimally invasive strategy to
manage SUI. Women expecting to be completely cured with
the initial treatment for either primary or recurrent SUI UBA
10. Mohr S, Siegelthaler M, Mueller MD, et  al. Bulking agents: and
treatments are likely not the first-line choice. However, mod-
ern UBAs, such as the PAGH, could be offered as an alterna-
tive first-line treatment option for patients who are not
willing to accept the risks of traditional anti-incontinence
surgery and prefer less invasive treatment or in whom surgi-
cal options are restricted.
References
1. Wu JM, Matthews CA, Conover MM, Pate V, Funk MJ. Lifetime
risk of stress urinary incontinence or pelvic organ prolapse surgery.
Obstet Gynecol. 2014;123:1201–6.
2. Blaivas JG, Purohit RS, Benedon MS, Mekel G, Stern M,
Billah M, Olugbade K, Bendavid R, Iakolev V.  Nat Rev Urol.
2015;12:481–509.
3. Klarskov N, Lose G. Urethral injection therapy: what is the mecha-
nism of action? Neurourol Urodyn. 2008;26:1–4.
4. Kotb AF, Campeau L.  Corcos J (2009) Urethral bulking agents:
techniques and outcomes. Curr Urol Rep. 2009;10:396–400.
5. Davis NF, Kheradmand F, Creagh T.  Injectable biomaterials for
treatment of stress urinary incontinence: their potential and pitfalls
as urethral bulking agents. Int Urogynecol J. 2013;24:913–9.
6. Kasi AD, Pergialiotis V, Perrea DN, Khunda A, Doumouchtsis
SK. Polyacrylamide hydrogel (Bulkamid) for stress urinary inconti-
nence in women: a systemic review of the literature. Int Urogynecol
J. 2016;27:367–75.
7. Siddiqui ZA, Abboudi H, Crawford R, Shah S. Intraurethral bulk-
ing agents for the management of female stress urinary inconti-
nence: a systematic review. Int Urogynecol J. 2017;28:1275–84.
8. de Vries AM, Wadhwa H, Huang J, Farag F, Heesakkers JPFA,
Kocjancic E.  Complications of urethral bulking agents for stress
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urinary incontinence: an extensive review including case reports.
Fem Pelv Med Reconstr Surg. 2018;24:392.
9. Lone F, Sultan AH, Thakar R. Long-term outcome of transurethral
injection of hyaluronic acid/dextranomer (NASHA/Dx gel) for the
treatment of stress urinary incontinence (SUI). Int Urogynecol J.
2010;21:1359–64.
analysis of 500 cases and review of the literature. Int Urogynecol J.
2012;24:241.
11. Pai A, Al-Singary W. Durability, safety and efficacy of polyacryl-
amide hydrogel (Bulkamid®) in the management of stress and
mixed urinary incontinence: three year follow up outcomes. Cent
Eur J Urol. 2015;68:428–33.
12. Sokol ER, Karram MM, Dmochowski R.  Efficacy and safety of
polyacrylamide hydrogel for the treatment of female stress incon-
tinence: a randomized, prospective, multicenter North American
study. J Urol. 2014;192:843–9.
13. Kirchin V, Page T, Keegan PE, Atiemo K, Cody JD, McClinton
S.  Urethral injection therapy for urinary incontinence in women.
Cochrane Database Syst Rev. 2012;(2):CD003881.
14. Schulz JA, Nager CW, Stanton SL, Baessler K. Bulking agents for
stress urinary incontinence: short-term results and complications in
a randomized comparison of periurethral and transurethral injec-
tions. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15:261–5.
15. National Institute for Health & Care Excellence. Urinary incon-
tinence—the management of urinary incontinence in women.
CG171. London: National Institute for Health & Care Excellence;
2013.
16. Lose G, Mouritsen L, Nielsen JB. A new bulking agent (polyacryl-
amide hydrogel) for treating stress urinary incontinence in women.
BJU Int. 2006;98:100.
17. Mouritsen L, Lose G, Møller-Bek K.  Long-term follow-up after
urethral injection with polyacrylamide hydrogel for female stress
incontinence. Acta Obstet Gynecol Scand. 2014;93:209–12.
18. Robinson D, Anders K, Cardozo L, Bidmead J, Dixon A, Balmforth
J, et al. What do women want? Interpretation of the concept of cure.
J Pelvic Med Surg. 2003;9:273–7.
19. Itkonen Freitas A-M, Mentula M, Rahkola-Soisalo P, Tulokas S,
Mikkola TS. Tension-free vaginal tape surgery versus polyacryl-
amide hydrogel injection for primary stress urinary incontinence: a
randomized clinical trial. J Urol. 2020;203:372–8.
 Artificial Urinary Sphincter in Women
25
Amrith Raj Rao and Philippe Grange

25.2 Artificial Urinary Sphincter

Learning Objectives
• To understand the working of the artificial urinary
sphincter
• To review the literature of AUS and its success rate
• To describe laparoscopic technique to insert the
AUS in women
The most commonly used device AMS 800™ (American
Medical Systems) consists of three main parts: inflatable
urethral cuff, pressure-regulating balloon reservoir and the
control pump. There are connected to each other with non-­
kink connecting tubings.

• The inflatable cuff (Fig. 25.1): The cuff surrounds the ure-
thra/bladder neck circumferentially. They range from 4 to
11 cm increasing by 0.5 cm. In women and children, the
25.1 Introduction cuff is placed around the bladder neck. In men, the cuff is
placed around the bulbar urethra.
Artificial urinary sphincter (AUS) is a surgical device that • Pressure-regulating balloon reservoir (Fig. 25.2): The
is implanted to restore continence control in men, women balloon is placed usually in the suprapubic region. It acts
and children. In women, AUS is usually considered as the both as a reservoir and also a pressure-regulating system.
last resort to restore continence after failure of other anti-­ Different pressure pre-set balloon reservoirs are available
incontinence procedures, albeit there are indications for (41–50, 51–60, 61–70, 71–80, 81–90 cm water). The bal-
the primary insertion of AUS.  The procedure requires loon with the lowest pressure required to occlude the
appropriate patient selection with proper counselling, bladder neck is selected. This can vary from patient to
operated upon by a surgeon who is well versed with the patient.
anatomy of the pelvis and possesses sound knowledge of • Control pump (Fig. 25.3): The control pump is placed
reconstructive techniques. The patient should be followed below the labia majora in women. The pump has a unidi-
up to detect any possible complications and manage them rectional valve, refill-delay resistor and a deactivation
accordingly. We outline in this chapter the device, indica- button. Squeezing and releasing the soft part of the pump
tions, contraindications, operative technique and a brief releases the pressure in the cuff by pushing the fluid to the
review of the current literature on the laparoscopic balloon-­reservoir allowing the patient to void. The refill-
approach to the insertion of AUS.

A. R. Rao
American Hospital, Dubai, UAE
e-mail: amrithrao@yahoo.com
P. Grange (*)
King’s College Hospital, London, UK
e-mail: pgrange@nhs.net Fig. 25.1  AMS 800™ inflatable cuff

© Springer Nature Switzerland AG 2021 343

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_25
344
Fig. 25.2  AMS 800™ pressure-regulating balloon reservoir
Fig. 25.3  AMS 800™ control pump
delay resistor slowly allows the fluid from the reservoir to
fill into the cuff (3–5 min) through the pump, thus occlud-
ing the urethra. The activation of the deactivation button
situated on the hard upper part of the pump stops the fluid
from being transferred between the components.
• Connecting tubing: The AMS 800™ comes with two
colour-­coded tubings. The clear tubing connects to the
pump from the cuff, and the dark tubing connects the
pump to the balloon reservoir. The tubings are connected
to their counterparts using Quick connect sutureless win-
dow connectors using a connecting assembly tool.
The filling solution for the device should be iso-osmotic
as the silicone elastomer over a period of time can allow the
fluid to shift across an osmotic gradient. Therefore, the man-
ufacturer’s recommend isotonic saline to fill the components
of the AUS. Certain centres prefer to use contrast media that
will aid the site of failure if the device malfunctions in the
future. The manufacturer’s strictly recommends the use of
recommended contrast mixtures as not all are iso-osmotic,
A. R. Rao and P. Grange
and failure to adhere can lead to leakage of the fluid leading
to mechanical failure. More information can be obtained
from their website [1].
25.3 Indications
Primary implantation for severe genuine type III stress
incontinence (intrinsic sphincter deficiency)
Secondary implantation after previous failed anti-­
incontinence procedures
• Salvage implantation for persistent incontinence
• In association with urethrolysis on an obstructed scarred
urethra
25.4 Contraindications
Previous pelvic radiotherapy
Any active perineal or pelvic infections
25.5 Operation
25.5.1 Preoperative Counselling
and Preparation
The patient should be thoroughly evaluated before undertak-
ing the procedure. Good manual dexterity is necessary both
to recycle the pump that is placed in the labia majora and
also to be able to self-catheterize if required in the immediate
post-operative period. Proper counselling should be provided
on how the device works, the preoperative work-up, the
operative procedure and the possible complications with its
implications. Therefore, the patient needs to have reasonable
mental aptitude to make an informed decision about under-
going the procedure.
Investigations such as urine culture, video-urodynamic
evaluation with urethral pressure profilometry and urethro-
cystoscopy (especially in patients with previous failed anti-­
incontinence procedure) should have been carried out. Any
focus of infection should be treated appropriately as this car-
ries a higher risk of prosthetic infection.
25.5.2 Open Procedure for Insertion of AUS
25.5.2.1 Abdominal Approach
Access to the bladder neck can either be transperitoneal or
preperitoneal route, using a lower midline or a Pfannenstiel
incision. The pelvic anatomy is first defined, and dissection
25  Artificial Urinary Sphincter in Women 345

is then carried out to free the bladder neck from the underly-
ing vaginal wall. The operation can be difficult in women
who have had previous pelvic operations or have had anti-­
incontinence procedures, as the scar tissue can be quite dense
and adherent. Careful dissection with control of haemostasis
is essential to avoid injuring the urethra, the bladder or
indeed the vagina. The risk of infection and erosion is higher
if the vaginal wall or the urethra is injured. Combined
transvaginal and transabdominal approach has also been
­
described for difficult cases.

25.5.2.2 Vaginal Approach

The transvaginal route of implantation of AUS has been
reported by few authors suggesting the advantage of avoid-
ing the scar secondary to previous surgery on the bladder
neck. In this approach, the balloon reservoir is placed in the
suprapubic region, and the pump is placed in the labia majora
through a separate suprapubic incision. Although the number Fig. 25.4  The patient position with a slight head-down position
of patients treated in this manner is not as many as that of
open abdominal approach, the results are encouraging with
one series of 34 patients showing a 100% success rate with
no case of erosion or extrusion [2].

25.5.2.3 Laparoscopic Extra-Peritoneal

Approach for Insertion of AUS
in Women

Patient Preparation
The patient is in a supine position preferably on an anti-slip
gel mattress. DVT prophylaxis includes TEDS® stockings
and the Flowtron® pump during the procedure and in the
immediate post-operative period. Unless contraindicated, we
routinely administer low molecular weight heparin in the
post-operative period. The pressure areas of the body are
protected with gel pads.
The abdominal wall, genitals and the perineum are
cleaned thoroughly with iodine-based solution. Sterile access
to the vagina is also required during surgery. A combination
of antibiotics (depending on the local microbiological resis-
tance) to cover gram-positive, gram-negative and anaerobic Fig. 25.5  Laparoscopic approach using the Freehand robotic camera
organisms is administered at induction and continued for holder
48 h after the operation.
A 16-Fr Foley catheter with 10  mL in the balloon is above the upper border of the symphysis pubis. Once the soft
inserted through the urethra into the bladder and emptied connective tissue of the space of Retzius is identified, CO2
completely. The patient is in a moderately head-down posi- gas insufflation is started. In our experience, a pressure of
tion with arms alongside the body (Fig. 25.4). The burden of 9 mmHg is sufficient enough to give adequate space to carry
holding a camera by the assistant is eased by using a robotic out the procedure. This space is developed using smooth
camera holder: Freehand® (Prosurgics Ltd), which maintains movements of the 10 mm zero degree telescope initially fol-
a stable picture throughout the operation (Fig. 25.5) [3]. A lowing the contour of the upper border of the symphysis
11 mm clear vision port (e.g. Visiport™) is inserted with a pubis and the pubic rami. There is an advantage of clarity
10  mm telescope in the midline about five fingers breadth with the newer HD stacks and a deflectable tip video-­
346
PS
LA
BI
Fig. 25.6  Exposure of the vagina and the anatomical landmarks. Bl,
bladder; LA, levator ani; PS, pubic symphysis
endoscope. We do not feel the need for a balloon dilatation
technique, which remains an alternative option. Once the
space is created, the useful landmarks to identify are pubic
symphysis; pectineal ligaments; pelvic diaphragm, endopel-
vic fascia and levator ani; external iliac veins with their char-
acteristic respiratory movements; and inferior epigastric
vessels (IEV) (Fig.  25.6). Two additional left ports are
inserted for the operator sitting on the left: one 12 mm port
medial to the left IEV and one 5 mm lateral to the IEV. The
moderate triangulation obtained may seem limited to sur-
geons used to more conventional broad triangulation.
However, this allows an ergonomic and comfortable position
preventing tiredness on the long run. An additional 5  mm
port is placed on the assistant’s side.
The key to success is the identification of the bladder
neck. The catheter balloon helps to recognize the anterior
wall of the bladder. The incision of the endopelvic fascia will
give access to the para-urethral vaginal wall. Like in open
surgery, a bidigital intravaginal palpation will give the feel-
ing of the thickness of the vaginal tissue via the tip of a
smooth instrument introduced through one of the ports. In
some cases, the pubo-urethral (anterior part of the pubococ-
cygeus) ligament can be divided; however, it is important in
any case to preserve the lateral urethral ligaments.
In secondary implantation, the principles remain the
same, but the difficulty is as expected related to the type and
number of prior procedures which could include use of vari-
ous non-absorbable materials. The key is to follow the pelvic
bone and then the pelvic wall. In the most challenging cases,
deliberately opening the anterior wall of the bladder is a safe
option if away from the BN itself.
A. R. Rao and P. Grange
Fig. 25.7  Dissecting the bladder neck with a right angled instrument
and the sucker
The real difficulty in such circumstances is to create a
plane between the bladder neck and vagina which often is
replaced by strong fibrotic scar tissue.
During the surgery, the three helpful things are patience,
patience and patience. Lacking in one of those three inevi-
tably will end up in perforating either the vagina or the
urethra. However, lacking two of these will invariably lead
to perforation of both! By using successively the suction
device and right-angled instrument, the bladder neck is
slowly freed from the underlying vaginal wall by alternat-
ing the dissection from either side (Fig. 25.7). The extent
of separation should be long enough to be able to accom-
modate safe insertion of the cuff. An approximate guide
would be a free movement of the measurement tape in the
space. The guide tape from the manufacturer is used to
measure the circumference of the bladder neck to select
the size of the cuff (as it comes in different sizes)
(Fig.  25.8). The components of the AMS 800™ AUS is
then prepared according to the manufacturers recommen-
dation. It is vital to remove all the air bubbles from the cuff
and both the tubes before occluding them to be inserted
inside the abdomen. The vacuumed cuff is then inserted
through the 12 mm port and is placed around the bladder
neck and locked (Fig. 25.9).
The pump is prepared according to the manufacturer’s
manual, and the tubing is clamped. The pump is placed in the
25  Artificial Urinary Sphincter in Women
Fig. 25.8  Measuring the bladder neck
Fig. 25.9  Passing the cuff around the bladder neck
fat of the labia majora. Access to the labia is performed lapa-
roscopically going anterior to the superior pubic ramus just
lateral to the insertion of the rectus muscle. This dissection is
also aided by manually feeling from outside on the labia
when performing blunt dissection by the laparoscopic suc-
tion device (Fig. 25.10).
Finally the vacuumed balloon reservoir is introduced
through the 12 mm port and placed in the space of Retzius
just lateral to the bladder (Fig. 25.11). The tubings of the
cuff, pump and balloon are exteriorized through the
12 mm port and connected to each other after filling the
chambers according to the manufacturer’s recommenda-
347
Fig. 25.10  Creation of the space for the pump in the labia majora
Fig. 25.11  Internalization of the balloon reservoir
tion (Fig. 25.12). The connecting tubings are then inter-
nalized. Haemostasis is controlled at low gas pressure.
The port incisions are closed. Drains are avoided to mini-
mize prosthetic infection. The pump is then squeezed and
released several times to remove all the fluid from the
cuff (deflate the cuff), and then deactivation button is
activated. In addition to other advantages of the laparo-
scopic approach, cosmetic result is quiet obvious
(Fig.  25.13). Reactivation is carried out usually around
4–6 weeks’ time.
348
Fig. 25.12  Exteriorization of the connecting tubing
Fig. 25.13  Four tiny scars of the laparoscopic approach
25.6 Complications
25.6.1 Per-operative Complications
25.6.1.1 During Trocar Placement
Injury to the intra-abdominal organs can occur with the
placement of the trocar. This can be minimized by the use of
Visiport™ that allows trocar placement under vision. Injury
can also be avoided by performing this procedure by the
extra-peritoneal approach. Injury to the bladder, the urethra
and the vagina may occur especially in a patient who has
undergone previous pelvic surgery.
A. R. Rao and P. Grange
25.6.2 Early Post-operative Complications
25.6.2.1 Urinary Retention
Most often, urinary retention is due to the oedema surround-
ing the bladder neck due to surgery. If failure to void after
removal of the catheter, the patient may be taught to perform
ISC till the oedema settles down.
25.6.2.2 Infection and Extrusion
of the Prosthesis
Staph epidermidis is the most common cause of prosthetic
infection, although other organisms are also implicated.
Infection invariably leads to extrusion of the prosthesis. Initial
conservative management with high-dose intravenous antibiot-
ics can be tried. However, if the infection persists, the entire
device needs to be removed and reimplanted a few months later.
The risk of early erosion or extrusion is higher if there has
been urethral injury during the time of implantation. The
reported incidence is around 1–3% which has decreased with
the introduction of delayed activation [4–6]. Erosion is also
common if AUS is implanted in women who have received
pelvic irradiation [7].
25.6.3 Late Post-operative Complications
25.6.3.1 Urethral Atrophy, Erosion or Extrusion
Constant extrinsic pressure by the cuff on the urethra may
lead to thinning of the wall and ultimately end up in erosion
of the prosthesis into the urethra. Another uncommon but
reported cause of urethral injury is the attempt of urethral
catheterization by a medical staff who do not understand the
functioning of the AUS cuff. Erosion or extrusion requires
removal of all the components of the AUS, and if suitable a
delayed implantation may be considered.
25.6.3.2 Mechanical Failure
The life of an AMS 800™ is around 10 years. Device failure has
been reported to occur in 7.6–21% of patients [5, 8]. The most
common cause of failure is the leakage of fluid, cuff being the
commonest site. If the leakage occurs early, only the defective
component can be replaced. However, if it is a delayed failure, it
is better to replace the entire system due to high probability of
other components failing in the subsequent period [5].
25.6.3.3 Recurrent/Persistent Urinary
Incontinence
Various factors can contribute to the incontinence following
the implantation of AUS.  Video-urodynamic evaluation
25  Artificial Urinary Sphincter in Women
should be carried out to rule out detrusor overactivity, and
the screening would indicate the position of the cuff and the
emptying and filling of the cuff (if contrast-based solution
was used to fill the components at the time of implantation).
Urethrocystoscopy should be carried to rule out cuff
erosion.
25.7 B
 rief Review of the Literature About
AUS Implantation in Women
25.7.1 Open Procedure
Transabdominal approach has been considered the gold stan-
dard in the insertion of AUS. This can be done either trans-
peritoneally or preperitoneal approach. The success rate of
open insertion of AUS is quoted to around 61–90% [9–11].
The disadvantages of open approach are the length of
incision, longer hospital stay and poor visualization in the
pelvis, especially in women with a very large body habitus,
the problems which could potentially be overcome by lapa-
roscopic approach.
25.7.2 Laparoscopic Procedure
There are only a few case reports and case series reporting
the laparoscopic implantation of AUS [12–14]. This reflects
the dramatic change in the management of SUI using the
tape procedure in the last decade. However, in a subset of
patients who fail after these procedures, AUS may be a suit-
able option.
Recently two series have published on their outcome of
laparoscopic approach to the implantation of AUS. Roupret
et al. reported on the outcome of 12 women who had laparo-
scopic insertion of AUS [13]. Eleven out of the 12 had previ-
ous anti-incontinence procedures. Incontinence was resolved
in eight women at a mean follow-up of about 12 ± 8 months.
They had to convert to open in three cases due to vaginal and
bladder injuries. Urinary retention was observed in five cases
but voided successfully at a later date. The mean operative
time was 181 ± 39 min. The authors concluded that laparo-
scopic approach was feasible, but larger studies with longer
follow-up are required to evaluate it further [13].
Recently Ferreira et  al. reported the outcomes of 52
women who underwent laparoscopic AUS insertion. After
a mean follow-up of 37.5  months, 38 (77.6%) patients
were considered to be fully continent, and 8 (16.3%)
improved their grade of incontinence. A total of seven redo
procedures and four permanent sphincter removals were
documented in their long follow-up. The main reasons for
349
redo procedures were six (11.2%) mechanical problems
and one vaginal erosion (2%) [14].
25.7.3 Robot-Assisted Artificial Urinary
Sphincter Insertion
Robot-assisted surgery has proved to be advantageous in
many surgical procedures in the pelvis. Three dimensional
vision, ten times the magnification, 7° of movement of the
Endowrist instruments providing enhanced dexterity and
filtration of tremors are some of the advantages over tradi-
tional laparoscopic procedures. The technical steps of
robot-­assisted artificial urinary sphincter (RA-AUS) inser-
tion are similar to that of the laparoscopic approach
described in this chapter.
Fournier et al. reported feasibility, safety and functional
results of RA-AUS insertion in six women from 2012 to
2013. With a mean duration of follow-up was 14.3 months;
they found that 83% of the patients achieved full conti-
nence. They also reported no intraoperative complications
or conversions and one patient had Grade 1 post-operative
complication [15].
Biardeau et al. reported the outcomes of 11 women from
2012 to 2014. With a mean follow-up of 17.6 months, three
patients had to have the AUS removed due to erosions. Among
the eight patients with AUS, seven had full continence with
one patient having social continence. Two vaginal injuries
and two bladder injuries occurred intraoperatively. Two
patients experienced early minor post-operative complica-
tions, and two had a major post-operative complication [16].
Although there has not been any randomised control trial,
Peyronnet et al. compared the outcomes of their open AUS
with that of RA-AUS. There were 16 women in the open and
eight in the robotic group. They reported similar operative
time (214 min vs. 211 min; p = 0.90) but found that there was
a trend toward a lower intraoperative complication rate
(37.5% vs. 62.5%; p = 0.25) and a lower post-operative com-
plications in the RA-AUS (25% vs. 75%; p  =  0.02).
Interestingly, they also reported a decreased blood loss
(17  mL vs. 275  mL; p  =  0.22) and shorter length of stay
(3.5  days vs. 9.3  days; p  =  0.09) in the RA-AUS group.
Continence rates were comparable in both groups (75% vs.
68.8%; p = 0.75). Three AUS explantations were needed in
the open group (18.8%) compared with one in the robot-­
assisted group (12.5%; p  =  0.70). They concluded that the
robotic approach was superior to that of open in reducing
complication rates [17].
Recently, Herve et al. reported the cause of failure in
two of their patients who underwent RA-AUS for urinary
incontinence. On re-exploration, they found that the cuff
350
around the bladder neck was loose, which was rectified
by using a smaller cuff. They postulated that insufficient
tightness of the cuff could be due to inability of the sur-
geon to feel the force while pulling the cuff around the
urethra due to the absence of haptic sensation in robotic
surgery [18].
25.8 Conclusion
AUS is an option to restore continence in women, most often
following failed anti-incontinence procedure. The success
rate of achieving continence is quite high, although patient
selection is of paramount importance to avoid any disap-
pointment. Insertion of AUS should be performed by sur-
geons who have adequate experience as the procedure can be
difficult due to previous surgeries and can carry a significant
morbidity. Post-operative follow-up should be diligent to
pick up complications and managed accordingly.
Traditionally, open abdominal approach has been used to
implant the AUS; however, recently laparoscopic insertion is
gaining popularity with the advantages attributed to mini-
mally invasive surgery.
Take-Home Messages
• Artificial urinary sphincter is a good option to
restore continence when other methods have been
unsuccessful.
• Insertion of AUS should be undertaken by special-
ists who are well versed with pelvic anatomy and
reconstructive techniques.
• Success rate is high; however, long-term follow-up
is needed to identify and treat complications.
References
1. www.AmericanMedicalSystems.com.
2. Appell R. Technique and results in the implantation of the artificial
urinary sphincter in women with Type III stress urinary inconti-
nence by a vaginal approach. Neurourol Urodyn. 1988;7:613–9.
A. R. Rao and P. Grange
3. Sharma D, Brown C, Kouriefs C, Sood H, Grange P, Patel H. Initial
experience with The FreeHand robotic camera holder in laparo-
scopic urology. J Endourol. 2009;23(1):A249.
4. Hussain M, Greenwell TJ, Venn SN, Mundy AR. The current role
of the artificial urinary sphincter for the treatment of urinary incon-
tinence. J Urol. 2005;174:418–24.
5. Ratan HL, Summerton DJ, Wilon SK, Terry TR. Development and
current status of the AMS 800 artificial urinary sphincter. EAU-­
EBU Update Ser. 2006;4:117–28.
6. Webster GD, Perez LM, Khoury JM, Timmons SL. Management of
type III stress urinary incontinence using artificial urinary sphinc-
ter. Urology. 1992;39(6):499–503.
7. Thomas K, Venn SN, Mundy AR. Outcome of the artificial urinary
sphincter in female patients. J Urol. 2002;167(4):1720–2.
8. Light JK.  Abdominal approach for implantation of the A.S.
800 artificial urinary sphincter in females. Neurourol Urodyn.
2005;7(6):603–11. (Special issue).
9. Costa P, Mottet N, Rabut B, Thuret R, Ben Naoum K, Wagner L. The
use of an artificial urinary sphincter in women with type III incon-
tinence and a negative Marshall test. J Urol. 2001;165(4):1172–6.
10. Petero VG Jr, Diokno AC. Comparison of the long-term outcomes
between incontinent men and women treated with artificial urinary
sphincter. J Urol. 2006;175:605–9.
11. Diokno AC, Hollander JB, Alderson TP. Artificial urinary sphincter
for recurrent female urinary incontinence: indications and results. J
Urol. 1987;138:778–80.
12. Grange P, Mignot H. Laparoscopic artificial sphincter implantation
in multioperated women. In: 2nd International Consultation on
Incontinence, Paris, France; 2001.
13. Rouprêt M, Misraï V, Vaessen C, Cardot V, Cour F, Richard F,
Chartier-Kastler E.  Laparoscopic approach for artificial urinary
sphincter implantation in women with intrinsic sphincter deficiency
incontinence: a single-centre preliminary experience. Eur Urol.
2010;57(3):499–504.
14. Ferreira C, Brychaert PE, Menard J, Mandron E.  Laparoscopic
implantation of artificial urinary sphincter in women with
intrinsic sphincter deficiency: mid-term outcomes. Int J Urol.
2017;24(4):308–13.
15. Fournier G, Callerot P, Thoulouzan M, Valeri A, Perrouin-Verbe
MA.  Robotic-assisted laparoscopic implantation of artificial uri-
nary sphincter in women with intrinsic sphincter deficiency incon-
tinence: initial results. Urology. 2014;84(5):1094–8.
16. Biardeau X, Rizk J, Marcelli F, Flamand V.  Robot-assisted lapa-
roscopic approach for artificial urinary sphincter implantation in
11 women with urinary stress incontinence: surgical technique and
initial experience. Eur Urol. 2015;67:937–42.
17. Peyronnet B, Vincendeau S, Tondut L, Bensalah K, Damphousse
M, Manunta A. Artificial urinary sphincter implantation in women
with stress urinary incontinence: preliminary comparison of robot-­
assisted and open approaches. Int Urogynecol J. 2016;27(3):475–81.
18. Hervé F, Lumen N, Goessaert AS, Everaert K.  Persistent uri-
nary incontinence after a robot-assisted artificial urinary sphinc-
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2016;2016:bcr2016216971.
 Pharmacological Treatment of Urinary
Incontinence and Overactive Bladder:
The Evidence
Dudley Robinson and Linda Cardozo
Learning Objectives
• To understand the prevalence of OAB and the
impact on HRQoL.
• To be aware of the pathophysiology of OAB.
• To be familiar with the investigation and diagnosis
of patients with lower urinary tract symptoms.
• To understand the benefit of conservative therapy.
• To have a detailed knowledge of the pharmacologi-
cal management of OAB including the different
therapeutic options.
26.1 Introduction
Overactive bladder (OAB) is the term used to describe the
symptom complex of urinary urgency, usually accompanied
by frequency and nocturia, with or without urgency urinary
incontinence, in the absence of urinary tract infection or
other obvious pathology [1].
Epidemiological studies from North America have
reported a prevalence of OAB in women of 16.9% increasing
with age rising to 30.9% in those over the age of 65 years [2].
Further prevalence data from Europe [3] has reported the
overall prevalence in men and women over the age of
40  years to be 16.6%. Frequency was the most commonly
reported symptom (85%) whilst 54% complained of urgency
and 36% urgency incontinence.
More recently a further population-based survey of lower
urinary tract symptoms in Canada, Germany, Italy, Sweden and
the United Kingdom has reported on 19,165 men and women
over the age of 18  years [4]. Overall 11.8% complained of
D. Robinson (*) · L. Cardozo
Department of Urogynaecology, King’s College Hospital,
London, UK
e-mail: dudley.robinson@nhs.net; linda@lindacardozo.co.uk
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_26
26
symptoms suggestive of OAB, and 64.3% reported at least one
urinary symptom. In addition OAB was found to be more prev-
alent than all types of urinary incontinence combined (9.4%).
Nocturia was the most commonly reported lower urinary tract
symptom, 48.6% of men and 54.5% of women.
These prevalence data derived from the EPIC study have
also been used to investigate the economic impact of OAB [5].
Overall the estimated average direct cost of OAB per patient
ranged between $262 in Spain and $619 in Sweden. The esti-
mated total direct cost for OAB per country was found to
range from $333 million in Sweden to $1.2 billion in Germany,
and the total annual direct cost in these six Western countries
was estimated to be $3.9  billion. In addition nursing home
costs were estimated at $4.7  billion per year, whilst work
absenteeism related to OAB costs around $1.1 billion per year.
There is also considerable evidence demonstrating a sig-
nificant impact of OAB on work productivity. A population-­
based cross-sectional Internet survey has been reported
involving 2876 men and 2820 women in the United States
[6]. Overall those men and women complaining of OAB
‘wet’, i.e. urgency incontinence, reported the lowest levels of
work productivity and the highest levels of daily work inter-
ference. Storage symptoms associated with OAB were most
consistently associated with work productivity outcomes
although there was also a significant association with other
storage and voiding phase lower urinary tract symptoms.
26.2 Pathophysiology
The symptoms of OAB in those with underlying detrusor
overactivity [1] are due to involuntary contractions of the
detrusor muscle during the filling phase of the micturition
cycle. These involuntary contractions are mediated by
acetylcholine-­induced stimulation of bladder muscarinic
receptors [7]. However, OAB is not synonymous with detru-
sor overactivity as the former is a symptom-based diagnosis,
whilst the latter is a urodynamic observation. It has been
estimated that 64% of female patients with OAB have
351
352
urodynamically proven detrusor overactivity and that 83%
of female patients with detrusor overactivity have symptoms
suggestive of OAB [8].
26.2.1  Muscarinic Receptors
Molecular cloning studies have revealed five distinct genes
for muscarinic acetylcholine receptors in rats and humans,
and it has been shown that five receptor subtypes (M1–M5)
correspond to these gene products [9]. In the human bladder,
the occurrence of mRNA encoding M2 and M3 subtypes has
been demonstrated although not for M1 [10]. The M3 recep-
tor is thought to cause a direct smooth muscle contraction
[11]. Whilst the role of the M2 receptor has not yet been clari-
fied, it may oppose sympathetically mediated smooth muscle
relaxation [12] or result in the activation of a non-specific
cationic channel and inactivation of potassium channels. In
general it is thought that the M3 receptor is responsible for
the normal micturition contraction although in certain dis-
ease states, such as neurogenic bladder dysfunction, the M2
receptors may become more important in mediating detrusor
contractions [13].
26.3 Detrusor Overactivity
26.3.1  Outflow Obstruction Hypothesis
The association of detrusor overactivity with outflow
obstruction has been recognised for some time [14] although
it is more important in men than women.
Outflow obstruction may lead to partial denervation, and
morphological studies have demonstrated a reduction in ace-
tylcholinesterase staining nerves in obstructed human blad-
der [15]. Pharmacological studies have shown that muscle
strips from patients with detrusor overactivity exhibit super-
sensitivity to acetylcholine [16].
In addition outflow obstruction may alter the contraction
properties of the detrusor muscle [17] leading to changes in
cell-to-cell propagation of electrical activity, and this in turn
may lead to a higher incidence of instability of membrane
potential [18]. These findings suggest that individual cells
are more irritable when synchronous activation is damaged.
Outflow obstruction has also been shown to lead to the
facilitation of the spinal reflex [19] mediated by C-fibres
with increased expression of nerve growth factor (NGF) and
tachykinins [20]. The latter have been shown to have an
effect on spinal and supraspinal control of the bladder via
neurokinin receptors [21].
D. Robinson and L. Cardozo
26.3.2  Neurogenic Hypothesis
The pathophysiology of detrusor overactivity remains
unclear. In vitro studies have shown that the detrusor muscle
in cases of idiopathic detrusor overactivity contracts more
than normal detrusor muscle. These detrusor contractions are
not nerve mediated and can be inhibited by the neuropeptide
vasoactive intestinal polypeptide [22]. Other studies have
shown that increased α adrenergic activity causes increased
detrusor contractility [23].
There is evidence to suggest that the pathophysiology of
idiopathic and obstructive overactive bladder is different.
From animal and human studies on obstructive overactiv-
ity, it would seem that the detrusor develops postjunctional
supersensitivity, possibly due to partial denervation [24],
with reduced sensitivity to electrical stimulation of its
nerve supply but a greater sensitivity to stimulation with
acetylcholine [25]. If outflow obstruction is relieved, the
detrusor can return to normal behaviour and reinnervation
may occur [26].
26.3.3  Urethral Reflex
Relaxation of the urethra is known to precede contraction
of the detrusor in a proportion of women with detrusor
overactivity [27]. This may represent primary pathology in
the urethra which triggers a detrusor contraction or may
merely be part of a complex sequence of events which orig-
inate elsewhere. It has been postulated that incompetence
of the bladder neck, allowing passage of urine into the
proximal urethra, may result in an uninhibited contraction
of the detrusor. However, Sutherst and Brown [28] were
unable to provoke a detrusor contraction in 50 women by
rapidly infusing saline into the posterior urethra using mod-
ified urodynamic equipment.
26.3.4  Myogenic Hypothesis
Brading and Turner [29] have suggested that the common
feature in all cases of detrusor overactivity is partial
denervation of the detrusor which may be responsible for
altering the properties of the smooth muscle, leading to
increased excitability and increased ability of activity to
spread between cells, resulting in coordinated myogenic
contractions of the whole detrusor [30]. They dispute the
concept of neurogenic detrusor overactivity, that is,
increased motor activity to the detrusor, as the underlying
mechanism in detrusor overactivity, proposing that there
26  Pharmacological Treatment of Urinary Incontinence and Overactive Bladder: The Evidence 353

is a fundamental abnormality at the level of the bladder Table 26.1  Common causes of frequency and urgency of micturition
wall with evidence of altered spontaneous contractile Urological
activity consistent with increased electrical coupling of Urinary tract infection
cells, a patchy denervation of the detrusor and a supersen- Detrusor overactivity
Small-capacity bladder
sitivity to potassium [31]. Charlton et al. [32] suggest that
Interstitial cystitis
the primary defect in the idiopathic and neuropathic blad- Chronic urinary retention/chronic urinary residual
ders is a loss of nerves accompanied by hypertrophy of Bladder mucosal lesion, e.g. papilloma
the cells and an increased production of elastin and col- Bladder calculus
lagen within the muscle fascicles. Urethral syndrome
Urethral diverticulum
Urethral obstruction
Gynaecological
26.3.5  Urothelial Afferent Hypothesis
Pregnancy
Stress incontinence
More recently the role of afferent activation in the urothe- Cystocoele
lium and suburothelial myofibroblasts has been investigated Pelvic mass, e.g. fibroids
as a factor in the pathophysiology of detrusor overactivity. Previous pelvic surgery
C-fibre afferents are known to have nerve endings in the sub- Radiation cystitis/fibrosis
urothelial layer of the bladder wall as well as in the urothe- Postmenopausal urogenital atrophy
Sexual
lium. Studies have revealed that ATP is released from the
Coitus
urothelium by bladder distension [33], and this may lead to Sexually transmitted disease
activation of purinergic receptors on afferent nerve terminals Contraceptive diaphragm
which in turn evokes a neuronal discharge leading to bladder Medical
contraction. Diuretic therapy
Prostanoids [34] and nitric oxide [35] are synthesised Upper motor neuron lesion
locally in the urothelium and are also released by bladder Impaired renal function
Congestive cardiac failure (nocturia)
distension. It is probable that a cascade of stimulatory (ATP,
Hypokalaemia
prostanoids, tachykinins) and inhibitory (nitric oxide) medi-
Endocrine
ators are involved in the activation of sensory pathways dur- Diabetes mellitus
ing bladder filling [36]. The role of C-fibres in the Diabetes insipidus
pathophysiology of detrusor contractions is also supported Hypothyroidism
by the use of intravesical vanilloids (capsaicin and resinifera- Psychological
toxin) in patients with idiopathic detrusor overactivity and Excessive drinking
hypersensitivity disorders [37]. Habit
Anxiety

26.4 Clinical Presentation

OAB usually presents with a multiplicity of symptoms.
Those most commonly seen are urgency, daytime frequency,
nocturia, urgency incontinence, stress incontinence, noctur-
nal enuresis and often coital incontinence. However, it is
important to remember that there are numerous other causes
of urgency and frequency (Table 26.1).
There are no specific clinical signs in women with overac-
tive bladder, but it is always important to look for vulval
excoriation, urogenital atrophy, a urinary residual and stress
incontinence. Occasionally an underlying neurological
lesion such as multiple sclerosis will be discovered by exam-
ining the cranial nerves and S2, S3 and S4 outflow.
26.5 Investigation
Whilst OAB is a symptomatic diagnosis, all patients require
a basic assessment in order to confirm the diagnosis as well
as excluding any other underlying cause for lower urinary
tract dysfunction. A midstream specimen of urine should be
sent for microscopy, culture and sensitivity in all cases of
incontinence in order to exclude a lower urinary tract
infection.
In addition all patients should complete a frequency/vol-
ume chart or bladder diary in order to evaluate their fluid
intake and voiding pattern. As well as the number of voids
and incontinence episodes, the mean volume voided over a
354
24-h period can be calculated as well as the diurnal and noc-
turnal volumes. Urgency is now generally regarded as being
the driving symptom of OAB and is known to play an impor-
tant role in the development of daytime frequency, nocturia
and urgency incontinence. Several validated urgency scoring
systems (Patient Perception of Intensity of Urgency Score
(PPIUS) [38], Urgency Perception Score (UPS) [39], Indevus
Urgency Severity Scale (IUSS) [40]) have been developed to
attempt to measure urgency severity, and these may be used
in conjunction with frequency volume charts in clinical
practice.
Quality of life (QoL) is assessed by the use of question-
naires completed by the patient alone or as part of the consul-
tation and allows the quantification of morbidity and the
evaluation of treatment efficacy as well as measuring how
lives are affected and coping strategies adopted.
Generic questionnaires, such as the Short Form 36 [41],
are general measures of QoL and are therefore applicable to
a wide range of populations and clinical conditions, whilst
disease-specific questionnaires, such as the Kings Health
Questionnaire (KHQ) [42], are designed to focus on lower
urinary tract symptoms. More recently the International
Consultation on Incontinence has now developed and vali-
dated a number of disease-specific questionnaires for use in
lower urinary tract dysfunction [43].
26.5.1  Urodynamic Investigations
Whilst a number of women complaining of symptoms sug-
gestive of OAB can be managed following the basic assess-
ment, those women with refractory or complex symptoms
may benefit from urodynamic investigations. Basic urody-
namic investigations include uroflowmetry, filling cystome-
try and pressure/flow voiding studies, but when these tests do
not replicate the patient symptoms, video urodynamics or
ambulatory urodynamics may be more informative.
26.5.2  Cystourethroscopy
Although endoscopy is not helpful in diagnosing OAB, it
may be used to exclude other causes for the symptoms asso-
ciated with OAB such as a bladder tumour or calculus. In
addition cystourethroscopy should be considered in all
women complaining of haematuria, painful bladder syn-
drome and recurrent incontinence.
26.6 Conservative Management
All women with OAB benefit from advice regarding simple
measures which can help to alleviate their symptoms. Many
patients drink too much, and they should be told to reduce
D. Robinson and L. Cardozo
their fluid intake to between 1 and 1.5  L/day [44] and to
avoid tea, coffee and alcohol if these exacerbate their prob-
lem. In addition there is also increasing evidence to suggest
that weight loss may improve symptoms of urinary inconti-
nence [45].
26.6.1  Bladder Retraining
Bladder retraining was first described by Jeffcoate and
Francis [46], and both inpatient and outpatient therapy can
be effective. A meta-analysis has concluded that bladder
retraining is more effective than placebo and medical therapy
although there is insufficient evidence to support the effec-
tiveness of electrical stimulation and too few studies to eval-
uate the effect of pelvic floor exercises and biofeedback in
women with urgency urinary incontinence [47]. Nevertheless
the National Institute of Clinical Excellence (NICE) [48] and
the International Consultation on Incontinence (ICI) [49]
recommend that bladder retraining should be considered as
first-line treatment in all women with OAB.
Antimuscarinic therapy may be a useful addition to non-­
drug therapy in the management of patients with OAB. In a
Cochrane review of 23 trials including 3685 patients, symp-
tomatic improvement was more common amongst those on
antimuscarinic therapy compared to bladder retraining (RR
0.74; 95% CI: 0.61–0.91), and combination treatment was
also associated with more improvement than bladder training
alone (RR 0.57; 95% CI: 0.38–0.88). Similarly there was a
trend towards greater improvement with a combination of
antimuscarinic therapy with bladder retraining compared to
antimuscarinic therapy alone (RR 0.80; 95% CI: 0.62–1.04)
although this was not statistically significant [50].
26.7 Medical Management
Whilst a conservative approach is justified initially, drug
therapy remains integral in the management of women with
OAB, and there are currently a number of different antimus-
carinic drugs available as well as the newer β3 agonist,
mirabegron.
26.8 Antimuscarinics
Traditionally tolerability, compliance and persistence have
limited the usefulness of many of the antimuscarinic agents
although with the introduction of newer bladder selective
drugs, once-daily dosing and differing routes of administra-
tion, it is possible that persistence with therapy may increase.
There are now a number of different licensed antimusca-
rinic drugs available on the market within the United
Kingdom. These have all been recently reviewed by the
26  Pharmacological Treatment of Urinary Incontinence and Overactive Bladder: The Evidence 355

Table 26.2  Drugs used in the treatment of overactive bladder In order to improve tolerability, a controlled release oxy-
Antimuscarinic drugs Level of evidence butynin preparation using an osmotic system (OROS) has
Grade of recommendation
Darifenacin 1 A been developed which has been shown to have comparable
Fesoterodine 1 A efficacy to immediate-release oxybutynin although associ-
Oxybutynin 1 A
Propiverine 1 A ated with fewer adverse effects [57]. In order to maximise
Solifenacin 1 A efficacy and minimise adverse effects, alternative delivery
Tolterodine 1 A systems have been evaluated. An oxybutynin transdermal
Trospium 1 A delivery system was compared to extended-release toltero-
dine in 361 patients with mixed urinary incontinence. Both
International Consultation on Incontinence [51] (Table 26.2), agents significantly reduced incontinence episodes, increased
and all have Level 1 evidence [52] and a Grade A recom- volume voided and led to an improvement in quality of life
mendation [53]. when compared to placebo. The most common adverse event
A systematic review and meta-analysis of 83 studies, in the oxybutynin patch arm was application site pruritus in
including 30,699 patients and six different drugs (fesotero- 14% although the incidence of dry mouth was reduced to
dine, oxybutynin, propiverine, solifenacin, tolterodine and 4.1% compared to 7.3% in the tolterodine arm [58].
trospium), support the efficacy of antimuscarinic therapy in A large prospective multicentre, randomised, double-­
the management of OAB. Overall there was a significantly blind placebo-controlled study has also been reported inves-
higher return to continence favouring active treatment over tigating the use of oxybutynin gel in the management of
placebo; the pooled RR across different studies and different overactive bladder in 704 patients [59]. Overall there was a
drugs is 1.3–3.5 (p < 0.01). Antimuscarinic therapy was also significant reduction in urge incontinence episodes in the
shown to be statistically significantly more effective in the gel arm compared to placebo, a significant reduction in day-
reduction of incontinence episodes per day, reduction in time frequency and increase in volume voided. Dry mouth
number of micturitions per day and reduction of urgency epi- was more common in the treatment arm when compared to
sodes per day [54]. placebo (6.9% vs. 2.8%), and skin site reactions were infre-
quent in both arms—5.4% and 1.0%, respectively.
Consequently oxybutynin gel may represent an important
26.8.1  Oxybutynin development over the oxybutynin patch in terms of patient
acceptability, but this formulation is currently only available
Oxybutynin is a tertiary amine that undergoes extensive first-­ in North America.
pass metabolism to an active metabolite, N-desmethyl oxy- In summary, the efficacy of oxybutynin is well docu-
butynin, which occurs in high concentrations and is thought mented although very often its clinical usefulness is limited
to be responsible for a significant part of the action of the by adverse effects. Alternative routes and methods of admin-
parent drug. It has a mixed action consisting of both an anti- istration may produce better patient acceptability and
muscarinic and a direct muscle relaxant effect in addition to compliance.
local anaesthetic properties. Oxybutynin has been shown to
have a high affinity for muscarinic receptors in the bladder
and has a higher affinity for M1 and M3 receptors over M2. 26.8.2  Tolterodine
The effectiveness of oxybutynin in the management of
patients with detrusor overactivity is well documented. A Tolterodine is a competitive muscarinic receptor antagonist
double-blind placebo-controlled trial found oxybutynin to with relative functional selectivity for bladder muscarinic
be significantly better than placebo in improving lower receptors. Whilst it shows no specificity for receptor sub-
urinary tract symptoms although 80% of patients com- types, it does target the bladder muscarinic receptors rather
plained of significant adverse effects, principally dry than those in the salivary glands. Several randomised,
mouth or dry skin [55]. double-­blind, placebo-controlled trials have demonstrated
The antimuscarinic adverse effects of oxybutynin are well a significant reduction in incontinent episodes and micturi-
documented and are often dose limiting, with 10–23% of tion frequency [60], whilst the incidence of adverse effects
women discontinuing medication [56]. Using an intravesical has been shown to be no different to placebo. When com-
route of administration, higher local levels of oxybutynin can pared to oxybutynin in a randomised double-blind placebo-
be achieved whilst limiting the systemic adverse effects. controlled parallel-group study, it was found to be equally
Intravesical administration of oxybutynin is an effective and efficacious and to have a lower incidence of side effects,
useful alternative for patients with neurogenic detrusor over- notably dry mouth [61].
activity who need to self-catheterise or who suffer from Tolterodine is also available as an extended-release once-­
‘bypassing’ an indwelling catheter. daily preparation. A double-blind multicentre trial of 1235
356
women has compared extended-release tolterodine to
immediate-­release tolterodine and placebo. Whilst both for-
mulations were found to reduce the mean number of urge
incontinence episodes per week, the extended-release prepa-
ration was found to be significantly more effective [62].
Extended-release oxybutynin (ER) and extended-release
tolterodine (ER) have also been compared. In the OPERA
(Overactive bladder: Performance of Extended Release
Agents) study, which involved 71 centres in the United
States, improvements in episodes of urge incontinence were
similar for the two drugs although oxybutynin ER was sig-
nificantly more effective than tolterodine ER in reducing fre-
quency of micturition [63].
In summary, the available evidence would suggest that
tolterodine is as effective as oxybutynin since although it has
fewer adverse effects patient tolerability and compliance are
improved.
26.8.3  Trospium Chloride
Trospium chloride is a quaternary ammonium compound
which is non-selective for muscarinic receptor subtypes and
shows low biological availability. It crosses the blood-brain
barrier to a limited extent and hence would appear to have
few cognitive effects [64]. A placebo-controlled, randomised,
double-blind multicentre trial has shown trospium to increase
cystometric capacity and bladder volume at first overactive
contraction, leading to significant clinical improvement
without an increase in adverse effects over placebo [65].
When compared to oxybutynin, it has been found to have
comparable efficacy but was associated with a lower inci-
dence of dry mouth and patient withdrawal from the study
[66]. At present trospium chloride would appear to be equally
effective as oxybutynin although it may be associated with
fewer adverse effects.
26.8.4  Solifenacin
Solifenacin is a potent M3 receptor antagonist that has selec-
tivity for the M3 receptors over M2 receptors and has much
higher potency against M3 receptors in smooth muscle than it
does against M3 receptors in salivary glands.
The clinical efficacy of solifenacin has been assessed in
a multicentre, randomised, double-blind, parallel-group,
placebo-­controlled study of solifenacin 5 and 10 mg once
daily in patients with overactive bladder [67]. The primary
efficacy analysis showed a statistically significant reduc-
tion of the micturition frequency following treatment with
both 5 and 10  mg doses when compared with placebo
although the largest effect was with the higher dose. The
most frequently reported adverse events leading to discon-
D. Robinson and L. Cardozo
tinuation were dry mouth and constipation. These were also
found to be dose related.
In order to assess the long-term safety and efficacy of
solifenacin, a multicentre open-label long-term follow-up
study has been reported. This was essentially an extension
of two previous double-blind placebo-controlled studies in
1637 patients [68]. Overall the efficacy of solifenacin was
maintained in the extension study with a sustained
improvement in symptoms of urgency, urge incontinence,
frequency and nocturia over the 12-month study period.
The most commonly reported adverse events were dry
mouth (20.5%), constipation (9.2%) and blurred vision
(6.6%) and were the primary reason for discontinuation in
4.7% of patients.
Solifenacin has also been compared with tolterodine
ER in the solifenacin (flexible dosing) od and tolterodine
ER as an active comparator in a randomised trial (STAR)
[69]. This was a prospective double-blind, double-dummy,
two-arm, parallel-group, 12-week study of 1200 patients
with the primary aim of demonstrating non-inferiority of
solifenacin to tolterodine ER. Solifenacin was non-inferior
to tolterodine ER with respect to change from baseline in
the mean number of micturitions per 24 h. In addition soli-
fenacin resulted in a statistically significant improvement
in urgency, urge incontinence and overall incontinence
when compared with tolterodine ER. The most commonly
reported adverse events were dry mouth constipation and
blurred vision and were mostly mild to moderate in sever-
ity. The number of patients discontinuing medication was
similar in both treatment arms (3.5% in the solifenacin arm
vs. 3.0% in the tolterodine arm).
26.8.5  Darifenacin
Darifenacin is a tertiary amine with moderate lipophilicity
and is a highly selective M3 receptor antagonist which has
been found to have a fivefold higher affinity for the human
M3 receptor relative to the M1 receptor.
A review of the pooled darifenacin data from the three
phase III, multicentre, double-blind clinical trials in patients
with OAB has been reported in 1059 patients [70].
Darifenacin resulted in a dose-related significant reduction
in median number of incontinence episodes per week.
Significant decreases in the frequency and severity of
urgency, micturition frequency and number of incontinence
episodes resulting in a change of clothing or pads were also
apparent, along with an increase in bladder capacity.
Darifenacin was well tolerated. The most common treatment-­
related adverse events were dry mouth and constipation,
although together these resulted in few discontinuations. The
incidence of CNS and cardiovascular adverse events were
comparable to placebo.
26  Pharmacological Treatment of Urinary Incontinence and Overactive Bladder: The Evidence 357

26.8.6  Fesoterodine longitudinal study of 13,004 participants over the age of

65 years taking anticholinergic medication. The overall use
Fesoterodine is a novel derivative of 3,3-diphenylpropyl-­ of drugs with an anticholinergic effect was associated with a
amine which is a potent antimuscarinic agent that has more 0.33 point decline in the Mini Mental State Examination
recently been developed for the management of OAB.  A (MMSE) (95% CI: 0.03–0.64; p  =  0.03) and an increased
Phase II dose-finding study was conducted in 728 patients in risk in terms of 2-year mortality (OR = 1.68; 95% CI: 1.30–
Europe and South Africa [71]. Fesoterodine 4, 8 and 12 mg 2.16; p < 0.001) [80].
were all found to show significantly greater decreases in The evidence would therefore suggest that anticholinergic
micturition frequency than placebo. The most commonly drugs should be used with caution in the elderly, and further
reported side effect was dry mouth with an incidence of 25% evidence is provided by a large prospective cohort study of
in the 4  mg group rising to 34% in the 12  mg group. 3434 participants from North America investigating the
Discontinuation rates were 6% and 12%, respectively. association of total standardised daily dose (TSDD) of anti-
Subsequently a phase III randomised placebo-controlled trial cholinergic and the onset of dementia and Alzheimer’s dis-
has been reported comparing fesoterodine 4 and 8 mg with ease. Overall there was a 10-year dose-response relationship
tolterodine ER 4 mg in patients complaining of OAB in 1135 observed for both dementia and Alzheimer’s disease (test for
patients at 150 sites throughout Australia, New Zealand, trend p < 0.001) with the greatest risk being associated with
South Africa and Europe [72]. Both doses of fesoterodine the highest anticholinergic dose: adjusted hazard ratio 1.54
demonstrated significant improvements over placebo in (95% CI: 1.21–1.96) [81].
reduction of daytime frequency and number of urge inconti- Consequently, whilst the use of antimuscarinic medica-
nence episodes per day and were found to be superior to tolt- tion is not contraindicated in the elderly, it is important
erodine. The current evidence from two large phase IV before treating OAB to be aware of co-morbidities and also
studies would support these findings and suggest that fes- the risk of polypharmacy. Many medications have an anti-
oterodine may offer some advantages over tolterodine in cholinergic effect, and it is important to be aware of this prior
terms of efficacy and flexible dosing regimens [73, 74]. to initiating therapy in order to reduce the overall anticholin-
ergic load, and this may be assessed clinically using an anti-
cholinergic burden scale [82].
26.8.7  Propiverine

Propiverine has both antimuscarinic and calcium channel-­
blocking actions. Open studies have demonstrated a benefi-
cial effect in patients with OAB [75] and neurogenic detrusor
overactivity [76]. Dry mouth was experienced by 37% in the
treatment group as opposed to 8% in those taking placebo,
with dropout rates being 7% and 4.5%, respectively. Overall
propiverine was found to have comparable efficacy to oxybu-
tynin but was better tolerated in terms of adverse effects.
More recently propiverine extended release has been intro-
duced and been shown to be as effective as the immediate-­
release preparation in the management of OAB [77].
26.9 Anticholinergic Burden
Whilst antimuscarinic therapy remains integral in the man-
agement of women with OAB, there is an increasing body of
evidence to suggest that these drugs may act on the central
nervous system and may lead to a long-term reduction in
terms of cognitive function and dementia [78].
A systematic review of 46 studies including 60,944 par-
ticipants has demonstrated a significant decline in cognitive
ability with increasing anticholinergic load in addition to an
increasing trend in terms of mortality although this was not
significant [79]. These findings are supported by a 2-year
26.10 β-Adrenoceptors and OAB
Adrenoceptors are members of a family of seven transmem-
brane receptors, with two main groups, α and β, with a num-
ber of subtypes comprising each group. β1-, β2- and
β3-adrenoceptors have been identified in human urothelium
and detrusor muscle, with β3 being highly expressed in the
urinary bladder [83, 84].
β3-adrenoceptors have been demonstrated as the predom-
inant subtype, with 95% of all β-adrenoceptor mRNA in the
human bladder relating to this β3 subtype; this receptor is
thought to be important for mediating human detrusor relax-
ation [85, 86]. This is supported by animal studies in which
β3-adrenoceptor agonists have been demonstrated to cause
dose-dependent detrusor relaxation during the storage phase
of the micturition cycle and to inhibit neurogenic detrusor
overactivity during in vitro studies [87, 88].
26.10.1  Mirabegron
Mirabegron is the first commercially available selective
β3-agonist for the treatment of OAB and has now been
approved for use in Japan, the United States, Canada and
Europe.
358
Mirabegron has been investigated in a comprehensive
programme of phase II and phase III studies. In a randomised
double-blind placebo-controlled North American trial in
1329, patients with OAB [89] mirabegron 50 and 100  mg
demonstrated significantly greater efficacy than placebo for
the co-primary endpoints of incontinence episodes and mic-
turition frequency. Since mirabegron is an adrenoceptor ago-
nist, it does not have the typical adverse effects associated
with antimuscarinic agents, and dry mouth rates were 1.5%,
0.5% and 2.1% in the placebo, 50  mg and 100  mg group,
respectively. Reassuringly there were no differences in the
incidence of hypertension between the mirabegron arm and
the placebo arm.
The efficacy and tolerability of mirabegron have also
been reported in a large multicentre randomised double-­
blind, parallel-group, placebo- and tolterodine-controlled
phase III trial in 1978 patients with OAB [90]. Overall mira-
begron 50 and 100 mg were found to be significantly supe-
rior to placebo in the co-primary endpoints of incontinence
episodes and micturition frequency although tolterodine was
not shown to be significantly better than placebo, and this
was supported by a significant improvement in QoL in the
mirabegron arm. Rates of dry mouth (2.8% and 2.6%) and
constipation (1.6% and 1.4%) in the mirabegron groups were
no different to placebo.
The long-term safety of mirabegron has also been investi-
gated in a 12-month randomised double-blind phase III study
in 2444 patients with mirabegron 50 and 100 mg and toltero-
dine ER 4 mg as an active comparator [91]. Dry mouth was
reported in 2.8%, 2.3% and 8.6% of patients, respectively,
whilst mean changes in systolic blood pressure were
0.2 mmHg, 0.4 mmHg and −0.5 mmHg, respectively.
Given the results from both the phase II and phase III pro-
grammes, the licensed dose of mirabegron in Europe is
50  mg od although this should be reduced to 25  mg od in
patients with renal or hepatic impairment.
26.10.2  Combination Therapy: Mirabegron
and Solifenacin
In order to examine whether combining mirabegron with
antimuscarinic treatments could improve efficacy in patients
with OAB, a randomised, double-blind, phase II trial
(SYMPHONY) evaluated the efficacy of combination of
solifenacin (2.5, 5 and 10  mg) with mirabegron (25 and
50 mg) compared to solifenacin and mirabegron monother-
apy (n = 1306) [92]. The mean volume voided per micturi-
tion was significantly improved in patients treated with
combination therapy with the adjusted difference compared
with solifenacin 5 mg monotherapy ranging from 18.0 mL
(95% CI 5.4–30.0) for solifenacin 5  mg plus mirabegron
D. Robinson and L. Cardozo
25 mg to 26.3 mL (95% CI 12.0–41.0) for solifenacin 10 mg
plus mirabegron 50 mg. Micturition frequency was signifi-
cantly reduced in patients treated with solifenacin 5 mg plus
mirabegron 50 mg, solifenacin 10 mg plus mirabegron 25 mg
and solifenacin 10  mg plus mirabegron 50  mg groups
(p < 0.05) compared with solifenacin 5 mg monotherapy.
All combinations were well tolerated with the incidence
and type of treatment-emergent adverse events similar
between patients treated with monotherapy and combination
therapies. This study demonstrated that combination therapy
significantly improved efficacy compared with solifenacin
5 mg monotherapy. The lack of additive effects of these two
treatments on safety parameters is important, with no new
clinically relevant safety concerns arising.
The efficacy and safety of combination therapy with solif-
enacin and mirabegron in patients with an inadequate
response to solifenacin monotherapy has also been investi-
gated in the BESIDE study [93]. This was a prospective ran-
domised double-blind study of 2174 patients refractory to
solifenacin 5 mg od monotherapy who were randomised to
combination therapy (solifenacin 5  mg and mirabegron
50 mg) or solifenacin monotherapy (5 or 10 mg). Overall the
efficacy of combination therapy was superior to solifenacin
5 mg with significant improvements in incontinence episodes
(p = 0.001) and micturition frequency (p < 0.001). In addition
combination was non-inferior to solifenacin 10 mg for mictu-
rition frequency and incontinence episodes over 3 days.
Whilst the evidence from the BESIDE study clearly dem-
onstrates the efficacy of combination therapy in women with
refractory symptoms, the use of primary combination ther-
apy is less clear. The SYNERGY study was a prospective,
double-blind randomised trial investigating the use of com-
bination therapy (solifenacin 5  mg and mirabegron 25 or
50  mg) compared to monotherapy in 3398 patients in 435
sites in 42 countries [94]. Overall combination therapy with
solifenacin 5  mg and mirabegron 25  mg and solifenacin
5  mg and mirabegron 50  mg provided consistent improve-
ments in efficacy compared with monotherapy. Interestingly,
whilst, the solifenacin 5 mg and mirabegron 50 mg groups
did not achieve a statistically significant effect when com-
pared to mirabegron 50 mg in the primary analysis of reduc-
tion in daily incontinence episodes the other co-primary
endpoints were met. Furthermore patient-reported outcome
measures and HRQoL have shown a clear benefit of combi-
nation therapy as compared to monotherapy demonstrating a
meaningful effect to patients [95].
The subtle differences between the BESIDE study and the
SYNERGY study would perhaps suggest that combination
therapy is more useful as a second-line therapy as compared
to primary therapy and may maximise efficacy and minimise
the side effects of antimuscarinics resulting in improved per-
sistence and adherence.
26  Pharmacological Treatment of Urinary Incontinence and Overactive Bladder: The Evidence 359

26.10.3  Desmopressin cacy. A double-blind placebo-controlled crossover study

using oral oestriol in 34 postmenopausal women produced
Desmopressin (1-desamino-8-d-arginine vasopressin; subjective improvement in symptoms [102], although a
DDAVP), a synthetic vasopressin, has been shown to reduce double-­blind multicentre study of the use of oestriol in post-
nocturnal urine production by up to 50%. It can be used for menopausal women complaining of urgency has failed to
children or adults with nocturia or nocturnal enuresis [96], confirm these findings [103].
but must be avoided in patients with hypertension, ischaemic There is some evidence to show that vaginal 17β-oestradiol
heart disease or congestive cardiac failure. There is good evi- tablets (Vagifem) therapy may be useful in managing the
dence to show that it is safe to use in the long term, and it symptoms of OAB and in particular improving the symptom
may be given orally or as buccal preparation. Desmopressin of urgency [104]. A further double-blind, randomised,
has also been used as a ‘designer drug’ for daytime placebo-­controlled trial has shown lower urinary tract symp-
­incontinence [97] and also in the treatment of overactive toms of frequency, urgency, urge and stress incontinence to be
bladder [98]. significantly improved although there was no objective uro-
Desmopressin is safe for long-term use, and a gender-­ dynamic assessment performed [105]. However, some of the
specific ultra–low-dose buccal preparation has now been subjective improvement in these symptoms may simply rep-
licensed for use in patients with nocturia due to nocturnal resent local oestrogenic effects reversing urogenital atrophy
polyuria [99]. However, the drug should be used with care in rather than a direct effect on lower urinary tract function.
the elderly because of the risk of hyponatraemia, and the cur- In a review of ten randomised placebo-controlled trials,
rent recommendations are that serum sodium should be oestrogen was found to be superior to placebo when consider-
checked in the first week following initiation of treatment. ing symptoms of urgency incontinence, frequency and noctu-
ria although vaginal oestrogen administration was found to be
superior to placebo for the symptom of urgency [106].
26.11 Oestrogens in the Management
of Overactive Bladder
26.11.1  Combination Therapy: Oestrogens
Whilst the effect of oestrogens on lower urinary tract func- and Antimuscarinics
tion remains controversial, there is evidence to show that
oestrogen deficiency may increase the risk of developing More recently there is emerging evidence regarding the syn-
OAB following the menopause. Animal data would suggest ergistic use of vaginal oestrogen therapy with antimuscarinic
that oestrogen might inhibit the function of Rho-kinase in medication in the management of postmenopausal women
bladder smooth muscle and hence affect smooth muscle con- with OAB although the results are contradictory.
traction, whilst having no effect on its expression. A 12-week prospective randomised trial comparing tolt-
Consequently oestrogen deprivation following the meno- erodine 2  mg bd and vaginal conjugated oestrogen cream
pause may lead to the development of OAB symptoms [100], versus tolterodine 2  mg bd alone has been reported in 80
and in vitro studies have demonstrated that ovariectomised postmenopausal women complaining of OAB [107]. Overall
rats showed a significant decrease in voided volume and an those women receiving combination therapy had a signifi-
increase in 24-h frequency with an increase in basal and cantly greater improvement in mean daytime frequency
stretch-induced acetylcholine release. Conversely there was (14.8–5.8 vs. 14.1–6.4; p  =  0.001) and voided volume
a reduction in acetylcholine release from nerve fibres. This (115.8–141.9 mL vs. 108.5–134.5 mL; p = 0.007) as com-
may explain why there is a decrease in detrusor contractility pared to the tolterodine arm. These objective observations
following the menopause with a corresponding increase in were also supported by a significantly greater improvement
the development of OAB symptoms. Interestingly oestrogen in HRQoL in the combination therapy group. Whilst there
replacement therapy reversed these changes [101]. was a trend to improvement in symptoms of nocturia,
Based on these findings, oestrogen replacement following urgency and urge incontinence, these findings were not sig-
the menopause may lead to an improvement in physiological nificantly different between the groups.
voiding function whilst at the same time reducing the risk of These findings are supported by a 12-week prospective
developing symptoms of OAB. Given the concerns regarding randomised trial comparing the oestradiol-releasing vaginal
the use of systemic oestrogen replacement therapy, the vagi- ring and oral oxybutynin 5  mg bd in 59 postmenopausal
nal route of administration may offer a better treatment women with OAB [108]. Those women who received oxybu-
approach. tynin had a mean decrease of 3.0 voids per day as compared
Oestrogens have been used in the treatment of urinary to a decrease of 4.5 voids per day in women using the oestra-
urgency and urgency incontinence for many years although diol ring although the difference between the groups was not
there have been few controlled trials to confirm their effi- significant. In addition there was a significant improvement
360
in QoL in both groups although again no difference between
groups. The authors concluded that low-dose topical vaginal
oestrogens were as effective as oxybutynin in reducing mic-
turition frequency in postmenopausal women with OAB.
More recently these findings have been supported by two
further small studies demonstrating the synergistic effect of
treatment with solifenacin [109] and fesoterodine [110] with
vaginal oestrogens in patients with OAB.
However, these findings in patients with OAB have not
been replicated in a 12-week prospective study of 229 post-
menopausal women with a urodynamic diagnosis of detrusor
overactivity treated with tolterodine extended release (ER)
4 mg od with or without vaginal oestriol [111]. Overall there
were no significant differences between the two treatment
groups in terms of efficacy which was assessed subjectively
using a three-point scale.
It remains unclear why the results of these studies are
contradictory. This may be due to the difference in the patient
populations; one study included women with detrusor over-
activity whilst the others simply recruited OAB patients. In
addition the different oestrogen preparations investigated
may also have a significant effect on efficacy as conjugated
oestrogens are absorbed systemically and therefore may
have a greater effect on the lower urinary tract.
26.12 Conclusions
OAB is a common and distressing condition which is known
to have a significant effect on HRQoL. The clinical diagnosis
of OAB is often one of exclusion although urodynamic
investigations are helpful in those women with refractory or
unusual symptoms. The majority of women will benefit from
conservative measures in the first instance although many
will eventually require drug therapy. For those with refrac-
tory symptoms, switching to an alternative class of therapy
may be useful, and there is now considerable evidence to
support the use of combination therapy in those women with
persistent symptoms. Should symptoms remain refractory
despite medical therapy, then patients may benefit from more
invasive therapy such as intravesical botulinum toxin [112],
percutaneous tibial nerve stimulation (PTNS) [113] or sacral
neuromodulation [114].
The available evidence would also appear to suggest that
whilst systemic oestrogens do not have a role in treating
OAB, vaginal oestrogens may be helpful and may also act
synergistically with antimuscarinic drugs.
Ultimately perhaps a better understanding of the patho-
physiology of OAB syndrome may facilitate the develop-
ment of new treatment modalities allowing effective
treatment of such a common and troublesome condition.
D. Robinson and L. Cardozo
Take-Home Messages
• OAB is a subjective clinical condition; detrusor
overactivity is an objective urodynamic diagnosis.
• OAB is a common condition and the prevalence
increases with increasing age.
• All patients with OAB should be managed with
conservative measures in the first instance.
• Antimuscarinic therapy remains the most common
treatment for OAB although drug therapy may be
limited by tolerability.
• β3-adrenoceptor agonists may be used in as an
alternative in women unable to tolerate antimusca-
rinic therapy.
• There is emerging evidence to support the use of
combination therapy prior to considering more
invasive treatment options.
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 Intravesical Botulinum Toxin
for the Treatment of Overactive Bladder
Pawel Miotla and Tomasz Rechberger
Learning Objectives
• To learn how botulinum toxin intravesical injec-
tions could inhibit undesired lower urinary tract
symptoms in idiopathic and neurogenic overactive
bladder.
27.1 Introduction
Overactive bladder (OAB) syndrome has been defined by an
International Urogynecological Association (IUGA) and
International Continence Society (ICS) joint report on the
terminology for female pelvic floor dysfunction as urinary
urgency, and this symptom is usually accompanied by fre-
quency and nocturia, with or without urgency urinary incon-
tinence [1]. The prevalence of OAB in population is over
16% and it increases with age [2]. In the cross-sectional,
population-based survey of urinary incontinence, overactive
bladder and other lower urinary tract symptoms (EPIC
study), it has been reported that OAB symptoms were
observed in 12.8% of women and 10.8% of men. Moreover,
almost half of the women with OAB symptoms also suffered
from urinary incontinence [3].
The mainstay of pharmacological treatment of OAB is
anticholinergics and mirabegron (antagonist of beta-3 recep-
tors) [4]. However, these drugs may be not effective and/or
well tolerated in some patients. The unpleasant side effects
Electronic Supplementary Material The online version of this
chapter (https://doi.org/10.1007/978-3-030-40862-6_27) contains
supplementary material, which is available to authorized users.
P. Miotla · T. Rechberger (*)
2nd Department of Gynaecology, Medical University of Lublin,
Lublin, Poland
e-mail: rechbergt@yahoo.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_27
27
of antimuscarinics such as dry mouth, constipation or blurry
vision during anticholinergics therapy may lead to poor per-
sistence in long-term perspective [5]. As a third line of OAB
treatment, intradetrusor onabotulinumtoxinA injections
(100  U) may be offered to patients who are refractory to
behavioural or pharmacological treatment with antimusca-
rinics and/or mirabegron. Before injections patients should
be advised about the necessity of post-treatment post-void
residual volume (PVR) assessment as well as the possibility
of development of transient urine retention [6].
Botulinum toxin (BTX) is a neurotoxin, which is pro-
duced by an anaerobe bacterium Clostridium botulinum.
There are seven types of botulinum toxin; however, botuli-
num toxin A (BTX-A) is mainly used for medical purposes.
Botulinum toxin A is formed as a single 150 kDa polypep-
tide chain, and after cleavage it can be released as a neuro-
toxin. During cleavage developed the formation of a light
(zinc-dependent protease) and a heavy chain (a haemaggluti-
nin), which are conjoined by a disulphide bond. The light
chains vary for each toxin subtype. The first step of BTX-A
action is associated with endocytosis in neuromuscular junc-
tion, and during this stage the heavy chains internalise the
toxin in the cell. In the second step, the light chains cut the
SNARE proteins and cleave SNAP-25 on the presynaptic
membrane, which leads to interruption of acetylcholine
release from presynaptic motor neurons. Finally, lack of ace-
tylcholine inhibits muscle contraction. What is more inter-
esting is that the effects of this paralysis appear at 24–72 h
after injection [7].
The BTX-A injections prevent the release of acetylcho-
line at the neuromuscular junction, and this mechanism is
responsible for the formation of an extensive network of
nerve-terminal sprouts. In the first step of the recovery pro-
cess, regulated vesicle recycling occurred only in these
sprouts. Then in the second step of the rehabilitation, the
vesicle turnover to the original terminals is reinstituted [8].
The administration of BTX-A supresses secretion of sub-
stance P in nerves, limits secretion of calcitonin gene-related
peptide (CGRP) and decreases secretion of glutamate [9]. In
365
366
another study the number of P2X3-immunoreactive and
TRPV1-immunoreactive fibres decreased at 4 and 16 weeks
after BTX-A administration, and this correlation was associ-
ated with improvements in subjective and objective parame-
ters such as the number of urgency episodes and urodynamic
findings. Therefore, the authors concluded that this attenua-
tion in sensory receptors could be responsible for a decreased
sensation of urgency. The administration of onabotulinum-
toxinA resulted in afferent innervation of the bladder, as well
as in the efferent innervation of the detrusor, with
­accompanied changes in afferent nerves. The clinical results
of BTX-A treatment in patients with detrusor overactivity
may be consider as consequences of decreased levels of sen-
sory receptors P2X3 and TRPV1 [10]. All these subsequent
changes result in suppression of pain transmission and
desensitisation as well as show an anti-inflammatory effect.
In this chapter are summarised the main studies consider-
ing the usage of onabotulinumtoxinA, which is still the only
one officially registered botulinum toxin A for the treatment
of idiopathic OAB and neurogenic bladder.
27.2 Recommendation for Practice
27.2.1 Injection Procedure
OnabotulinumtoxinA is administered into the detrusor mus-
cle during rigid or flexible cystoscopy.
The practice considering the usage of antibiotics before,
during or post-procedure varies between practices; however,
such prophylaxis is recommended by onabotulinumtoxinA
manufacturer [11]. The procedure can be conducted in local,
spinal or general anaesthesia. For local anaesthesia the blad-
der is instilled with 2% lidocaine solution for 20–30  min
before the procedure. Schurch et al. recommend local anaes-
thesia, which contains a mixture of 30–50 mL 2% lidocaine
and 8.4% bicarbonate sodium solution infused into the blad-
der for 10 min [12]. Then the bladder is emptied by natural
micturition or catheterisation and rinsed with 0.9% sodium
chloride solution.
For the treatment of idiopathic OAB, onabotulinumtox-
inA (100 U) can be dissolved in 10 mL of 0.9% sodium chlo-
ride solution and administered in 20 injections (each contains
0.5 mL of solution) [13]. Patients with neurogenic bladder
can be injected with 200 or 300 U of onabotulinumtoxinA
dissolved in 30 mL of saline at 30 different sites (10 U of
BTX-A per milliliter and per site) sparing the trigone [14,
15]. OnabotulinumtoxinA should be reconstituted directly
before the procedure; however, it is possible to store the
reconstituted drug even for 24 h in the refrigerator at 2–8 °C
with preservation of sufficient effectiveness for such time
interval [11].
P. Miotla and T. Rechberger
However, in a comparative study conducted by Liao et al.,
patients with refractory detrusor overactivity were randomly
assigned into three groups. BTX-A (100 U) was dissolved in
10 mL, and then patients received 10, 20 or 40 intravesical
onabotulinumtoxinA injections. The authors did not observe
differences between the groups in both therapeutic effects
and adverse events’ rates. Therefore, they have concluded
that ten injections (each with 1 mL of solution) are adequate
to achieve an optimal therapeutic effect for refractory OAB
patients [16].
The other researchers have decided to significantly
decrease the number of BTX-A injections, and in a prospec-
tive study on BTX-naïve patients with neurogenic detrusor
overactivity or idiopathic detrusor overactivity, they man-
aged patients with one, two or three injections. The dosage of
BTX-A (Botox, Allergan) ranged from 100 to 300 U, and it
was dissolved in sodium chloride to achieve the concentra-
tion of 20 U/1 mL. The dose of 100 U was administered in
one injection site in the midline of the posterior bladder wall.
Patient injected with two or three sites received 160 U and
300 U, respectively. The authors did not observe the differ-
ences between the number of injections and treatment
response rates when compared these results to randomised
clinical trials with the standard number of performed injec-
tions, 10 or 30 for idiopathic OAB and for neurogenic blad-
der, respectively. For idiopathic detrusor overactivity and
neurogenic bladder, the authors achieved subjective improve-
ment rate, which was comparable to positive treatment
response reported in the randomised trials. Therefore, the
authors have postulated that neural migration of the BTX-A
did not require multiple injection sites to occur [17].
The injections are conducted in two or three horizontal
lines sparing the trigone. For practical reasons it is recom-
mended to start from the bottom horizontal line and then
move up to the top line. Such strategy protects from unde-
sired poor visualisation in case of unexpected bleeding from
the bladder wall. In some countries it is recommended to
stop an intake of antiplatelet therapy or anticoagulants with
sufficient time window before injections to prevent unde-
sired, excessive bleeding during the procedure [11]. The tip
of needle should be inserted 3–5 mm depth. In a prospective
study, 45 patients with refractory idiopathic detrusor overac-
tivity received onabotulinumtoxinA (100 U) after randomi-
sation into three groups. Then participants were injected into
detrusor, suburothelial and bladder base. The therapeutic
efficacy was significantly longer in patients treated with sub-
urothelial and detrusor injections in comparison with bladder
base administration [18].
Patients must be informed that routinely onabotulinum-
toxinA shows a therapeutic effect after approximately
1–2 weeks and the duration of improvement is estimated for
4–10 months [11] (Fig. 27.1).
27  Intravesical Botulinum Toxin for the Treatment of Overactive Bladder
Fig. 27.1  Technique of onabotulinumtoxinA injections in the bladder
wall—the potential injections sites are located over the trigone and are
marked as black dots
BTX-A injections are presented in the attached movie
(Movie 27.1).
Patients should be asked before injections about all previ-
ous BTX-A therapies, independently of indications.
Retreatment can be conducted after at least 12  weeks from
previous BTX-A injections. The results of the study pub-
lished by Lange et al. conducted in patients treated due to dif-
ferent conditions showed that the interval between BTX
retreatments may be important in development of immunoge-
nicity. An increased proportion of patients with neutralising
antibodies was observed in participants treated at <3 months
intervals between reinjections [19]. Antibodies can be formed
bidirectional against botulinum toxin and/or complexing pro-
teins. From the clinical point of view, the antibodies against
BTX are more important, because they are responsible for the
lack of therapeutic efficacy after treatment [20].
Moon et al. published the first case of anaphylactic reac-
tion in a woman who received botulinum toxin A injections
for dermatological purposes. The woman had previously
received injections without complications. Five minutes after
BTX injections, the patient developed severe rhinorrhoea
and nasal obstruction. The patient received intramuscular
epinephrine and these symptoms were resolved [21]. There
is a potential risk that similar allergic reaction may be
observed in patients treated with repeated BTX injections for
urological conditions.
BTX treatment is not recommended for pregnant women.
According to the US Food and Drug Administration, ona-
botulinumtoxinA received pregnancy category C product,
367
which means that animal reproduction studies have shown an
adverse effect on the foetus and there are no adequate and
well-controlled studies in humans. A 24-year retrospective
review of the Allergan safety database, which contains
reports of onabotulinumtoxinA administration before
(≤3 months before conception) or during pregnancy, showed
that (conceived or pregnant) women received onabotulinum-
toxinA most frequently for cosmetic indications (50.5%),
movement (16.8%) or pain disorders (14.2%). Two hundred
and thirty-two women had completed data considering preg-
nancy outcome. In the vast majority (96%), an exposure to
onabotulinumtoxinA occurred during or before the first tri-
mester. Of the 137 prospective cases (139 foetuses), 110
(79.1%) were live births, whilst 29 (20.9%) have ended in
pregnancy loss (21 spontaneous and eight induced abor-
tions). Among the 110 live births, the abnormal outcomes
were observed in four cases, including one major foetal
defect. Based on these results, the calculation of prevalence
rate for overall foetal defects was 2.7%, which seems to be
comparable with rates observed in the general population
[22]. However, women in childbearing potential should be
counselled on potential risk for pregnancy and advised to
start reliable contraception method before BTX treatment.
Post-treatment evaluation should include performing of
abdominal ultrasound or bladder scan to assess post-void
residual after BTX-A injections [11]. Based on the results of
how the PVRs have changed in time in OAB patients, this
assessment should be optimally assessed in the first 2 weeks
after intradetrusor BTX-A administration; however, patients
with significant symptoms of incomplete bladder emptying
sensation or voiding difficulties should be immediately
counselled by a physician due to risk of urine retention [23].
27.2.2 Neurogenic Detrusor Overactivity
(NDO) Treatment
with OnabotulinumtoxinA
Schurch et al. evaluated the efficacy of onabotulinumtoxinA
intradetrusor in patients with neurogenic bladder. Patients
presented detrusor hyperreflexia due to traumatic spinal cord
injury, and their bladders were emptied by clean intermittent
self-catheterisation. The participants did not respond suffi-
ciently to standard anticholinergic therapy. Complete urody-
namic investigation was conducted in all participants. Then
cystoscopy was performed with onabotulinumtoxinA injec-
tions—200 or 300 U was administered at 20–30 sites (10 U
per milliliter per site) sparing the trigone. Follow-up evalua-
tions were conducted at 6, 16 and 36 weeks after treatment,
and 19 patients underwent a complete examination 6 weeks
after the procedure, whilst 11 completed at follow-up visits.
The authors observed that incontinence was achieved in 17 of
19 cases. All patients followed at 36 weeks were still conti-
368 P. Miotla and T. Rechberger

nent during the visit and did not require retreatment with ated the efficacy and safety of onabotulinumtoxinA (200 or
BTX-A injections. A significant increase in mean reflex vol- 300  U) in comparison with placebo in patients presented
ume and mean maximum cystometric and a significant with NDO due to spinal cord injury (at T1 level or lower)
decrease in maximum detrusor voiding pressure after ona- (n = 121) or multiple sclerosis (n = 154). Patients were not
botulinumtoxinA injections were noticed. Worse results were oblige to conduct clean intermittent catheterisation (CIC) at
observed in patients treated with 200 U of onabotulinumtox- the baseline; however, they had to be willing to start CIC in
inA. Interestingly, the authors did not report any side effects case of significant increase of post-void residual. The study
of this therapy. Additionally, hypersensitive crisis during drug (BTX-A 200 U or BTX-A 300 U or placebo) was dis-
voiding disappeared after treatment in three patients. This solved in 30 mL of saline and administered during cystos-
study proved that onabotulinumtoxinA bladder injections are copy in 30 intradetrusor injections avoiding the trigone.
valuable treatment options for patients with neurogenic blad- Patients completed a 7-day bladder diary before the treat-
der after spinal cord injuries, and successfully treated patients ment and then for each scheduled visit. Moreover, urody-
became continent for at least 9 months. A higher dose (300 U) namic studies were conducted before treatment and at week
of onabotulinumtoxinA seemed to be more effective [24]. 6 of follow-up. The change of number of urinary inconti-
Fifty-nine patients with neurogenic detrusor overactivity nence episodes was considered as a primary study endpoint.
were enrolled in the study comparing the safety and efficacy The authors also analysed the changes in maximum cysto-
of different doses of onabotulinumtoxinA (200 or 300  U metric capacity, maximum detrusor pressure and quality of
Botox) vs. placebo injected intradetrusorally. All participants life assessed with Incontinence Quality of Life total score. At
required CISC and demonstrated urinary incontinence before baseline visit patients reported similar number of urge uri-
treatment. Most of the included patients presented NDO due nary incontinence per week in all groups (Table 27.1).
to spinal cord injury (n  =  53); however, multiple sclerosis
(MS) was responsible for the development of detrusor over- Table 27.1  Mean baseline and changes from baseline in urinary
activity in six participants. The results of therapy were moni- incontinence episodes, some urodynamic parameters and volume per
tored with bladder diary, dedicated the Incontinence Quality void up to week 12 (adopted from [15])
of Life (I-QOL) questionnaire and urodynamic assessment, Placebo
as well. The investigated groups did not significantly differ at group OnabotulinumtoxinA OnabotulinumtoxinA
Parameter (n = 92) 200 U (n = 92) 300 U (n = 91)
baseline in the mean daily frequency of urinary incontinence
Urinary episodes/week; mean (SD)
episodes, and the incidence of urinary leakage among the Baseline 36.7 32.5 (18.4) 31.2 (18.1)
300 U BTX-A, 200 U BTX-A and placebo groups was 2.8, (30.7)
1.9 and 3.0, respectively. The number of incontinence epi- Week 2 −9.7 −18.8 (16.7)∗ −15.8 (25.8)∗∗
sodes significantly decreased after the injections in both (17.9)
actively treated groups, and it was represented as a reduction Week 6 −13.2 −21.8 (18.1)∗∗ −19.4 (25.7)∗∗
(20.0)
in incontinence episodes of approximately 50% baseline val-
Week 12 −12.2 −20.5 (18.9)∗∗ −19.8 (18.6)∗
ues. Patient included in placebo group did not report signifi- (22.2)
cant improvement. These observations consisted of Volume/void, mL; mean (SD)
maximum cystometric capacity (MCC), reflex detrusor vol- Baseline 147.4 158.8 (113.0) 167.9 (118.4)
ume (RDV) and maximum detrusor pressure (MDP) during (94.2)
bladder contraction assessed by urodynamics. A significant Week 2 12.7 55.3 (117.6)∗∗ 62.6 (140.6)∗∗
(71.4)
improvement in I-QOL scores was reported by patients in Week 6 16.7 109.1 (120.1)∗ 101.8 (155.4)∗
both BTX-A groups throughout the 24-week follow-up vis- (80.3)
its. Urinary tract infections (UTIs) were the most commonly Week 12 21.5 105.2 (122.5)∗ 100.3 (140.8)∗
reported adverse event (AE) in this study and were observed (73.2)
in four (21.1%), six (31.6%) and three patients (14.3%) in Maximum cystometric capacity, mL; mean (SD)
Baseline 249.4 247.3 (147.6) 246.8 (149.1)
the 300  U BTX-A, 200  U BTX-A and placebo groups,
(139.3)
respectively. Pain in injection site, even was observed, disap- Week 6 6.5 157.0 (164.8)∗ 157.2 (185.2)∗
peared within 1 h after injections. Based on these results, the (144.8)
authors concluded that intradetrusor onabotulinumtoxinA Maximum detrusor pressure during first involuntary detrusor
injections are effective and well-tolerated treatment options contraction, cm H2O; mean (SD)
Baseline 41.5 51.7 (41.0) 42.1 (33.2)
for patients with neurogenic detrusor overactivity during a
(31.2)
24-week study period [25]. Week 6 6.4 −28.5 (47.8)∗ −26.9 (33.2)∗
In the first large, randomised, placebo-controlled trial (41.1)
conducted at 63 centres in Europe, North America, Latin ∗
p < 0.001
America, South Africa and Asia-Pacific, the authors evalu- ∗∗
p < 0.01
27  Intravesical Botulinum Toxin for the Treatment of Overactive Bladder
Patients, independently of recognition (MS or SCI),
declared improvements in decreasing number of urinary
incontinence incidences after the treatment since week 2 of
follow-up. The similar effect in reduced number of UI epi-
sodes as well as improvements in urodynamic studies was
observed at week 6  in both BTX-A groups. Most of the
patients needed retreatment after 42  weeks from primary
procedure in both onabotulinumtoxinA groups, which was
significantly longer when compared to placebo group
(13  weeks, p  <  0.001). During the first cycle of treatment,
urinary tract infection and urine retention were the most
commonly occurring adverse events. Urinary tract infections
were recognised in 27.5% and 38.2% of participants treated
with 200 U and 300 U of onabotulinumtoxinA, respectively.
Due to significant increase in post-void residual, 30% and
42% of patients initiated de novo CIC in 200 U and 300 U
subgroups, respectively. Despite these undesired adverse
events, onabotulinumtoxinA (200 or 300  U) significantly
decreased the number of urinary incontinence episodes and
improved quality of life with no significant differences in
efficacy between doses [15].
The analysis of long-term study assessed the efficacy and
safety of repeated onabotulinumtoxinA injections in NDO
patients and showed no clinically relevant differences in effi-
cacy or duration of therapeutic effect between 200 and 300 U
of onabotulinumtoxinA. Patients observed significant relief
in detrusor overactivity symptoms for 9–10 months. Patients
were observed till five retreatments cycles, and they reported
consistently reduced number of urinary incontinence as well
as improvements in quality of life when compared to base-
line values. As it was described in previous study, urinary
tract infection and urine retention were the most commonly
observed adverse events after BTX-A injections, indepen-
dently of the number of retreatments [26].
Mehnert et  al. evaluated whether 100  U onabotulinum-
toxinA could effectively treat OAB symptoms in patients
with multiple sclerosis. The main reason for a decrease of
routinely administered doses (200 or 300 U) was the need to
reduce the incidence of urinary retention after BTX-A treat-
ment. Twelve MS patients were included in this study and
received ten intradetrusor injections. After treatment a sig-
nificant increase of maximum bladder capacity (from 352 to
538 mL) and significant decrease in maximum detrusor pres-
sure, as well as frequency and urgency, were observed.
Reinjections were conducted approximately after 8 months
from primary treatment due to recurrence of OAB symp-
toms. It seems that in MS patients presenting overactive
bladder symptoms, the dose of 100 U of onabotulinumtox-
inA may be sufficient to improve quality of life without sig-
nificant impact on increase of post-void residual [27].
It has been also reported that switching to abobotulinum-
toxinA may be useful in the treatment of neurogenic detrusor
overactivity in non-responder to onabotulinumtoxinA. Bottet
369
et al. assessed the outcomes of switching to abobotulinum-
toxinA (Dysport, Ipsen Biopharmaceuticals) in NDO patients
who were not adequately treated with onabotulinumtox-
inA.  In this retrospective multicentre study, patients were
switched to intradetrusor abobotulinumtoxinA injections in
case of primary or subsequent Botox treatment. Most of the
included patients had received 750  U of abobotulinumtox-
inA, which was dissolved in 20 mL of 0.9% sodium chloride
solution and administered in 20 sites. As a major result out-
come, the authors assessed data in bladder diary and urody-
namic parameters. More than half of participants observed a
significant decrease in the number of urinary incontinence
episodes. The urodynamic study showed an increase in max-
imum cystometric capacity and a decrease in maximum
detrusor pressure. The authors observed that more than 56%
of patients refractory to Botox can be effectively treated with
Dysport. However, it should be mentioned that abobotu-
linumtoxinA remains not officially registered by the FDA for
NDO treatment [28].
Denys et al. investigated whether response to first treatment
cycle with onabotulinumtoxinA can affect long-term retreat-
ment outcome in NDO patients. All patients (n = 195) included
in this study received 200 U of onabotulinumtoxinA in retreat-
ment cycles, and majority of them (83.1%) achieved at least
50% reduction in the number of urinary incontinence episodes
after first treatment. Interestingly, in patients who achieved a
low response after first treatment, more than 37% experienced
≥50% UI reduction in further subsequent treatment cycles.
Therefore, the authors concluded the importance of perform-
ing at least a second treatment with onabotulinumtoxinA in
NDO patients before matching patients as non-responders for
onabotulinumtoxinA therapy [29].
27.2.3 Overactive Bladder Treatment
with OnabotulinumtoxinA
In the multicentre study, a dose response across a range of
doses of onabotulinumtoxinA in refractory OAB patients
was assessed. Patients were randomly assigned into six sub-
groups (placebo and onabotulinumtoxinA at doses of 50,
100, 150, 200 or 300  U). Demographics characteristics
between groups were comparable at the baseline. Three hun-
dred and thirty-one female and male patients, aged
18–85  years, with refractory OAB were included in this
study. After randomisation patients received 20 injections
(0.5 mL per site) with preceding local anaesthesia into the
detrusor muscle, sparing the trigone. Patients completed a
7-day bladder diary before treatment and all participants
underwent urodynamic testing. The primary efficacy out-
come was defined as the change in a weekly number of
urgency urinary incontinence, whilst within the scope of sec-
ondary outcomes were frequency, urgency and nocturia per
370
week as well as changes of volume voided per micturition.
Almost 87% of the participants completed the study accord-
ing to the protocol. After 3 months of follow-up, a decrease
from baseline in UUI episodes per week was observed as
follows: −17.4, −20.7, −18.4, −23.0, −19.6 and −19.4 and 50
U, 100 U, 150 U, 200 U and 300 U for the placebo and ona-
botulinumtoxinA subgroups, respectively. The major differ-
ence in differentiation from placebo was observed in the
proportion of incontinence-free patients. At week 12 com-
plete reduction in UUI episodes was reported as 15.9%,
29.8%, 37.0%, 40.8%, 50.9% and 57.1% in the placebo and
50, 100, 150, 200 and 300 U dose groups. The analysis of
adverse event incidence showed the highest rate of increased
residual volume, necessity of CIC conduction and urinary
tract infection in subgroups treated with at least 200 U ona-
botulinumtoxinA. Based on these results, the authors have
concluded that 100 U of BTX-A seems to be the dose that
appropriately compromises between clinical efficacy and
undesired side effects [30].
In the dose-ranging study conducted at 40 sites, 288 OAB
female patients with OAB, who presented ≥8 UUI episodes
per week, were injected intradetrusorally with placebo or
different doses of onabotulinumtoxinA (50, 100, 150, 200 or
300 U). The major aim of this study was to assess disease-­
specific and quality-of-life outcomes after BTX-A treatment.
Patients were assessed with dedicated questionnaires, such
as the Incontinence-Specific Quality-of-Life Instrument
(I-QOL), the King’s Health Questionnaire (KHQ) and the
36-Item Short-Form Health Survey. After the treatment with
onabotulinumtoxinA at doses ≥100 U, patients reported sig-
nificant improvements in all analysed quality-of-life param-
eters when compared with placebo subgroup. The authors
had concluded that after single cycle of treatment with BTX-­
A (doses ≥100 U), patients were able to perceive significant
improvement in the quality of life even for 9 months [31].
In the third phase of RCT, 557 patients with OAB with no
response to anticholinergics were enrolled. Patients had to be
at least 18 years old and had experienced three or more urgency
UI episodes and 8≥ micturitions daily documented in the
3-day bladder diary. Post-void residual was checked before
treatment, and only patients with PVR ≤100 mL were allowed
to enter the study. During randomisation they were assigned
into placebo or a dose of 100  U of onabotulinumtoxinA
groups. OnabotulinumtoxinA 100 U or placebo was dissolved
in 10 mL of saline and administered in 20 intradetrusor injec-
tions. Follow-up visits were scheduled for weeks 2, 6 and 12
and then every 6  weeks till week 24. Patients could also
request for retreatment after first cycle; however, it was possi-
ble at least 3  months from previous BTX-A injections, and
they had to experience ≥2 urgency urinary incontinence epi-
sodes in 3-day bladder diary. Participants had to complete the
bladder diary before all consecutive visits as well as they rated
their perception of treatment during each visit.
P. Miotla and T. Rechberger
The primary endpoints of the study included the change
in the number of UUI and proportion of patients with
improvement after treatment when compared to baseline val-
ues. The authors assessed also the changes in frequency,
urgency, nocturia, volume voided, proportion of continent
patients and the quality of life as secondary study endpoints.
The necessity of conducting CIC was defined as PVR in the
range of 200–350 mL with co-existing voiding difficulties or
≥350  mL independent of other symptoms. Finally, 280
patients had received injections with onabotulinumtoxinA
100 U, whilst 277 patients were injected with placebo.
At week 12 of follow-up, patients treated with BTX-A
reported significant relief in OAB symptoms, a decrease in
daily UUI was −2.65 and this reduction was significantly
higher when compared to placebo (−0.87). The proportion
of decrease in daily UUI was almost 48% in BTX-A group in
comparison with baseline values. Moreover, at this visit
22.9% and 6.5% became completely continent in onabotu-
linumtoxinA and placebo groups, respectively.
More than 60% of the participants in BTX-A group
reported positive treatment response, which was significantly
higher than in placebo group (29.2%). Patients treated with
onabotulinumtoxinA reported significantly higher daily
decrease in other OAB symptoms such as frequency (−2.15)
or urgency (−2.93) when compared to placebo −0.91 and
−1.21, respectively. Based on the bladder diary results,
patients in BTX-A group also reported an increase in voided
volume (+41 mL per micturition). Moreover, patients in ona-
botulinumtoxinA group declared a significant improvement in
the quality-of-life questionnaires during consecutive visits.
More than 15% of patients in BTX-A group had uncom-
plicated UTI in the first 12 weeks of observation, whilst this
AE was observed in only 5.9% of participants assigned into
placebo subgroup. Only patients assigned in BTX-A group
had to perform CIC (n = 17, 6.1%) during the first treatment
cycle. In most of the cases, the duration of CIC did not
exceed 6 weeks. In this study onabotulinumtoxinA was sig-
nificantly superior to placebo in improvement objective and
subjective endpoints of analysis. Patients reported clinically
relevant relief in OAB symptoms, and what is more BTX-A
therapy was well tolerated [32].
It has been also observed that intravesical onabotulinum-
toxinA injections can improve nocturia and urgency urinary
incontinence at night in refractory OAB women. Participants
treated with 100 U of Botox perceived a significant improve-
ment in reduction of nocturia episodes (−0.98) as well as in
night-time urgency urinary incontinence episodes (−0.37)
when compared to baseline. Therefore, the authors con-
cluded that intravesical onabotulinumtoxinA injection sig-
nificantly decreased the burdensomeness of nocturia in OAB
patients without nocturnal polyuria [33].
One of the most discussed side effects after intravesical
onabotulinumtoxinA injections is urinary retention with spe-
27  Intravesical Botulinum Toxin for the Treatment of Overactive Bladder
cial caution in case requiring clean intermittent catheterisa-
tion. The rate of urine retention as well as indication to
initiate CIC varies between published studies. However, the
incidence of CIC in previous RCTs considering the usage of
100 U of onabotulinumtoxinA to treat refractory OAB symp-
toms was estimated as 6.1–6.9% [32, 34].
In the analysis conducted in 299 patients (mean age of
participants was 66.4 years), who were treated with 100 U of
onabotulinumtoxinA, the CIC was necessary to initiate in
2.7% of patients after first treatment cycle. Even in the
retreatment cycles (two and three), the incidence of de novo
CIC remained relatively low (3.2%), which was smaller than
in previously mentioned RCTs. The range of duration of CIC
was from 4 days to a maximum of 122 days [35].
The authors did not find the potential influence of comor-
bidities, age or parity on the incidence of CIC; however,
other authors had reported that elderly or multiparous women
are at increased risk of urinary retention after intradetrusor
BTX-A injections. The duration of CIC in this study ranged
from 20 to 83 days [23].
Patel et  al. reported that in the group of 99 OAB female
patients, CIC was required only in 1.6% of participants, and in
all cases the necessity for CIC disappeared within 4 weeks [36].
27.3 Future Directions
The changes in the route of delivery for botulinum toxin A
might be a very attractive option for both patients and physi-
cians. In a proof of concept study Kuo et al. created an inno-
vative delivery system for onabotulinumtoxinA, using
liposomes to increase penetration of urothelium. Patients
included in the study received intravesical instillation of
Lipotoxin (liquid liposomal delivery of 200  U of onabotu-
linumtoxinA) or placebo [37]. Such a strategy may be very
attractive because many of the patients are afraid of having
cystoscopy and bladder injections. However, the cumulative
efficacy of Lipotoxin instillation after 3  months was only
28%. Therefore, administration of onabotulinumtoxinA dur-
ing cystoscopy still remains a gold standard. Chuang et al.
assessed the efficacy of catheter instillation of 200  U ona-
botulinumtoxinA formulated with liposomes for the treat-
ment of refractory OAB symptoms. After 1 month patients
reported a statistically significant decrease in urgency sever-
ity scores [38]. These results need more RCTs to deliver
more evidence-based data; however, such simple procedure
as instillation of onabotulinumtoxinA could be conducted
even in general practitioners’ offices.
In a network meta-analysis, a comparative assessment of
efficacy of oral/transdermal anticholinergics, mirabegron
and onabotulinumtoxinA in the treatment of OAB symptoms
in adult patients was conducted. The authors included 56
randomised trials with licensed doses for each drug into this
371
analysis. Based on the results achieved after 12  weeks of
therapy, they concluded that patients who received onabotu-
linumtoxinA had the greatest reduction in urge urinary
incontinence episode, frequency and urgency. Moreover,
onabotulinumtoxinA treatment had the highest odds of
achieving completely dryness, as well as ≥50% decrease in
number of urge urinary incontinence. Therefore, the authors
concluded that at 3 months of follow-up, onabotulinumtox-
inA produced greater improvement for OAB when compared
to other pharmacotherapies [39]. This observation may sup-
port an idea to initiate OAB pharmacotherapy in elderly
patients with onabotulinumtoxinA as a prevention of poly-
pharmacy and undesired drug interactions. It has been also
hypothesised that usage of liposomes with BTX-A might
prevent an undesired influence on the bladder such as detru-
sor underactivity after onabotulinumtoxinA injections. This
strategy might be very important for the treatment of elderly
patients with low detrusor contractility, because it could help
in keeping balance between the desired therapeutic efficacy
and undesired side effects [40].
27.4 Conclusion
OnabotulinumtoxinA administered into the detrusor muscle
during cystoscopy in a dose of 100 U in patients with idio-
pathic OAB and 200 U in patients with neurogenic bladder is
an effective treatment option in majority of patients who did
not respond to behavioural and oral therapy (anticholinergics
and/or mirabegron).
Take-Home Messages
The intradetrusor onabotulinumtoxinA injections sig-
nificantly decrease the incidence and severity of unde-
sired storage phase symptoms in patients presenting
OAB or NDO symptoms. The rate of urinary retention
after onabotulinumtoxinA treatment in real-life prac-
tice seems to be lower than presented in RCTs. It
seems that in majority of patients suffering from OAB,
100 U dose is sufficient to achieve clinically meaning-
ful improvement with very low incidence of undesired
side effects such as urinary retention and bladder infec-
tion after treatment.
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 Sacral Nerve Stimulation for Overactive
Bladder and Voiding Dysfunction
Philip E. V. Van Kerrebroeck
Learning Objectives
• This chapter introduces sacral nerve stimulation as a
treatment for patients with chronic lower urinary
tract dysfunctions as the overactive bladder, with or
without urgency incontinence and nonobstructive
voiding dysfunction, refractory to maximal conser-
vative management.
• The historical development of the technique, includ-
ing the actual procedure and equipment, is presented.
• The mode of action of sacral neuromodulation is
described, as well as the different indications and
selection procedures.
• The results of sacral nerve stimulation for lower uri-
nary tract dysfunctions are discussed, as well as the
predictive factors for success and the potential
complications.
• Finally some experimental alternatives are looked at,
in view of their future clinical application.
28.1 Historical Overview
Electric current has been used to treat urological pathology
sine antiquity. In 1878, Saxtorph [1] reported on the use of
intravesical electrostimulation in patients with an acontractile
bladder and complete urinary retention. Katona described in
1975 [2] intravesical electrostimulation in patients with
chronic neurogenic retention and neurogenic overactivity.
Later research mainly focused on the use of electrical stimu-
lation at the level of the spinal cord and the sacral roots.
P. E. V. Van Kerrebroeck (*)
Department of Urology, Maastricht University Medical Center,
Maastricht, The Netherlands
e-mail: urolmaas@hotmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_28
28
In the late 1960s, Nashold [3] started experiments with
spinal cord stimulation, and subsequently transferred the
experience gained to humans. In 1972 he reported on the first
four patients with stimulator implants. In 1975, Jonas et al.
[4] examined the parameters for the most effective stimula-
tion of the spinal cord. In 1972, Brindley et al. [5] initiated
experiments with electrical stimulation of the sacral ventral
roots in baboons and from 1976 on [6] implanted an anterior
sacral root stimulator in paraplegic patients with inconti-
nence, presenting their experience with the first 50 implants
in 1986.
Tanagho used a canine model for sacral root stimulation
because the anatomy of the sacral nerves is similar to that in
humans. In 1982, Tanagho and Schmidt [7] presented the
first results of sacral root stimulation in paraplegic dogs.
After many experimental studies of the parameters of nerve
stimulation performed by Thuroff, Tanagho and his team
started the first human clinical trial in 1982.
In patients with neurogenic bladder dysfunction after spi-
nal cord injury, the best model to achieve continence and
promote bladder evacuation proved to be a combination of
stimulation of the ventral roots of S3 or S4, after extensive
dorsal rhizotomies from S2 to S4 and eventually additional
selective peripheral neurotomies. The observation by
Tanagho and Schmidt [8] that sphincteric contraction sup-
presses detrusor activity and stabilizes the entire micturition
reflex mechanism in patients where the sensory pathways are
intact was the basis for the clinical application of neuromod-
ulation in lower urinary tract dysfunction. However the effect
of sacral nerve stimulation on the lower urinary tract was
already described by Habib in 1967 [9].
In 1988, Schmidt [10] described the three stages of elec-
trode placement. First a needle was placed into a sacral fora-
men near the sacral root, preferably S3, for test stimulation.
In case of root integrity, the needle was replaced by a wire
electrode for temporary percutaneous stimulation. If the
patient demonstrated a significant improvement, a perma-
nent neural prosthesis was implanted.
375
376
28.2 Mode of Action
The different elements of the mode of action in sacral neuro-
modulation (SNM) are still a topic of ongoing research, but
the global mechanisms have been documented with modern
investigational techniques. The stimulation of afferent nerve
fibers modulates reflex pathways involved in the filling and
evacuation phase of the micturition cycle, through spinal cir-
cuits mediating somato-visceral interactions within the
sacral spinal cord [11]. Two mechanisms are important:
1. Activation of afferent fibers causes inhibition at a spinal
and/or supraspinal level.
2. Reflex activation of efferent fibers to the striated urethral
sphincter that causes detrusor relaxation.
The S3 sacral nerve is the preferential site of lead implan-
tation because it is the site of 60.5% of the overall pudendal
afferent activity [12], although obviously supraspinal path-
ways are also involved.
Positron emission tomography (PET) and functional
magnetic resonance imaging (fMRI) have been used to
study brain activity in patients with detrusor overactivity or
urinary retention. Detrusor overactivity is associated most
prominently with differences in activity in the orbitofrontal
cortex [13] and cerebellum [14]. Furthermore, neuromodu-
lation in women with urinary retention changed activity in
the midbrain, cerebellum, cingulate gyrus, and prefrontal
cortex [15].
Brain activity has also been investigated in patients with
urgency incontinence during acute and chronic sacral neuro-
modulation, and it is possible that some of the beneficial
effects observed originate from supraspinal brain areas,
which are inhibited or activated via the caudal spinal cord.
28.3 Indications
The US Food and Drug Administration (FDA) approved
SNM for intractable urgency incontinence in 1997 and for
urgency–frequency and nonobstructive urinary retention in
1999.
The classical indications for SNM are unsuccessful
attempts at conservative treatments for overactive bladder
with or without urgency incontinence and nonobstructive
urinary retention.
The use of SNM in patients with (partial) spinal cord
injury, multiple sclerosis (MS), peripheral neuropathy, par-
kinsonism, or myelodysplasia is controversial. SNM in MS
may be effective, but as bladder symptoms in individuals
with MS can deteriorate over time with progression of the
disease, the medium and long-term outcome is debatable.
P. E. V. Van Kerrebroeck
SNM is not approved by the FDA for the pain that is a
prevalent component of interstitial cystitis (IC) or other
forms of bladder pain. For some symptoms of IC such as
urinary urgency and frequency, and some forms of nocturia,
SNM can be a potential beneficial treatment modality.
SNM has been used in conditions of chronic genitouri-
nary pain; the results have shown a dramatic reduction in
visual analog pain scores, but evidence is only available from
small series or case reports with short-term follow-up. The
few available long(er)-term follow-up studies in general
show a significant decline of results over time [16].
28.4 Selection Criteria
Basic patient selection consists of history taking, physical
examination, urinalysis (and eventually urine culture), void-
ing diaries, and other simple diagnostic tests such as pelvic
ultrasound and cystoscopy to exclude specific causes of
lower urinary tract dysfunction.
Urodynamic examination is used to detect detrusor over-
activity with or without urgency incontinence, to evaluate the
degree of detrusor underactivity or to diagnose detrusor
acontractility. Ambulatory monitoring allows for more reli-
able clinical decision-making, as it is associated with void-
ing diary improvement during the SNM test period. Using
ambulatory UDS to confirm success could in the future even-
tually justify the shortening of the test period [17].
However the most important element of patient selection
for SNM is a successful trial stimulation. This test is per-
formed with placement of a temporary or permanent (two-­
stage implant technique) electrode under local or general
anesthesia.
28.5 Implant Technique
Initially lead placement was performed by an open surgical
procedure through a midline incision, and the lead was
secured to the sacral periosteum. With this invasive proce-
dure, the lead was positioned under direct visualization. In
2002 a new technique was developed after the introduction
of a self-anchored tined lead. Since then it is possible to
place the lead percutaneously under radiological guidance
with less risk of infection and less trauma (Fig.  28.1).
However, with this “blind” technique, it is necessary to use
reliable landmarks (superior iliac spine, L5-S1 transition,
and tip of the coccyx), and additionally fluoroscopic control
is advised.
The basic technique of testing for SNM (Medtronic
InterStim™ technique) is a two-step procedure. During the
first step, indicated as percutaneous nerve evaluation (PNE),
28  Sacral Nerve Stimulation for Overactive Bladder and Voiding Dysfunction
a b
Fig. 28.1  Percutaneous implantation of the sacral lead electrode. (a)
The test needle in the sacral foramen. (b) The lead introducer and sheet
that allow for positioning the sacral electrode. (c) The sheet after
Fig. 28.2  The self-anchoring electrode (tined lead) for implantation in
the sacral foramen
the physician evaluates the bladder symptoms for 7–14 days.
For the initial test, a test needle is inserted into the third
sacral foramen to stimulate the sacral root. This procedure is
used during an acute phase to test neural integrity. A typical
S3 motor response is an inward movement of the pelvic
floor, plantar flexion of the big toe, and tingling sensation in
the anal area, perineum, scrotum, or vagina. Fluoroscopy can
be used for S3 localization in anterior/posterior and lateral
imaging. The temporary electrode is connected to an external
stimulator. This temporary electrode is prone to dislocation,
not allowing sufficient time for proper evaluation and also
does not mimic completely the situation with a permanent
electrode. Nevertheless if the patient’s symptoms improve by
at least 50%, then they are a candidate to undergo step 2, in
which a permanent implantable pulse generator is implanted
into the soft tissue of the patient’s buttock.
377
c d
removal of the introducer. (d) Testing of the electrode after introduction
in the sacral foramen through the introducer
Some patients who fail a PNE test are still good candi-
dates for SNM therapy; for this reason a two-step implant
technique was developed. Under local anesthesia, a perma-
nent tined lead electrode (Fig.  28.2) is implanted and con-
nected to an external stimulator. This tined lead electrode has
four sets of self-anchoring tines, allowing minimally inva-
sive percutaneous placement. This technique is widely used
in Europe and the USA.
A group of experienced European implanters proposed a
clinical consensus on a standardized and optimal electrode
placement technique based on data from the literature and
clinical experience [18]. The principles as indicated should
allow for a minimal stimulation threshold (<2 V) and a maxi-
mum of active contact (minimal two out of four). The opti-
mal setting will offer maximal programming possibilities
and reduce energy consumption. This should increase effi-
cacy, as well the percentage of successful patients but also
the maximal global effect that can reached in individual
patients [19]. It can also be expected that adverse events
should be minimized. Moreover low-amplitude stimulation
will extend the battery life and reduce the re-intervention
rate for battery change.
Stimulation with an external stimulator is performed for a
maximum of 2 weeks following instructions of the company
(Medtronic Inc.) that produces the equipment. Sometimes
the test period is extended up to 4 weeks to allow for addi-
tional observation or diagnostic procedures. However it is
not certain when the onset of the therapy effect can be
expected. Recently results of a prospective study were pub-
lished that evaluated the average onset time of sacral neuro-
modulation in patients with lower urinary tract symptoms
[20]. Of the 45 patients included, 29 (64%) were successful.
Mean time to success was 3.3 days (range 1–9). There was
no significant difference in mean time to success between
patients with overactive bladder and nonobstructive urinary
retention (3.25  days and 3.5  days, respectively). If these
results can be confirmed, a test stimulation of >9 days would
not be necessary to estimate the results in a reliable fashion
378
Fig. 28.3  The Medtronic InterStim II implantable pulse generator for
sacral neuromodulation
if a cutoff of 50% or greater improvement is adopted.
However further improvement was observed with prolonged
test stimulation, and this might be important since it can have
implications for long-term results.
If there is a good clinical response (>50% amelioration of
the major symptom), a permanent implantable pulse genera-
tor (Fig. 28.3) will be implanted.
The standard technique uses unilateral stimulation,
although some authors have claimed that bilateral stimula-
tion may be more effective for some patients with voiding
dysfunction. In a prospective randomized crossover trial [21]
that compared the unilateral approach with bilateral sacral
nerve stimulation, no significant differences were found
when comparing the global results of unilateral versus bilat-
eral stimulation. However bilateral stimulation might be
indicated when a unilateral test fails [22], as there are some
individual patients, especially with voiding dysfunction after
back hernia surgery, that could additionally benefit from
bilateral stimulation.
28.6 Results
In 1999, Schmidt et al. [23] published the results of the first
prospective randomized study in which the results of SNM
therapy for urgency incontinence were evaluated. Overall, 76
patients were treated in a multicenter trial: 34 patients were
implanted, and 42 patients were treated with standard con-
servative therapy. After 6 months of treatment, there was a
significant difference in results between two groups: in the
first group, 47% of patients were completely dry, and 29%
showed a greater than 50% reduction in incontinence epi-
sodes. In the control group, the results were significantly
worse. During evaluation of therapy after 6 months, the stim-
ulation group returned to baseline symptoms when stimula-
tion was stopped.
P. E. V. Van Kerrebroeck
In 2001, Jonas et  al. [24] published a multicenter trial
which enrolled 177 patients with urinary retention refractory
to conservative therapy; 37 patients were assigned to the
treatment group and 31 to the control group. After 6 months
in the stimulation group, 69% of patients had had their cath-
eterization removed, and 14% showed more than 50% reduc-
tion in voiding volume per catheterization. The effectiveness
of SNM therapy was sustained for 18 months after implanta-
tion. The 5-year follow-up results of these patients were pub-
lished by Van Kerrebroek [25] and reported on a total of 172
patients implanted, for urgency incontinence (103), urgency–
frequency (28), and urinary retention (31). In total 84% of
implanted patients with urgency incontinence, 71% with
urgency–frequency, and 78% with urinary retention went on
to have a successful outcome at 5-year follow-up if they had
shown a successful outcome after 1 year. These results have
been confirmed in several single center studies [26–29].
Failures during the first year probably were due to unsuc-
cessful selection related to the rather limited screening with
the temporary wire stimulation. Furthermore these patients
were implanted with the open surgical procedure and the
abdominal position of the implantable pulse generator (IPG).
Application of the percutaneous electrode placement and the
buttock position of the IPG have reduced the adverse event
and surgical revision rate.
Siegel [30] presented the 5-year follow-up results of a
prospective US trial in patients with overactive bladder syn-
drome. Of the 340 patients that completed the test stimula-
tion, 272 had an implant, of whom 91% were female. The
5-year therapeutic success rate was 67% using modified
completers analysis and 82% using completers’ analysis.
Subjects with urinary urgency incontinence had a mean
reduction from baseline of 2.0 ± 2.2 leaks per day, and sub-
jects with urgency–frequency had a mean reduction of
5.4 ± 4.3 voids per day (each completers analysis p < 0.0001).
This multicenter study confirms that SNM has sustained effi-
cacy through 5 years in patients with overactive bladder syn-
drome with the actual technique.
28.7 Predictive Factors
Many papers reported on predictive factors for a successful
result with SNM. In 2002 Scheepens et al. tested 212 patients
with a PNE test and found that intervertebral disk prolapse
and urgency incontinence were found to be significant posi-
tive predictive factors, while duration of complaints and neu-
rogenic bladder dysfunction were negative predictive factors
[31]. Currently, no useful predictive factors have been
described in electing successful patients with voiding dys-
function. However Bertapelle et  al. performed a study that
demonstrated lower success rates in patients who showed a
lack of detrusor response to acute stimulation of the sacral
28  Sacral Nerve Stimulation for Overactive Bladder and Voiding Dysfunction
nerve [32]. Another study concluded that patients with absent
contractility on ambulatory urodynamics have a consider-
ably lower chance of SNM success [33]. Hence, ambulatory
urodynamics could be used to select patients with a con-
firmed acontractile bladder and predict SNM failure. More
recently, Rademakers et al. were able to predict SNM treat-
ment outcome in men with impaired bladder emptying [34].
They showed that pre-assessment of bladder outlet resistance
and bladder contractility by pressure-flow studies and, after-
ward plotting the results in the Maastricht–Hannover nomo-
gram, can potentially predict SNM success.
Most patients who are eligible for SNM have had com-
plaints for many years and have been shown to be refractory
to conservative treatment such as bladder training, pelvic
floor exercise, behavioral therapy, and antimuscarinics or a
beta-3-adrenergic receptor agonist before SNM is offered.
Considering the time frame of duration of specific voiding or
storage symptoms, and the subsequent chance of success of
SNM, very little is known. Most studies reported on duration
of complaints before SNM treatment only as a secondary
outcome measure, while other possible predictive factors in
SNM outcome were investigated primarily [31, 35–39].
These studies mostly consisted of small groups of patients
with a variable range of duration of complaints (up to
5 years). The results of these studies are contradictory and
hence no final conclusions can be drawn.
It has been proposed that the incidence and degree of
psychological problems might influence treatment outcome
of SNM and psychiatric comorbidity has previously been
indicated as a negative predictor. Marcelissen et al. prospec-
tively studied the role of a broad spectrum of psychological
factors related to SNM treatment by using validated psycho-
logical screening questionnaires [40]. They also assessed
the relationship between psychiatric history and the out-
come of chronic SNM treatment and concluded that there
was no evidence that psychological screening can predict
the outcome of SNM treatment. However patients with a
medical history of psychiatric disease appear to be more
likely to encounter adverse events with permanent SNM
treatment. The same results were confirmed in a study by
Drossaerts et  al. that concluded that although it is known
that psychological factors play a role in the severity of
LUTS, they do not predict SNM outcome [33]. They con-
cluded that SNM should not be withheld from complex
patients with affective conditions but should be offered in
the framework of an integrated care.
Recently the Maastricht neuromodulation group found
that QoL and affective symptoms can significantly improve
in LUTS patients who are successfully treated with SNM
[41]. However when divided per indication, a significant
improvement in affective symptoms together with QoL was
only reported in successful patients with OAB and not in
successfully treated patients with NOR.
379
28.8 Complications
Siegel et  al. reported on complications in a series of 914
stimulation test procedures [42]. In total 181 adverse events
occurred (19.8%): lead migration (11.8% of procedures),
technical problems (2.6%), and pain (2.1%) represent the
main adverse events. For the 219 patients who underwent
implantation of the permanent system, adverse events were
pain at the stimulator site (15.3%), new pain (9%), suspected
lead migration (8.4%), transient electric shock (5.5%), pain
at the lead site (5.4%), and adverse change in bowel function
(3%). Surgical revision of the implanted neurostimulator was
performed in 2.2% of patients.
Hijaz et  al. [43] described the complications of 161
patients implanted with the tined lead. In these series eight
explants were necessary due to infection and seven due to
loss of effect. In 26 patients, a revision was performed due to
a decrease in clinical response.
In 2006, van Voskuilen et al. [27] described 194 adverse
events in 149 patients undergoing SNM after testing with a
wire electrode and after the former open procedure. In total
129 reoperations were performed (repositioning of the
implanted pulse generator, revision of electrode), and 21
patients had their system explanted. Additionally van
Voskuilen reported data on complications in 39 patients
implanted with the tined lead: there were seven severe
adverse events, of which three needed reoperations. Three
patients had a reoperation to reposition the IPG because of
persistent pain at the level of implanted pulse generator not
linked to stimulation [38]. In US study, the most common
device-related adverse events were an undesirable change in
stimulation in 60 of the 272 subjects (22%), implant site pain
in 40 (15%), and therapeutic product ineffectiveness in 36
(13%) [44].
Based on the available literature and our own clinical
experience, there is a decrease in reoperation rate with the
tined lead implantation, and overall SNM has an acceptable
safety profile, even with a follow-up of 5-years.
The life span of the actual implantable pulse generator
(InterStim II) varies between 5 and 7 years after which a bat-
tery replacement is necessary with an open procedure.
Recently a new rechargeable device (Axonics r-SNM
System™, Fig. 28.4) has been tested in a European clinical
trial [45]. In this procedure a similar electrode is placed in
the sacral foramen and connected to a rechargeable battery
that should last for at least 15 years and can be charged with
an external device. A total of 51 OAB patients were implanted
in a single-stage implant procedure. A total of 31 of 34
patients (91%) that responded during an initial trial period
continued to benefit from therapy at 1-year based on bladder
diary criteria, and 84% were satisfied with the therapy. Of the
total group, 98% found their charging experience acceptable
[46]. No serious device-related adverse events occurred, but
380
Fig. 28.4  The rechargeable
battery of the Axonics r-SNM
system for sacral
neuromodulation (left),
compared to a 2-Euro coin
(middle) and the Medtronic
InterStim II implantable pulse
generator (right)
19.6% of patients experienced device-related adverse events,
most notably discomfort due to stimulation, which was
resolved with reprogramming. This miniaturized, recharge-
able system is expected to provide clinical and cost benefits
over current non-rechargeable systems by eliminating
replacement surgeries. Currently a US–European trial is
ongoing with this device in order to apply for FDA approval.
28.9 Newer and Investigational
(Experimental) Neuromodulation
Techniques
With more than 300,000 patients implanted worldwide,
SNM with the recharge-free device (InterStim™ II,
Medtronic, Minneapolis, MN) is the standard approach, but
is only approved for magnetic resonance imaging (MRI)
head scans. However, recently, two commercialized recharge-
able devices that are conditional MRI-safe received CE mark
and FDA approval. These devices provide full-body MRI
safety for both 1.5 and 3  T, and the clinical effectiveness
appears to be similar to that of the current recharge-free
device. The need for full-body MRI-safe implants is obvi-
ous, since about 50% of patients with neurostimulators will
have an indication for an MRI over their lifetime, and up to
23% of SNM explantations are currently due to the need for
MRI. Therefore, it is expected that these new technologies
will enable more patients to choose SNM as the preferred
therapeutic option.
Rechargeable batteries result in a smaller volume implant-
able pulse generator (IPG) and potentially allow more com-
fort for patients. Currently available SNM systems include
the recharge-free InterStim II system (14 cm3), the recharge-
able Axonics system (5.5  cm3), and the InterStim Micro
technology (2.8  cm3) that reduces the size by about 80%
when compared with the InterStim II (Fig. 28.5). However,
smaller devices will not be a benefit to all patients because
about 40% of the global adult population is obese. A correct
implantation of a small rechargeable device with the neces-
sity for recharges may be challenging in obese patients, since
the angle and distance between the superficially implanted
P. E. V. Van Kerrebroeck
IPG and recharger may change significantly between
recharging sessions, thus making the recharge more cumber-
some. Furthermore, the stability of the IPG inside the subcu-
taneous tissue could be compromised, and the patient might
be more likely exposed to twiddler’s phenomenon.
An important aspect of rechargeable systems relates to the
requirement for IPG changes. The battery life of rechargeable
devices has been estimated at 15 years compared to the lon-
gevity of the current InterStim II, which is about 5–7 years. As
a result, rechargeable IPGs will be associated with a reduced
need for reoperation. Hence, life expectancy of patients will be
an important factor when considering rechargeable devices,
besides cognition and patient’s dexterity. Additionally, the
recent adoption of an optimized tined lead placement tech-
nique allows for lower amplitudes, and hence, longer battery
life can be expected also with recharge-­free systems.
There are also some potential additional pitfalls associ-
ated with rechargeable devices. Patients must be compliant
and should have the cognitive capability and the manual dex-
terity to recharge their IPG. Although the recharging process
can be done at home without being connected to a power
socket, the therapeutic noncompliance of patients can be an
issue. Since a lack of compliance will lead to a loss of effec-
tiveness and/or an increased burden for the healthcare pro-
fessionals, careful screening of candidates for a rechargeable
device is imperative. Recharge-free devices require no regu-
lar or frequent interactions with the patient programmer, and
patients with a poorer compliance may better qualify for
recharge-free devices. Another factor is disease awareness as
the psychological and patient perception of their problem
will be experienced differently between individuals with a
rechargeable or a recharge-free system. One of the greatest
benefits that patients describe is their ability to forget about
their medical condition once an SNM device is implanted. A
recharge-free system allows the patient to set and forget the
treatment, but with a rechargeable system, patients are
actively reminded of their condition every 1–2 weeks.
Good indications for rechargeable devices are therefore
available in technology-savvy, compliant, and highly moti-
vated patients or in patients who are in need of high-energy
stimulation with expected reduction of battery life, slim patients
28  Sacral Nerve Stimulation for Overactive Bladder and Voiding Dysfunction
Fig. 28.5  The Medtronic InterStim Micro system battery for sacral
neuromodulation compared to the InterStim II battery
Fig. 28.6  The AHLeveeS System (Neuspera Medical Inc., San Jose,
CA, USA) for sacral neuromodulation
with insufficient fat tissue at the implant site, patients with a
history of pain, or patients with significant infection risks for
device replacements. When assessing patient compliance for
rechargeable SNM, it is recommended to look at all factors that
may impact therapeutic noncompliance. These include demo-
graphic factors (age, gender, education, available caregivers);
psychosocial factors (motivation, attitude), health literacy,
patient knowledge, physical ­difficulties, forgetfulness, or his-
tory of good compliance; complexity of therapy maintenance
(finding the right spot to recharge); potential side effects of
therapy maintenance (potential discomfort due to mild heating
depending on battery technology); compatibility with lifestyle
(frequent travelling); lack of accessibility for therapy mainte-
nance (frequent travelling, easy access in case of lost recharger,
helpline in case of technical questions); cost issues (insurance
in case of lost recharger); and patient motivation.
A shared decision-making process between patient and
physician is recommended by making the patient aware of
all advantages and disadvantages of each system.
Recently, a new approach to sacral nerve stimulation has
been developed, consisting of a miniature implantable stimu-
381
lator and proprietary wireless mid-field powering unit
(AHLLevees System, Neuspera Medical Inc, San Jose, CA,
Fig. 28.6), eliminating the need for an implanted pulse gen-
erator [47].
Several technical innovations in the field of urological neu-
romodulation have emerged in recent years and continue to be
evaluated. These must allow for better acceptance by patients
and healthcare providers and extend the indications for this
therapy while keeping up with the excellent clinical results.
28.10 Conclusions
Sacral nerve modulation procedures can deliver objective
and subjective benefit in patients with voiding dysfunctions
as the overactive bladder syndrome, with or without urgency
incontinence, but also in nonobstructive urinary retention. In
a group of patients with highly therapy-resistant lower uri-
nary tract dysfunction, SNM is safe, minimally invasive, and
reversible. The minimally invasive percutaneous approach
for SNM with a tined lead is easy to perform, and the com-
plication rate is low. SNM does not carry the risk of systemic
side effects encountered in pharmacologic therapy or the
potential morbidity that open surgical procedures may cause.
Therefore SNM should be considered in any patient with
chronic voiding dysfunction resistant to conservative therapy
and proposed as an alternative to treatment with onabotuli-
num toxinA injections. Technical ameliorations such as the
rechargeable battery will allow to reduce surgical revisions
and increase cost efficacy, and MRI compatible pulse gen-
erators will reduce the limitations in patients in whom total
body MRI examination is anticipated. New implant develop-
ments will further limit the amount of implanted material
and will allow for other anatomical stimulation sites as the
tibial nerve but still will have to find their exact place in the
neuromodulation algorithm.
Take-Home Messages
• Sacral nerve stimulation allows for successful neu-
romodulation of lower urinary tract dysfunctions as
overactive bladder (with or without urinary urgency
incontinence) and voiding dysfunction, refractory
to maximal conservative therapy.
• The actual sacral nerve stimulation technique pro-
duces sustained efficacy in non-neurogenic patients
and has an acceptable safety also in the long term,
with adverse events that can be treated effectively.
• New techniques for neuromodulation of the lower
urinary tract will allow for a more cost-effective
therapy with lower morbidity and limited re-inter-
vention rate.
382 P. E. V. Van Kerrebroeck

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 Part V
Anal Incontinence
 Overview: Epidemiology and Aetiology
of Anal Incontinence
Alison J. Hainsworth, Andrew B. Williams,
and Alexis M. P. Schizas
Learning Objectives
• Know the prevalence of anal incontinence and
understand how estimates of prevalence are affected
• Understand how prevalence rates and the burden of
disease may change in the future
• Understand the mechanisms which allow normal
continence
• Know the different causes of anal incontinence and
understand that it is usually multifactorial
• Understand which groups of patients are affected
by incontinence and the predisposing risk factors
towards anal incontinence
29.1 Introduction
Anal incontinence is defined as the recurrent uncontrolled
passage of faecal material in an individual [1]. It is common,
chronic and debilitating and adversely affects quality of life.
Despite this, its prevalence is inconsistently reported, and its
incidence is seldom referred to.
Previously, it has been assumed that anal incontinence is
more common in women and is primarily due to obstetric
injury, with either injury to the anal sphincter or pudendal
nerve. The other common risk factors include irritable bowel
syndrome (more often seen in women) and lastly neurologi-
cal diseases such as diabetes. However, population studies
show that prevalence of anal incontinence is also high in
men, and so other causes in addition to injury following
childbirth must also be appreciated [2].
In the era of increased patient expectation and as barriers
to reporting anal incontinence are broken down, it is expected
A. J. Hainsworth (*) · A. B. Williams · A. M. P. Schizas
Colorectal Surgery, Guy’s and St Thomas’ Hospital, London, UK
e-mail: allyhainsworth@gmail.com; aschizas@hotmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_29
29
that prevalence and demand to treatment will increase.
Accurate information about prevalence and aetiology of anal
incontinence will contribute to breaking down barriers to
reporting. Prevention by modifying risk factors and success-
ful treatment will depend upon a comprehensive understand-
ing of the causes of anal incontinence.
29.2 Epidemiology of Anal Incontinence
29.2.1 Prevalence
Anal incontinence is a common condition, but its true preva-
lence may be unknown [3]. There have been three systematic
reviews which examine prevalence of anal incontinence.
Each found a wide variation in study design, data collection
methods, selection bias and the definition of anal inconti-
nence (type of stool and frequency). The heterogeneity of
studies and the paucity of high-quality prevalence studies
mean a wide variety of prevalence rates have been reported.
The authors of all three reviews called for high-quality popu-
lation studies, cross-sectional studies to minimise bias, the
use of validated self-administered questionnaires which
include quality of life and the use of a standardised definition
of anal incontinence.
In 2016 Sharma et  al. performed a systematic review
which examined 30 articles from 1966 to 2015 and found
that the prevalence of anal incontinence in the community
varied from 1.4% to 19.5%. When a threshold of at least one
episode per month of incontinence to solid or liquid stool
was applied, prevalence was 8.3–8.4% for face-to-face inter-
views and 11.2–12.4% for postal surveys [4]. Personalised
data collection methods are an established reason for under-­
reported prevalence rates [5].
Ng et  al. examined 38 studies in 2015 to determine the
prevalence of anal incontinence in the community. Median
prevalence was 7.7% (range 2–20.7%). Anal incontinence
equally affected men (median 8.9%; range 2.3–16.1%) and
women (median 8.8%; range 2.0–20.7%) and increased with
387
388
age (15–34 years, 5.7%; >90 years, 15.9%). Only six studies
were considered high quality, and the median for prevalence
in these studies was 11.2% (range 8.3–13.2%) [6].
An earlier systematic review in 2004 found that preva-
lence of anal incontinence varied from 0.4% to 18% (2–24%
including flatus incontinence). The prevalence in studies
which minimised significant bias was 11–15% [7].
29.2.2 How Future Estimates of Prevalence
May Be Affected
The prevalence of anal incontinence and the demand for
treatment are expected to increase in the future. Examination
of rural communities in Northern Queensland, Australia, in
2013 with a postal survey found faecal incontinence rates to
be 12.7% (174/1366), but only ten respondents with faecal
incontinence had consulted their doctor in the preceding
year. The authors predict that changes in the population (an
ageing population and more assertive cohorts) will see a rise
in the number of patients seeking treatment [8].
Brown et al. have worked with patient groups in the USA
to examine the prevalence of anal incontinence and the barri-
ers to patients reporting symptoms and requesting treatment
[9]. They studied 5817 women with an Internet-based ques-
tionnaire and found nearly one fifth of US women over
45 years suffer with bothersome bowel leakage at least once
a year. Predictors were bowel disorders, urinary inconti-
nence, stroke, age 55–64, diabetes mellitus and prior vaginal
delivery. Being married, black or American Indian/Alaska
Native race/ethnicity and an income >$40,000 per year were
associated with decreased risk of anal incontinence [10].
Patient-focused groups and cognitive interviews with 39
women (aged 46–85) revealed that fewer than 30% of women
with anal incontinence seek medical care. Barriers to report-
ing symptoms included the lack of knowledge that anal
incontinence is a medical condition. All barriers were encom-
passed by three overarching themes: the internalised self in
relation to anal incontinence; perceptions about anal inconti-
nence and its treatments; and interaction with the healthcare
system. The authors advocate that interventions to promote
access to treatment for anal incontinence should include
information about prevalence [9].
The recent change in the Rome IV diagnostic criteria for
faecal incontinence means that faecal incontinence should, at
least for research purposes, occur at least twice in 4 weeks to
quantify diagnosis (Rome III required an episode more than
once in 3 months). This more restrictive criteria may result in
lower prevalence rates in future research (though it is not
known if it will identify those with more bothersome symp-
toms) [11].
With decreased barriers to symptom reporting and if
future studies use a standardised definition of anal inconti-
A. J. Hainsworth et al.
nence, use cross-sectional studies to minimise bias and use
self-validated questionnaires which account for impact on
quality of life, then there may be less variation in the estima-
tion of prevalence [12].
29.2.3 Incidence
There are some clinical trials which report incidence of anal
incontinence following treatment but none which report inci-
dence prior to treatment. Two Cochrane reviews examining
the treatment for anal fissure found rates of anal incontinence
to flatus varied from 0% to 30% following treatment [13].
29.2.4 Risk Factors
Anal incontinence is multifactorial. Some of the risk factors
include increasing age, nursing home residents, female in the
younger population, obesity, childbirth, surgery, neurologi-
cal disease, diarrhoea and constipation [12]. These are dis-
cussed later in the chapter.
29.2.5 Future Directions
• Future studies which examine prevalence should be cross-­
sectional population studies that minimise bias, include a
consensus definition of anal incontinence and use vali-
dated self-administered questionnaires which account for
quality of life.
• The prevalence of anal incontinence and the demand for
treatment may increase in the future as medical health
professionals work to break down barriers to reporting
symptoms.
• Conversely, the Rome IV criteria for faecal incontinence
may lead to decreased prevalence rates in research papers
though it is not known if this new definition distinguishes
those with symptoms which adversely affect quality of
life.
• Studies are needed to determine true incidence of anal
incontinence.
29.3 Aetiology of Anal Incontinence
29.3.1 Continence
Continence is maintained by the integrity and function of the
anorectal unit [14]. Multiple factors including stool consis-
tency and delivery to the rectum, rectal storage and the abil-
ity of the anal sphincter mechanism contribute to maintain
continence and sensation in the anal canal (Table 29.1) [15].
29  Overview: Epidemiology and Aetiology of Anal Incontinence 389

Table 29.1  Factors which affect continence

Action Contributing factors
Delivery to Stool consistency
the rectum Capacity of the sigmoid colon to retard progress of the stool
Rectal Rectal capacity
storage Rectal compliance
Rectal urgency
Anal Normal internal anal sphincter
sphincter • Involuntary smooth muscle, tonic activity maintains anal continence at rest
mechanism Normal external anal sphincter [14]
• Contributes to resting tone, but primary function is voluntary or reflexive squeeze when stool or flatus is present or increased
intra-abdominal pressure [12]
Conjoined longitudinal muscle
•S uggested roles are a supportive meshwork for the anal sphincters and assistance in closure or flattening of the anal cushions [12]
Normal puborectalis
• Phasic contractions to maintain the anorectal angle
• Responds to increased abdominal pressure (coughing, straining) and rectal distention by contracting [12]
Anal mucosal folds and anal vascular cushions maintain tight seal [14]
Nerve Pudendal nerve
supply [12] • Motor (including external anal sphincter) and sensory (anal sensation) function
A rich supply of enteric, sympathetic, parasympathetic and extrinsic spinal sensory neurones
Cerebral cortex
• Rectal distention produces activations in multiple areas of the cerebral cortex
Reflexes
• Rectoanal inhibitory reflex (distention of the rectum causes relaxation of the internal anal sphincter and contraction of the
external anal sphincter)
• Sampling reflex (transient relaxation of the internal anal sphincter allows the anorectum to ‘sample’ the contents to distinguish
between flatus and stool)
• Cough reflex (increased abdominal pressure leads to increased pressure in the external anal sphincter and puborectalis)
• Rectoanal contractile reflex (rectal distention leads to contraction of the external anal sphincter)
Physical Ability to reach the bathroom in a required timeframe
mobility

29.3.2 Incontinence may be caused by neuropathy or systemic sclerosis [14].

Interruption to any of these mechanisms may cause anal
incontinence (Table 29.2). Anal incontinence may be caused
by structural and neurogenic causes or functional causes.
However, the emerging consensus from experts is that there
are multiple overlapping factors which contribute to anal
incontinence [11]. Up to 80% of patients with anal inconti-
nence possess more than one pathological abnormality on
anorectal physiology [16]. Given that anal incontinence rarely
occurs solely due to psychological problems or ­problems
related to bowel habit, the recent Rome IV diagnostic criteria
propose that clinicians do not try to distinguish functional
abnormalities from structural or neurogenic causes.
Passive anal incontinence with faecal seepage occurs
when the anal canal does not close properly. This may occur
due to either damage or weakness of the internal anal sphinc-
ter or anal vascular cushions (leads to a poor seal and
impaired sampling reflex). Damage to the internal anal
sphincter most commonly occurs due to obstetric anal
sphincter injury (OASIs) but may also be seen with surgical
or accidental trauma. Weakness of the internal anal sphincter
Rectal prolapse may also prevent full closure of the anal
canal. There is increasing evidence that loss of sensation
(due to peripheral neuropathy, damage to the spinal cord and
cerebral cortex) with rectal hyposensitivity also contributes
to passive incontinence [12, 17].
Urge faecal incontinence is the result of the continence
mechanisms being overwhelmed, either the rectum cannot
distend to act as a reservoir to hold the faecal material or the
anal sphincter mechanism cannot contain the stool. Rectal
storage is disrupted when the capacity or compliance of the
rectum is disrupted, for example, following radiation or sur-
gery. Rectal hypersensitivity means the threshold for the
urge to defaecate is lower than normal; it is affected by
decreased rectal compliance and increased sensitivity of both
peripheral and central pathways [12]. The external anal
sphincter is primarily responsible for voluntary continence
when the urge to defaecate occurs; it may be affected directly
by mechanical damage (e.g. obstetric injury) or problems
with its nerve supply. Uncontrolled delivery of stool to the
rectum can also overwhelm continence mechanisms and lead
to urge faecal incontinence.
390 A. J. Hainsworth et al.

Table 29.2  Causes of anal incontinence [14, 15] and 49  years and 11.6% aged 80  years and older suffered
Mechanism for anal incontinence with more frequent and severe symptoms
Action anal incontinence
Risk factors in older patients [19].
Delivery to Rapid transit Inflammation (inflammatory bowel Although an increase in prevalence with age is well docu-
the rectum disease, ischaemic colitis,
microscopic colitis)
mented, the physiological effect of age on continence is still
Infection not clear. Studies with endoanal ultrasound and MRI have
Irritable bowel syndrome shown that the external anal sphincter becomes thin and atro-
Malignancy phic with age [20–23] and faecal incontinence relates to atro-
Post-cholecystectomy diarrhoea
Polypharmacy
phy of the external anal sphincter [24]. However, anal
Tube feeds squeeze pressures may [25, 26] or may not [27, 28] decrease
Sports such as running with age. Rectal sensation may decrease [29].
Constipation with Nursing home residents Other risk factors seen in the elderly population such as
faecal impaction Behavioural, lifestyle factors
polypharmacy (which can cause loose and frequent stool),
Medication
Rectal Rectal compliance Ulcerative colitis urinary incontinence, impaired mobility and dementia are
storage and capacity Crohn’s disease additive risk factors for anal incontinence [30].
Radiation proctitis
Rectal tumour 29.3.3.2 Nursing Home Residence
Spinal cord injury
Rectal surgery The most prominent and common association with anal
Anal Sphincter muscle Obstetric trauma incontinence is with nursing home residence [2]. If preva-
sphincter injury Surgical trauma (lateral lence of anal incontinence in the community is considered
mechanism sphincterotomy or anal stretch, 7–8% and prevalence in the elderly around 10%, then the
anorectal surgery for haemorrhoids
or anal fistula)
prevalence in nursing homes may approach 50% [31]. A sur-
Accidental trauma vey of 18,000 nursing home residents in Wisconsin found
Puborectalis Obstetric trauma causing 47% had anal incontinence [32]. Interestingly, this survey
dysfunction denervation so that anorectal angle found no association between age and anal incontinence
is not maintained
(mean age 84  years), but rather the risk factors for faecal
Pelvic floor dyssynergia leading to
incomplete evacuation and incontinence were primarily urinary incontinence followed
subsequent soiling by the loss of ability to perform personal daily living activi-
Injury to anal Obstetric trauma ties, tube feeding, physical restraints, diarrhoea, dementia,
mucosal folds Surgical trauma impaired vision and constipation with faecal impaction.
which maintain
tight seal
Prevention of Mucosal or full-thickness rectal 29.3.3.3 Gender
closure of the anal prolapse Most attention has been focused on anal incontinence in
canal women, and although prevalence may be higher in women in
Nerve Pudendal nerve Obstetric trauma younger age groups, community-based studies show that
supply injury Idiopathic
Peripheral neuropathy
prevalence in men is essentially comparable to women [12,
Loss of sensation Obstetric trauma 19, 33–35]. Women seek medical treatment for faecal incon-
to the anorectum Idiopathic tinence more readily than men which is why there may be a
Peripheral neuropathy perceived increase in females [33].
Central nervous system injury (spina
The risk factors and aetiologies for anal incontinence are
bifida, spinal cord injury, stroke)
Nerve supply to Obstetric trauma different between the sexes, but more work is needed to
external anal examine the aetiology of anal incontinence in men. In
sphincter and younger women childbirth is the main risk factor for anal
puborectalis incontinence. The effects of obstetric trauma may not be
Physical Inability to reach Immobility
mobility toilet in time Dependence on others for
noticed until after the menopause; some propose that the
activities of daily living menopause is an independent risk factor for anal inconti-
Nursing home residents nence, but this is difficult to prove. There are oestrogen and
progesterone receptors in the internal and external anal
sphincter, but the role of hormone receptors and late-onset
29.3.3 Risk Factors for Incontinence incontinence is not yet known.
In older patients the risk factors also differ. In a study
29.3.3.1 Age where 1345 older subjects were interviewed, age, depres-
The prevalence of anal incontinence increases with age [18]; sion, heart disease, urinary incontinence and polypharmacy
a study of 10,116 found 4% of men and women between 40 were risk factors in women and malnutrition a risk factor in
29  Overview: Epidemiology and Aetiology of Anal Incontinence
men. Increased dependence for activities of daily living were
a risk factor for both [36]. Sphincter defects, low resting and
squeeze pressures and pelvic organ prolapse are more com-
mon in women (i.e. the silique of childbirth), and rectal
hypersensitivity and evacuatory disorders with normal rest-
ing and squeeze pressures are more often seen in men [12].
29.3.3.4 Childbirth
Mechanisms for Anal Incontinence After Childbirth
Obstetric trauma is an important and common cause of anal
incontinence [12]. Obstetric trauma includes mechanical
trauma (obstetric anal sphincter injuries (OASIs)) and neuro-
genic trauma.
OASIs is classified according to Table 29.3 (see Fig.13.2).
The incidence of OASIs has increased due to increased recog-
nition and the advent of imaging with endoanal ultrasound
and MRI (see Chap. 32). Prior to endoanal ultrasound, unless
a woman presented with an obvious third- or fourth-degree
tear, it was assumed that any anal incontinence symptoms
were due to neurogenic injuries. Sultan et al. were the first to
identify ‘occult’ obstetric anal sphincter injuries which were
not recognised at the time of injury. They performed endoanal
ultrasound before and after delivery in 150 women. There
were only two women who had a recognised obstetric anal
sphincter injury during delivery, but 35% of primiparous
women and 44% of multiparous women demonstrated an anal
sphincter injury on endoanal ultrasound 6 weeks post-partum.
There was a strong association between a defect on ultra-
sound and symptoms [37].
As our understanding of the anal sphincter anatomy and
mechanism has improved, so has the rate of recognised
obstetric anal sphincter injuries (increased from 1.8% to
5.9% for first vaginal deliveries) [38]. This provides opportu-
nity for obstetricians to perform immediate sphincter repair
(there is evidence that repair of the internal anal sphincter is
beneficial; more research is needed to determine the repair
Table 29.3  Classification of OASIs
Obstetric anal
sphincter injury Description
First degree Laceration of the vaginal epithelium or
perineal skin only
Second degree Involvement of the perineal muscles but not
the anal sphincter
Third degree Disruption of the anal sphincter muscles
which are subdivided into:
3a <50% thickness of the external anal
sphincter is torn
3b >50% thickness of the external anal
sphincter is torn
3c internal anal sphincter also torn
Fourth degree Third-degree tear with disruption of the anal
epithelium
391
techniques for and the benefits of repair to a damaged exter-
nal anal sphincter) [12].
Neurogenic trauma includes pudendal neuropathy and
denervation of the striated pelvic floor muscles, particularly
the external anal sphincter and puborectalis muscles.
Pudendal nerve damage is associated with multiparity, for-
ceps delivery, increased second stage of labour, third-degree
tears and increased birth weight. However, pudendal nerve
conduction studies in up to 60% of women may return to
normal within 2 months of delivery [39].
Other obstetric factors including damage to the levator ani
muscle are also being investigated.
There are modifiable risk factors which can affect obstet-
ric trauma; ventouse delivery is less likely to cause perineal
and anal sphincter trauma compared to forceps, mediolateral
episiotomy reduces the risk of a third- or fourth-degree tear
compared to a midline episiotomy, liberal use of episiotomy
is not beneficial, a prolonged second stage of labour leads to
denervation and should be avoided, caesarean may be benefi-
cial if there is prior anal sphincter damage, or previous pro-
lapse surgery without symptoms and appropriate perineal
support during delivery may reduce perineal and anal sphinc-
ter trauma [12].
Epidemiology of Anal Incontinence After Childbirth
A survey of 8774 American women in the first 3–6 months
post-partum found that 29% reported anal incontinence
(46% of these women experienced incontinence to stool and
38% to flatus) [40]. A prospective Canadian study of 949
women found that 3.1% complained of faecal incontinence
and 25.5% of flatus incontinence in the 3 months following
birth [41].
Obstetric anal sphincter injury can cause long-term anal
incontinence in up to 50% of patients [42–45]. A study of
304 women 10  years after their first delivery showed that
57% of women with a sphincter tear and 28% of all women
had anal incontinence. Severe anal incontinence at baseline
and 5 years after delivery were independently strong predic-
tors of severe anal incontinence at 10 years [42].
Factors thought to be associated with anal incontinence
following childbirth include higher BMI, longer second
stage, forceps-assisted delivery and anal sphincter tears. A
systematic review in 2008 examined 18 studies with a total
of 12,237 participants. The risk of anal incontinence doubled
with a forceps delivery and increased by a third with a spon-
taneous vaginal delivery compared with caesarean section.
Instrumental deliveries resulted in more symptoms than
spontaneous vaginal delivery (significant for forceps deliver-
ies but not ventouse). When only considering liquid or solid
anal incontinence, the same trends were observed, but they
were not statistically significant [46]. A systematic review in
2010 found that third- or fourth-­degree rupture was the only
aetiological factor which was strongly associated with post-
392
partum anal incontinence. There were no associations which
other postulated risk factors, for example, birth weight or
instrumental delivery. However, it was acknowledged that
the potential coexistence of different risk factors impedes the
interpretation of the influence of a single delivery-related
risk factor [45].
There have been questions surrounding the safest mode of
delivery for a second birth if a first delivery is complicated
by anal sphincter injury. The aim is to reduce risk of recur-
rent anal sphincter injury and long-term anal incontinence. A
population-based questionnaire study of women whose first
delivery had been complicated by anal sphincter injury and
had then undergone second delivery via vaginal delivery
(1472 women) or caesarean section (506) found that mode of
second delivery did not significantly affect the risk of long-­
term anal incontinence symptoms. However, those who had
undergone a second vaginal delivery were at risk of further
deterioration of long-term anal incontinence symptoms [47].
It is not fully understood why some women with anal
sphincter injury only develop symptoms of anal incontinence
later in life. Symptoms may only occur many years after
delivery (this may be due to the contributory effects of the
menopause or progression of neuropathy) [12].
29.3.3.5 Urinary Incontinence
Urinary incontinence and anal incontinence commonly coex-
ist. This probably represents the fact that both arise from
similar aetiologies rather than one causes the other.
29.3.3.6 Diabetes
Up to 20% of people with diabetes mellitus suffer anal incon-
tinence [48].
Microvascular changes may cause damage to the nerves
and muscles of the pelvic floor, and anal incontinence may
be caused by decreased rectal sensation or reduced function
of the external anal sphincter or both [49]. One study
showed that rectoanal inhibitory reflex recovery time cor-
related with anal incontinence in 31 type I diabetics (19
with incontinence) and 42 type II diabetics (26 with incon-
tinence); the authors hypothesised that this may be due to
decreased sympathetic nerve innervation [48]. However,
two epidemiological studies of 190 and 114 diabetic
patients, respectively, showed no association between neu-
ropathy and anal incontinence, questioning this hypothesis
[50, 51].
29.3.3.7 G  astrointestinal Disorders and Stool
Consistency
Stool consistency, volume and frequency of stool as well as
irritants in the stool can contribute towards incontinence. It is
only possible to maintain continence in the presence of high
volume, liquid stool if there is good anal sensation, a compli-
ant rectal reservoir and strong anal sphincters. Irritants
A. J. Hainsworth et al.
within the stool, such as in the case of bile salt malabsorp-
tion, can lead to the rapid accumulation of gas and liquid
stool which can overwhelm continence mechanisms [14].
Diarrhoea
Diarrhoea may be caused by infection, inflammation, irritable
bowel syndrome, malignancy, medications and some sports
including running (Table  29.2). It is an important cause of
anal incontinence; a survey of 2800 US woman identified
diarrhoea as the most important independent risk factor for
anal incontinence [52]. A case series of 76 patients with diar-
rhoea found that 51% suffered with incontinence [53].
Diarrhoea is also an additive risk factor in those with another
risk factor, such as obstetric anal sphincter injury [54].
Rectal Urgency
Rectal urgency is a risk factor for anal incontinence; it also
contributes to anal incontinence in those with other risk fac-
tors [12]. The function of the rectum as a storage facility and
the reasons behind rectal urgency are still poorly understood
and require further research. Rectal urgency may lead to
incontinence either by rapid transit into the rectum which
overwhelms its function as a reservoir or by hypersensitivity
or a combination [55, 56]. Rectal urgency may be seen in
irritable bowel syndrome [12].
Constipation/Faecal Impaction
Constipation and anal incontinence coexist as frequently as
urinary incontinence and anal incontinence do [12]. Factors
which contribute to constipation include depression, immo-
bility, inadequate dietary fibre or fluid intake, metabolic dis-
orders such as hypothyroidism, neurological conditions and
medications.
Prolonged retention of stool within the rectum, particu-
larly in the elderly, causes faecal impaction. Reduced peri-
anal and rectal sensation means that the patient does not have
the desire to defaecate when the rectum has reached a normal
full capacity [57]. Faecal impaction causes prolonged relax-
ation of the internal anal sphincter, but the lack of sensation
and perception stops the normal contraction of the external
anal sphincter. Liquid stool from above the stool bolus seeps
around the impacted faeces and leaks out of the anus.
Symptoms may be aggravated by laxatives [14, 57, 58].
Irritable Bowel Syndrome
Irritable bowel syndrome may comprise of alternating con-
stipation and diarrhoea leading to a chaotic bowel habit and
rectal urgency.
29.3.3.8 Neurological/Psychiatric Disorders
Stroke, multiple sclerosis, Parkinson’s disease, systemic
sclerosis, myotonic dystrophy, amyloidosis, spinal cord
injury, Hirschsprung’s disease, retarded or interrupted toilet
29  Overview: Epidemiology and Aetiology of Anal Incontinence
training, dementia and depression can all cause anal inconti-
nence. Many of these affect patient mobility, ability to per-
form activities of daily living, diarrhoea or faecal impaction
[12]. Altered mental state and acute delirium secondary to
hospitalisation, surgery and medications can also cause
problems with continence [12, 59].
Dementia
The influence of dementia on anal incontinence was exam-
ined in a random sample of 85-year-olds from Gothenburg,
Sweden (485 subjects). Anal incontinence was seen in 34.8%
of demented subjects and only 6.7% of non-demented sub-
jects [60]. In nursing home residents, although diarrhoea was
found to be the strongest risk factor for anal incontinence,
dementia actually played a stronger role in the development
of anal incontinence [61].
Depression
Depression is a risk factor for anal incontinence. The reasons
behind this association are multifactorial. Poor nutritional state
in the elderly is associated with both depression and anal incon-
tinence questioning the true causal relationship between the
two [12]. Anal incontinence may contribute to depression, but,
unfortunately, anti-depressants may also cause diarrhoea and
worsen symptoms. There is still much to be learnt about the
true relationship between gastrointestinal function, neurotrans-
mitters and mental health disorders. It is not known if anal
incontinence is really the cause or result of depression [62].
29.3.3.9 Nutrition
Obesity
Obesity is the most modifiable risk factor associated with
anal incontinence, but the studies of the relationship between
the two are inconsistent [12]. Some reports show an increased
risk of anal incontinence in obesity [63], and some show no
association between obesity and anal incontinence [6].
Studies tend to be focussed on women and lack both control
groups and physiological testing [64].
Chronically elevated intra-abdominal pressure is thought
to cause pelvic floor dysfunction leading to anal inconti-
nence [65]. Confounding factors which may affect the appar-
ent association between obesity and anal incontinence
include diarrhoea, which is seen in obesity [64], low dietary
intake, which highlights the possibility that diet may also
contribute [66], diabetes and neurological changes [12].
There is a reduction in anal leakage following bariatric sur-
gery, but other factors may also change (e.g. diet, activity
levels) [67, 68].
Vitamin D
Vitamin D deficiency is prevalent in women with anal incon-
tinence, and Vitamin D is an important micronutrient in mus-
393
cle function [69]. However, any association between vitamin
D deficiency and anal incontinence may simply represent the
fact that both occur in the elderly.
29.3.3.10 Physical Mobility
Impaired mobility may prevent someone from reaching the
toilet on time following the urge to defaecate and is an inde-
pendent risk factor for anal incontinence [55]. Causes for
impaired mobility include musculoskeletal (e.g. arthritis,
fracture) and neurological (stroke) disorders.
A study of long-term patients found that immobility was
the most important predictor for anal incontinence [59].
However, toilet access and mobility may be modifiable. Up
to 30% of patients suffer an episode of incontinence within
the first week of having a stroke, with rehabilitation this
decreases to 15% at 3 years [70].
29.3.3.11 Radiation
Indications for pelvic radiotherapy include prostate, rectal,
anal and gynaecological cancers. Incidence of anal inconti-
nence may be as high as 43% [71]. As discussed below radia-
tion for rectal cancer contributes to anal incontinence
following restorative rectal resection. For prostate and gyn-
aecological cancer, increased dose of radiotherapy to the
anal sphincter, puborectalis, sigmoid and small intestines is
associated with anal incontinence [72, 73].
The exact mechanism for radiotherapy leading to inconti-
nence is unclear though it is thought to affect the ability of the
rectum to act as a storage facility. A systematic review of anal
and rectal changes following radiotherapy for prostate cancer
shows that patients who have received pelvic radiation have
decreased anal resting pressures and impaired rectal distensi-
bility but less consistent changes in squeeze pressures [74].
29.3.3.12 Prolapse
There is little information available regarding the prevalence,
incidence and risk factors regarding pelvic organ prolapse
and anal incontinence. Experts have called for worldwide
surveys and epidemiological research [12].
Incomplete evacuation due to obstructed defecation can
lead to post-defaecatory passive anal incontinence with soil-
ing and seepage. Obstructed defaecation is caused by either
structural abnormalities such as a rectocoele (posterior vagi-
nal wall prolapse) which retains stool or internal rectal pro-
lapse (intussusception) or functional abnormalities such as
dyssynergic defaecation. Many also have impaired rectal
sensation [14].
Mucosal, external or internal rectal prolapse can cause
anal incontinence. Though importance of rectal prolapse in
anal incontinence is now better appreciated, research is
required to fully understand its pathophysiology.
Up to 63% of patients with prolapsing haemorrhoids or
mucosal prolapse report soiling [75, 76].
394
External rectal prolapse may be the result of pudendal
neuropathy and pelvic floor weakness or can lead to damage
to the internal anal sphincter. Chronic straining and constipa-
tion with or without a history of vaginal childbirth can lead
to pelvic floor weakness and pudendal neuropathy and sub-
sequent perineal descent, sensory loss of the anorectum and
motor deficiency of the external sphincter, rectal prolapse
and anal incontinence. Conversely, rectal prolapse may pre-
vent closure of anal canal, cause damage to the internal anal
sphincter by repetitive stretching and may lead to anal incon-
tinence. Alternatively, damage to the internal anal sphincter
by some other mechanism (e.g. obstetric anal sphincter
injury) can result in persistent rectal prolapse and anal incon-
tinence [14].
Though internal rectal prolapse (intussusception) mani-
fests primarily as incomplete evacuation, over 50% of
patients also complain of anal incontinence [77]. This may
either be due to chronic straining secondary to incomplete
evacuation resulting in a stretch injury and consequent neu-
ropathy of the pudendal nerve or the infolding rectal folds
leading to rectal distention and initiation of the rectoanal
inhibitory reflex. As our understanding of intussusception
improves, the pathophysiology behind its role in anal incon-
tinence will also improve.
29.3.3.13 Surgery
Anorectal surgery including sphincterotomy, fistulectomy,
fistulotomy, haemorrhoidectomy, ileoanal pouch and rectal
resection are risk factors for anal incontinence. Other surger-
ies include ureterosigmoidostomy after urinary bladder
resection, hysterectomy and cholecystectomy.
Anorectal Surgery
Damage to the internal anal sphincter during anorectal sur-
gery can cause anal incontinence. Up to 8% of patients
undergoing lateral sphincterotomy and 52% of patients
undergoing fistulotomy may have anal incontinence [78, 79].
Newer techniques which preserve the anal sphincter for the
treatment of these pathologies have decreased the risk [78,
80]. The anal sphincter may also be damaged during haemor-
rhoidectomy though there may be other causes for anal
incontinence such as division of the anoderm. One study
found that 40 out of 418 patients undergoing Milligan haem-
orrhoidectomy suffered with anal incontinence—19 of these
agreed to investigation to find out why and only four were
found to have an anal sphincter injury [81]; anal inconti-
nence has been found to be as high as 33% following haem-
orrhoidectomy without anal sphincter injury [82].
Rectal Resection
Indications for rectal resection include rectal cancer and
inflammatory bowel disease. In the majority of patients, it is
possible to preserve the anal sphincters during rectal resec-
A. J. Hainsworth et al.
tion, but a significant number of patients can still suffer with
anal incontinence to the point where a stoma may be prefer-
able [83, 84].
For rectal cancer, restorative rectal resection and radio-
therapy affect the ability of the rectum to act as a reservoir.
The position of the tumour and the level of the anastomosis
affect the risk of anal incontinence; low tumour height and
the use of neoadjuvant therapy are key risk factors for poorer
outcomes [85]. A reduction in rectal sensation and a change
in colonic motility are also seen post-operatively which indi-
cates that nerve damage may also contribute.
Various methods exist to attempt to replace the rectal stor-
age reservoir including the formation of an ileoanal pouch
and the colonic J pouch. There is a paucity of data examining
long-term outcomes, but at 18  months, the risk of faecal
incontinence is less with a colonic J pouch compared to a
straight anastomosis [84].
Other Surgeries
Ureterosigmoidostomy
Mixing stool with urine produces loose stool which can
affect anal continence [2].
Hysterectomy
There is conflicting evidence regarding the association
between hysterectomy and anal incontinence [54]. Nerve
injury is thought to be a possible cause though this has not
been proven.
Cholecystectomy
Cholecystectomy is an independent risk factor for anal
incontinence [54]. The reasons may be due to post-­
cholecystectomy diarrhoea or rectal irritation and therefore
rectal urgency secondary to bile salt malabsorption.
29.3.3.14 Smoking
Smoking is an independent risk factor for anal incontinence
in patients over 40 years [54]. There is also an association
between smoking and anal incontinence and smoking in
post-partum patients [86]. Possible mechanisms for include
fast transit secondary to nicotine and the anti-oestrogen
effect of nicotine [12].
29.3.4 Future Directions
• It is now clear that anal incontinence occurs in men to the
same degree as women, and so future research will likely
concentrate on pathophysiology in males.
• Modifications in delivery techniques and education of
doctors and midwifes are needed to reduce to rate of
obstetric trauma.
29  Overview: Epidemiology and Aetiology of Anal Incontinence
• The multifactorial nature of anal incontinence is begin-
ning to be appreciated, but more work is needed to under-
stand the interaction between the pelvic floor and the gut;
the microbiome may influence gastrointestinal function
more than we realise.
• Research on the ageing process and its contribution to
anal incontinence is underway with the hope that prevent-
able and modifiable risk factors will be found. The ability
to identify specific phenotypes or genotypes which are
susceptible may be possible.
• A true understanding of the rectum as a storage facility
and the causes of rectal urgency is required.
• Epidemiological studies of pelvic organ prolapse and anal
incontinence are required.
Take-Home Messages
• Anal incontinence is a common condition whose
prevalence and burden is expected to increase in the
future. Better-quality epidemiological studies are
expected as barriers to reporting symptoms are bro-
ken down.
• Anal incontinence is multifactorial and is just as
important in men as in women. A better understand-
ing of its aetiology will mean that risk factors can
be modified to aim for prevention rather than cure.
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 Patient-Reported Outcome Assessment
in Anal Incontinence
Toshiki Mimura
Learning Objectives
• To obtain concise idea of how a Patient-Reported
Outcome Assessment Measure (PROM) is devel-
oped and how its reliability, validity, and respon-
siveness are evaluated
• To know the currently available and widely used
PROMs for anal incontinence
• To know how to choose appropriate PROMs for
clinical practice and research in patients with anal
incontinence
30.1 Introduction
Fecal, flatus, and mucus incontinence are defined as “the
involuntary loss of feces,” “the involuntary loss of rectal gas
or flatus,” and “the involuntary loss of mucus only (without
feces)”, respectively, according to the 6th International
Consultation on Incontinence [1]. Anal incontinence (AI) is
an umbrella term to cover the fecal, flatus, and mucus incon-
tinence, being defined as “the involuntary loss of feces and/
or flatus and/or mucus.” AI impairs the quality of life (QOL),
causing embarrassment and psychological distress, as well
as limiting daily activities [2]. To choose an optimal therapy
and evaluate the efficacy of treatment, individual symptoms
and their impact on QOL must be assessed as accurately and
objectively as possible. In order to evaluate the AI symptoms
and its impact on QOL, reliable and valid instruments must
be used, particularly in research settings.
A Patient-Reported Outcome Assessment (PRO) is
defined as “any report of the status of a patient’s health con-
dition that comes directly from the patient, without interpre-
T. Mimura (*)
Division of Gastroenterological, General and Transplant Surgery,
Jichi Medical University, Tochigi, Japan
e-mail: mimurat@jichi.ac.jp
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_30
30
tation of the patient’s response by a clinician or anyone else”
[3]. PROs measure different aspects of symptom severity and
its impact on QOL such as symptom frequency and degree,
health-related quality of life (HRQoL), and satisfaction for
treatment.
For the evaluation of AI including FI, many Patient-­
Reported Outcome Assessment Measures (PROMs) have
been developed and validated including Cleveland Clinic
Florida Fecal Incontinence Score (CCFIS, namely, Wexner
score) [4], St Mark’s Incontinence Score (SMIS) [5], Fecal
Incontinence Severity Index (FISI) [6], Fecal Incontinence
Symptom Severity Scale (FISS) [7, 8], Fecal Incontinence
Quality of Life Scale (FIQL) [9], Modified Manchester
Health Questionnaire (MMHQ) [10], International
Consultation on Incontinence Questionnaire Bowels
(ICIQ-B) [11], and so forth. The CCFIS, SMIS, and FISI are
mainly used to evaluate AI symptomatic severity although
many of them include a few QOL components including life-
style alteration and usage of pads due to AI or anxiety for
AI. On the other hand, the FIQL, MMHQ, and ICIQ-B are
used to assess the AI- or FI-specific QOL, although MMHQ
and ICIQ-B include several items to evaluate symptomatic
severity.
In this chapter, firstly, the principal methods to develop
PROMs and to evaluate their reliability, validity, and respon-
siveness are briefly described. Secondly, the currently avail-
able and relatively widely used PROMs for AI are described.
Lastly, it is proposed how to choose appropriate PROMs for
AI in clinical practice and research.
30.2 Development of PROMs
The development of a PROM with its evaluation of reliabil-
ity and validity is an extremely complicated, demanding, and
time-consuming task, while its efforts are well rewarded if it
is widely used in clinical practice as well as in research set-
tings for the benefits of patients, healthcare professionals,
and researchers. Although its detailed explanation is not a
399
400
scope of this chapter, it is briefly described so that the char-
acteristics and significance of each PROM and the difference
between them can be understood.
For a formal development of a PROM, candidate items
for relevant questions are generated by a panel of experts and
preferably with patients. After they are administered to a
group of patients, the final PROM is formed by removing
redundant questions and is grouped into subscales by princi-
pal component analysis (namely, exploratory factor analy-
sis). At the same time, their wordings and expressions are
refined so that patients can understand them more clearly and
easily. Ideally, it is to be evaluated by confirmatory analysis
in another group of patients to confirm that the grouping of
the subscales is appropriate. In the development of FIQL [9],
for example, a 41-item questionnaire was generated by an
expert panel including colorectal surgeons and health service
researchers, and it was reduced into a final 29-item question-
naire by principal component analysis. The number of sub-
scales was also reduced from 6 to 4 by confirmatory
analysis.
30.3 Evaluation of Reliability, Validity,
and Responsiveness of PROMs
All PROMs must demonstrate reliability, validity, and
responsiveness, although their demonstration is not easy to
perform due to variations in scale construction, data report-
ing, and validity testing [12].
Reliability  refers to the ability of a measure to produce
similar results when assessments are repeated. Two methods
should be performed to demonstrate the reliability. One is the
questionnaire’s internal consistency, which indicates how
well individual items within the same subscale correlate. To
assess internal consistency, Cronbach’s alpha coefficient is
used and should be greater than 0.70 to demonstrate good
internal consistency reliability [13, 14]. The other is test-­
retest reliability, or reproducibility, which indicates how
well the results can be reproduced with repeated question-
naire. To assess test-retest reliability, the same patient com-
pletes the questionnaire twice at baseline and again after
some interval, usually 2–4  weeks while the conditions of
patients remain almost the same. Too short interval could
cause recall bias, while too long interval may question the
stability of patients’ conditions including their symptoms.
The intraclass correlation coefficient is used to demonstrate
reproducibility and should be 0.70 or over to demonstrate
good test-retest reliability [13, 14].
Validity  refers to the ability of a questionnaire to measure
what it is intended to measure.
T. Mimura
To demonstrate validity, content validity and construct
validity consisting of convergent validity and discriminant
validity as well as criterion validity should be performed
[13, 14].
Content validity is a qualitative assessment of whether the
questionnaire evaluates the content it is intended to measure.
To obtain content validity, patients review the measure and
provide feedback as to whether the questions are clear,
unambiguous, and comprehensive.
Convergent validity is a quantitative assessment of
whether the questionnaire measures the theoretical construct
it is intended to measure. It indicates whether a questionnaire
has stronger relationships with similar concepts or variables.
To demonstrate convergent validity, stronger relationships
should be seen with the most closely related constructs with
Spearman’s correlation coefficient of at least 0.70.
Discriminant validity indicates whether the questionnaire
can differentiate between known patient groups (e.g., those
with mild, moderate, or severe disease). To demonstrate dis-
criminant validity, the scores of the questionnaire should be
significantly different among the known patients’ groups
divided depending on the severity of disease or symptom
using some established score or test.
Criterion validity reflects the correlation between the new
questionnaire to be evaluated and an accepted reference or
gold standard. One difficulty in demonstrating criterion
validity is that a gold standard measure might not be avail-
able. When criterion validity can be established with an
existing measure, the correlation should be between 0.40 and
0.70; correlations approaching 1.0 indicate that the new
questionnaire may be too similar to the gold standard and
therefore is not worthy to be developed.
Responsiveness  indicates whether the measure can detect
change (for better or worse) in a patient’s condition. To dem-
onstrate responsiveness, the score should be significantly dif-
ferent before and after some intervention.
30.4 A
 nal or Fecal Incontinence Symptom
Severity Scales
More than 20 scales have been reported for rating the sever-
ity of anal or fecal incontinence [1]. Among them, the most
widely used has been Cleveland Clinic Florida Fecal
Incontinence Score (CCFIS, namely, Wexner score) [4],
which was published in 1993. The scales that were reported
before CCFIS are now rarely used and were reviewed by
Pescatori et al. [15]. Eight scales that are currently used are
summarized in Table 30.1 with their characteristics as well
as the presence or absence of confirmation regarding reli-
ability, validity, and responsiveness. Among them, the
Table 30.1  Anal/Fecal Incontinence Symptom Severity Scale
Inclusion Inclusion
Inclusion of of amount of
Published gas Inclusion of fecal HRQOL Internal Test-retest Content Convergent Discriminant Criterion
year Content included in score incontinence of urgency leakage items consistency reliability validity validity validity validity Responsiveness
CCFIS [4] 1993 Frequency of leakage of Yes No No Yes: 1 No [16] Yes [5, – Yes [5, 16] Yes [17] Yes [17] Yes [5, 18]
flatus, liquid stool, and item 16]
solid stool, pad use, and
lifestyle alteration
SMIS [5] 1999 Frequency of leakage of Yes Yes No Yes: 1 No [16] Yes – Yes Yes [19] Yes [19] Yes [18, 19]
flatus, liquid stool, and item
solid stool, pad use and
lifestyle alteration,
urgency, use of
constipating medication
FISI [6] 1999 Frequency of leakage of Yes No No No Yes Yes – – Yes Yes Yes [28]
flatus, mucus, liquid
stool, and solid stool
Weighting of each
symptom and frequency
was made
FISS [7] 2004 Frequency of FI, type/ Yes Yes Yes No Yes Yes – Yes Yes Yes Yes
30  Patient-Reported Outcome Assessment in Anal Incontinence

amount of leakage (flatus

only, small or moderate-
large amount of stool),
pad use, urgency
RFIS [16] 2013 Frequency of leakage of No Yes Yes Yes: 1 Yes Yes – Yes Yes Yes Yes
liquid and solid stool, item
urgency, need to change
underwear, lifestyle
alteration
LARS 2012 Frequency of leakage of Yes Yes No Yes: 1 – Yes Yes Yes Yes Yes No
[22] flatus and liquid stool, item
urgency, bowel frequency,
clustering of defecation
MMHQ 2005 Frequency of leakage of Yes Yes No Yes: 24 Yes Yes – Yes – Yes Yes
[10] flatus, mucus, liquid items
stool, and solid stool
ICIQ-B 2011 Bowel pattern score: 5 Yes Yes No Yes: 6 Yes Yes Yes Yes Yes Yes Yes
[11] items items
Bowel control score: 7
items
CCFIS, Cleveland Clinic Florida Fecal Incontinence Score; SMIS, St Mark’s Incontinence Score; FISI, Fecal Incontinence Severity Index; FISS, Fecal Incontinence Symptom Severity Scale;
RFIS, Revised Faecal Incontinence Scale; LARS, Low Anterior Resection Syndrome; MMHQ, Modified Manchester Health Questionnaire; ICIQ-B, International Consultation on Incontinence
Questionnaire Bowels
– indicates no validation study found
401
402 T. Mimura

CCFIS, St Mark’s Incontinence Score (SMIS) [5], and Fecal Table 30.3  St. Mark’s Incontinence Score (SMIS) (Ref [5])
Incontinence Severity Index (FISI) [6] are the most widely Never Rarely Sometimes Weekly Daily
used in clinical studies at present. Incontinence for solid 0 1 2 3 4
stool
Incontinence for 0 1 2 3 4
Cleveland Clinic Florida Fecal Incontinence Score liquid stool
(CCFIS)  (Table 30.2) was introduced in a paper published Incontinence for gas 0 1 2 3 4
in 1993, including the frequency of leakage of flatus and liq- Alteration in lifestyle 0 1 2 3 4
uid and solid stool as well as the frequency of pad usage and No Yes
lifestyle alteration [4]. It has been called “Wexner score” Need to wear a pad or 0 2
after the name of Dr Steven D. Wexner, who is a worldwide plug
Taking constipating 0 2
famous surgeon and the last author of the CCFIS paper, medicines
although its first author is J. Marcio N. Jorge. Nowadays, it Lack of ability to defer defecation for 0 4
tends to be called CCFIS rather than Wexner score following 15 min
the public trend to use a general term rather than a proper Never, no episodes in the past 4  weeks; rarely, 1 episode in the past
name. Besides, at the time of its publication, CCFIS was not 4 weeks;
validated as a PROM and was just introduced as one of the Sometimes, >1 episode in the past 4 weeks but <1 a week; weekly, 1 or
more episodes a week but <1 a day;
instruments used in clinical practice at Cleveland Clinic Daily, 1 or more episodes a day
Florida. One of the important roles of PROMs is that the Add one score from each row: minimum score = 0 = perfect continence;
same scale is widely used in many studies so that the results maximum score = 24 = totally incontinent
can be easily and reliably compared among them even if the
scale itself is not perfect, and CCFIS has achieved that role. Table 30.4  Fecal Incontinence Severity Index (patient’s perspective)
Later on, the reliability [5, 16], validity [5, 16, 17], and (Ref [6])
responsiveness [5, 18] of CCFIS were confirmed by other Two or Two or
studies, most of which used it to compare with their scales in One to more more
their validation studies. three times Once a times a Once times a
Never a month week week a day day
Gas 0 4 6 8 11 12
St Mark’s Incontinence Score (SMIS)  (Table 30.3) was Mucus 0 3 5 7 10 12
created on the basis of CCFIS and added two new items Liquid 0 8 10 13 17 19
including an assessment of fecal urgency and the use of con- stool
stipating medication [5]. SMIS is sometimes called “Vaizey Solid 0 8 10 13 16 18
stool
score” after the name of Ms. Carolynne J. Vaizey, who is the
first author of the SMIS paper. Fecal urgency is obviously an The question asked “For each of the following, please indicate on aver-
age how often in the past month you experienced any amount of acci-
important symptom in patients with fecal incontinence (FI) dental bowel leakage: Check only one box per row”
even if it does not result in actual FI because they cannot help
staying near the toilet to avoid FI due to their fear of fecal urgency, which is an extremely distressing symptom. It is
questionable, however, whether fecal urgency can be cor-
Table 30.2 Cleveland Clinic Florida Fecal Incontinence Score rectly evaluated with the item used in SMIS, which is “Lack
(CCFIS) (Ref [4]) of ability to defer defecation for 15 min.” Even some people
Frequency who have no symptoms of FI in their daily life might find it
Type of incontinence Never Rarely Sometimes Usually Always difficult to defer defecation for 15 min. Therefore, a lower
Solid stool 0 1 2 3 4 threshold, perhaps 5  min, might be more appropriate.
Liquid stool 0 1 2 3 4 However, it has been demonstrated that SMIS correlates
Gas 0 1 2 3 4 moderately well with patients’ subjective perception and is
Wears pad 0 1 2 3 4
suitable for the severity assessment of FI and the evaluation
Lifestyle alteration 0 1 2 3 4
of a treatment outcome [19].
0 = perfect
20 = complete incontinence
Never = 0 (never) Fecal Incontinence Severity Index (FISI)  (Table 30.4) is
Rarely = <1/month based on the frequency of leakage of gas, mucus, and liquid
Sometimes = <1/week, ≥1/month and solid stool [6]. FISI has two distinct characteristics com-
Usually = <1/day, ≥1/week
Always = ≥1/day pared with CCFIS and SMIS. One of them is that FISI purely
The continence score is determined by adding points from the above evaluates the severity of anal incontinence (AI) without any
table, which takes into account the type and frequency of incontinence component of QOL. Both CCFIS and SMIS include usage of
and the extent to which it alters the patient’s life
30  Patient-Reported Outcome Assessment in Anal Incontinence 403

pad and lifestyle alteration with the former reflecting of gastrointestinal symptoms, particularly FI, constipation,
patients’ degree of fastidiousness and the latter being influ- and irritable bowel syndrome [7]. FISS is a part of FICA and
enced by their degree of anxiety for AI.  Even if patients contains only four questions regarding frequency of FI, usual
become completely continent to feces by some therapy, most type of bowel incontinence, number of protective pads
of them are still worried about the possibility of bowel acci- changed per day, and urgency. FISS evaluates the amount of
dents and keep wearing pads and staying near the toilet. This fecal leakage dividing it into three degrees, although it is a
is why FI is called a symptom of “anxiety.” The scores of subjective and gross classification of “Gas only or only
CCFIS and SMIS, therefore, do not become zero for a long enough to stain your underwear (size of quarter),” “Small
time even when AI itself is completely cured until patients amount of stool,” and “Moderate to large amount of stool.”
become sufficiently confident. From this aspect, CCFIS and
SMIS are not just scales to evaluate AI symptom severity Revised Faecal Incontinence Scale (RFIS)  (Table 30.6)
alone, reflecting AI-specific QOL to some extent. On the was developed examining the psychometric properties of
other hand, FISI evaluates only AI symptoms, and its score many fecal incontinence items including CCFIS, which were
becomes zero if the AI is completely cured by some therapy included in a large community survey of 2915 subjects [21].
no matter how much patients are still worried about it. RFIS does not contain gas incontinence purely evaluating FI,
whereas all the other scales include gas incontinence result-
The other characteristic of FISI is that each score of AI
type and frequency combination has weightings in FISI, Table 30.5  Fecal Incontinence Symptom Severity Scale (FISS) (Ref [7])
whereas gas and liquid and solid stool incontinence have the 1 2 3
same score from 0 to 4 depending on its frequency in CCFIS Frequency of Up to once/month <2/week ≥2–3/week
and SMIS. In other words, solid stool incontinence is regarded incontinence
as indicating the same severity as gas incontinence in CCFIS Usual type of Gas only/only Small Moderate to
and SMIS, which might not be realistic nor acceptable to bowel enough to stain amount of large amount
incontinence your underwear stool of stool
patients. The weightings like in FISI were proposed by Miller (size of quarter)
et al. [20] in 1988, in which, however, each score from 1 to 9 Number of None One >1
was simply given to three types of incontinence (flatus, fluid, protective pads
and solid stool)  ×  three kinds of frequency combination in changed/day
order. In FISI, its weightings were performed with more sci- Urgency Never Sometimes Often/usually
entific way, and each of AI type and frequency combination Maximum total score = 12. Scores of 1–4, 5–8, and 9–12 were catego-
rized as mild, moderate, and severe fecal incontinence, respectively
was weighted by colorectal surgeons and patients with AI,
which resulted in Table  30.4 from patients’ perspective.
Surgeons and patients had very similar weightings for each of Table 30.6  Revised Faecal Incontinence Scale (RFIS) (Ref [16])
the type and frequency combination, but interestingly in the Often or
frequency of “once a day” and “two or more times a day,” the Never Rarely Sometimes usually Always
scores of liquid stool incontinence were higher than those of Do you leak, have 0 1 2 3 4
accidents, or lose
solid stool incontinence (17 vs. 16 and 19 vs. 18, respectively)
control with solid
from patients’ perspective, whereas the scores of liquid stool stool?
incontinence were lower than those of solid stool inconti- Do you leak, have 0 1 2 3 4
nence (16 vs. 17 and 18 vs. 19, respectively) from surgeons’ accidents, or lose
perspective. This is probably because surgeons tend to think control with liquid
stool?
that solid stool incontinence is a more severe symptom than Do you leak stool if 0 1 2 3 4
liquid stool incontinence assuming that FI is mainly caused you don’t get to the
by poor anal function. On the other hand, some patients might toilet in time?
have had the experience of liquid stool incontinence inflicting Does stool leak so 0 1 2 3 4
that you have to
more severe impact on their QOL than solid stool inconti-
change your
nence, because leaked liquid stool is more difficult to handle underwear?
compared with solid stool. Does bowel or stool 0 1 2 3 4
leakage cause you
Fecal Incontinence Symptom Severity Scale (FISS)  (Table to alter your
lifestyle?
30.5) was developed as a part of Fecal Incontinence and
Rarely, less than once in the past 4 weeks; sometimes, less than once a
Constipation Assessment (FICA) [7] and was separately val- week, but once or more in the last 4 weeks;
idated as a symptom severity scale for AI [8]. The FICA, Often or usually, less than once a day but once a week or more; always,
which contains 98 questions, is a reliable and valid measure once or more per day or whenever you have a bowel movement
404 T. Mimura

ing in AI scales. In the large community survey, the flatus
item of CCFIS had a low item-total correlation, suggesting
redundancy. Besides, the internal consistency of CCFIS was
low (Cronbach’s alpha = 0.58) but improved if the flatus item
was deleted [21]. RFIS also effectively evaluates the amount
of leakage by asking “Does stool leak so that you have to
change your underwear?”. The reliability, validity, and
responsiveness of RFIS were confirmed, being compared
with CCFIS and SMIS [16]. RFIS was demonstrated to have
superior internal consistency and test-retest reliability to
CCFIS and SMIS.
Low Anterior Resection Syndrome (LARS) Score
(Table 30.7) was developed specifically to evaluate the bowel
disorders including FI in patients after rectal resection [22].
Each question has weightings depending on the frequency of
symptoms or bowel movements. One of the characteristics of
patients with LARS is that they have frequent bowel motions
in a short period of time called “clustering,” which is evalu-
ated in LARS score. Besides, a constipation symptom is
evaluated by giving a score of 5 to the infrequent bowel
motion of “less than once per day.” Patients with LARS are,
however, mainly troubled by difficulty evacuating in consti-
pation which is not included in LARS score.
30.5 A
 nal or Fecal Incontinence-Specific
Quality of Life Questionnaire
AI can have a devastating impact on QOL [2], which can be
evaluated by generic or symptom-specific instruments. Most
symptom severity scales also include one or two questions
related to impact of AI on QOL including lifestyle alteration
[4, 5, 7, 16]. AI-specific QOL questionnaires have more
questions that provide a refined assessment of the impact of
AI on QOL, including Fecal Incontinence Quality of Life
Scale (FIQL) [9], Modified Manchester Health Questionnaire
(MMHQ) [10], and International Consultation on
Incontinence Questionnaire Bowels (ICIQ-B) [11]. The
MMHQ and ICIQ-B provide a combination of symptomatic
evaluation as well as an assessment of QOL, whereas FIQL
is the only one dedicated FI-specific QOL questionnaire that
is widely used in clinical studies. These three questionnaires
are summarized in Table 30.8.

Fecal Incontinence Quality of Life Scale (FIQL)  was

developed and validated as a part of the project by the
Table 30.7  Low Anterior Resection Syndrome (LARS) score (Ref
[22]) American Society of Colon and Rectal Surgeons (ASCRS)
Add the scores from each Never Less At least
to evaluate FI-specific QOL [9]. It is, therefore, sometimes
five answers to one final than once called ASCRS questionnaire or Rockwood questionnaire
score once per after the first author’s name of the FIQL paper [9]. It was
per week formally developed through item generation by an expert
week
panel, item reduction by a principal component analysis, and
Do you ever have occasions 0 4 7
when you cannot control subscale classification by a confirmatory analysis. Rockwood
your flatus (wind)? et al. [9] confirmed its internal consistency, test-retest reli-
Do you ever have any 0 3 3 ability, discriminant validity, and convergent validity. Its
accidental leakage of liquid responsiveness was also demonstrated by other studies pub-
stool?
lished later [18]. It has 29 questions, consisting of four sub-
More 4–7 1–3 Less
than 7 times times than scales including lifestyle, coping/behavior, depression/
times per day per day once self-perception, and embarrassment.
per day (24 h) (24 h) per day
(24 h) (24 h)
The FIQL is the best FI-specific PROM available at pres-
How often do you open your 4 2 0 5
bowels? ent and deserves to be called the gold standard for the evalu-
Never Less At least ation of the QOL of patients with FI, because it has been
than once most frequently used in many high-quality studies and has
once per been translated and validated in many languages [23–32].
per week
week
The utilization of the FIQL makes it easy to compare inter-
Do you ever have to open 0 9 11 national studies on FI and enables us to conduct international
your bowels again within 1 h multicenter studies in several languages. Using item response
of the last bowel opening? theory, however, Peterson et al. [33] identified some specific
Do you ever have such a 0 11 16 improvements that can be made to each subscale of FIQL
strong urge to open your
bowels that you have to rush and to the FIQL overall. It was proposed that formatting,
to the toilet? scoring, and instructions of FIQL might be simplified, and
Interpretation: 0–20, no LARS; 21–29, minor LARS; 30–42, major that the embarrassment domain should be significantly
LARS revised before use, although the lifestyle domain could be
Table 30.8  Anal/Fecal Incontinence-Specific Quality of Life Questionnaire
No of items Item generation Psychometric
Published for QOL and reduction, Internal Test-retest Convergent Discriminant Criterion validation in
year evaluation Subscale factor analysis consistency reliability validity validity validity Responsiveness other languages
FIQL [9] 2000 29 Lifestyle Yes Yes Yes Yes Yes – Yes [18] Yes
Coping/behavior
Depression/
self-perception
Embarrassment
MMHQ 2005 24 Role limitations No Yes Yes Yes Yes – Yes No
30  Patient-Reported Outcome Assessment in Anal Incontinence

[10] Physical/social
limitations
Personal
relationships
Emotions
Sleep/energy
Sexual activity
Lifestyle
adaptation
ICIQ-B 2011 6 Sexual impact Yes Yes Yes Yes – – Yes Yes
[11] Quality of life
FIQL, Fecal Incontinence Quality of Life Scale; MMHQ, Modified Manchester Health Questionnaire; ICIQ-B, International Consultation on Incontinence Questionnaire Bowels
– indicates no validation study found
405
406
used as is [33]. The low internal consistency for the embar-
rassment domain (Cronbach’s alpha = 0.68) was also reported
by Ogata et al. [28], and it was proposed to remove the item
Q2-1 from the embarrassment domain because its question is
about a symptom only asking “I leak stool without even
knowing it,” which has no association with the feeling of
embarrassment.
Another problem of FIQL is a simple typo in the original
paper of FIQL [9]. In its table of “scale scoring,” item of Q3d
is included in both Scale 2 and Scale 3. The Q3d in Scale 2
is a simple typo and should be changed to Q3c. This simple
mistake was formally pointed out by Pares et al. [34], which
was acknowledged by Rockwood [35].
30.6 C
 ombined Questionnaire of Anal
Incontinence Severity Scale and Anal
Incontinence-Specific Quality of Life
Questionnaire
In order to assess the severity of AI and to evaluate the effi-
cacy of treatment, particularly in clinical research, both
symptomatic severity and its impact on QOL must be
assessed as accurately and objectively as possible. It is
because the purpose of the therapies for AI is the improve-
ment of patients’ QOL through their symptomatic ameliora-
tion. Symptom severity and its impact on QOL can be
evaluated separately, for example, with FISI and FIQL,
respectively. The CCFIS, SMIS, and RFIS include one ques-
tion about QOL but cannot evaluate AI-specific QOL from
sufficient aspects and are usually used as instruments to
assess symptomatic severity. On the other hand, Modified
Manchester Health Questionnaire (MMHQ) and International
Consultation on Incontinence Questionnaire Bowels
(ICIQ-B) have enough items to evaluate both symptomatic
severity and AI-specific QOL in patients with AI.  Similar
evaluation can be performed with Comprehensive Fecal
Incontinence Questionnaire (C-FIQ), which is a combina-
tion of FISI and FIQL [36]. Therefore, the usage of C-FIQ is
practically the same as using both FISI and FIQL.
Modified Manchester Health Questionnaire
(MMHQ)  was developed to evaluate AI symptom severity
and its impact on QOL with telephone interview [10]. For
the symptomatic severity, it has five questions comprising
four items from FISI and one item of fecal urgency. In the
validation study of MMHQ, the telephone-administered FISI
scores were significantly lower than those yielded by the
self-administered FISI, probably due to the embarrassment
of patients who were reluctant to discuss their symptoms of
AI with interviewers. The correlation between the telephone
and self-administration of FISI was also not high (r = 0.5),
reflecting the individual difference of embarrassment. The
T. Mimura
test-retest reliability for the two-telephone administration of
FISI was high (r = 0.75).
Regarding the AI-specific QOL evaluation, MMHQ has
24 questions consisting of seven subscales including role
limitations, physical/social limitations, personal relation-
ships, emotions, sleep/energy, sexual activity, and lifestyle
adaptation in addition to seven general questions about
bowel habits, sexual activity, and medical history. Kwon
et al. [10] concluded that the telephone-administered version
of the MMHQ showed good-to-excellent validity, internal
consistency, and test-retest reliability.
International Consultation on Incontinence
Questionnaire Bowels (ICIQ-B)  The International
Consultation on Incontinence Questionnaire (ICIQ) modular
questionnaire was developed to meet the need for a univer-
sally applicable standard guide for the selection of question-
naires for use in clinical practice and clinical research for
pelvic dysfunction including urinary tract, vaginal, and
bowel symptoms [37]. The three aims of ICIQ include (1)
recommendation of high-quality self-completion question-
naires according to evidence of validation, (2) promotion of
wider use of questionnaires to standardize assessment of
lower urinary tract and pelvic dysfunction and its impact on
patients’ lives, and (3) facilitation of communication in dif-
ferent patient settings and different patient groups both in
clinical practice and wider clinical research. Sixteen ICIQ
modules/questionnaires are currently available for use, and
the bowel module (ICIQ-B) [11] is one of them. Besides,
more than 50 language versions of various modules have
been validated according to established protocol.
ICIQ-B is a 21-item questionnaire to evaluate AI symp-
toms and their impact on QOL. To evaluate AI symptoms, it
has 15 questions comprising three subscales of bowel pat-
tern, bowel control, and other bowel symptoms, while six
questions are used to assess AI-specific QOL consisting of
two subscales including sexual impact and quality of life.
After all, ICIQ-B contains 17 questions arranged in three
scored subscales of bowel pattern, bowel control, and quality
of life. Besides, a question of “How much does this bother
you?” is asked in 20 items combined with questioning the
frequency of each symptom. It has been demonstrated that
ICIQ-B has acceptable validity, good-to-very-good reliabil-
ity, and reasonable responsiveness [11]. Cotterill et al. [11]
concluded that ICIQ-B is a psychometrically robust, self-­
report instrument for the evaluation of anal incontinence and
its impact on QOL.  Moreover, the committee of the 5th
International Consultation on Incontinence recommends
ICIQ-B as the highest Grade A+ of recommendation to evalu-
ate both symptomatic severity of anal incontinence including
fecal urgency and its impact on QOL [37].
30  Patient-Reported Outcome Assessment in Anal Incontinence
30.7 Recommendation for Practice
in Choosing Appropriate PROMs
for Anal Incontinence
It is commonly assumed that the QOL in patients with AI
worsens with an increase in AI symptomatic severity. This
might be true if they are evaluated in the same individual, but
it does not necessarily mean that AI-specific QOL is always
correlated with AI symptomatic severity. For example, even
if an 80-year old woman, who lives alone and mostly stays at
home due to her knee problems, has daily incontinence to
gas as well as to a small amount of liquid and solid stool and
wears a pad, she might not have to change her lifestyle due to
the anal incontinence because she can change pads and
underwear without being noticed by others and stays home
anyway due to her other health problems. Her symptomatic
severity, therefore, is rated as severe (CCFIS = 16), whereas
her FI-specific QOL would not be so poor (high FIQL score).
On the other hand, if a 35-year-old man, who usually com-
mutes by bus, leaks only solid stool once every other month,
very occasionally in a bus, which cannot be protected by a
pad, he would not be able to leave home every day before he
opens his bowels at home. Consequently, his symptomatic
severity is rated as mild (CCFIS = 5), whereas his FI-specific
QOL would be poor (low FIQL score). In a study by
Bordeianou et  al. [38] which examined the correlation
between FISI and FIQL scores in 502 patients with FI, only
weak to moderate correlations were found between FISI and
all subscales of FIQL (r  =  negative 0.29–0.41). As they
stressed the need of measuring both variables to determine
the true impact of any treatment for FI, it is essential to eval-
uate both AI symptomatic severity and AI-specific QOL in
clinical practice as well as in research settings.
To choose appropriate PROMs for AI, characteristics of
each PROM should be considered. CCFIS has been most
widely used and can evaluate both AI symptomatic severity
and simple AI-specific QOL with only five questions,
although it lacks the ability to evaluate fecal urgency. SMIS
is also frequently used to assess AI symptomatic severity
with a simple evaluation of QOL and urgency. Recently, FISI
has been more and more widely utilized and evaluates AI
symptoms only. Its scores, therefore, become zero if the AI
symptoms are completely cured regardless of patients’ sub-
jective feelings. It also possesses a great advantage of weight-
ings of each symptom and frequency combination. FISS
contains a question to evaluate the amount of leaked stool but
is rarely used. RFIS is similar to SMIS, including a question
of fecal urgency and a simple component of QOL but is also
rarely used. FIQL has been most widely used in clinical stud-
ies to evaluate FI-specific QOL, although it is not suitable for
clinical practice except at dedicated specialized institutions
407
because it consists of as many as 29 questions. MMHQ and
ICIQ-B also have many questions to evaluate both AI symp-
tomatic severity and AI-specific QOL.  They are less fre-
quently used than FIQL probably because of their complexity
to use.
Another issue to be considered is the burdens for patients
to answer PROMs and for healthcare professionals to pre-
pare and calculate them. In clinical practice, therefore,
CCFIS or SMIS is recommended to use, because both can
evaluate AI symptoms along with QOL with a small num-
ber of questions. If fecal urgency is an important issue,
SMIS is more recommended than CCFIS. Bols et al. [18]
also concluded that “there are suggestions that the CCFIS
is most suitable for severity assessment and the FIQL for
evaluating QOL” in a study for responsiveness and inter-
pretation of incontinence severity scores and FIQL in
patients with FI. FISI and FISS should not be used on its
own because they evaluate AI symptoms only, while FIQL
should not be used alone because it assesses only FI-specific
QOL. In clinical research, particularly if it is a prospective
full-scale study, both FISI and FIQL should be used to eval-
uate AI symptomatic severity and FI-specific QOL, respec-
tively and separately. Ideally, CCFIS and SMIS are
recommended to use at the same time for the comparison of
the results with those from other previous studies, because
both of them, particularly CCFIS, have been utilized in
many clinical studies.
30.8 Future Directions
1. CCFIS, SMIS, and FISI will continue to be used to evalu-
ate the symptomatic severity of anal incontinence depend-
ing on each situation of clinical practice and research
settings.
2. FISI might be revised to include a component of fecal
urgency, because no instrument exists that evaluates only
symptomatic severity of anal incontinence including fecal
urgency.
3. FIQL will continue to be used as a gold standard to evalu-
ate the fecal incontinence-specific quality of life.
4. FIQL might be revised, particularly for the domain of
embarrassment, although it could cause some interna-
tional confusion because it has already been translated
and validated in many languages.
5. ICIQ-B is recommended to use in clinical research to
evaluate both symptomatic severity of anal incontinence
including fecal urgency and its impact on quality of life,
because the committee of the 5th International
Consultation on Incontinence recommends it as the high-
est Grade A+ of recommendation.
408
Take-Home Messages
• In clinical practice, CCFIS is recommended to use
for the evaluation of symptomatic severity and sim-
ple assessment of its impact on quality of life in
patients with anal incontinence.
• If fecal urgency is an important issue, SMIS, FISS,
or RFIS is recommended to use in order to evaluate
the symptomatic severity of anal incontinence
including fecal urgency and to simply assess its
impact on quality of life.
• The scores of CCFIS, SMIS, FISS, and RFIS do not
become zero for a long time even when symptoms
of anal incontinence are completely cured until
patients become sufficiently confident. It is because
they continue to wear pads due to their fastidious-
ness and keep staying near the toilet due to their
anxiety for fecal incontinence.
• In clinical research, particularly if it is a prospective
full-scale study, both FISI and FIQL should be used
to evaluate symptomatic severity and its impact on
quality of life, respectively and separately, in
patients with anal incontinence.
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11. Cotterill N, Norton C, Avery KNL, et al. Psychometric evaluation
of a new patient-completed questionnaire for evaluating anal incon-
tinence symptoms and impact on quality of life: the ICIQ-B. Dis
Colon Rectum. 2011;54:1235–50.
12. Lee JT, Madoff RD, Rockwood TH.  Quality-of-life measures
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14. Revicki DA, Osoba D, Fairclough D, et al. Recommendations on
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tional claims in the United States. Qual Life Res. 2000;9:887–900.
15. Pescatori M, Anastasio G, Bottini C, et al. New grading and scor-
ing for anal incontinence. Evaluation of 335 patients. Dis Colon
Rectum. 1992;35:482–7.
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for assessment and outcomes evaluation. Dis Colon Rectum.
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18. Bols EM, Hendriks HJ, Berghmans LC, et al. Responsiveness and
interpretability of incontinence severity scores and FIQL in patients
with fecal incontinence: a secondary analysis from a randomized
controlled trial. Int Urogynecol J. 2013;24:469–78.
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 Anorectal Manometry
31
Filippo Pucciani and Iacopo Giani

tive data from a large number of healthy individuals [2], it

Learning Objectives is considered a valuable and precious test for diagnosis and
• The objective of the chapter is to give information management of fecal incontinence [3].
about the role of the manometry in patients affected
by fecal incontinence. Do not last remember the
role of the manometers in the decision-making pro- 31.2 Manometric Data
cess of patients affected by fecal incontinence and
in the rehabilitation path. Routine diagnostic manometry entails the following:

• Exploration of the anal sphincter apparatus, including

smooth and striated components. Anal resting pressure
31.1 Introduction
(ARP) reflects the tonic activities of both the internal anal
sphincter (IAS) and external anal sphincter (EAS); sev-
Fecal incontinence is defined as failure to control the elimi-
eral studies attribute approximately 55% of ARP to the
nation of stool and/or flatus [1]. The cause may be multifac-
IAS, 15% to the vascular anal cushions, and the remain-
torial because incontinence is often a consequence of
ing 30% to the EAS [4, 5]. Maximal voluntary contrac-
concurrent disruption of some balance mechanisms that
tion (MVC) is the squeeze pressure obtained by asking
maintain continence (anal sphincters, rectal reservoir, rectal
the patient to maximally contract the anus; it reflects the
sensation, pelvic floor integrity, nerve supply to the pelvic
contractile activity of the external anal sphincter
floor, cortical awareness, stool volume and consistency).
(Fig. 31.1).
Diagnostic work-up of fecal incontinence is based on imag-
• Evaluation of the rectoanal inhibitory reflex (RAIR).
ing techniques, to discover abnormalities of anatomical and
RAIR is the reflex inhibition of IAS tone that is elicited
structural integrity involving the sphincter muscles, and on
by distending a rectal balloon with different volumes of
functional instrumental studies, to evaluate the neuromuscu-
air. It is part of the sampling reflex responsible for trigger-
lar function of anorectum.
ing the impulse to defecate [6, 7]. Transient relaxation of
Anorectal manometry is used to identify functional
the IAS allows the stool contents from the rectum to come
sphincter weakness, anorectal reflexes abnormalities, poor
into contact with specialized sensory organs in the upper
rectal compliance, and rectal sensation impairment. Despite
anal canal; typifying of rectal content alerts the patient to
the anorectal manometry limitation secondary to the rela-
discharge flatus or to defecate (Fig. 31.2).
tive absence of standardization of test protocols and norma-
• Detection of rectal sensation. Volumetric perception of
fecal mass is reproduced by distending a rectal balloon
with increasing volumes [3]. Conscious rectal sensitivity
F. Pucciani (*)
Department of Experimental and Clinical Medicine, threshold (CRST) is the lowest volume of air that evokes
University of Florence, Firenze, Italy the first sensation; constant sensation (CS) is the volume
e-mail: pucciani@unifi.it that calls to stool; maximum tolerated volume (MTV)
I. Giani measures the threshold volume for urgency to defecate
Proctology Unit, USL Toscana Centro, Firenze, Italy and for pain.
e-mail: iacopo.giani@uslcentro.toscana.it

© Springer Nature Switzerland AG 2021 411

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_31
412 F. Pucciani and I. Giani

Fig. 31.1  Maximal voluntary

contraction. Top: Control.
Sustained voluntary
contraction
(amplitude ≈ 70 mmHg;
duration ≈ 30″). Below: Fecal
incontinence. Sustained
voluntary contraction
(amplitude ≈ 25 mmHg;
duration ≈ 15″)

Fig. 31.2 Rectoanal
inhibitory reflex (RAIR). (a)
Control. RAIR is elicited by
balloon inflation (arrow:
40 mL): relaxation (measured
by relaxation time—RT) is
followed by contraction
(measured by contraction
time—CT). (b) Fecal
incontinence: contraction time
(CT) is prolonged
31  Anorectal Manometry
• Monitoring of rectal compliance. Rectal compliance, as
determined by the pressure/volume ratio at several dif-
ferent distending volumes, reflects tonic adaptation of
rectal wall (rectum distensibility) to the incoming fecal
load [8].
31.3 A
 norectal Manometry and Fecal
Incontinence
Thanks to these intrinsic features, anorectal manometry is
capable of providing objective information about the mecha-
nisms of fecal continence. When used in incontinent patients,
manometric data suggest which continence mechanisms may
be malfunctioning. However, manometric findings in incon-
tinent patients are aspecific and must be completed with data
obtained using other diagnostic techniques, both morpho-
logic (clinical evaluation and anoscopy, MRI, endoanal
ultrasound) and functional (anal neurophysiologic tests), to
obtain a correct pathophysiological profile of incontinence.
Anal resting pressure may be reduced in fecal inconti-
nence [9]. Dysfunction of the internal anal sphincter may be
suspected in these patients, especially if they have passive
fecal incontinence [10], and endoanal ultrasound will con-
firm the suspicion. A positive correlation between ARP and
the presence of sphincter defects on endoanal ultrasound
[11] has been proven. Incontinent patients with sphincter
defects had significantly lower mean ARP than those without
sphincter defects. It should be noted that the discriminative
power of ARP data between continent and incontinent
patients is poor, with low sensitivity and specificity [12]
because of the wide range of normal pressures. However,
manometry is more precise than a digital examination for the
evaluation of anal tone [13].
Maximal voluntary contraction is frequently impaired in
patients affected by fecal incontinence. Amplitude and dura-
tion of squeeze tone are lower than in healthy controls, with
high sensitivity (92%) and specificity (97%) [14]. This sign
is related to external anal sphincter dysfunction, and often
patients have urge incontinence with loss of stool because of
inability to suppress defecation [10]. Endoanal ultrasound
will be able to detect EAS lesions, and neurophysiologic
anal tests (EMG, pudendoanal reflex) could be useful in
diagnosing pudendal nerve injury [3, 15].
Rectoanal inhibitory reflex, the transient decrease in rest-
ing anal pressure in response to rapid inflation of a rectal
balloon, often cannot be elicited when anal pressures are
very low (<10  mmHg). Therefore, in some incontinent
patients with low ARP, it is not possible to judge if the reflex
is present or absent, if normal or not. However, there are
some reports on RAIR modifications in patients affected by
fecal incontinence. A longer RAIR duration has been showed
in patients with fecal soiling and pruritus ani than in controls
[16]. An ambulatory manometric study confirmed that abnor-
413
mal transient IAS relaxation may lead to fecal soiling and
pruritus ani [17]. The duration of RAIR is also longer in
patients affected by idiopathic fecal incontinence than in
controls; a prolonged contraction time (CT), with a slow
return to the pre-stimulation values, is the typical sign [18].
A longer RAIR impairs the fecal continence mechanism.
When small amounts of stool elicit RAIR with a prolonged
CT in patients with a poor external anal sphincter recruit-
ment and in the presence of a conscious rectal sensitivity
threshold which is higher than that of the RAIR threshold,
fecal passive incontinence may occur.
A significant decrease or loss of rectal sensation (>CRST,
>CS) may contribute to fecal incontinence by impairing the
recognition of impending defecation. When stool enters the
rectum, the perception of rectal distension gives the con-
scious stimulus to contract the anal sphincter for the preser-
vation of continence; if stool is not perceived, the contractive
voluntary response is not elicited and fecal incontinence may
occur. Diabetes mellitus [19] and multiple sclerosis [20] may
exhibit this pathophysiological mechanism of incontinence,
but some other types of patients have the same dysfunction.
Some studies suggest that biofeedback training improves
sensory thresholds [21, 22]. Normalization or reduction of
the first detectable sensation (CRST) correlates with thera-
peutic success, and it is considered of value in the biofeed-
back training of patients with fecal incontinence [3].
The compliance of the rectum, as with the maximum tol-
erated volume, may contribute to fecal incontinence. A
reduction of rectum distensibility decreases rectal capacity,
as testified by simultaneous impairment of MTV, and sub-
stantial decreases in compliance are associated with an
increased frequency of stool, rapid transit of stool through
the rectum, and urge fecal incontinence [3]. Rectal inflam-
mation, fibrosis of the rectum, and radiotherapy and replace-
ment of the rectum, as with sphincter-saving operations, are
all factors that decrease rectal compliance.
31.4 A
 norectal Manometry and Pelvic
Floor Rehabilitation
Anorectal manometry is a diagnostic testing, but above all, it
provides information that can guide management of fecal
incontinence and even a rehabilitation program.
Rehabilitative treatment is the first-line conservative ther-
apy of incontinence after failure of medical treatment. A sys-
tematic review has shown that rehabilitation cures up to half
and improves up to two-thirds of patients [23]. Multimodal
rehabilitation may be used as rehabilitative protocol [24].
The algorithm for this rehabilitation management is based on
manometric reports. Biofeedback and pelviperineal kinesi-
therapy are indicated by low anal resting pressures or weak
maximal voluntary contraction. Volumetric rehabilitation
(sensory retraining) is indicated for disordered rectal sensa-
414
tion or impaired rectal compliance. Electrostimulation is
only a preliminary step when patients need to feel the ano-
perineal plane and increase their awareness. The usual proce-
dural sequence is (1) volumetric rehabilitation, (2)
electrostimulation, (3) pelviperineal kinesitherapy, and (4)
biofeedback. Their combination is suggested by manometric
data. The same protocol of multimodal rehabilitation has
also been used in patients incontinent after sphincter-saving
operations [25]. Very low anal pressure (mean pressure
<17 mmHg) and impairment of both compliance and MTV
were associated with bad postrehabilitative results.
Furthermore, anorectal manometry can help to select candi-
dates for surgical therapy of fecal incontinence. Low anal
resting pressures (<10 mmHg) and low maximal voluntary
contraction (<40  mmHg) are considered cutoff values for
overlapping sphincteroplasty [26]. The same cutoff values
identify those patients with rectal prolapse who are at high
risk for postoperative incontinence, modifying the surgical
strategy of simple correction of prolapse [27].
Particular attention must be paid to these patients who
demonstrate some functional deficit on a neurological basis.
These patients, even if rehabilitated, will demonstrate a
reduction in effectiveness over time [24].
In this particular cohort of patients, it seems to be useful
to introduce in the rehabilitation program, also as a first step,
the use of neuro-rehabilitation. Specifically, the tibial nerve
stimulation given the simplicity of use seems to be the most
suitable instrument in this type of patient [28].
Alternative to the tibial nerve stimulation, we have also
available sacral neuromodulation which has proved effective
ranging from 50% to 90% of treated patients [29].
The therapeutic success of all neuromodulation treat-
ments applied to fecal incontinence seems to be related to a
significant increase of both desire volume to defecate and
maximal tolerated volume [30] able to determine an improve-
ment in the functional balance at the base of the complex
mechanism underlying continence.
Fig. 31.3  Maximal voluntary contraction
F. Pucciani and I. Giani
31.5 High-Resolution Manometry
and High-Definition Three-­
Dimensional Anorectal Manometry
The introduction of high-resolution manometry (HRM) and
high-definition three-dimensional (3D) anorectal manometry
(HDM) has given a new life to the use of anorectal manom-
etry (Figs. 31.3 and 31.4).
These two new options have led to improvements such as
a reduction of secondary movement artifacts to the pull-­
through, no longer necessary with solid-state probes, but
above all an extremely thorough anorectal pressure profile.
In particular, they were able to highlight secondary pressure
asymmetries to defects in a specific muscle portion. Despite
these, HRM and HDM impact on anorectal diseases and in
particular on fecal incontinence was lower than what
occurred for esophageal disorders and above all initial
expectations.
The high cost, the dimensions and the rigidity of the
probes used, the dissimilarity of execution, and reporting of
the examination are the first problems that need a rapid reso-
lution. Then, it will be necessary to evaluate the real impact
of these two methods in the daily clinical practice of the cen-
ters involved in the diagnosis and treatment of anorectal dis-
orders [31].
Take-Home Messages
In conclusion, anorectal manometry may be consid-
ered an important tool in the diagnostic work-up of
fecal incontinence. It offers decisive data for under-
standing the pathophysiology of fecal incontinence
and can modify the therapeutic strategy.
31  Anorectal Manometry 415

Fig. 31.4  RAIR (rectoanal inhibitory reflex) is elicited by balloon inflation (30–40–50 mL): relaxation (measured by relaxation time—RT) is
followed by contraction (measured by contraction time—CT)

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ance: a critical reappraisal. Int J Colorectal Dis. 1990;5:37–40.
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9. Bharucha AE, Fletcher JG, Harper CM, et al. Relationship between
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symptoms and disordered continence mechanisms in women with
21. Miner PB, Donnelly TC, et  al. Investigation of mode of action
idiopathic fecal incontinence. Gut. 2005;54:546–55.
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10. Engel AF, Kamm MA, Bartram CI, et  al. Relationship of symp-
1990;35:1291–8.
toms in fecal incontinence to specific sphincter abnormalities. Int J
22. Ozturk R, Niazi S, Stessman M, et  al. Long-term outcome and
Colorectal Dis. 1995;10:152–5.
objective changes of anorectal function after biofeedback therapy
11. Bordeianou L, Kil Yeon L, Rockwood T, et al. Anal resting pres-
for fecal incontinence. Aliment Pharmacol Ther. 2004;20:667–74.
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23. Norton C, Kamm MA. Anal sphincter biofeedback and pelvic floor
index and with presence of sphincter defects on ultrasound. Dis
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Aliment Pharmacol Ther. 2001;15:1147–54.
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24. Pucciani F, Iozzi L, Masi A, et al. Multimodal rehabilitation for fae-
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sound and anorectal physiology findings affecting continence after
sphincteroplasty. Dis Colon Rectum. 1997;40:462–7.
27. Yoshioka K, Hyland G, Keighley MRB.  Anorectal function after
abdominal rectopexy: parameters of predictive value in identifying
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 Endoanal Ultrasonography in Anal
Incontinence 32
Giulio Aniello Santoro, Luigi Brusciano, and Abdul H. Sultan

Table 32.1  Ultrasonographic scoring system to define the severity of

Learning Objectives sphincter lesion [14]
• To understand the ultrasonographic abnormalities of Defect characteristic Score 0 Score 1 Score 2 Score 3
the anal sphincters in patients with fecal incontinence Internal sphincter
• To understand the role of endoanal ultrasound in the Length of defect None Half or less More than half Whole
Depth of defect None Partial Total –
treatment algorithm for fecal incontinence
Size of defect None ≤90° 91–180° >180°
External sphincter
Length of defect None Half or less More than half Whole
Depth of defect None Partial Total –
32.1 Introduction Size of defect None ≤90° 91–180° >180°

Anal incontinence (AI) is a complex disorder with a multifacto-
rial etiology. Childbirth and anorectal surgery (hemorrhoidec-
tomy, lateral internal sphincterotomy, fistulotomy, and transanal
stapling) are the main causes why the anal sphincters and the
pudendal nerve may be damaged [1–4]. A systematic evaluation
is fundamental for revealing the underlying pathophysiology and
lead to adequate treatment. As previously reported in Chap. 8,
endoanal ultrasonography (EAUS) has been recommended by
the 6th International Consultation on Incontinence (ICI, Tokyo
2017) as the “gold standard” technique for the assessment of
anal sphincters integrity [5]. Features shown by EAUS can help
differentiate between incontinent patients with intact anal
sphincters and those with sphincter lesions (defects, scarring,
thinning, thickening, and atrophy) [6–11]. In addition, a major
impact of EAUS has been to detect undiagnosed sphincter tears
G. A. Santoro (*)
Tertiary Referral Pelvic Floor and Incontinence Center,
IV°Division of General Surgery, Regional Hospital, Treviso,
University of Padua, Padua, Italy
e-mail: giulioasantoro@yahoo.com
L. Brusciano
Division of General and Obesity Surgery, Master of Coloproctology,
University of Campania “Luigi Vanvitelli”, Napoli, Italy
e-mail: luigi.brusciano@unicampania.it
A. H. Sultan
Urogynaecology and Pelvic Floor Reconstruction Unit Croydon
University Hospital, St George’s University of London, London, UK
e-mail: asultan29@gmail.com
(previously believed to be occult tears), reported in up 33% of
primiparous females after vaginal deliveries [4, 12, 13].
Specific scores have been reported to define the severity
of the sphincter damage [14–16]. Starck et al. [14] used a
score from 0 to 16 to describe the extent of the endosono-
graphic defects, with a score of 0 indicating no defect and a
score of 16 indicating a defect of >180° involving the whole
length and depth of the sphincter (Table  32.1). Tears are
defined by an interruption of the fibrillar echotexture.
Scarring is characterized by loss of normal architecture,
with an area of amorphous texture that usually has low
reflectiveness. The operator should identify if there is a
combined lesion of the internal (IAS) and external (EAS)
anal sphincters, and of the puborectalis muscle (PR), or if
the lesion involves just one muscle. The number, circumfer-
ential (radial angle in degrees or in hours of the clock site)
and longitudinal (proximal, distal, or full length) extension
of the defect, presence of scarring, differences in echo-
genicity and thickness of the sphincters, and other local
alterations should be carefully assessed and should always
be described. However, finding a sphincter defect does not
necessarily mean that it is the cause of AI [17]. Indeed,
patients with AI may have intact anal sphincters and puden-
dal neuropathy [3] or primary degeneration of the internal
sphincter [18]. The size of the defects appears to correlate
with the severity of AI, as reported by Thakar and Sultan
[9]; however, Voyvodic et  al. [19] failed to demonstrate a
relationship between muscle injuries and the severity of

© Springer Nature Switzerland AG 2021 417

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_32
418 G. A. Santoro et al.

clinical symptoms. Ultrasonography should, therefore, inte- ric trauma is associated with combined IAS and EAS
grate with anorectal manometry, neurophysiologic tests, or injuries (Fig. 32.4) [14, 16]. A thinning of the IAS of less
other imaging modalities [20, 21]. than 2 mm in a patient more than 50 years old is abnormal,
and the term “primary degeneration of the IAS” has been

32.2 Internal Anal Sphincter Abnormalities

The majority of lesions to the IAS are due to obstetric or

iatrogenic injuries, often in combination with injuries to the
EAS. Minor degrees of AI (soiling) due to IAS injuries have
been reported in 29% of patients after hemorrhoidectomy or
mucoprolapsectomy [22]. Manual anal dilatation [23] or lat-
eral internal sphincterotomy [24] for the treatment of anal
fissure has been associated with AI in 27% and 50% of
patients, respectively. Up to 60% of patients can become
incontinent following fistula surgery [25]. Defects of the
IAS are easily recognized given the prominent appearance
of the IAS in the mid-anal canal, and they appear as hyper-
echoic breaks in the normally hypoechoic ring. The pattern
of sphincter disruption is related to the type of surgery.
Patients who are incontinent after sphincterotomy have a
single defect in the IAS associated with a thickening of the
remaining muscle for a retraction phenomenon (“half-
moon” sign) (Fig.  32.1). Patients who are incontinent fol-
lowing manual dilatation exhibit a diffuse thinning of the
IAS or fragmentation of the IAS at more than one site Fig. 32.2  Endoanal ultrasound performed with 2052 rotating trans-
(Fig. 32.2) [26]. Patients who became incontinent following ducer (BK Medical). Fragmentation of the internal anal sphincter fol-
lowing manual dilatation. Reproduced with permission from Santoro
hemorrhoidectomy have defects in the site of the hemor- GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders. Springer-
rhoidal cushions (Fig. 32.3) [27]. Fistula surgery or obstet- Verlag Italy, 2010

a b

Fig. 32.1  Endoanal ultrasound performed with 2052 rotating trans- retraction phenomenon (half-moon sign). (b) Internal sphincter lesions
ducer (BK Medical). (a) Complete division of the internal anal sphinc- between 3 o’clock and 9 o’clock. Reproduced with permission from
ter between 12 o’clock and 4 o’clock following a left lateral internal Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders.
sphincterotomy for fissure. The remaining muscle appears thicker for a Springer-­Verlag Italy, 2010
32  Endoanal Ultrasonography in Anal Incontinence 419

a b

Fig. 32.3  Endoanal ultrasound performed with 2052 rotating trans- (90°). (b) Three-­dimensional reconstruction in the coronal plane allows
ducer (BK Medical). Internal anal sphincter lesions following hemor- to measure the length of the defect (arrow). Reproduced with permis-
rhoidectomy. (a) Two defects (arrows) can be demonstrated between 2 sion from Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor
o’clock and 6 o’clock (120°) and between 7 o’clock and 10 o’clock Disorders. Springer-­Verlag Italy, 2010

a b

Fig. 32.4  Endoanal ultrasound performed with 2052 rotating transducer (half-moon sign). (b) Reconstruction in the longitudinal plane shows the
(BK Medical). (a) Combined anterior internal and external anal sphincter complete loss of both sphincters anteriorly and the presence of scar.
damage due to obstetric trauma between 10 o’clock and 2 o’clock. The Reproduced with permission from Santoro GA, Wieczorek AP, Bartram
remaining internal sphincter appears thicker for a retraction phenomenon CI (eds) Pelvic Floor Disorders. Springer-Verlag Italy, 2010

used to describe it. Vaizey et  al. [18] reviewed the EAUS
examinations of 38 patients with passive AI and intact anal
sphincter. The IAS appeared thinner than normal and hyper-
echoic, and these conditions were combined with reduced
resting pressure and normal squeeze pressure, rectal sensi-
tivity, and pudendal latency. Incontinent patients with IAS
degeneration were found to be older than those with obstet-
ric trauma. An apparently opposite EAUS condition is an
abnormal thickening of the IAS (Fig. 32.5), typical of older
ages [7], and also seen in patients suffering from myotonia
420
a b
Fig. 32.5  Endoanal ultrasound performed with 2052 rotating trans-
ducer (BK Medical). Abnormal thickness of the internal anal sphincter
(4.1 mm) (arrows) in a 42-year-old female with intra-anal prolapse. (a)
dystrophica. Ultrasonographic imaging helps to assess
results after treatment [28] (Figs. 32.6, 32.7, and 32.8). In a
study by de la Portilla et al. [29], 3D-EAUS evaluation of
injectable silicone biomaterial (PTQ) implants to treat fecal
incontinence due to IAS damage demonstrated that all the
implants were properly located at 3 months. At 24 months,
75% (33/37) of implants were still properly located. The
authors found that the continence deterioration suffered by
most patients after the first year from the injection was not
related to the localization and number of the implants.
32.3 E
 xternal Anal Sphincter
Abnormalities
The most frequent cause of AI is childbirth injury to the
EAS.  Obstetric anal sphincter injuries (OASIS) is a term
used to define trauma to the perineum during vaginal deliv-
ery that includes third- (injury to perineum involving the anal
sphincter complex—EAS and IAS) and fourth-degree tears
(injury to perineum involving the anal sphincter complex and
anal epithelium). When the diagnosis of OASIS is obtained
from EAUS evaluation within 2 months of delivery, the inci-
dence of any degree of anal sphincter defect in primiparous
women is reported to be as high as 27–35%. Between 4%
and 8.5% of multiparous women have a new sphincter defect
[30]. When women sustain an OASIS, they are at increased
risk of developing AI either immediately following c­ hildbirth
or later in life. The true prevalence of AI related to OASIS
may be underestimated. The reported rates of AI following
primary repair of OASIS range between 15% and 61%, with
a mean of 39% [30].
G. A. Santoro et al.
Axial plane; (b) coronal plane. Reproduced with permission from
Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders.
Springer-­Verlag Italy, 2010
All obstetric trauma affects the sphincters anterior to a
horizontal line through the mid-canal. Any tear of the anal
sphincters posterior to this line is usually due to some other
etiology. External sphincter tears from obstetric trauma can
involve any part or thickness of the sphincter and quite often
extend to the full length of the sphincter [4, 9–11]. The ultra-
sonographic appearance of an EAS defect is a break in the
circumferential integrity of the mixed hyperechoic band. A
defect can have either a hypoechoic or hyperechoic density
pattern. This corresponds to replacement of the normal stri-
ated muscle with granulation tissue and fibrosis. The major-
ity of OASIS are associated with a single, large defect in the
anterior EAS but can be associated with a defect of the IAS
(Figs. 32.9, 32.10, 32.11, and 32.12). In examining a female,
it is important to remember the ultrasonographic differences
between the natural gaps (hypoechoic areas with smooth,
regular edges, occurring in the upper part of the anal canal)
and the sphincter ruptures (mixed echogenicity due to scar-
ring, with irregular edges and loss of symmetry) occurring at
the upper anterior part of the anal canal. There is some evi-
dence to suggest that EAUS performed after vaginal birth
and before the tear has been repaired could lead to improved
primary repair of the IAS and EAS resulting in reduced rates
of AI and improved quality of life for women. One random-
ized trial of 752 primiparous women compared clinical
examination (routine care) to the use of EAUS prior to peri-
neal repair. EAUS was associated with a reduction in the rate
of severe AI at greater than 6 months postpartum (risk ratio
RR 0.48) (Level of Evidence 2) [31]. More high-quality ran-
domized controlled trials are needed before the routine use
of EAUS on the labor ward can be supported. Cost and train-
ing required to implement EAUS should be considered.
32  Endoanal Ultrasonography in Anal Incontinence
a b
Fig. 32.6  Endoanal ultrasound performed with 8838 linear transducer
(BK Medical). (a) Bulking agent injection (PTQ), seen as three hyper-
echoic round-shape areas into the intersphincteric space at 5, 7, and 11
o’clock position, in a female with fecal incontinence due to internal
Endoanal US has an important role in detecting clinically
occult anal sphincter injuries after a vaginal delivery [4, 9–
13]. Using EAUS, Donnelly et al. [32] found anal sphincter
injury in 35% of primiparous vaginal deliveries. Sultan et al.
[4] reviewed EAUS findings in 79 primiparous women
before and after vaginal delivery and identified anal sphinc-
421
sphincter lesion after sphincterotomy for fissure. Reconstructions in the
coronal (b) and sagittal planes (c) allow evaluation of the correct posi-
tion and extent of the material injected
ter defects in 28 (35%), of whom 9 (32%) reported altered
continence to stool. Sphincter defects were not identified in
those women who delivered by caesarean section. Deen et al.
[33] studied 46 patients with postpartum AI and found that
87% had a recognizable anal sphincter defect on EAUS. In a
prospective study, de Parades et  al. [13] did not confirm
422
a b
Fig. 32.7 Endoanal ultrasound performed with 8838 linear transducer
(BK Medical). Gatekeeper implants into the intersphincteric space at 2, 7,
and 11 o’clock position, at the middle level of the anal canal (asterisks).
p­ revious observations that anal sphincter injury is common
after forceps delivery. In a large population of 93 healthy
females, anal sphincter injury was identified by ultrasonog-
raphy in <13% of cases after forceps delivery, and the devel-
opment of FI was not related to these defects. The only factor
with ­significant predictive value for anal sphincter injury was
perineal tear. Pinta et al. [34] analyzed possible risks factors
associated with sphincter rupture during vaginal delivery. A
total of 52 females with a third- or fourth-degree perineal
laceration were compared with 51 primiparous females with
no clinically detectable perineal laceration. EAUS found a
persistent defect of the EAS in 39 females (75%) in the rup-
ture group, compared with 10 females (20%) in the control
group (P < 0.001). An abnormal presentation was the only
risk factor for anal sphincter rupture during vaginal delivery.
Anal incontinence related to anal sphincter defects is likely
to occur even in an elderly population of women who expe-
rienced vaginal deliveries earlier in life [10]. Oberwalder
et  al. [35] reported that 71% of women with late-onset AI
had occult sphincter defects on EAUS results. The onset of
AI was at a median age of 61.5 years. Data are controversial
for the routine use of EAUS in asymptomatic patients after
vaginal delivery [5]. There are no cost-benefit studies of
EAUS in this setting, nor any data on whether asymptomatic
patients could benefit from it. Currently, there is no recom-
mendation about screening women later after vaginal deliv-
ery for occult sphincter defects. Sioutis et al. [36] highlighted
the risk of over diagnosis of third-degree tears, which
occurred in 7% of cases.
G. A. Santoro et al.
The internal sphincter is interrupted from 6 to 9 o’clock position due to
fistula surgery. The remaining muscle appears thicker for a retraction phe-
nomenon (half-moon sign) (a) axial plane; (b) multiplanar reconstruction
Distinguishing isolated tears of the EAS from those
involving the support structures is often difficult, as these
structures are an integral part of the sphincter [37]. Tears of
the puboanalis create asymmetry of the low reflective trian-
gular area just inside the PR that extends down into the lon-
gitudinal layer (Fig.  32.13). Tears to the transverse perinei
are seen as asymmetrical to these structures just below and
lateral to the PR (Fig. 32.14). A limitation of EAUS is the
definition of EAS atrophy in patients with idiopathic AI
because of the vague contours of the muscle ring [38]. The
reason for this is that fat replacement and loss of muscle
fibers reduce the clarity of the outer interface reflection, so
that the outer border of the EAS is not visible and therefore
it is impossible to measure its thickness. Endoanal magnetic
resonance imaging (MRI) is more accurate in detecting atro-
phy as there is a thinner EAS, with replacement of muscle by
fat [38–40]. High-resolution multiplanar ultrasonography
may help to detect sphincter damage [41–45]. Three-­
dimensional reconstruction offers the possibility of measur-
ing EAS length, thickness, area, and volume. The relationship
between the radial angle and the longitudinal extent of a
sphincter tear can be assessed and graded. The length of the
remaining intact sphincter muscle can also be evaluated,
improving the selection of patients for surgical repair of the
anal sphincter complex and helping the surgeon to judge how
far the repair should extend. A rendering technique can be
particularly useful in evaluating anal sphincter lesions [42].
By using a combination of different postprocessing display
parameters, the rendered image provides better visualization
32  Endoanal Ultrasonography in Anal Incontinence 423

a b

c d

Fig. 32.8  Endoanal ultrasound performed with 2052 rotating trans-
ducer (BK Medical) in a 56-year-old male, with persisting incontinence
after Gatekeeper implants. Ultrasound shows that the Gatekeeper
(arrows) was not implanted in the correct position: (a) the Gatekeeper
at 7 o’clock was implanted at the puborectalis muscle level; (b) the
Gatekeeper at 9 and 11 o’clock was implanted into the muscular fibers
of the external sphincter; (c) the Gatekeeper at 5 o’clock was implanted
outside the external sphincter into the ischioanal space; (d) the
Gatekeeper at 3 o’clock position was implanted at the lower level of the
anal canal, into the subcutaneous space

performance when there are minor degrees of difference of
echogenicity between lesions and surrounding tissues.
Compared with normal mode, a rupture of the EAS in the
anal canal can be better visualized by setting the render mode
with high-opacity, normal-thickness, and high-luminance
parameters (Fig. 32.15). An EAS tear will appear as a low-­
intensity defect in the context of the brightest segments of
this striated muscle. It is also possible to detect EAS atrophy
by using render mode with a normal-opacity, high-thickness,
and high-luminance setting, in order to separate the color
and the intensity data of muscular fibers and fat tissue
replacement [39].
EAUS also serves as a surveillance tool to monitor results
after sphincteroplasty or graciloplasty (Figs.  32.16 and
32.17) [46–48]. EAUS may have a role after perineal repair
in the evaluation of residual injury and in the management
of subsequent pregnancies (Figs.  32.18, 32.19 and 32.20)
[49]. There are no systematic reviews or randomized con-
trolled trials to suggest the best method of follow-up after
OASIS. Studies show a high frequency of endosonographic
424 G. A. Santoro et al.

a b

Fig. 32.9  Endoanal ultrasound performed with 8838 linear transducer (BK Medical). Obstetric anal sphincter injuries grade 3A. At 12 o’clock
position, there is a damage (arrows) involving lesser than 50% of the external sphincter. (a) Axial plane; (b) axial plane; (c) coronal plane

sphincter defects after primary repairs in between 54% and
93% of women [50–52]. These data emphasize the impor-
tance of adequate repair of OASIS and demonstrate that
repair can be difficult or underestimated. The current guide-
lines of the UK Royal College of Obstetricians and
Gynecologists (RCOG) do not make recommendations
about using EAUS for confirming a complete primary repair
[53]. According to this guidelines, if a woman is experienc-
ing AI at follow-up after repair, referral to EAUS should be
­considered. A persistent ultrasound-detected defect in the
anal sphincter muscles after OASIS is associated with AI
[54]. Reconstruction of the entire length of the EAS is cru-
cial. Incontinence after primary repair of OASIS is related
to relative length of reconstructed EAS and to the extent of
the ultrasonographic defects demonstrated by 3D-EAUS
(Fig.  32.20) [55]. In a prospective study that assessed at
long term the function and morphology of the anal sphinc-
ters and the pelvic floor after primary repair of OASIS,
women who experienced deterioration of continence over
time following repair had a significantly shorter anterior
EAS at 3D-EAUS (Fig. 32.20). EAS length correlated with
increased severity of AI [56]. Savoye-Collet et al. [46] noted
improvement in AI in 18/21 (86%) of patients in whom
EAUS documented closure of the EAS defect after overlap-
ping anterior sphincter repair. In contrast, eight of the ten
patients who had a persistent defect in the EAS still had
significant AI.  Dobben et  al. [47] also found that patients
with a persistent ultrasonographic EAS defect had a worse
32  Endoanal Ultrasonography in Anal Incontinence
clinical outcome than those without an EAS defect
(P  =  0.003). Starck et  al. [48] reported that the extent of
endosonographic EAS defects after primary repair of OASIS
increased over time and was related to AI.
Hemorrhoidectomy, fistulectomy or fistulotomy, anal
dilatation, or lateral internal sphincterotomy can cause AI,
due to anal sphincter injury. This is more likely to occur
during treatment of complex, high fistulas or in patients
who have undergone multiple operations for a recurrent or
persistent fistula. Clinical severity of AI after anorectal sur-
gery is related to EAUS features. More frequently, in
patients with higher clinical severity score, the IAS is
always affected and thicker [57] (Level of Evidence 3).
Fig. 32.10  Endoanal ultrasound performed with 8838 linear trans-
ducer (BK Medical). Obstetric anal sphincter injuries grade 3B. At 12
o’clock position, there is a damage involving the full thickness of the
external sphincter. The internal sphincter is intact
a b
Fig. 32.11  Endoanal ultrasound performed with 8838 linear transducer (BK Medical). Obstetric anal sphincter injuries grade 3C. At 12 o’clock
position, there is a damage (arrows) involving both the external and the internal sphincters. (a) Axial plane; (b) coronal plane
425
EAUS has been used to select the surgical treatment in
patients with AI and to assess the clinical efficacy of the
treatment. In a multicenter observational study on the
implantation of prostheses in patients with AI, EAUS was
used preoperatively to select cases (either intact sphincters
or IAS lesions extending for less than 60° of the anal cir-
cumference), intraoperatively to perform the implants into
the intersphincteric space, and postoperatively to evaluate
the results of surgery and complications (prostheses dis-
lodgement) [58, 59]. 3D-EAUS can be used to quantify
how much sphincter can be safely divided during fistulot-
omy. In a prospective, consecutive study, a strong correla-
tion was found between preoperative 3D-EAUS
measurements of fistula height with intraoperative and
postoperative 3D-EAUS measurements of IAS and EAS
division. Fistulotomy limited to the lower two thirds of the
EAS is associated with excellent continence and cure rates
[60] (Level of Evidence 3).
32.4 Puborectalis Muscle Abnormalities
Defects of the PR are related to childbirth or to anorectal
surgery. At EAUS, a shorter length or complete loss of one or
both branches of the PR can be detected (Fig. 32.21). It is not
possible, however, to identify the detachment of the branches
from the pubic rami, as these cannot be seen with EAUS. For
this reason, endovaginal (EVUS) or transperineal ultraso-
nography (TPUS) represent the best modalities for assessing
PR abnormalities and levator ani damage (see Chaps. 48 and
49). At 3D- and 4D-TPUS, a sharp decrease in echogenicity
is generally observed soon after delivery, which is most
likely caused by stretch trauma of the PR and subsequent
426
a b
Fig. 32.12  Endoanal ultrasound performed with 2052 rotating trans-
ducer (BK Medical). Obstetric anal sphincter injuries grade 4, involving
both the external and the internal sphincters and the anal mucosa. (a)
formation of hematoma and edema [61]. At long-term, an
increased echogenicity of the PR may be due to the replace-
ment of muscular fibers with scar tissue or fibrosis [62].
32.5 Accuracy and Reliability
The main indication for EAUS in patients with AI is to detect
anal sphincter defects and damage to the pelvic floor mus-
cles. Dobben et al. [63] found that anal inspection and digital
rectal examination were not appropriate to detect IAS defects
and inaccurate (true positive rate 36%) for determining EAS
defects <90°. Therefore, in daily clinical practice, a suffi-
cient diagnostic work-up in evaluating AI should include
EAUS [5]. The accuracy of EAUS in the assessment of AI
G. A. Santoro et al.
Damage from 10 to 2 o’clock position replaced by a mixed echogenic
tissue (scar); (b) damage from 9 to 3 o’clock position; (c) coronal plane
reconstruction showing the anterior loss of the anal sphincters
has been supported by surgical findings. Gold et  al. [8]
reported that sensitivity and specificity in locating the defect
were 100%, and accuracy in the topographic detection of the
defect was 90%. Deen et al. [64] investigated 44 incontinent
patients with EAUS.  All sonographically detected EAS
defects were confirmed at operation, and 21 of 22 IAS
defects were also confirmed at surgery. The sensitivity and
specificity of EAUS were 100% for EAS defects and 100%
and 95.5%, respectively, for IAS lesions. Sultan et al. [10]
compared preoperative ultrasonographic findings with intra-
operative findings in 12 consecutive patients who underwent
surgical repair for AI. Endoanal ultrasound correctly identi-
fied all sphincter defects (confirmed histologically) at the
time of surgery. Sentovich et al. [65] examined the accuracy
and reliability of EAUS.  In 22 incontinent women with
32  Endoanal Ultrasonography in Anal Incontinence
a b
Fig. 32.13  Endoanal ultrasound performed with 2052 rotating trans-
ducer (BK Medical). (a) Axial endosonographic image showing a tear
of the left puboanalis (PA) appearing as a scar in the medial aspect of
the puborectalis (PR). BS bulbospongiosus, TP transverse perinei; (b)
a b
Fig. 32.14  Endoanal ultrasound performed with 2052 rotating trans-
ducer (BK Medical). (a) Axial endosonographic image showing a tear
of the left transverse perinei (TP). (b) In the coronal plane, the lesion of
the transverse perinei appears as a hypoechoic band lateral to the exter-
known anal sphincter injury, the accuracy was 100%.
However, in nulliparous women, EAUS falsely identified
sphincter injury in 5–25% of normal anal sphincters. In this
group, an intact IAS was more accurately predicted than an
intact EAS (95% vs. 85%). Overall clinical agreement in the
427
three-dimensional reconstruction in the coronal plane. Reproduced
with permission from Santoro GA, Wieczorek AP, Bartram CI (eds)
Pelvic Floor Disorders. Springer-Verlag Italy, 2010
nal sphincter ring (EAS). Reproduced with permission from Santoro
GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders. Springer-
Verlag Italy, 2010
interpretation of the ultrasound results between experienced
ultrasonographers (interobserver reliability) was good (81%
agreement). Agreement was significantly better for the IAS
(74%, fair) than the EAS (61%, poor; P  =  0.0002) and in
evaluating the distal anal canal (0–1.5  cm) (78%) than the
428 G. A. Santoro et al.

a b

Fig. 32.15  Endoanal ultrasound performed with 2052 rotating trans-
ducer (BK Medical). A 57-year-old female with a large anterior exter-
nal anal sphincter tear between the 9 o’clock and 3 o’clock position,
combined with an internal sphincter defect between the 7 o’clock and
11 o’clock position as a consequence of an obstetric trauma. Compared
with normal mode (a), volume render mode with high-opacity, normal-
thickness, and high-luminance setting provides a better visualization of
the anterior defect of the external sphincter and of the mixed echo-
genicity scar tissue (b). Reproduced with permission from Santoro GA,
Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders. Springer-
Verlag Italy, 2010

a b

Fig. 32.16  Endoanal ultrasound performed with 2052 rotating trans- confirms that the repair was extended to the whole length of the anal
ducer (BK Medical). (a) Anterior external sphincter repair by overlap- canal (anterior thickness of the external sphincter: 15.7 mm)
ping technique (arrows). (b) The reconstruction in the coronal plane

proximal anal canal (2.0–2.5 cm from the anal verge) (48% with respect to combined or isolated IAS tears, although
agreement; P  <  0.0001). However, Gold et  al. [8] found a there was some disagreement regarding isolated EAS tears.
very good (kappa = 0.80) interobserver agreement for diag- Abramowitz et al. [12] demonstrated interobserver concor-
nosis of sphincter disruption. There was no disagreement dance in 98.9% of cases. Benefits of 3D-EAUS in the evalu-
32  Endoanal Ultrasonography in Anal Incontinence
Fig. 32.17  Endoanal ultrasound performed with 2052 rotating trans-
ducer (BK Medical) in a patient with graciloplasty. The gracilis muscle
appears to encircle the whole circumference of the anal canal.
Reproduced with permission from Santoro GA, Wieczorek AP, Bartram
CI (eds) Pelvic Floor Disorders. Springer-Verlag Italy, 2010
ation of AI have been reported [41–45]. Christensen et  al.
[43] investigated the differences between 3D- and 2D-EAUS
in visualizing damage to the anal sphincter complex. The
overall agreement between two observers was 98.2% using
3D and 87.9% using 2D methods. Santoro and Fortling
assessed the differences between 2D- and 3D-EAUS in
defining the longitudinal extent of a sphincter defect in a
series of 33 patients with AI due to obstetrical injury [42].
The longitudinal extent of EAS tear was graded as either
proximal, central, or distal only, or a combination of two lev-
els, or full length involvement. Two-dimensional EAUS
localized the defect in the mid-anal canal in 94% of patients.
After 3D reconstruction, the defects were localized in the
upper plus mid-anal canal in 4 patients (12%), limited to the
mid-anal canal in 22 patients (67%), and in the mid plus dis-
tal anal canal in 6 patients (18%). The overall agreement
between 2D- and 3D-EAUS was moderate (kappa = 0.25) for
EAS tears in the upper plus mid-anal canal, good
(kappa  =  0.71) for mid-anal canal only lesions, and poor
(kappa = 0.14) for defects extending to the mid plus distal
anal canal. West et  al. [44] evaluated whether 3D-EAUS
measurements (EAS length, thickness, area, and volume)
can be used to detect EAS atrophy and compared the results
with MRI measurements. Agreement between 3D-EAUS
and endoanal MRI was 61% for IAS defects and 88% for
EAS defects. However, correlation was poor for EAS atro-
phy, suggesting that 3D-EAUS measurements are not suit-
429
able parameters for assessing EAS atrophy. In another study,
the same authors [66] found that AI in parous females was
not associated with loss of sphincter volume. Williams et al.
[67] assessed changes to anal canal morphology in the
absence of sphincter trauma. After delivery, there was sig-
nificant shortening of the length of the anterior portion of the
EAS, which could only be demonstrated with 3D reconstruc-
tions on longitudinal and coronal planes. This change did not
correlate with any functional symptoms. The authors
reported that only 68% of females with third-degree tears
had 3D-EAUS evidence of sphincter damage. In another
series of 45 women who had had vaginal delivery, the same
authors [45] found evidence of postpartum trauma in 29% of
cases. Damage involved the EAS in 11% of patients, the
puboanalis in 11% of cases, and the transverse perinei in 7%
of cases. External sphincter defects were associated with a
significant decrease in squeeze pressure and an increase in
incontinence score and represented the only functionally sig-
nificant component. Tears to the puboanalis or transverse
perinei did not affect pressure or incontinence score.
Endoanal ultrasonography is the anorectal physiology
modality most likely to change a patient’s management
plan. Liberman et  al. [20] reported that 11% of patients
within a medical group were treated surgically after EAUS
findings of sphincter lesions and 7% of patients were
changed from surgical to medical therapy because of nor-
mal-appearing sphincters at EAUS. Groenendijk et al. [68]
demonstrated a considerable diagnostic value of EAUS in
directing therapy of patients with AI. A decision about the
mode of delivery of pregnancy after OASIS based on symp-
toms, anal manometry, and EAUS helps in preserving anal
sphincter function and avoiding unnecessary caesarean sec-
tions [69–71]. In a descriptive study on a cohort of women
who had OASIS from 2006 to 2013, vaginal delivery was
recommended to asymptomatic women with normal investi-
gations (EAUS and anal manometry), and elective caesar-
ean section was recommended for women with fecal
symptoms anal sphincter defects of more than 30° or low
resting or incremental anal pressures. Caesarean section was
done in 22 women and 28 women delivered vaginally.
Worsening of AI symptoms and reduction in anal pressures
were not observed in the planned vaginal delivery or elec-
tive caesarean section groups. There were no new sphincter
defects or recurrent OASIS in any of the women in the study
group. EUAS can be useful to select patients with AI that
could benefit from rehabilitation. Therapy may be less effec-
tive in patients with sphincter lesions, and there is a linear
relationship between post-rehabilitative scores of AI sever-
ity and severity of sphincter defects [72]. Currently, there is
no evidence to support the use of real-time elastography in
the evaluation of AI. There was an absence of a correlation
in elastogram color distributions of the IAS and EAS with
430 G. A. Santoro et al.

a b

c d

Fig. 32.18  Endoanal ultrasound performed with 8838 linear transducer (BK Medical). (a, b) Failed anterior external sphincter repair by end-to-
end technique. (c, d) The reconstruction in the coronal plane confirms that discontinuation of the anterior repair

major clinical and functional parameters; elastography does
not seem to provide additional information in the diagnostic
work-up of AI [73].
32.6 EAUS Versus EVUS and TPUS
TPUS and EVUS have been recently evaluated as alternative
imaging modalities for the investigation of sphincter integ-
rity in AI [74–78] (Level of Evidence 3). Advantages of these
procedures include the availability of commonly used trans-
ducers, absence of distortion of the anal canal, better patient
acceptability, and possibility for functional studies [77].
Currently there are limited studies that directly compare
these techniques with EAUS [79, 80]. Although the sensitiv-
ity for the detection of sphincter defects ranges from 44% for
EVUS to 50% for TPUS, these modalities can be used in
combination with EAUS, to provide additional information
on pelvic floor muscles and levator hiatus damage. In a pro-
spective, observational study, defects of the pubovisceral
muscle (PVM) were identified with 3D-EVUS in 27% of
women with AI who had undergone vaginal delivery. Severity
of incontinence was related to the extent of damage of the
PVM and to the enlargement of the levator hiatus [81]. These
findings were not confirmed in a retrospective study where
worsening of levator ani deficiency among patients with
major AI did not reach statistical significance [82]. TPUS
may be used as screening modality for the detection of undi-
agnosed anal sphincter injuries after vaginal delivery (Level
of Evidence 2, Recommendation Grade B). 3D-TPUS has
shown good agreement with the gold standard 3D-EAUS and
a high sensitivity in detecting residual defects [83]. In a pro-
32  Endoanal Ultrasonography in Anal Incontinence 431

a b

c d

Fig. 32.19  Endoanal ultrasound performed with 8838 linear transducer (BK Medical). (a, b) Residual defect after anterior external sphincter
repair by end-to-­end technique. (c, d) The reconstruction in the coronal plane shows that the external sphincter was not repaired in the upper part
of the anal canal

spective, randomized controlled trial, the undiagnosed tear
rate increased from 3.5% (clinically detected) to 11.5% by
ultrasound [84]. Future studies should focus on technique
standardization and method as well as on the predictive value
of both EVUS and TPUS compared with EAUS in the detec-
tion of sphincter defects.
32.7 EAUS Versus MRI
Several studies have compared the diagnostic accuracy of
EAUS and endoanal or external phased-array MRI in assess-
ing anal sphincter integrity [38, 85]. The results of these
studies vary, with some of the variability attributable to dif-
ferences in study design, patient population, and the level of
experience of readers [38, 85]. Dobben et al. [86] found fair
agreement (kappa = 0.24) between both imaging techniques
in a multicenter study with a large cohort of patients with
AI.  Malouf et  al. [87] evaluated 2D-EAUS and endoanal
MRI prospectively in 52 patients with AI and reported that
both techniques are comparable in diagnosing EAS defects.
However, 2D-EAUS appeared to be superior in demonstrat-
ing IAS lesions. Rociu et al. [88] retrospectively compared
2D-EAUS and endoanal MRI to surgery in 22 patients with
AI and found MRI to be the most accurate for depicting IAS
and EAS defects. They also found that EAS atrophy can
only be accurately depicted at endoanal MRI and not at
2D-EAUS.  Williams et  al. [41] found that patients with a
thin IAS (<2  mm) and/or a poorly defined EAS at EAUS
were more likely to have EAS atrophy and endoanal MRI
should be considered to determine whether the sphincter is
grossly atrophic. West et  al. [44] evaluated whether
432 G. A. Santoro et al.

a b

c d

Fig. 32.20  Endoanal ultrasound performed with 8838 linear transducer (BK Medical). Short anterior reconstruction of the external sphincter
visualized in the coronal (a–c) and longitudinal planes (d)

3D-EAUS could be used to detect EAS atrophy in 18 32.8 Current Recommendations

females with AI. They reported that, despite the multiplanar
capability, 3D-EAUS was not able to demonstrate EAS atro-
phy. The current consensus is that both techniques can be
used for demonstrating defects of the anal sphincter com-
plex and can be considered useful in the selection of patients
for surgery [86]. Since EAUS is an economical, quicker, and
easily available imaging modality, it may be used as a pref-
erable investigation for the diagnosis of EAS defects in
patients with AI [89].
for Research for EAUS
• Evaluate the role of levator ani damage, visualized with
pelvic floor ultrasound, on AI symptoms and therapy
results.
• Further characterize and standardize the utility of pelvic
floor ultrasound in the clinical assessment of patients with
AI and if it adds extra information useful for clinical
decision-making.
• Assess if pelvic floor ultrasound during rehabilitation pro-
vides more effective treatments for patients.
32  Endoanal Ultrasonography in Anal Incontinence
a b
Fig. 32.21  Endoanal ultrasound performed with 2052 rotating trans-
ducer (BK Medical). Puborectalis muscle damage (arrows). (a) Partial
lesion of the right branch of the puborectalis; (b) Complete loss of the
32.9 Conclusions
Compared with clinical examination (routine care), the use
of EAUS prior to perineal repair of OASIS is associated with
a reduction in the rate of severe AI at greater than 6 months
postpartum (Level of Evidence 2) [31]. Incontinence after
primary repair of OASIS is related to relative length of the
reconstructed EAS and to the extent of the ultrasonographic
defects demonstrated by 3D-EAUS (Level of Evidence 3)
[55, 56]. Clinical severity of AI after anorectal surgery is
related to EAUS features (Level of Evidence 3) [57].
Take-Home Messages
Current Recommendations for Practice for EAUS:
• Decision about the mode of delivery of pregnancy
after OASIS based on symptoms, anal manometry,
and EAUS helps in preserving anal sphincter func-
tion and avoiding unnecessary caesarean sections
(Recommendation Grade B) [31].
• TPUS and EVUS represent alternative imaging
modalities for the investigation of sphincter integ-
rity in AI (Recommendation Grade C) [74–78].
TPUS may be used to screen for undiagnosed anal
sphincter injuries after vaginal delivery
(Recommendation Grade B) [84].
• 3D-EAUS can be used to quantify how much
sphincter can be safely divided during fistulotomy
(Recommendation Grade C) [60].
433
right branch of the puborectalis. Reproduced with permission from
Santoro GA, Wieczorek AP, Bartram CI (eds) Pelvic Floor Disorders.
Springer-­Verlag Italy, 2010
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 Transperineal Ultrasonography
in the Assessment of Anal Incontinence
and Obstetric Anal Sphincter Injuries
Cristina Ros-Cerro, Eva Maria Martínez-Franco,
and Montserrat Espuña-Pons
Learning Objectives
• This chapter has been written to describe how to visu-
alise the anal sphincter complex in patients with faecal
incontinence or history of obstetric anal sphincter
injury (OASI), using exoanal routes. Additionally,
data of the comparison between the exoanal approach
(transperineal, endovaginal) and endoanal ultrasound
(considered the gold standard) are described.
33.1 Introduction
According to the literature, there is a strong relationship
between obstetric anal sphincter injury (OASI) and faecal
incontinence (FI) [1], with the onset appearing immediately
postpartum or years later [2, 3]. After a sphincter tear, the risk
of FI increases in subsequent deliveries [4]. Therefore, imag-
ing techniques are used in the follow-up of women after OASI
to assess the success of intrapartum primary repair as well as
to advise on eventual subsequent pregnancies [5]. The pres-
ence and severity of residual lesions is a prognostic factor and
determines the therapeutic management to be followed [6].
Three-dimensional endoanal ultrasound (3D-EAUS) has
been defined as the gold standard imaging technique for the
evaluation of anal sphincter defects by the International
Consultation on Incontinence (ICI), International Continence
Society (ICS) and International Urogynecological
Association (IUGA) [1, 7]. Nevertheless, although com-
C. Ros-Cerro (*) · M. Espuña-Pons
Pelvic Floor Unit, Institut Clínic de Ginecologia,
Obstetrícia i Neonatologia (ICGON), Hospital Clínic de Barcelona,
Universitat de Barcelona, Barcelona, Spain
e-mail: cros@clinic.cat; mespuna@clinic.cat
E. M. Martínez-Franco
Parc Sanitari Sant Joan de Déu, Sant Boi del Llobregat,
Barcelona, Spain
e-mail: eva.martinezf79@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_33
33
monly used by colorectal surgeons and radiologists, the
equipment and the expertise may not be readily available to
all obstetricians and gynaecologists. In addition, 3D-EAUS
is intrusive because it involves the introduction of a probe
into the anal canal, which some patients consider embarrass-
ing. The endoanal cone of this internal evaluation may also
distend the anal canal. Therefore, since 1994, several exo-
anal approaches, such as transperineal (TPUS) and endovag-
inal ultrasound (EVUS), have been evaluated for the
assessment of anal sphincter integrity. Nonetheless, their use
remains controversial [8–12].
In 1994, Sultan [8] was the first to describe the vaginal
route to visualise the anal sphincter complex. The 360° rotat-
ing probe previously designed for the endoanal approach
was used endovaginally, obtaining clear images of the anal
mucosa, external anal sphincter (EAS) and internal anal
sphincter (IAS). Sphincter defects could be described, deter-
mining that the thickness of the IAS was greater than in
EAUS because the probe did not distend in the interior of the
anus.
After the endovaginal route, the transperineal route was
described, which is currently the exoanal route most fre-
quently used for the evaluation of the sphincter of the anal
complex.
Comparing to EAUS, exoanal routes have the advantatge
of being non-intrusive and more accesible to gynaecologists.
On the other hand, disadvantages of exoanal approaches are
lower resolution than EAUS (1) and possible distorsion of
the upper quadrant of the sphincter (which is the region of
greatest interest in patients with a history of OASI). Finally,
probes for exoanal routes are not in the exact direction of the
anal canal (Table 33.1).
Similar to EAUS, with the exoanal approach, the IAS is
also identified as a homogeneous hypoechoic circular band,
whereas the EAS is defined as a mixed echogenic circular
structure surrounding the IAS [13]. The rectal mucosa is
shown as a star-shaped hyper-refringent image. The puborec-
tal muscle is also observed at the most proximal level.
437
438 C. Ros-Cerro et al.

The optimal timing for postnatal imaging using TPUS is 33.2 Recommendations for Practice
considered at 10–12 weeks postpartum, similar to
3D-EAUS. Since TPUS is non-intrusive, it may be performed 33.2.1 Endovaginal Ultrasound (EVUS)
immediately postpartum [14]; however, oedema, suture
material and haematoma may alter the image leading to As mentioned previously, in the beginning, EVUS was first
inconclusive results [13]. performed using rotating probes, which were first two-­
dimensional and later three-dimensional [8]. Today several
Table 33.1  Advantages and disadvantages of the endoanal ultrasound probes have been specifically designed for the vaginal route,
and the exoanal routes (endovaginal, 2D and 3D transperineal ultra- having a variable sensitivity and specificity for detecting
sound) to visualise the anal sphincter complex OASI [10]. According to some studies, EVUS can reliably
Advantages Disadvantages detect normal anatomy of the anal sphincter [10–15]
EAUS High resolution Not easily available (Fig. 33.1). However, the correlation with EAUS is not good,
Standardised classificationIntrusive making images and volumes difficult to interpret [10, 16].
of defects Distend anal canal
Some studies have reported a percentage of volumes which
EVUS Less intrusive Volumes difficult to interpret
Not easily available and non evaluables are non-evaluable due to poor image quality of up to 47%
2D-TPUS Non-intrusive Low sensitivity and [16]. Therefore, this approach is currently not considered the
Available specificity technique of choice for evaluation of the anal sphincter com-
Low resolution plex (Table 33.1).
No visualisation of the
deepest part of the anal
canal
Non-standardised 33.2.2 Transperineal Ultrasound (TPUS)
classification of defects
3D-TPUS Non-intrusive Distortion of the upper
To visualise the anal sphincter complex, TPUS may be per-
Good correlation with quadrant of the EAS
EAUS to detect the defects Non-standardised formed using a convex multi-frequency probe or an endo-
Available classification of defects cavitary probe. In the latter case, it is also called introital
EAS external anal sphincter, EAUS endoanal ultrasound, EVUS endo- ultrasound. The advantage of introital ultrasonography is
vaginal ultrasound, TPUS transperineal ultrasound that the endocavitary probe works at a higher frequency than

a b

Fig. 33.1  Axial plane of the anal sphincter complex obtained by arrow), whereas the external anal sphincter is defined as a mixed echo-
3D-rotational probe (type 2050, Ultraview 800, BK Medical). (a) genic circular structure surrounding the IAS (red arrow). No defects are
Endovaginal approach; (b) endoanal approach. Internal anal sphincter visible in the image
(IAS) is identified as a homogeneous hypoechoic circular band (yellow
33  Transperineal Ultrasonography in the Assessment of Anal Incontinence and Obstetric Anal Sphincter Injuries 439

a b

Fig. 33.2  Position of the probes to obtain the axial plane of the anal sphincter complex by transperineal approach. (a) Convex multi-frequency
probe inclined in the posterior compartment. (b) Endocavitary probe perpendicular to the horizontal compartment (perineal body)

the convex multi-frequency probe, thereby providing a
higher quality of image in the evaluation of superficial struc-
tures such as the anal sphincter in the introital zone. Probes
with 3D and 4D technology can be used in both routes
(Table 33.1).
The probe should be inserted into the introitus using a
large quantity of gel and with little pressure to avoid distort-
ing the image. The convex probe should be inclined in the
posterior compartment while the endocavitary probe should
be perpendicular to the horizontal compartment (perineal
body) (Fig. 33.2).
33.2.2.1 2D-TPUS
It has been demonstrated that with the use of 2D-TPUS, it is
possible to correctly identify the sphincters [9, 11, 16, 17] in
both asymptomatic women and in those with dysfunction of
the pelvic floor, despite the deepest part of the anal canal
being difficult to evaluate (Fig. 33.3).
This approach can also evaluate lesions in the sphinc-
ters (interruption of the route), although the correlation
with 2D-EAUS is controversial. Some studies have found
a good correlation while others have not [9, 17]. Compared
with 3D EAUS, 2D-TPUS has a good sensitivity for
defects in the EAS but a low sensitivity for defects of the
IAS.
According to the literature available on this technique, it
is not the best exoanal technique for evaluating the anal
sphincter.
33.2.2.2 3D-TPUS
The addition of 3D technology provides better definition of
the anatomical structures and visualisation of the deepest
part of the anal canal. This approach provides volumes which
may be digitally stored and reviewed and discussed offline
by different interpreters, including multiplanar images and
more precise measurements.
440 C. Ros-Cerro et al.

a b

Fig. 33.3  Axial plane of the anal sphincter complex obtained by echogenic circular structure surrounding the IAS (red arrow). (a) No
2D-transperineal ultrasound (2D-TPUS). Internal anal sphincter (IAS) tears are visible; (b) Defects are visible in both IAS and EAS. Arrows
is identified as a homogeneous hypoechoic circular band (yellow show the ends of the defect
arrow), whereas the external anal sphincter (EAS) is defined as a mixed

a b

c d

Fig. 33.4  3D acquisition of the anal sphincter complex. Mid-sagittal (a), coronal (b) and axial plane (c) are shown. (d) is the 3D reconstruction
in the axial plane. No defects are visible in the external anal sphincter (red arrow) nor the internal anal sphincter (yellow arrow)

3D-TPUS is able to describe normal anatomy, evaluating
the whole route of the sphincter complex [14] and measuring
the normal thickness of the sphincters [18].
Criteria of abnormality have been established based on
anatomical normality. Sphincter defects are identified as a
disruption or discontinuity in the ultrasonographic texture of
the sphincters (Fig.  33.4). Defects of the IAS include the
half-moon sign which is translated into retraction of the ends
of the IAS: the image shows a reduction in IAS thickness at
the ends with an increase in thickness in the central zone in
33  Transperineal Ultrasonography in the Assessment of Anal Incontinence and Obstetric Anal Sphincter Injuries
Fig. 33.5  Methodology to describe the sphincters tears as proposed by
Dietz [13], using the tomographic ultrasound imaging technique (TUI).
After obtaining the longitudinal slice of the entire anal canal, 3D–4D
technology is applied, and the option of eight slices is used. The top left
image shows the mid-sagittal plane, whereas the remaining eight
images represent coronal slices through the anal canal. The whole
the shape of a half-moon [19]. Defects are usually described
according to clock face positions, with defects located at the
position between 9 and 12 o’clock being the most frequent
localisations of OASI. The star shape is lost when there are
rectal mucosa lesions. In addition, the thickness of the EAS
may increase after surgery repair providing a heterogeneous
image [19].
To evaluate the presence or not of EAS defects, the cor-
relation with 3D-EAUS is very good [16], improving the
results of 2D-TPUS and showing a high sensitivity for recog-
nising a defect in both sphincters (95% and 73%,
respectively).
Different classification systems of the lesions used in the
EAUS, such as the Starck or Norderval [20], have been
attempted to classify a defect detected by TPUS. Neither sys-
tem has demonstrated to be useful on comparing the trans-
perineal with the endoanal route. Therefore, the group of
H.P. Dietz [21] proposed the definition of ‘significant exter-
nal anal sphincter trauma’ as visible defects of at least 30° in
circumference in at least 4/6 tomographic slices using the
tomographic ultrasound imaging (TUI) technique in
3D-TPUS. This definition attempts to adapt the definition of
Sultan for 3D-EAUS (defect of >30° in 2/3 of the length of
the anal canal) to 3D-TPUS. Methodologically, acquisition
and aperture angles should be reduced to 60–70°, being less
than pelvic floor imaging for levator ani morphology. It is
441
length of the anal canal is analysed by placing the cranial slice (slice n°
1) at the level of the anorectal junction and the last slice (slice n° 8) at
the level of the anal verge, assessing the six central slices. Significant
external anal sphincter trauma is considered when visible defects of at
least 30° in circumference are present in at least 4/6 tomographic slices.
No tears are visible in the image
recommended to obtain the image with the pelvic floor mus-
cle in contraction, although this does not provide any advan-
tage in terms of validity [13]. After obtaining the longitudinal
slice of the entire anal canal, 3D–4D technology is applied.
If TUI is available, the option of eight slices is used. The top
left image shows the mid-sagittal plane, whereas the remain-
ing eight images represent coronal slices through the anal
canal. The whole length of the anal canal is analysed by plac-
ing the cranial slice (slice n° 1) at the level of the anorectal
junction and the last slice (slice n° 8) at the level of the anal
verge, assessing the six central slices (Fig.  33.5). The dis-
tance between the slices depends on the length of the anal
canal, and therefore varies and is adjusted in each patient. As
mentioned previously, significant EAS trauma is considered
when visible defects of at least 30° in circumference are
present in at least 4/6 tomographic slices. It is important to
add that this definition was obtained on analysing a total of
78 women with FI of different aetiologies and severities. In
this population the method presented a good correlation with
the presence of clinical manifestations. However, in a later
study by the same group, a good correlation was not found
between the number of affected slices and the severity of the
symptomatology [22]. It is known that FI is a complex mech-
anism that involves the anatomy of the anal sphincter com-
plex as well as proper functioning of the levator ani muscle,
pudendal nerves and central nervous system [23]. Therefore,
442
Fig. 33.6  Anal sphincter complex visualised using tomographic ultra-
sound imaging technique (TUI) by 3D-transperineal approach, follow-
ing Dietz’s method. Significant external anal sphincter trauma is visible
we cannot define what a clinically relevant lesion is only tak-
ing into account the anatomy of the EAS and the IAS.
If TUI technology is not available, it is also possible to
evaluate the anal canal using the sweeping technique similar
to the analysis of volumes obtained with 3D-EAUS.  The
sweeping technique consists in dragging the render box fol-
lowing the anal canal, from the anal verge to the level of the
anorectal junction, in the longitudinal plane and looking at
the volume rendered to evaluate the anal sphincter and define
the defect (Fig. 33.6).
33.3 Conclusions
–– EAUS with a rotational probe is the gold standard tech-
nique for visualisation of the anatomy of the anal sphinc-
ter complex.
–– The anal sphincter complex can be visualised and eval-
uated using exoanal techniques such as TPUS and
TVUS.
–– The 3D-TPUS exoanal technique has shown a good cor-
relation with clinical manifestations and EAUS, having a
C. Ros-Cerro et al.
because defects (red arrow) of at least 30° in circumference are present
in at least 4/6 tomographic slices (defect in 6/6 in the image)
better sensitivity and specificity for the detection of
sphincter defects than 2D-TPUS or EVUS.
–– There is currently no valid system to classify sphincter
defects observed by TPUS.
–– 3D-TPUS could be proposed as a tool for the initial evalu-
ation or screening of women with symptoms of FI or to
identify residual defects following primary repair of an
OASI, to thereby decide which women have indications
to undergo an endoanal study to more clearly define the
characteristics of the lesion.
–– However, routine use of exoanal routes (TVUS, TPUS)
for the visualisation of the anatomy of the anal sphincter
complex is not recommended [1].
Take-Home Message
The anal sphincter complex can be visualised and eval-
uated using exoanal techniques such as TPUS and
TVUS. However, its use remains controversial due to
the lack of a valid classification system and the stan-
dardisation of the methodology.
33  Transperineal Ultrasonography in the Assessment of Anal Incontinence and Obstetric Anal Sphincter Injuries 443

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defects. Br J Obstet Gynaecol. 1997;104(9):999–1003.
 Magnetic Resonance Imaging
Jeroen A. W. Tielbeek and Jaap Stoker
Learning Objectives
• Recognize the imaging features of fecal
incontinence.
• Describe the accuracy, advantages and disadvan-
tages of EAUS and MRI.
• Identify sphincter defects and atrophy on MRI.
34.1 Introduction
The workup of patients with fecal incontinence primarily com-
prises clinical history, physical examination, anofunctional tests
(e.g., manometry), and endoanal ultrasound (EAUS). Magnetic
resonance imaging (MRI) was introduced in the 1990s as an
alternative for EAUS.  The primary reason was the difficult
delineation of the external sphincter at EAUS. MRI has a high
intrinsic contrast resolution, which has proved to be beneficial
for delineating the external sphincter. In this chapter the role of
MRI in patients with fecal incontinence is described. As treat-
ment is primarily aimed at the external sphincter, the emphasis
is on evaluation of the external sphincter.
34.2 Technique
34.2.1 MRI Coil
In patients with fecal incontinence, MRI has primarily been
studied using an endoluminal coil. The advantage of a dedi-
J. A. W. Tielbeek · J. Stoker (*)
Department of Radiology and Nuclear Medicine, Academic
Medical Center, University of Amsterdam,
Amsterdam, The Netherlands
e-mail: j.a.w.tielbeek@amsterdamumc.nl;
j.stoker@amsterdamumc.nl
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_34
34
cated coil is the high signal to noise ratio (SNR) close to the
coil. This high SNR can be used for obtaining images with
high spatial resolution. As the anal sphincter muscles are
only a few millimeters thick, optimal spatial resolution is
advantageous. The distension caused by the coil could be
considered a disadvantage, as the anal sphincter components
are stretched. Although some thinning will occur which
might be disadvantageous, the information obtained by the
high spatial resolution of an endoanal coil will more than
compensate for this. Subtle changes in the architecture of
anal sphincter components and in signal intensity are visible.
It is possible that some distension might be beneficial to
visualize a sphincter defect. This will occur as overlapping
torn sphincter parts are displaced, which may help in identi-
fying the defect.
Our experience is based on a 17 mm cylindrical coil with
a length of 8  cm. The coil is protected by a 19  mm outer
diameter coil holder, which has a length of 10 cm [1]. The
diameter of the endoanal coil is comparable to the diameter
of an endosonography transducer, facilitating comparison of
findings.
34.2.2 Preparation
The coil we use is a multiple-use coil (we use the coil in
hundreds of examinations), and appropriate hygienic mea-
sures are taken (including disinfectant) for each procedure. A
condom covers the coil and some lubricant is applied. It is
introduced in the left lateral position. After careful position-
ing of the coil, the patient turns to a supine position, and
prior to imaging the coil position is checked.
To prevent artifacts of peristalsis, we ask patients not to
eat or drink for 4 h prior to the examination, and we use a
bowel relaxant (butylscopolamine bromide, Buscopan,
Boehringer, Ingelheim, Germany). When butylscopolamine
bromide is not approved for this application (such as in the
USA), glucagon can be used as an alternative. However, glu-
cagon is more effective for reducing small bowel peristalsis
445
446
than large bowel contractions. For further reduction of arti-
facts, we ask patients not to squeeze their anal sphincter, pel-
vic floor muscles, or gluteal muscles during the examination.
As endoanal MRI is highly sensitive to motion artifacts, we
position the patients as comfortable as possible using sup-
portive material, including supporting the legs so that patients
can be as relaxed as possible.
34.2.3 Imaging Protocol
A practical imaging approach comprises an axial oblique
and coronal oblique moderately T2-weighted turbo spin-­
echo sequences (TSE) (at 1.5  T TR 2500  ms; TE 70  ms).
These imaging sequences are angulated at the anal axis for
optimized visualization of the anal sphincter muscles.
In patients with fecal incontinence, the endoanal MRI
procedure is well tolerated and probably comparable to that
at EAUS [2]. Endoanal MRI is more time-consuming than
EAUS (approximately 30 min vs. 10 min room time).
When visualization of the complete pelvic floor is needed,
or dynamic information about the pelvic floor, additional
sequences with an external coil are mandatory.
Although experience is limited, the anal sphincter can
also be studied with external phased array coils [3]. External
coil MRI is less intrusive and uncomfortable for the patient
and can therefore be a valuable alternative. This is especially
advantageous as it can be performed with almost any MRI
machine in only 15 min. Experienced readers achieve com-
parable results to endoanal MRI for external sphincter
defects and external sphincter atrophy [4, 5]. To our knowl-
edge, no recent studies have compared endoanal MRI to
external coil MRI.
34.3 MRI Findings
External sphincter lesions primarily concern local defects
and scarring. A defect is demonstrated as a discontinuity of
the external sphincter, often with some scar tissue (Fig. 34.1).
More frequently, no conspicuous defect is visible, but nor-
mal sphincter tissue is replaced by scar tissue. Scar tissue can
be recognized as tissue with low signal intensity (relative
black) and disturbed architecture. Normal anal sphincter tis-
sue has a multilayered appearance, which is distorted by the
scar tissue. Identification of subtle scar tissue is facilitated by
scar tissue in the fat containing ischioanal space, directly
adjacent to the external sphincter (Fig.  34.2). The external
sphincter can either be thickened, thinned, or of approxi-
mately normal thickness at the area of scar tissue. Internal
sphincter defects have a similar appearance, although scar
tissue can be somewhat less hypointense (Fig.  34.3).
However, the normal internal sphincter has high signal inten-
J. A. W. Tielbeek and J. Stoker
Fig. 34.1  Endoanal axial T2-weighted turbo spin-echo in a 50-year-­
old female patient with severe fecal incontinence. She had a history of
a complete rupture and episiotomy with primary repair. MRI shows an
anterior external sphincter defect (arrows). The edges and adjacent
parts of the torn external sphincter are fibrous (scar tissue) with dis-
torted architecture and low signal intensity (compare to posterior part of
external sphincter (ES))
sity, and therefore there is considerable contrast between
scar tissue and normal internal sphincter.
Interobserver agreement of endoanal MRI for sphincter
defects is best when the sphincters are either both intact or
both disrupted [6]. For individual sphincters, interobserver
agreement for defects is fair (external anal sphincter) and
moderate (internal anal sphincter) [6]. A study in 30 patients
reported moderate to good interobserver agreement for
external sphincter defects [4]. Intraobserver agreement was
fair to very good and depended upon experience.
Generalized atrophy of the external sphincter can present
as either thinning, fatty replacement, or—most frequently—
both. Measuring the external sphincter thickness is helpful.
However, visual evaluation of the presence of fat is impor-
tant, as in some patients fascial borders remain intact while
the muscle bulk is greatly reduced (Fig. 34.2).
With ageing, there is a physiological thinning of the exter-
nal sphincter. At endoanal MRI, the external sphincter is
4.32 mm in women aged 35 years or younger and 3.9 mm in
women older than 65 years [7]. In men the values are 5.21
and 3.45 mm, respectively. Internal sphincter atrophy is vis-
ible as thinning of the internal sphincter. With ageing, there
is a physiological thickening of the internal sphincter. These
physiological changes of the external and internal sphincter
were also demonstrated at EAUS [8]. An internal sphincter
34  Magnetic Resonance Imaging
a b
Fig. 34.2  Endoanal coronal (a) and axial (b) T2-weighted turbo spin-­
echo in a 56-year-old female patient with fecal incontinence show
severe atrophy of the external sphincter (ES) and scar tissue of the left
anterolateral external sphincter (arrows) with adjacent scar tissue in the
with a thickness less than 2 mm, in a middle-aged or elderly
individual, is considered atrophied (Fig. 34.2).
34.4 Accuracy for Sphincter Defects
In the more than 20 years since the introduction of endoanal
MRI, several studies have been published on the accuracy of
endoanal MRI in detecting anal sphincter defects. Initial
studies concerned rather small series, demonstrating that
accuracy is good (up to 95%) for demonstrating external
sphincter defects [9, 10]. As EAUS is the standard technique
for demonstration of anal sphincter defects, a comparison of
endoanal MRI and EAUS is important. Two single-center
studies and one larger multicenter comparative study have
been performed.
The first comparative study retrospectively compared
both techniques to findings at surgery. The study concerned
22 patients with fecal incontinence undergoing anterior anal
sphincter repair [11]. There was better agreement of endo-
anal MRI with surgical results for external sphincter defects
compared to findings at EAUS for diagnosing lesions of the
external anal sphincter (к MRI 0.85 vs. EAUS 0.53) and
internal anal sphincter (к MRI 0.64 vs. EAUS 0.49).
447
ischioanal space (arrowhead). There is also atrophy of the internal
sphincter (IS) and moderate atrophy of the puborectal muscle (PR) and
levator ani (LA). Compare to Fig. 34.3
These findings were not confirmed in a prospective study
in a larger number of patients. In this study, findings at EAUS
and endoanal MRI in 52 patients were compared to the final
diagnosis made by an expert panel, based on all available
information [12]. Complete agreement between endoanal
MRI and EAUS and the final diagnosis was found in 62%.
Findings at EAUS were more frequently confirmed by the
expert panel than findings at endoanal MRI. Discordant find-
ings primarily concerned internal sphincter lesions. The
authors concluded that MRI is inferior in diagnosing internal
anal sphincter injury. The differences between both studies
are probably related to differences in experience with either
technique and differences in the disease spectrum and refer-
ence standard.
The third study compared EAUS and endoanal MRI for
detection of external sphincter defects [13]. This multi-
center study concerned 237 patients (214 women). There
was agreement between endoanal MRI and EAUS in 146
patients (61%; κ  =  0.24: fair agreement). A selection of
patients (n = 36) underwent anterior anal sphincter repair.
In these patients there was no significant difference in the
detection of external anal sphincter defects between endo-
anal MRI and EAUS (P = 0.23). The sensitivity and posi-
tive predictive value of endoanal MRI were 81% and 89%,
448 J. A. W. Tielbeek and J. Stoker

a b

Fig. 34.3  Endoanal coronal (a) and axial (b) T2-weighted turbo spin-­
echo in a 46-year-old male patient with anal pain demonstrates normal
anatomy of the external sphincter (ES) and puborectalis muscle (PR) at
the right side. The inferior part of the internal sphincter (IS) is abnormal
(best seen in the axial plane (a); compare to Fig. 10.5), with disturbed
architecture of the complete inferior internal sphincter ring and scar tissue
of the internal sphincter left posterolateral (black arrow in a; white arrow
in b) after previous surgery. BS bulbospongiosus muscle, G gluteus mus-
culature, IC ischiocavernosus muscle, LA levator ani (white arrow in a);
TPM transverse perineal muscle, R coil with tip in distal rectum

respectively, and 90% and 85%, respectively, for EAUS).

Based on these three studies, one can conclude that EAUS
and endoanal MRI are comparable in the detection of
external sphincter defects.
Obstetric trauma is considered to be a major cause of
sphincter defects. These sphincter defects may coincide with
defects of other pelvic floor muscles, which may also result
from obstetric trauma. In a study of 105 severe fecal-­
incontinent patients, defects of the puborectal muscle or
levator ani were identified [14]. These defects were rarely
solitary findings but associated with internal or external
sphincter defects in these patients presenting with fecal
incontinence. Atrophy of the puborectal muscle or levator
ani muscle almost always coincided with external sphincter
atrophy.
In patients who have experienced unsuccessful anterior
anal repair, imaging can be performed to identify the cause
of the failure. A study with 30 patients with fecal inconti-
nence has shown that at endoanal MRI, patients with a visi-
ble overlap and less than 20% fat tissue had a better clinical
outcome (Fig. 34.4) [15]. Further, preserved external sphinc- Fig. 34.4  Endoanal axial T2-weighted turbo spin-echo in a 34-year-­
ter thickness correlated significantly with better surgical out- old female patient with fecal incontinence. She had a complete rupture
come (see Sect. 34.5 on sphincter atrophy). Residual external 4 years earlier and underwent anterior anal repair for an anterior exter-
sphincter defects were better demonstrated at EAUS, which nal defect at EAUS. Fecal incontinence had not improved after anterior
anal repair. At endoanal MRI there is reasonable left-over-right overlap
might be related to the rather limited experience with post- of the external sphincter parts (arrows). There is some atrophy of the
surgical endoanal MRI. To our knowledge, MRI has not been external sphincter. Susceptibility artifact anterior (arrowhead). ES
studied in evaluating other surgical treatments. external anal sphincter
34  Magnetic Resonance Imaging
34.5 Accuracy for Sphincter Atrophy
External sphincter atrophy was a finding known from elec-
tromyography. This entity had become somewhat neglected
following the widespread replacement of electromyography
by EAUS.
As the external sphincter is very well delineated at endo-
anal MRI, detection of atrophy was an easy task (Fig. 34.2).
A study with histopathological verification in 25 patients
demonstrated that endoanal MRI is accurate in detecting
external sphincter atrophy [16]. Endoanal MRI had a sensi-
tivity of 89%, specificity 94%, positive predictive value 89%,
and negative predictive value 94% for external sphincter
atrophy.
External sphincter atrophy is a finding related to sphincter
function. In a prospective series of 200 patients, external anal
sphincter atrophy was present in 123 patients (62%) at endo-
anal MRI [17]. The atrophy was severe in 44 patients (22%)
and mild in 79 (40%). Maximal squeeze pressure and squeeze
increment pressure were significantly decreased in individu-
als with external sphincter atrophy. Patients with severe atro-
phy had a significantly lower maximal squeeze and squeeze
increment pressure than patients with mild atrophy. This is
concordant with an earlier study in which 16 patients with
fecal incontinence and decreased squeeze pressure, and 9
controls with normal squeeze pressures, were studied [18].
Anal squeeze pressure correlated with external sphincter vol-
ume and fat content.
Two studies have evaluated the role of endoanal MRI in
predicting the outcome of anterior anal repair. One study
performed endoanal MRI in 20 female patients scheduled for
anterior anal repair. Eight of these patients had external
sphincter atrophy. The outcome was significantly better in
those patients without external sphincter atrophy [19]. A fur-
ther study in 30 patients demonstrated that baseline measure-
ment of preserved external anal sphincter bulk correlated
with a better outcome [15]. These studies demonstrate that
external sphincter atrophy at endoanal MRI is a negative pre-
dictor of outcome of anterior sphincter repair.
Studies on EAUS and detection of external sphincter atro-
phy are sparse and have limited patient numbers and conflict-
ing results. In a comparative study of 20 female patients,
external sphincter atrophy was identified in 8 patients at
endoanal MRI and in no patients with EAUS [19]. In a study
of 18 patients, three-dimensional (3D) EAUS and endoanal
MRI showed no difference in the assessment of external anal
sphincter atrophy, but there was a substantial difference in
grading [20]. However, another study with 18 fecal-­
incontinent patients showed that correlation between EAUS
and endoanal MRI for external anal sphincter thickness,
length, and area was poor [21]. The decreased delineation of
the external anal sphincter border in external sphincter atro-
phy probably impairs accurate evaluation.
449
Abnormal thinning (<2 mm) of the internal anal sphincter
can be found in patients with idiopathic degeneration [22].
Atrophy of the internal anal sphincter is most easily appreci-
ated at an axial image, and a cutoff of 2 mm thickness is used
to identify internal sphincter atrophy in older individuals.
Internal sphincter atrophy is nicely demonstrated at both
endoanal MRI (Fig. 34.2) and EAUS.
34.6 M
 RI in the Management
of Fecal-­Incontinent Patients
The results of EAUS and endoanal MRI in the detection of
external sphincter defects are comparable. The widespread
experience and availability, and lower costs and time effi-
ciency, favor EAUS as the first-choice technique for detect-
ing external sphincter defects. Endoanal MRI can be used as
an alternative. In experienced hands, external phased array
MRI can replace endoanal MRI.  This is a time-efficient
alternative, which lacks the discomfort associated with the
introduction of an endoanal device, a drawback of both
endoanal MRI and EAUS.
The principal role of endoanal MRI is in demonstrating
and grading external sphincter atrophy. This finding is a neg-
ative predictor of the outcome of anterior anal repair. With
current knowledge, MRI is the preferred method to demon-
strate external sphincter atrophy. Data on EAUS are sparse
and conflicting. Therefore, in patients considered for anterior
anal repair, MRI should be performed to identify individuals
with external sphincter atrophy. The use of external phased
array MRI is a valuable alternative in experienced hands.
Neither EAUS nor endoanal MRI play a role in selecting
patients for pelvic floor rehabilitation. In a series of 250
fecal-incontinent patients, neither technique had substantial
predictive value for the outcome of pelvic floor rehabilitation
[23]. More research into this area is needed.
34.7 Conclusions
The evidence on the role of endoanal MRI in fecal inconti-
nence is considerable but not extensive. Endoanal MRI can
be used as an alternative to EAUS for detecting external
sphincter defects. Current evidence indicates that endoanal
MRI should be used in patients considered for anterior anal
repair because of external sphincter atrophy identification.
The role of MRI in other surgical treatment options is an
obvious topic for future research. One can speculate that
external sphincter atrophy at MRI could be an important
finding for sacral neuromodulation. However, one study
reports that sacral nerve stimulation can be effective in
patients with fecal incontinence related to atrophy of the
external anal sphincter, regardless of the severity of atrophy
450
detected by MRI [24]. Technical developments in MRI, such
as diffusion weighted imaging, diffusion tensor imaging, and
fiber tracking [25], could be of value in patients with fecal
incontinence.
Take-Home Messages
• In patients with fecal incontinence, MRI is well tol-
erated and comparable to EAUS.
• The widespread experience and availability, and
lower costs and time efficiency, favor EAUS as the
first-choice technique for detecting external sphinc-
ter defects.
• Endoanal and external coil MRI are both accurate
in detecting external sphincter atrophy.
References
1. Stoker J, Rociu E, Zwamborn AW, Laméris JS. Endoluminal MR
imaging of the rectum and anus: technique, applications, and pit-
falls. Radiographics. 1999;19:383–98.
2. Deutekom M, Terra MP, Dijkgraaf MG, et  al. Patients’ percep-
tion of tests in the assessment of faecal incontinence. Br J Radiol.
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3. Kessels IM, Fütterer JJ, Sultan AH, et al. Clinical symptoms related 19. Briel JW, Stoker J, Rociu E, et al. External anal sphincter atrophy
to anal sphincter defects and atrophy on external phased-array MR
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4. Terra MP, Beets-Tan RG, van der Hulst, et  al. Evaluating anal
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5. Terra MP, Beets-Tan RG, van der Hulst VPM, et al. MR imaging
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 Neurophysiological Evaluation:
Techniques and Clinical Evaluation
Mitul Patel, Kumaran Thiruppathy, and Anton Emmanuel
Learning Objectives
• Discuss the neural control of colorectal motility.
• Overview of general principals of nerve conduction
studies and electromyography (EMG).
• Discuss the method of performing pudendal nerve
terminal motor latency and its clinical utility.
• Discuss method of performing pelvic floor EMG,
its clinical uses and limitations.
• Exhibit the future of evaluating the brain-gut axis
using cortical evoked potentials and motor evoked
potentials.
• Exhibit novel methods of assessing the autonomic
innervation of the anorectum.
• Summary of use of sacral nerve stimulators in mod-
ulating the neurophysiology of the pelvic floor as a
treatment modality.
35.1 Introduction
A great deal of interest has been attributed to anal sphincter
function in the maintenance of continence, and this has been
due to the relative ease with which it can be evaluated through
imaging and anal manometry. However, the importance of
the brain-gut axis in gastrointestinal and anorectal function is
apparent. Though other tests mentioned in this book can give
an indication of the function and integrity of the neuromus-
cular system, neurophysiological testing remains crucial for
M. Patel · K. Thiruppathy
Division of Colorectal Surgery, Royal Berkshire Hospital,
Reading, UK
e-mail: mitulpateldr@gmail.com; kum.nhs@googlemail.com
A. Emmanuel (*)
GI Physiology Unit, University College Hospital, London, UK
e-mail: a.emmanuel@ucl.ac.uk
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_35
35
this assessment. Combining history, physical examination,
imaging modalities and other diagnostic tests with neuro-
physiological tests of the pelvic floor assists in diagnosis of
various pelvic floor disorders and is increasingly being used
to research the aetiology of such disorders.
Most of the published work on neurophysiological assess-
ment of the gut has been in patients with either neurological
disorders or obstetric injuries and has served to improve our
understanding of normal gastrointestinal and anorectal func-
tion. Neurological disease can be associated with a high inci-
dence of bowel dysfunction and incontinence, for example,
20% of diabetics, 70% of multiple sclerosis and up to 75% of
spinal cord injury patients being affected specifically with
faecal incontinence [1, 2]. Correlations between extent of
symptoms and neurological component are difficult to deter-
mine due to the multimodal effects of such diseases impart
due to lack of anorectal and pelvic floor control, disruption
of normal gut motility patterns and loss of mobility [3].
Neurophysiological tests may help provide models on which
to base further research to explain challenges such as idio-
pathic faecal incontinence and dyssynergia. The majority of
tests outlined are used in the research setting at the current
time; however, as more knowledge is gained of the aetiology
of anorectal dysfunction, their role within clinical practice
may become more widespread and aid in developing further
treatment.
35.2 Neural Control of Colorectal Motility
The key nerve supply of the anorectum is the pudendal nerve
which arises from the second, third and fourth sacral nerves
(S2, S3 and S4) and innervates the external anal sphincter
(EAS). This nerve is a mixed nerve serving sensory and
motor function. Other pelvic floor muscles such as the leva-
tor ani specifically the upper portion of the puborectalis mus-
cle are innervated by direct branches of the anterior S3 and
S4 rather than traveling with the pudendal nerve. Therefore,
451
452
the puborectalis muscle and the EAS have separate neuro-
logical innervation. This is evident from pudendal blocks
which does not abolish voluntary contraction of the pelvic
floor. Blocking of the pudendal nerve results in loss of sensa-
tion in the perianal and genital skin and weakness of the anal
sphincter muscle, but does not affect rectal sensation [4].
Additionally, pudendal nerve blocks eliminate rectoanal
contractile reflexes (RACR) which suggests that pudendal
neuropathy may affect the rectoanal contractile reflex
response. The RACR is either a subconscious effort or a pri-
mordial reflex that prevents accidental release of rectal con-
tents, for example, when the intraabdominal pressure is
raised when coughing or sneezing. The RACR is mediated
by both pelvic splanchnic and pudendal nerves and is inde-
pendent of rectal sensation [5].
The somatic innervation does not fully dictate bowel and
anorectal function. The autonomic nerve supply of the pelvic
viscera travels within the pelvic plexus anterior to the pelvic
muscles.
Furthermore, the gastrointestinal system has a unique
nerve supply known as the enteric nervous system (ENS).
The ENS is an integrated system of neurons with structural
complexity and functional heterogeneity similar to those of
the brain and the spinal cord. The ENS’s role within the gut
includes control of gut motor function, mucosal blood flow,
mucosal transport and secretion and modulation of immune
and endocrine function.
The anorectum is innervated by somatic (sensory and
motor), autonomic nerves and the enteric nervous system
creating a complex interplay of mechanisms to allow for the
intricacy of gut function and defecation.
Defaecation commences with rectal sensory awareness
at a threshold level of filling which is conveyed to the cere-
bral cortex as the perception of the need to evacuate the
rectum. The threshold volume of the rectum is dependent
on the nature of the contents (gas, liquid or solid) and the
physical properties of the rectum itself in terms of compli-
ance and sensitivity of the mucosal lining. These physical
properties, in turn, depend on the individual’s autonomic
tone and mood.
When the subject is in a socially appropriate setting for
defaecation, determined by learned higher cortical functions,
a position is adopted to flex the hips to permit straightening
of the rectal angle and allows a more effective anatomical
position to expel the contents. The rectal contents stimulate
reflex relaxation of the anal sphincters and puborectalis. The
subject then performs a Valsalva manoeuvre by breathing
against a closed glottis, to raise the abdominal pressure and
the muscles of the anterior abdominal wall contract to funnel
the pressure down to the pelvis. The relaxation of the pelvic
floor then allows some stool to enter the lower rectum. This
in turn tends to initiate the spontaneous giant rectosigmoid
contractions which pushes stool through the relaxed anal
M. Patel et al.
canal. Further large propulsive contractions of the rectum
occur until the rectum is empty.
A sensory input from the anus maintains this propulsive
activity until the rectum is fully voided. This seems to be a
reflex mediated at spinal cord level since even spinally
injured patients can void a complete stool from the rectum,
once initiated.
As the stool passes through the anal canal, it stretches the
external anal sphincter generating a traction force upon it.
After the last stool is passed, the “closing reflex” of the exter-
nal sphincter is stimulated by the release of traction [6].
A number of reflexes have been described in addition to
the aforementioned RACR that play a fundamental role in
neural control of the anorectum.
The rectoanal inhibitory reflex (RAIR) is initiated result-
ing in decent of rectal contents into the upper anal canal
which allows the discrimination of solid, liquid or gaseous
luminal contents. After rectal filling sensation reaches con-
sciousness, the parasympathetic-driven defecation reflex is
initiated unless voluntarily inhibited. The absence of this
reflex is pathognomonic of Hirschsprung’s disease and after
low anterior resection (Fig. 35.1).
There are a number of neurophysiological tests that are per-
formed within tertiary centres to evaluate the anorectum. These
tests can be used in conjunction with other modalities to provide
an improved understanding of the pathophysiology of disorders
of the anorectum and allow for their better management.
35.3 Nerve Conduction Studies
The unique anatomical character of the pelvis means neuro-
physiological testing produces its own challenges; however,
before approaching specific tests, a basic understanding of
the principles and techniques used is essential for the pelvic
floor surgeon.
With any neuromuscular disorder, the first step in diagnos-
tic evaluation is to determine which portions of the nerve and
muscle are intact. Symptoms can arise from insult at the neu-
ron, the axon, the neuromuscular junction or the muscle fibres.
The second step is to determine the exact location of the injury.
Three common tests are frequently used to evaluate neu-
romuscular disorders:
1. Nerve conduction studies, which evaluate the velocity of
propagation of an action potential along different nerve
segments.
2. Repetitive nerve stimulation, which tests the consistency
of transmission across the neuromuscular junction. The
aforementioned test is not routinely used for pelvic floor
studies.
3. Electromyography, which evaluates the intramuscular
response to inherent neuronal signals [7].
35  Neurophysiological Evaluation: Techniques and Clinical Evaluation
Fig. 35.1 Rectoanal Stimulus
inhibitory reflex (RAIR).
(Figure reproduced from
Pressure (cmH2O)
Thiruppathy K, Roy A,
Preziosi G, Pannicker J,
Emmanuel A. Morphological
abnormalities of the rectoanal
inhibitory reflex reflects
symptom pattern in
neurogenic bowel. Dig Dis
Sci. 2012;57(7):1908–1914)
Resting
pressure
Excitation latency
Nerve conduction studies introduce an action potential in
the peripheral nervous system, and the subsequent recording
of the neural impulse at a location distant from the site of stim-
ulation is taken. The velocity of the action potential and the
size of the response can allow for an assessment of the health
of the tested nerve. Three different types of response can be
measured—pure sensory nerve action potential (SNAP), com-
pound nerve action potential (CNAP) for mixed sensory and
motor nerves and pure motor nerve evaluations by measuring
compound muscle action potentials (CMAPs). CMAPs have
been traditionally used to evaluate pelvic floor disorders.
A CMAP is the biphasic waveform obtained from stimu-
lating a nerve proximal to a muscle and recording the poten-
tial directly over the muscle. The CMAP response is a
summation of all the muscle fibres that are depolarized by a
single stimulated nerve.
The CMAP has a number of parameters. Onset latency
represents the arrival time of the fastest conducting nerve
fibres at the recording electrode over the muscle. This time
reflects neural activation from the stimulus, propagation of
the action potential along the nerve and transmission across
synapses at the neuromuscular junction. Disruption at any of
these sites will result in a prolonged latency. The largest,
heavily myelinated, fastest conducting axons in a nerve will
be those evaluated by the latency. Normal onset latency can
be seen despite there being a significant loss of axons as only
a few healthy myelinated axons are required to produce the
first stimulus to the muscle. Prolonged onset latency how-
ever can allow one to assume there is significant loss of neu-
romuscular function.
453
Duration of reflex
Maximum
stimulation
Amplitude
reduction
2/3 recovery
Recovery time
Time (seconds)
Amplitude is measured from the baseline to the maximal
point of the waveform and provides the number of axons and
muscle fibres being tested. This gives an estimate of the amount
of functional tissue. The area under the waveform above the
baseline provides a better estimate of functioning tissue; how-
ever, even this can be unreliable for the pelvic floor as the dis-
tance between the electrode and the muscle can significantly
attenuate the signal. Duration of the action potential is mea-
sured from the onset latency to when it crosses the baseline.
Nerve conduction velocities can be measured by dividing
the distance the action potential has travelled by the time
taken. For motor nerve conduction, the latencies between
two different sites of stimulation are subtracted to account
for the delay at the neuromuscular junction. Due to the
unique anatomical path of the pudendal nerve and the inabil-
ity to stimulate it at two defined anatomical points, nerve
conduction velocities are difficult to obtain [7, 8].
35.4 P
 udendal Nerve Terminal Motor
Latency (PNTML)
The pudendal nerve terminal motor latency (PNTML) mea-
sures neuromuscular integrity between the terminal portion
of the pudendal nerve and the anal sphincter. An injury to the
pudendal nerve leads to denervation of the anal sphincter
muscle and muscle weakness.
Thus, measurement of PNTML can help identify if a
weak sphincter muscle is due to nerve injury rather than
muscle injury. This can be useful in the assessment of
454
patients with faecal incontinence prior to anal sphincter
repair and helpful in predicting the outcome of surgery.
Furthermore, its value in assessing perineal decent and con-
stipation has also been described [5].
The commonest method of measuring PNTML is with a
disposable St. Mark’s electrode. This specially designed
electrode consists of two stimulating electrodes and two
recording electrodes which can be attached to a gloved index
finger. The stimulating electrode is found at the tip of the
finger and the recording electrode at the base. The pudendal
nerve is then stimulated at the ischial spine with the record-
ing electrode located at the EAS (Fig. 35.2).
The nerve inside the rectum is stimulated with a low elec-
trical current which should cause the sphincter muscle to con-
tract. A CMAP is generated and from this the latency can be
calculated. The normal range is of the order of 2.0–2.5 ms with
prolonged times being associated with pudendal neuropathy.
The primarily tools used in research and clinically to
determine neuropathy are pudendal nerve terminal motor
latencies (PNTMLs) and single-fibre or concentric needle
electromyography (EMG). As EMG is not routinely per-
formed due to associated morbidity, patient discomfort and
need for experienced specialist to perform the tests, PNTMLs
have been the favoured choice till recently.
Women who deliver vaginally with a prolonged second stage
of labour or forceps delivery have been found to have prolonged
PNTML. Furthermore, after a birth injury, women who develop
faecal incontinence have been shown to have both pudendal
neuropathy and anal sphincter defects. In one study, women
with obstetric injury developed faecal incontinence only when
there was associated pudendal neuropathy [9]. This highlights
the multifactorial nature of faecal incontinence, and a combina-
tion of investigations is required to determine aetiology.
Fig. 35.2  Diagram showing
the technique used to measure
pudendal nerve terminal
motor latencies
M. Patel et al.
PNTML can be used to predict the outcome of sphincter
repair surgery post-obstetric injury one study showed that
surgical repair produced a good to excellent result in 80% of
women with faecal incontinence but without pudendal neu-
ropathy compared with 11% of women with neuropathy
[10]. However, the utility of PNTML in patient management
has been questioned with studies suggesting it does not have
bearing on patient selection for surgical intervention and that
even those with unilateral or bilateral prolonged pudendal
nerve terminal motor latency should be offered surgery as
there is still a significant functional improvement [11, 12].
The utility of PNTML has been disputed. The American
Gastroenterology Association does not recommend the use of
PNTML for the use of faecal incontinence as it correlates
badly with clinical and histological finding as well as having
poor sensitivity and specificity and being user-dependent
[13]. Additionally, a normal PNTML does not exclude puden-
dal neuropathy as only a few patent nerve fibres are required
to provide a normal result. PNTMLs measure conduction of
thick well-myelinated nerve fibres which is not an accurate
representation of integrated pudendal nerve function.
It is also usual to get unilateral prolonged PNTML; how-
ever, both nerves anatomically cross over and are thought to
cross innervate [14, 15]. This in part may explain discrepan-
cies between PNTML and inconsistent correlation with
symptoms [14]. Such inconsistencies have been further
shown in a recent study where PNTML was only associated
with median maximum anal squeeze pressure and was not
associated with patient-reported severity of symptoms of
faecal incontinence, changes in quality of life attributable to
faecal incontinence, median mean resting anal pressure or
median maximum resting anal pressure suggesting its rou-
tine use should be questioned [16].
35  Neurophysiological Evaluation: Techniques and Clinical Evaluation
35.5 Electromyography (EMG)
Electromyography (EMG) refers to the study of the pattern
of electrical activity moving along the muscle fibres. The
electrical activity originating from a nerve can be determined
and give an indication of a nerve function. In its complete
utility, EMG can discriminate between normal, denervated
and reinnervated as well as myopathic muscle.
EMG allows for assessment of individual motor unit
action potentials (MUAPs). Motor units consist of a neu-
ron, its axon and the multiple muscle fibres it serves. At
the level of the muscle, the axon branches to innervate
muscle fibres scattered throughout the muscle in a mosaic
pattern. For the majority of pelvic floor sphincter mus-
cles, the neuronal cell bodies from which the action
potential is relayed lie in the anterior horn of the spinal
cord known as Onuf’s nucleus.
Kinesiologic EMG assesses the presence or absences of
muscle activity during certain manoeuvers. Surface elec-
trodes are placed on the skin over the muscle being tested,
and a summation of electrical muscle activity can be evalu-
ated. This method does not allow for assessment of individ-
ual MUAPs and so is not used to diagnose or quantify
neuropathy. Alternatively, needle EMG provides a more
accurate picture to diagnose neuropathy or myopathy and
still remains the gold standard EMG test.
Needle EMG can be performed using a multitude of nee-
dle electrodes—monopolar, single-fibre and concentric each
with their own distinctive properties. The commonest used
remains the concentric needle electrode which consists of a
bevelled needle with a platinum wire (active electrode) at the
tip surrounded by a steel cannula. The uptake area for the
needle is equivalent to approximately 20 muscle fibres [7, 8].
EMG of the pelvic floor can be performed to identify
areas of sphincter injury by mapping the EAS, to determine
whether the muscle contracts or relaxes (by the number of
motor units firing) and to identify denervation-reinnervation
potentials indicative of nerve injury.
EMG of the striated pelvic floor muscles can be per-
formed using a needle electrode, a surface electrode on the
perianal skin or an anal plug.
The needle electrode can be a concentric which can sam-
ple a number of motor units or single-fibre electrode which
has a smaller recording surface and detects single motor
units. Needle EMG can be used to map the striated muscle
fibres of the EAS and when compared to anal ultrasound
assessment for sphincter injury show agreement; however,
anal ultrasound was more sensitive and as expected better
tolerated with a lower risk of infections [17]. Needle elec-
trode EMG is therefore not recommended at the current time
outside of research use.
Surface EMG is an alternative mechanism of assessing
sphincter activity but is less reliable due to the inconsistent
contact with the anal canal. Surface electrodes provide quali-
455
tative information about muscle behaviour and may there-
fore be used in constipated patients to determine defecation
dyssynergia in the laboratory. In one study using surface
EMG techniques, the dyssynergia pattern correlated with
inability to expel a balloon filled with 50 mL of water from
the rectum in 83% of patients studied [18].
Surface EMG with the advent of vaginal and anal devices
has shown to be useful during biofeedback pelvic floor
retraining to provide a visual or audible signal when the
appropriate contraction of the pelvic floor is undertaken.
35.6 Developments Neurophysiological
Investigations
Most current neurophysiological tests have focused on the
rectum, anus and surrounding nerves, but newer tests are
emerging. We know the neuronal pathways between the
brain and gut are intimately involved in negotiating sensa-
tions and reflexes that control anal and rectal function. These
bidirectional pathways from the anus, rectum, pelvic floor,
spinal cord and brain can be assessed using various tech-
niques. The afferent pathways can be assessed using a multi-
tude of novel tests functional MRI (fMRI), examining PET,
cortical evoke potentials and magnetic encephalography.
35.7 Cortical Evoked Potentials (CEP)
Cortical evoked potentials have been used for over 60 years
to study somatosensory, visual, auditory and pain pathways.
This technique involves a brief sensory stimulation, which is
time- and phase-locked to the electroencephalogram record-
ing via surface electrodes placed on the scalp. The event-­
related signal is small in amplitude but occurs at the same
moment in time following each stimulus, while the large
amplitude background electroencephalogram occurs ran-
domly. In order to extract the desired signal, repeated stimuli
are given, and the subsequent brain activity is averaged. The
resultant waveform represents the brain’s response to a stim-
ulus as it changes with each millisecond. CEP responses of
the GI tract (oesophagus, stomach, duodenum, and sigmoid
colon) have been mapped for pain stimuli to create the
“human visceral homunculus” [19].
Furthermore, it has been used in the anus and rectum to
study irritable bowel syndrome. Twenty-two pairs of age-­
matched healthy females and IBS patients had CEP recorded
in response to rhythmic rectal distensions. IBS patients dem-
onstrated higher prevalence of cerebral evoked potential early
peaks postprandially and uniformly shorter cerebral evoked
potential latencies, both before and after a meal. Another
study, patients with IBS had shorter latency and increased
amplitude compared with controls. The outcomes of these two
studies offer evidence for hypersensitivity of visceral afferents
456
with effects at a cortical level [5]. CEPs are reliable and repro-
ducible measures of early sensory processing and have been
used to subcategories IBS into four pathophysiological groups.
This highlights the syndrome’s heterogeneous nature and how
personalised treatment may be beneficial in the future [20].
35.8 Motor Evoked Potentials
The efferent motor pathways can be assessed using stimula-
tion of the motor cortex using transcranial magnetic stimula-
tion (TMS). Magnetic flux is created when a current is
rapidly discharged through a conducting coil. This magnetic
flux can be used to stimulate neural tissue in a non-invasive
and painless method. Cortical mapping with transcranial
magnetic stimulation suggests that rectal and anal responses
are bilaterally represented on the superior primary motor
cortex—Brodmann area 4 [21].
35.9 M
 ucosal Blood Flow: Laser Doppler
Flowmetry (LDF)
Gastrointestinal mucosal blood flow is thought to be regu-
lated at least in part by the enteric nervous system; it has
been postulated that assessment of mucosal blood flow may
provide a surrogate, sensitive, quantitative measure of the
level of activity of the extrinsic autonomic nerves innervat-
ing the gut. Mucosal blood flow is influenced by local neural
and endocrine factors, but given a steady-state situation, the
variation in blood flow may be accounted for by differences
in extrinsic nerve activity. Measurement of the mucosal
blood flow can be performed using laser Doppler flowmetry
(LDF) a technique which has been previously used in assess-
ing perfusion in skin grafts, Raynaud’s phenomenon and
cerebral hypoperfusion [22]. Within the gut this technique
has been validated to measure extrinsic autonomic hind gut
function and though is not used clinically has been used to
research gut dysfunction in spinal cord injury (SCI), multiple
sclerosis and diabetic patients. The use of LDF has been used
to show reduced mucosal blood flow in SCI patients with
constipation and thus altered autonomic innervation [23, 24].
35.10 Sacral Nerve Stimulators
Neuromodulation of the anorectum to improve incontinence
has shown recent promise. The origins of electrical stimula-
tion of the anorectum date back to the 1960s [25]. Sacral nerve
stimulators (SNS) and neuromodulation originally were first
used for those with urinary dysfunction; however, this has now
been adopted for faecal incontinence [26]. The advent of SNS
has allowed for a bridge between conservative management of
incontinence and surgical interventions to sphincters or the
M. Patel et al.
bowel itself. An attraction of SNS is that, unlike direct surgery
to the sphincter or colon, they have the potential to modify all
aspects of the coordinated neuromuscular functions [27].
SNS involves direct, chronic, low-voltage electrical stimu-
lation of the sacral nerve roots using an electrode placed via a
sacral foramen usually S3. Though the technology has evolved
over time, the commonest current form utilises a percutane-
ously sited, commercially manufactured quadripolar electrode
lead system connected to an implanted pulse generator
(InterStim® Therapy, Medtronic Inc., Minneapolis, US)
placed within the subcutaneous fat. A temporary percutaneous
nerve evaluation (PNE) system is also available which allows
for a trial period before permanent implantation [28].
For FI patients in whom the primary aetiology appears to
be neurogenic and in whom a sphincter defect is not found at
investigation, SNS is now considered the first-line surgical
intervention when conservative treatments have failed [29].
A large number of case series studies have shown the ben-
efit of SNS in reducing faecal incontinence. Systematic
review has shown favourable mid- and long-term positive
outcomes for SNS of approximately 80% based on a greater
than 50% reduction in FI episodes, although this figure is
reduced to approximately 60% when all available partici-
pants who start therapy are included (comparable with
intention-­to-treat principles) [28, 30].
The most recent Cochrane systematic review on the topic
analysed six trials concluding that SNS can improve continence
in a proportion of patients with faecal incontinence. However, it
did not improve symptoms in patients with constipation [28].
The exact mechanism of how SNS improve incontinence
is not known. The initial hypothesis that the mechanism of
SNS was primarily peripheral motor neurostimulation is not
supported by the majority of studies. Due to the large body of
evidence demonstrating effects outside of the anorectum, it
appears likely that the influence of SNS on anorectal function
occurs at a pelvic afferent or central level [31]; however, stud-
ies in patients with tenesmus failed to show changes in ano-
rectal sensory function. Though investigations continue, it is
well recognised that the lack of understanding of the exact
mechanism of action of SNS limits the current potential of
this treatment option in terms of better patient selection,
improved technology, patient outcomes and healthcare costs.
35.11 Conclusion
Our knowledge of neuroanatomy and neurophysiology of the
colo-rectum has been based on classical descriptions with
few advances in recent years. Studying neural control of
colorectal function is difficult as there are:
• Few studies
• Poor animal models to extrapolate to human neuro-gut
function
35  Neurophysiological Evaluation: Techniques and Clinical Evaluation
• Difficulty extrapolating from neurological disease
(because of co-factors related to disease)
• Poor reproducibility of physiological measures to date
• Dependence on assessment of reflexes
Recently opportunities have been improving; however,
the majority of tests are used for research purposes. In part
this has been due to emerging physiological investigational
methods. In vivo studies have also focused on the role of
anorectal sensory function and how it complements motility,
while in vitro organ culture models have evaluated histologi-
cal change. The better classification of neuro disease
subtypes—i.e. homogenous groups with narrower
­ C. Pudendal nerve testing does not contribute to surgical decision
“ranges”—has allowed for pure study groups and reducing
cofounding factors. New treatment techniques (SNS, puden-
dal nerve stimulation) allow pre- and post-treatment com-
parisons in function, physiology and clinical outcome. Thus
we can begin to understand the neurophysiology of anal con-
tinence and potentially better understand pathophysiology in
both neurological and idiopathic patients.
Take-Home Message
Though neurophysiology tests have their limitations
and play a bigger role in the research setting currently,
they can be beneficial in evaluating specific aspects of
patients’ pathological process leading to symptoms.
Pelvic floor neurophysiological tests should be per-
formed by trained neurophysiologists in dedicated
units, with quality control of the results. The useful-
ness of these tests must be decided on an individual
basis and overall clinical picture to explain the correla-
tion between neurophysiological findings and pelvic
floor dysfunction.
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 Behavioral Therapies and Biofeedback
for Anal Incontinence
Bary Berghmans, Esther Bols, Maura Seleme,
Silvana Uchôa, Donna Bliss, and Toshiki Mimura
Learning Objectives
• The reader should be able to understand the clinical
reasoning and skills of the pelvic physiotherapist
related to assessment, conservative interventions,
and evaluation of pelvic floor rehabilitation for
adult patients with anal incontinence.
• The reader should be able to understand the current
status of the scientific evidence related to assess-
ment, conservative interventions, and evaluation of
pelvic floor rehabilitation for adult patients with
anal incontinence.
• The reader should be able to understand prognostic
factors and predictive factors for success using edu-
cation, pelvic floor muscle training, biofeedback, and
electrostimulation in adult patients with anal
incontinence.
ICI6 Committee 16
Electronic Supplementary Material The online version of this
chapter (https://doi.org/10.1007/978-3-030-40862-6_36) contains
supplementary material, which is available to authorized users.
B. Berghmans (*)
Pelvic Care Center Maastricht, Maastricht University Medical
Centre, Maastricht, The Netherlands
e-mail: bary.berghmans@maastrichtuniversity.nl
E. Bols
Department of Epidemiology, Maastricht University, Maastricht,
The Netherlands
M. Seleme
abafi-HOLLAND, Maastricht, The Netherlands
Faculdade Inspirar, Curitiba, Brazil
S. Uchôa
Universidade Católica de Pernambuco - Recife, Pernambuco,
Brazil
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_36
36
• The reader should be able to understand the current
position and place of the pelvic physiotherapist as
member of the clinical team assessing, treating, and
evaluating adult patients with anal incontinence.
36.1 Introduction
At the end of 2014, a summary of the Evidence Statement
Anal Incontinence (AI) of the Royal Dutch Society for
Physical Therapy (KNGF) was published in the International
Journal of Urogynecology [1]. The Evidence Statement AI
outlined practice-driven problem definitions with regard to
definition of anal incontinence (AI), prevalence, incidence,
costs, etiological and prognostic factors, predictors of
response to therapy, prevention, and diagnostic and thera-
peutic physical therapy process. The main objective of this
chapter is to present a summary of the current, updated state
of knowledge and to formulate recommendations for a
methodic and systematic physiotherapeutic assessment and
treatment for patients with AI and to place the (so far limited)
evidence in a broader perspective of current developments.
Behavioral therapies and biofeedback are included in the
overall term pelvic physiotherapy.
This evidence statement used the terminology defined
by the International Urogynecological Association (IUGA)
and the International Continence Society (ICS) [2]. AI as a
symptom is defined as “complaints of involuntary loss of
D. Bliss
University of Minnesota School of Nursing, Minneapolis, MN,
USA
e-mail: bliss@umn.edu
T. Mimura
Division of Gastrointestinal Surgery, Department of Surgery, Jichi
Medical University, Tochigi, Japan
e-mail: mimura0523@aol.com
459
460
feces or flatus” [2]. The term AI is used for incontinence for
solid and liquid feces and flatus, while the term fecal incon-
tinence (FI) refers only to incontinence for liquid and solid
feces. Here, AI is used as an umbrella term, and it is explic-
itly indicated where the specific symptoms of flatal inconti-
nence or FI are meant.
A summary of recommendations for the diagnostic and
therapeutic process is presented at the end of the chapter.
36.2 Etiological Factors
Etiological factors for FI or AI are as follows:
1. Women
• Postpartum FI or AI: third- or fourth-degree tear and
AI during pregnancy (level 1) [2]
• ≥50 years (FI): history of rectocele (e.g., resulting
from chronic straining) (level 3) [3]
• ≥65 years (FI): stroke, cognitive impairments,
Caucasian ethnicity, depression, and chronic diarrhea
(level 3) [4, 5]
• AI: abdominal and vaginal hysterectomy (combined
bilateral salpingo-ovariectomy, higher age at time of
surgery, and a history of obstetric damage further
increase the risk) (level 3) [6, 7]
2. Men
• FI: ≥85 years and kidney problems (level 3) [5]
• Flatal incontinence: radiotherapy for treatment of
prostate cancer (reduced rectal capacity by radiation
proctitis) (level 3) [8]
3. Women and men
• FI: kidney problems, diarrhea, feeling of incomplete
evacuation, history of pelvic radiation treatment,
Table 36.1  Levels of evidence: classification of methodological quality of individual studies
Intervention, prevention
A1: Systematic review of at least two independent A2-level
studies
A2: Randomized, double-­blind, comparative clinical trial of good Prospective cohort study with sufficient sample size and follow-up,
quality and sufficient sample size
B: Comparative study not meeting all criteria mentioned under
A2 (including case-control studies and cohort studies)
C: Non-comparative study
D: Expert opinion, for instance, the members of the guideline
development team
Level of conclusions
Conclusion based on:
Level 1: one study at A1-level or at least two independent
A2-level studies
Level 2: one study at A2-level or at least two independent B-level
studies
Level 3: one B- or C-level study
Level 4: expert opinion
B. Berghmans et al.
urgency complaints, and urinary incontinence (level 3)
[3–5]
4. Older people in residential homes
• FI: advanced age (level 1) [9]
• FI: urinary incontinence, limited mobility, having a neu-
rological disorder, cognitive decline, dementia, problems
of trunk control, non-Caucasian ethnicity and difficulties
with general activities of daily living (level 2) [9]
(Table 36.1).
36.3 F
 actors Predicting Response to Pelvic
Physiotherapy
Prognosis for recovery in AI depends on the underlying
nature and severity of AI.  The following predictors of the
response to pelvic physiotherapy can be distinguished:
1. Increased chance of recovery
• Sufficient training dosage (training specific muscles
three times a day, 2–3 times a week for 5 months, with
8–12 slow and virtually maximal contractions) and
sufficient therapy compliance (level 1) [10]
• Higher level of motivation on the part of the patient
and better interaction between patient and therapist
(level 4) [11]
• Teaching patients to cope with their health problem
and inspiring patients (level 4)
2. Reduced chance of recovery
• Neurological disorder or a disorder of or damage to
the spinal cord which means that the patient is
unable to follow or comprehend instructions (level
4) [12, 13].
Etiology, prognosis
effectively controlled for confounding and with effective measures to
prevent selective follow-up
Prospective cohort study, not meeting all criteria mentioned under A2, or
retrospective cohort study
Recommendation based on the level of the conclusion:
It has been demonstrated that…
It is plausible that…
There are indications that…
In the opinion of the evidence statement development team, …
36  Behavioral Therapies and Biofeedback for Anal Incontinence 461

Factors specifically associated with the chances of recov-

ery after electrostimulation (ES), biofeedback (BF) with pel-
vic floor muscle training (PFMT), and a combination of BF
with PFMT and ES are reported in the original document
KNGF Evidence Statement AI [14].

36.4 Diagnostic Process

In the diagnostic process, the pelvic physiotherapist examines

the nature, severity (assessed on the basis of the International
Classification of Functioning, Disability and Health (ICF))
[15], and degree of modifiability of the patient’s health problem
(general and local impeding factors). This information is
derived from history-taking, self-­reports by the patient, ques-
tionnaires, defecation diaries, and a pelvic physiotherapy
examination. Intake assessment focuses on reason for contact;
red flags (i.e., clinical indicators of possible serious underlying
conditions); proctologic, gynecological, obstetric, urological,
and sexological history in relation to the musculoskeletal sys-
tem; comorbidities; coping strategies; psychosocial problems;
defecation and micturition patterns; nutrient and fluid intake;
status of the components of the continence mechanism (muscle
function, reservoir function, consistency of stools, awareness,
and acknowledgement of health problem, and their interac-
tions); the patient’s pattern of expectations. This process can be
integrated with education and advice.
Fig. 36.1  External anal sphincter—Optimal testing is asking for 3
times a maximal conscious contraction to guarantee that the patient
36.4.1 Measurement Instruments understands well how to do this contraction. The correct movement is
up- and inward
Recording the severity of a patient’s AI and its consequences
for their everyday life and sense of self-respect is important
for the patient’s perception of the health problem. Moreover, consistency of the stools and can be included in a defecation
they are essential to evaluate the effects of physiotherapy. The diary [24]. An example of a defecation diary including the
Wexner (Cleveland Clinic) score is a suitable instrument to BSS is presented in the original document [14].
assess the severity of AI as a health problem and how well the
patient is coping [13]. In view of its simplicity and manage-
ability, the Global Perceived Effect (GPE) can be used to 36.4.2 Physical Examination
evaluate patient-perceived changes in health status [16]. The
International Consultation on Incontinence Questionnaire-­ Physical examination includes:
Bowels (ICIQ-B) is a recently developed and fully validated
questionnaire for use in individuals with AI of varying causes • General inspection: breathing, spinal column, pelvis,
[17]. It also provides assessment of the impact of these symp- hips, and gait analysis
toms on quality of life. The findings of psychometric studies • Local inspection of vagina, anus, and perineum:
and systematic reviews of the literature suggest that the Fecal inspection of the pelvic floor at rest, during contrac-
Incontinence Quality of Life Scale (FIQL) [18] might be rec- tion (contraction strength, lifting and inward move-
ommended as an instrument to assess disease-­specific quality ment of the pelvic floor during contraction, relaxation,
of life [19–22]. A patient’s defecation diary enables the thera- co-contractions, breathing), coughing, and straining
pist to determine the defecation frequency and the severity of (Fig. 36.1)
the FI [19, 23]. It is recommended to keep a defecation diary • Supplementary functional examination: palpation at rest,
until the consistency and frequency of defecation have nor- palpation during contraction, endurance, pre-contraction,
malized and certain regularity has been established. The straining, Valsalva and coughing, relaxation, reflexive
Bristol Stool Scale (BSS) is a good instrument to monitor the contraction (anocutaneous reflex) (Fig. 36.2)
462
Fig. 36.2 Anocutaneous
reflex is the reflexive
contraction of the external
anal sphincter by lightly
touching the skin around the
anus. A normal reaction is a
rapid contraction of the anal
sphincter
• Supplementary functional examination: rectal balloon
and electromyography (EMG). Filling a rectal balloon
intrarectally with air allows the therapist to measure and
the patient to become aware of initial sensory perception
of filling, the rectoanal inhibitory reflex (RAIR), the ini-
tial feeling of urgency, and the maximum tolerable vol-
ume. In addition, EMG can be used to measure the
activity at rest and during contraction and relaxation, as
well as the response of the pelvic floor muscles to filling
and Valsalva and straining with an inflated balloon.
36.5 Physiotherapy Analysis/Diagnosis
It is very important to analyze whether and to what extent
there is sufficient balance between strain and physical condi-
tion. The physical condition may be affected by dysfunctions
of the continence mechanisms:
• Damage to or weakness of the pelvic floor muscles (exter-
nal anal sphincter and m. levator ani)
• Damage to or weakness of the internal anal sphincter
• A neurological problem: nuclear/infranuclear dysfunc-
tion, peripheral innervation, spinal cord, brainstem or
lack of awareness.
The physical condition partly depends on other factors,
such as general mobility, diet, intestinal system (peristalsis
or fecal composition), medication, problematic history
(e.g., adverse sexual experiences, physical violence), and
comorbidity. The patient’s physical condition (at local, per-
sonal, and participation level) determines how much they
can bear.
The analysis process is used to determine the nature,
severity, and modifiability of the problem. The Dutch guide-
line development team, in consultation with a feedback
B. Berghmans et al.
group of experts in the field, has distinguished four problem
categories for patients with AI (for further subdivision, con-
sult the full-text Evidence Statement of the original docu-
ment and flowchart at www.fysionet-evidencebased.nl [14]):
1. AI with pelvic floor dysfunction and awareness of loss of
stools (urgency). The treatment plan is developed based
on the presence or absence of a neurological problem,
anorectal sensation, voluntary or involuntary control, and
factors that adversely affect pelvic floor function.
2. AI with pelvic floor dysfunction without awareness of
loss of stools (passive). The treatment plan is developed
based on the presence or absence of a neurological prob-
lem and anorectal sensation.
3. Al without pelvic floor dysfunction.
4. AI with or without pelvic floor dysfunction, in combina-
tion with general factors impeding the recovery or adjust-
ment processes. The treatment plan is developed based on
the presence or absence of comorbidity.
The nature and severity of any pain symptoms must be
taken into consideration for all four problem categories, as
these represent a complicating factor.
36.6 Therapeutic Process
The therapeutic process includes the actual treatment, evalu-
ation, and conclusion of treatment. The treatment plan relates
to the identified problem category, and the objective is to
improve one or more of the following components of conti-
nence: muscle function, reservoir function, consistency of
stools, awareness and acknowledgement of the health prob-
lem, or interactions between these components. No adverse
effects or worsening of symptoms have been reported for any
of the forms of therapy discussed below.
36  Behavioral Therapies and Biofeedback for Anal Incontinence 463

Fig. 36.3  Correct position to defecate. Mobile applications, like iPelvis, that show exercises and life hygiene advices on coloproctological dys-
functions, may be useful to improve long-term adherence

The following therapeutic interventions can be preferences, and expectations, the pelvic physiotherapist
identified: explains any relevant aspects, using visual aids where
necessary, and discusses the normal function of the conti-
1. Providing education and advice: a patient-specific educa- nence mechanism and defecation (level 4) (Fig. 36.3).
tion plan is used for each problem category (problem cat- 2. Electrostimulation: ES is applied in various ways, using
egories I–IV). Taking account of the patient’s views, different stimulation parameters and combining it with
464
other therapies (like BF or PFMT). The precise mecha-
nism of action of ES is unknown, but the main ­mechanism
may be based on an increased awareness of the anal
sphincter. It has been demonstrated that there is insuffi-
cient evidence to recommend ES for the treatment of AI,
based on only few studies, which were heterogeneous in
terms of patient sample, treatment protocol, and outcome
measures (level 1) [25]. There have also been uncon-
trolled studies that repeatedly mention that “the interna-
tional literature, as well as our own research findings,
confirm that ES is effective and that ES plays an impor-
tant role as a component of conservative treatment for
some patients with AI” [25]. Therefore, it is recom-
mended that ES is useful for a specific group of patients,
to improve the voluntary control of the pelvic floor in
patients who lack this voluntary control (problem cate-
gory IA) (level 4).
A specific type of ES is tibial nerve stimulation (TNS).
This is a form of ES in which a surface electrode is placed
on the skin over the tibial nerve on one ankle and refer-
enced to another electrode on the ipsilateral foot (transcu-
taneous, TTNS) or a needle inserted beneath the skin
close to the tibial nerve on one side and is referenced to an
electrode on the ipsilateral foot (percutaneous, PTNS)
[26]. Typical TTNS stimulation parameters are 250  μs
pulses at a frequency of 10  Hz and current of up to
30  mA.  Typical PTNS stimulation parameters are 200–
250 μs pulses at a frequency of 10–20 Hz and up to 9 mA.
3. Pelvic floor muscle training: PFMT consists of repeated
voluntary contractions and relaxations of the pelvic floor
muscles in order to improve muscle strength, voluntary
control of muscle relaxation, endurance, repeatability,
coordination, and correct position of the pelvic floor.
Where necessary, PFMT aims to train the patient’s aware-
ness regarding the way in which and the extent to which
the pelvic floor muscles can be used (Fig. 36.4).
It has been demonstrated that some elements of PFMT
have a therapeutic effect, but no definitive conclusion can
be drawn about the role of anal sphincter exercises in the
Fig. 36.4  Anal contraction
B. Berghmans et al.
treatment of patient with AI (level 1) [11]. Supported by
the recommendations of the “International Consultation
on Incontinence” and based on the low costs and the
absence of adverse effects of the therapy, PFMT can be
part of an integrated approach, which involves education/
advice, training the patient’s awareness of the way in
which and the extent to which the pelvic floor muscles
can be used, where necessary with the help of BF and/or
rectal balloon training (for problem categories IC, ID, II–
IV) (level 4) (Fig. 36.5).
Besides, exercises to reduce the anorectal angle, focus-
ing on the m. puborectalis (similar to “the knack”
described for the inward movement of the urethra), can be
used to improve the patient’s voluntary control of their
pelvic floor (for problem category IB) (level 4).
4. Biofeedback can be used in various ways for patients
with AI:
• To reduce or increase rectal sensation using a rectal
balloon
• Strength training (EMG (activity of motor units) or
pressure (anal manometry or probe)): BF is used to
visualize the activity of a patient’s anal sphincter and/
Fig. 36.5  Rectal balloon—Rectal balloon training as an adjunctive
method for pelvic floor muscle training in conservative management of
fecal incontinence
36  Behavioral Therapies and Biofeedback for Anal Incontinence
or pelvic floor muscles, such as the m. puborectalis,
and to enable awareness of contraction and relaxation.
As the patient sees or hears the signal, they are encour-
aged to increase their contraction strength and keep up
the contraction longer or to put more attention to
proper relaxation (Figs. 36.6 and 36.7).
• Coordination training (triplet): a balloon is inserted into
the rectum. Two other, smaller, pressure-­recording bal-
loons are introduced into the upper and lower parts of
the anal canal. As the rectal balloon is filled, it elicits the
RAIR. This causes anal relaxation, which is visualized
by the two recording balloons and which the patient
must become aware of and must learn to counteract by
means of a voluntary anal sphincter contraction. This
Fig. 36.6  Combining pelvic floor muscle training with biofeedback
facilitates pelvic floor muscle awareness to improve the severity of anal
incontinence
Fig. 36.8  Gametherapy is an innovative strategy to improve pre-contraction
465
contraction must be long and powerful enough to allow
the resting pressure to return to its initial value.
It has been demonstrated that some BF elements have a
therapeutic effect. PFMT with BF appears to be more effective
than PFMT alone, and BF with ES appears to be more effec-
tive than ES alone. However, the available literature does not
allow any definitive conclusions to be drawn on the role of BF
in the treatment of patients with AI (level 1) [11]. However, in
the opinion of the evidence statement development team, BF
can be used when there is doubt about the ability of a patient
without voluntary control of the pelvic floor to perform pelvic
floor contractions (problem category IA) or if a patient shows
insufficient progress, in order to accelerate progress in the
context of an integrated approach (e.g., education and advice,
voluntary control, PFMT) based on all modifiable components
(problem categories IC, ID, II, and IV) (level 4) (Fig. 36.8).
Fig. 36.7 Biofeedback can improve PFM perception and
coordination
466 B. Berghmans et al.

36.7 Evaluation reviews relevant to this topic were reviewed in Table 16-5,

pp. 2045–2046, 6th edition Incontinence, ICI [28]).
The therapist should evaluate the treatment with the mea-
surement instruments used during assessment and should
also evaluate the modifiable components of the continence 36.8.1 Prior (2013) Assessment of Electrical
mechanism that emerged from the physical examination. The Stimulation of the Anal Mucosa or
therapist and patient may jointly consider arranging a re-­ Perineum
evaluation, in the form of a checkup or reminder therapy, at
predefined dates after the conclusion of the treatment. In the previous ICI report [27], reviewers concluded: “There
is no support for the addition of electrical stimulation from
non-implanted devices….” This conclusion was based on the
36.8 Updating the Evidence After lack of good quality RCTs during the period from 2008 to
Publication of the Dutch Evidence January 2012 and the absence of any Cochrane systematic
Statement review of the effects of ES from peripheral devices since
2007 [25].
Besides our systematic reviewing for the evidence statement,
relevant literature on the effectiveness of ES, PFMT, BF, and
TNS was also previously reviewed up to January 2012, to 36.8.2 Prior (2013) Assessment of Pelvic Floor
serve the Fifth International Consultation on Incontinence Muscle Exercises
(ICI) [11, 27]. Recently, the ICI Committee 16 updated rec-
ommendations on assessment and conservative management The Fifth ICI concluded: “PFMT is possibly effective for the
of AI and quality of life in adults for the Sixth Consultation treatment of AI.” This conclusion was based on a study
on Incontinence by reviewing in detail relevant literature showing that PFMT was more effective than conservative
published between January 2012 and March 2016 [28]. For management, although it was less effective that BF com-
this, a search was conducted in the electronic databases of bined with PFMT [31].
the Cochrane Library, PubMed, EMBASE, PEDro, and
CINAHL.  This search with no restrictions on language of
publication was limited to studies in which the study popula- 36.8.3 Prior (2013) Assessment of Biofeedback
tion was adult humans. The search terms were fecal inconti- Therapy
nence OR anal incontinence or accidental bowel leakage
AND biofeedback OR neuromuscular conditioning OR pel- In the last ICI, the working committee concluded with a cau-
vic floor exercise OR Kegel exercise OR electrical stimula- tious endorsement of biofeedback: “Manometric biofeed-
tion OR percutaneous tibial nerve stimulation. Published back training is possibly effective” but “the variability
since January 2012, 327 articles were identified of which 80 between studies suggests that results may be dependent on
were reviews. So, 247 papers were screened by title, and 65 the training and experience of the therapist.” The evidence
papers were identified for further review of their abstracts. supporting this conclusion was based largely on an RCT by
Abstract review further reduced the analysis set to 24 publi- Heymen [31] and an updated Cochrane review [11]. Other
cations. These were assigned to five sets with some overlap studies included in this review were judged to have signifi-
allowed. The reference sets were (1) biofeedback, (2) home cant limitations.
biofeedback training, (3) pelvic floor muscle training, (40 In the Heymen study, patients with at least weekly solid or
electrical stimulation of the anal mucosa or perineum, and liquid FI were randomized to either BF + PFMT or PFMT
(5) posterior tibial nerve stimulation. These reference sets alone for six sessions [31]. However, before they began their
were read carefully to identify randomized controlled trials investigational treatment, all patients were first provided
(RCTs) or cohort studies with appropriate comparison with 4 weeks of conservative management consisting of
groups. Seven relevant systematic reviews were also identi- patient education about the physiology of FI and instructions
fied and reviewed. After eliminating duplicate references, in how to normalize stool consistency with fiber or non-­
studies containing fewer than 10 patients per treatment con- prescription medication. Only patients who failed to report
dition and uncontrolled studies, 16 published studies con- adequate relief from conservative management (79%) were
taining original data met inclusion criteria (Table  16-4, allowed to continue and be randomized to receive BF +
pp. 2038–2043, 6th edition Incontinence, ICI [28]). Two of PFMT or PFMT alone.
these studies were published before 2012 but are included The primary assessment was at 6 months, corresponding
because they were not considered in the ICI 2013 review of to 3 months after the end of the 3-month treatment period.
this literature [29, 30]. An additional seven systematic Patients who reported adequate relief at 3 months were
36  Behavioral Therapies and Biofeedback for Anal Incontinence
followed up again at 12 months, whereas patients not report-
ing adequate relief at 3 months were assumed to be non-­
responders at 12 months. Patients treated with BF + PFMT
were significantly more likely than patients treated with
PFMT alone to report adequate relief (76% vs. 41%).
Continence (zero FI episodes in the previous month) was
achieved by 44% of biofeedback-treated patients compared
to 21% of PFMT-only patients. Scores on the validated Fecal
Incontinence Severity Index also showed significantly
greater improvement in the biofeedback patients compared
to the PFMT-only patients at 3 months and again at 12
months follow-up [32]. Biofeedback-treated patients
increased their anal canal squeeze pressures and decreased
their abdominal wall tension significantly more than PFMT-­
only patients when squeezing to prevent stool leakage. This
study showed that BF + PFMT was superior to PFMT alone
in patients with moderate to severe FI.  It also showed that
treatment benefits for both biofeedback and PFMT were not
explained by non-specific effects of conservative treatment.
The updated Cochrane review surveyed the literature through
January 2012 and identified 21 studies for analysis [11].
Unlike the previous Cochrane review [33], this one yielded a
qualified endorsement of biofeedback for the treatment of
FI: “We found some evidence that biofeedback and electrical
stimulation may enhance the outcome of treatment com-
pared to electrical stimulation alone or exercises alone…
While there is a suggestion that some elements of biofeed-
back therapy and sphincter exercises may have a beneficial
effect, this is not certain.”
36.9 U
 pdate: Review of Evidence
from January 2012 to May 2016
Electrical stimulation: Two RCTs evaluated the efficacy of a
Triple Therapy (3T) protocol in which medium frequency
electrical stimulation (3000 Hz, 500 μV) plus EMG BF was
compared to either EMG BF alone [29] or to low-frequency
ES (100 Hz, 50 μV) alone [30]. (These two studies were pub-
lished prior to 2012 but were inadvertently missed in the previ-
ous review. Triple therapy is a complex protocol in which
patients are directed to practice during two 20-min sessions
each day at home. In the morning session, they received EMG
BF and alternately contracted their pelvic floor muscles volun-
tarily or stimulated contractions with medium frequency
ES. In the afternoon session, they received EMG BF and were
also provided with medium frequency ES contingent on vol-
untary contractions that exceeded an individually determined
threshold. The threshold required to trigger ES was progres-
sively raised as performance improved in an effort to encour-
age stronger contractions. Triple therapy was provided by
battery-operated devices at home. A minimum of 6 months of
twice-daily sessions was required to improve FI.
467
The 2010 Schwandner study (29) compared 3T to EMG
BF alone and found that the 3T group improved significantly
more than the group treated with EMG BF at 9 months but
not at 3 months. However, this study had limitations: Some
patients had only mild FI and 15% were only incontinent for
flatus. In addition, the dropout rate was high: Only 24% of
the EMG BF-only group completed the 9 month trial, and
only 54% of the combined ES plus BF group completed the
trial. However, these limitations do not explain the findings
because the data were analyzed by intention to treat.
A second study from this group of investigators compared
3T to low-frequency (100 Hz, 50  μV) ES, with both treat-
ments provided twice a day for 20 min each for a total of 6
months [30]. There were few dropouts: 92% of the 3T group
and 84% of the EMG BF group completed the 6 month trial.
The 3T group showed significant improvement by 3 months,
whereas the low-frequency ES group showed no change
from baseline at 3 or 6 months. A limitation of this study was
the lack of blinding.
Two other studies tested low-frequency ES alone [34] or
combined ES with BF [35]. The aim of the first study was to
compare daily home ES to standard BF training in six weekly
sessions provided in the clinic. There was no difference
between these two treatments in overall improvements in FI,
although there was a significant decrease in FI frequency
from baseline to the end of treatment for the ES group. Home
ES was less costly than BF provided in the clinic [34].
In the second study, ES was combined with BF but only in
half of patients (28/62, and then only if, in the opinion of the
investigators, ES was needed to “help the patient identify and
contract their sphincter.” There was no difference in FI sever-
ity or FI quality of life between the BF/ES group and the
dextranomer-injected group at the 6-month assessment [35].
Tibial nerve stimulation: This variant of ES is to stimu-
late through electrodes attached to the skin overlying the
tibial nerve of one ankle (transcutaneous stimulation, abbre-
viated TTNS) or to stimulate through a needle inserted
through the skin and into the region of the tibial nerve (per-
cutaneous stimulation, abbreviated PTNS). A systematic
review of tibial nerve stimulation published in 2014 [26]
reviewed two RCTs of TNS and PTNS published up to 2013
and multiple uncontrolled studies of both percutaneous and
transcutaneous TNS [36, 37]. This review concluded that
transcutaneous TNS was not superior to sham electrical
stimulation and that no adequate RCT of percutaneous TNS
was available by 2013. A pilot study published by Thin in
2015 compared sacral nerve stimulation to PTNS and found
support for the efficacy of PTNS [38]. Subsequently, a rigor-
ous RCT of PTNS was reported by the same group [39].
They randomized 227 patients with FI from 17 clinical sites
to receive 12 weekly sessions of percutaneous PTNS or sham
PTNS. There were no significant differences in the primary
outcome measure, which was the proportion achieving at
468
least a 50% reduction in FI episodes (38% in PTNS, 31% in
sham). However, some of the secondary outcomes showed
differences: The average number of FI episodes decreased
significantly more in the PTNS group than in the sham group,
and this was found to be due to a greater reduction in urgency-­
related FI episodes but not in the number of passive FI epi-
sodes. Thus, this well-conducted study failed to show a
significant benefit of PTNS on the a priori selected primary
outcome measure, but it leaves doubt about whether PTNS
may be an effective treatment for urgency-related FI. Further
research is needed in groups stratified at the outset between
urgency and passive FI [39].
PFMT studies: Daily pelvic floor muscle exercises are
often combined with clinic-based BF [40]. Three studies
published since 2012 evaluated PFMT as the primary treat-
ment [41–43]. Glazener and colleagues reported the long-­
term follow-up of a study comparing PFMT to standard
medical care [42]. All 747 women included in this study had
urinary incontinence 3 months after vaginal delivery, and
15.7% of them also reported FI.  PFMT had a significantly
greater impact on FI than standard medical care at 1-year
follow-up but not at 12 years. Limitations to this study are
that comparisons at 12 years are confounded by some
patients undergoing additional treatments, especially if they
had an inadequate response to the initial treatment, and pro-
gression of underlying disease. Peirce and colleagues (2013)
compared PFMT alone to PFMT supplemented by clinic-­
based BF in 120 women with a third-degree sphincter lacera-
tion during vaginal delivery, to determine whether
supplemental BF is more effective at preventing FI [41]. No
differences were seen, but the study was underpowered to
detect a difference in incident cases of FI. Lin and colleagues
(2016) tested whether PFMT instructional DVD pamphlet
were more effective than the pamphlet alone in reducing FI
following low anterior resection for cancer [43]. (This very
low dosage) PFMT, taught by a research assistant prior to
discharge from the hospital, was associated with lower rates
of FI at 1, 3, and 6 months follow-up. An unanswered ques-
tion remains whether PFMT taught by digital palpation of
pelvic floor muscles rather than by verbal or printed instruc-
tions, is as effective as BF augmented by PFMT, as some
earlier studies suggested [44, 45].
Biofeedback compared to standard medical care: Two
new RCTs followed a traditional design by comparing BF to
standard medical care, defined as dietary counseling and use
of antidiarrheal drugs or laxatives to normalize stool consis-
tency. Damon and colleagues (2014) randomized patients to
receive either standard medical care alone or standard medi-
cal care plus 20 sessions of BF and found that significantly
more of the BF-treated patients met the responder definition
compared to the standard medical care only group [46].
Sjodahl et  al. (2015) used a crossover design in which
patients were initially randomized to receive either standard
B. Berghmans et al.
medical care or three sessions of EMG BF in phase 1 and the
combination of standard medical care and BF in phase 2
[40]. There was no evidence of differential effects in phase 1,
but the combined treatment was associated with significant
improvement compared to baseline. Since most patients had
tried standard medical care prior to the study and the BF
training was less than is usually employed in phase 1, this
study may also be seen as supporting the efficacy of BF.
The Pelvic Floor Disorders Network, which is a consor-
tium of eight academic surgical divisions supported by the
National Institute for Child Health and Human Development,
is conducting a multicenter trial of biofeedback and/or loper-
amide for the treatment of FI. Results are not yet available,
but the study design and methods have been published [47].
This study uses a factorial design which compares four
groups: biofeedback plus loperamide, loperamide plus edu-
cation (control for biofeedback), biofeedback plus placebo
tablets, and patient education plus placebo tablets. A detailed
protocol for conducting biofeedback training using new soft-
ware which provides the therapist with prompts to help stan-
dardize the biofeedback intervention across sites as well as
individualizing biofeedback to the patient’s specific deficits
has been published [48].
Home biofeedback training: The efficacy of home-
based BF, which allows for more frequent BF training and
reduces the amount of professional time required, was the
focus of six studies. Two studies in which 3T was provided
twice daily for 6–9 months were described above; both sup-
ported the efficacy of 3T [29, 30]. (1) Dehli compared intra-
anal injections of a bulking agent to 6 months of twice-daily
BF and found that both treatments improved FI severity and
quality of life with no significant difference between treat-
ments [35]. (2) Damon compared 4 months of home-BF to
standard medical care and reported that significantly more
patients in the BF group were responders [46]. (3) Bartlett
tested whether the addition of home BF to clinic BF improved
outcomes compared to clinic BF alone: For the whole group,
supplementation with home BF did not significantly improve
outcomes, but a post hoc analysis showed that the youngest
half of the patients (below the median age of 61) did benefit
significantly more when clinic-based BF was augmented by
home BF [49]. (4) A study by Peirce et al. (2013) compared
daily home BF to daily PFMT for 3 months to determine
whether either treatment could prevent FI in women with a
third-degree sphincter laceration sustained during childbirth
[41]. There was no evidence that home-based biofeedback
training prevented the development of FI, but the study was
underpowered to show a difference in incident cases of FI.
The six studies of home biofeedback described above
suggest that home practice 1–2 times daily with a battery-­
operated BF device is more beneficial than either ES or BF
in the clinic or standard medical care. Home BF may also be
less costly to provide. However, these studies also suggests
36  Behavioral Therapies and Biofeedback for Anal Incontinence
that home BF has possible limitations: (1) longer periods of
BF training may be required (at least 6 months according to
one investigator); (2) on average, younger patients benefit
more than older patients; and (3) daily practice is a burden
which may increase the dropout rate.
Systematic reviews and meta-analyses: Table  16-5,
pp. 2045–2046, 6th edition of ICI Incontinence [28] lists the
systematic reviews and guidelines documents published
since January 2012 that addressed the use of BF, ES, TNS,
and PFMT for the treatment of AI [11, 26, 50–53]. The
Cochrane review [11] published in 2012 provided qualified
evidence for the efficacy of biofeedback as summarized in its
conclusion: “While there is a suggestion that some elements
of biofeedback therapy and sphincter exercises may have a
therapeutic effect, this is not certain. Larger well-designed
trials are needed to enable safe conclusions.” The other
reviews and guidelines documents that addressed BF
(Table 16-5 ICI Incontinence [28]) were consistent in recom-
mending it, alone or in combination with PFMT or ES, for
the treatment of FI.
36.10 Conclusions
This chapter reflects the current state of knowledge for a
methodic and systematic physiotherapeutic assessment and
treatment for patients with AI.  Overall, evidence is (still) 1. Diagnostic process
(fairly) weak, and therefore the cited Dutch Evidence
Statement reflects also consensus among experts. The benefit
of this evidence statement is to improve quality and unifor-
mity in care and increase transparency to the involved clini-
cians and patients. More high-quality research is needed to
validate the consensus-based recommendations.
36.11 Spin Off
The Royal Dutch Society for Physiotherapy (KNGF) decided
to publish an evidence statement instead of a guideline as
this enabled the society, by combining evidence, expert judg-
ment, and consensus, to support health-care providers to
methodically approach their patients, notwithstanding the
paucity of published evidence [14].
AI covers only one important domain of symptoms that
pelvic physiotherapists are able to treat. Other important
domains are among others stress and urgency urinary incon-
tinence, prolapses (bladder, uterus or intestines), sexual
problems, constipation, pelvic pain, and support before and
after surgery (gynecologic, urologic, and gastrologic). Pelvic
physiotherapists are musculoskeletal experts and well-­
trained and well-utilized to assess and treat the consequences
of the various health problems mentioned earlier. The KNGF 2. Therapeutic process
Evidence Statement AI [14] contributes to more transpar-
469
ency and visibility on the important role of pelvic physio-
therapy throughout the field of clinicians that are involved
(often in a multidisciplinary context) in continence care.
Moreover, efforts should be undertaken to work toward evi-
dence statements or guidelines for the other treatable
domains of pelvic physiotherapy. Irrespective of the limited
evidence base, conservative treatment is unanimously rec-
ommended, singly or in combination, for the majority of
patients with AI [1, 14]. Clinicians should keep in mind that
conservative treatment is a first-line approach and should be
considered before surgery mainly due to the low costs and
absence of side effects [14, 28].
Our recommendations will raise discussion and future
research questions, which will ultimately result in advance-
ments in the area of pelvic physiotherapy in AI. Future chal-
lenges are to conduct further high-quality RCTs (with
adequate training intensity, sample size, methodological
quality, and consistent use of consensus-based terminology)
and to perform studies to get insight into adequate stimula-
tion parameters and which methodologically sound measure-
ment instrument to choose.
36.12 Recommendations for Practice
• Measurement instrument—in the opinion of the evi-
dence statement development team, the screening,
diagnostic, and treatment evaluation processes should
involve a patient-reported outcome measure (level 4).
• Wexner score—in the opinion of the evidence state-
ment development team, the Wexner score is a suitable
instrument to assess the severity of AI as a health prob-
lem and how well the patient is coping (level 4).
• GPE—in the opinion of the evidence statement devel-
opment team, the GPE is a suitable instrument to evalu-
ate patient-perceived changes in health status (level 4).
• Defecation diary—in the opinion of the evidence state-
ment development team, a defecation diary should be
used to assess the defecation frequency and the sever-
ity of the AI (level 4).
• Bristol Stool Scale—in the opinion of the evidence
statement development team, the BSS is a suitable
instrument to assess the consistency of a patient’s
stools (level 4).
• ICIQ-B and FIQL—the evidence statement develop-
ment team recommends the ICIQ-B to assess bowel
symptoms and impact of these symptoms on quality of
life and the FIQL to assess disease-specific quality of
life (level 4).
Providing education and advice
470
• Patient-specific education plan—in the opinion of the
evidence statement development team, a patient-spe-
cific education plan should be used for each individual
problem category (level 4).
Electrostimulation
• It has been demonstrated that low-frequency ES is
weakly effective or not effective when used alone or in
combination with BF for the treatment of FI. The 3T
involving electrical stimulation at a frequency of
3000  Hz combined with BF, when practiced twice
daily for at least 6 months, may be more effective than
BF alone or low-frequency (100 Hz) ES alone (level
2). Based on only limited studies, which were hetero-
geneous in terms of patient sample, treatment proto-
col, and outcome measures, it is unclear on what basis
patients should be selected for ES and what ES modal-
ity would be optimal (level 1).
• In the opinion of the evidence statement development
team, ES is useful for a specific group of patients, to
improve the voluntary control of the pelvic floor in
patients who lack this voluntary control (problem cat-
egory IA) (level 4).
• It is plausible that PTNS has a possibly effective
approach to the treatment of FI (level 2), but PTNS
remains an investigational treatment protocol currently
not (yet) recommendable for clinical practice
Pelvic floor muscle training
• It has been demonstrated that some elements of PFMT
have a therapeutic effect and therefore is recommended
as an early intervention in the treatment of AI. However,
no definitive conclusion can be drawn yet about the
role of anal sphincter exercises in the treatment of
patients with AI (level 1).
• In the opinion of the evidence statement development
team, PFMT can be recommended as part of an inte-
grated approach, which involves education/advice,
training the patient’s awareness of the way in which
and the extent to which the pelvic floor muscles can be
used, where necessary with the help of BF and/or rec-
tal balloon training (for problem categories IC, ID, II–
IV) (level 4). This evidence is supported by the
recommendations of the International Consultation on
Incontinence and is partly based on the low cost and
the absence of adverse effects of the therapy.
• In the opinion of the guideline development team,
exercises to reduce the anorectal angle, focusing on
the m. puborectalis (similar to the “knack” described
for the inward movement of the urethra), can be used
to improve the patient’s voluntary control of their pel-
vic floor (for problem category IB) (level 4). The
“knack” is a voluntary contraction which a person can
use to learn to contract their pelvic floor muscles just
B. Berghmans et al.
before a cough or lifting a heavy object, to prevent the
loss of urine or stools.
Biofeedback
• It has been demonstrated that some BF elements have
a therapeutic effect. PFMT with BF appears to be more
effective than PFMT alone, and BF with electrostimu-
lation appears to be more effective than ES alone, but
no definitive conclusion can be drawn regarding the
role of BF in the treatment of patients with AI (level 1).
• There are indications that a combination of manome-
try BF or rectal balloon training and PFMT is more
effective than PFMT alone if previous conservative
treatments have failed (level 3).
• In the opinion of the evidence statement development
team, BF can be used when there is doubt about the
ability of a patient without voluntary control of the
pelvic floor to perform pelvic floor contractions (prob-
lem category IA) or if a patient shows insufficient
progress, in order to accelerate progress in the context
of an integrated approach (e.g., education and advice,
voluntary control, PFMT) based on all modifiable
components (e.g., for problem categories IC, ID, II
and IV) (level 4).
36.13 Future Directions
Further RCTs of ES, PTNS, PFMT, and BF are needed to
define the most optimal physiological parameters to improve
or restore anorectal function and bowel control.
Protocols of pelvic floor rehabilitation for AI need to be
standardized.
Take-Home Messages
• Based on adequate patient selection and nature and
severity of AI, pelvic floor rehabilitation should be
considered as a first-line treatment for patients with
AI, taking into account degree of modifiability of
the patient’s health problem (general and local
impeding factors).
• Using the ICF, the physiotherapeutic diagnostic
process serves to identify the nature and severity of
AI and its degree of modifiability by pelvic floor
rehabilitation.
• Pelvic floor rehabilitation aims to improve and
restore anorectal dysfunction and bowel control
and has its place in the multidisciplinary treat-
ment of AI.
36  Behavioral Therapies and Biofeedback for Anal Incontinence
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 Sphincter Repair and Postanal Repair
Adam Studniarek, Johan Nordenstam,
and Anders Mellgren
Learning Objectives
After completing this chapter, the reader should be able to:
• Describe the diagnostic workup and indications for
sphincteroplasty
• Discuss the technique of overlapping sphinctero-
plasty and associated technical pearls
• Present short-term and long-term results of
sphincteroplasty in different patient populations
• Discuss the quality of life for patients who undergo
sphincteroplasty based on most recent fecal
incontinence grading scales
• Describe the indication for postanal repair and
associated success rates after the procedure
37.1 Introduction
Fecal incontinence (FI) significantly affects patients’ social,
personal, and occupational life, and in severe cases FI symp-
toms can lead to social isolation and depression in otherwise
healthy individuals. FI prevalence ranges from 2.2% to 17%,
depending on the study population and the criteria use for
defining FI [1].
Several factors are considered to produce symptoms of
FI, including consistency and amount of stool (e.g., diar-
rhea), damage to the mucosa of the colon and rectum (e.g.,
colitis), neurologic factors (e.g., diabetes, Parkinson’s dis-
ease), and injuries to the anal sphincter and pelvic floor mus-
Electronic Supplementary Material  The online version of this chapter
(https://doi.org/10.1007/978-3-030-40862-6_37) contains supplementary
material, which is available to authorized users.
A. Studniarek · J. Nordenstam · A. Mellgren (*)
Division of Colon and Rectal Surgery,
University of Illinois at Chicago, Chicago, IL, USA
e-mail: anders.mellgren@icloud.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_37
37
cles. Surgeons frequently see patients who have developed
FI after obstetric trauma or anorectal procedures. Anal
incontinence secondary to sphincter tears is mainly found in
female patients after third- or fourth-degree tears [2].
Previous anorectal surgeries, such as fistula surgery [3],
hemorrhoidectomy [4], manual dilatation (Lord’s proce-
dure) [5], or lateral internal sphincterotomy for the treatment
of anal fissure [6], have all been described as causes of
FI.  With midline episiotomies and/or operative vaginal
delivery, the incidence of anal sphincter injuries can reach
50% [7].
Anal sphincter damage sustained during childbirth is one
of the most common causes in middle-aged women [8].
Occult sphincter defects during vaginal deliveries have been
diagnosed by anal ultrasound in up 35.4% of primiparous
women and 43.8% of multiparous women and are especially
common after forceps deliveries [9]. Prospective studies
have confirmed a high rate of injuries after vaginal deliveries
[10]. More recent meta-analysis demonstrates that the inci-
dence of occult anal sphincter disruption after vaginal deliv-
ery is higher than previously estimated [11]. However, at
least two-thirds of postpartum occult defects are asymptom-
atic. Damon et al. found that if signs of clinical FI and a his-
tory of vaginal delivery were present, an anal sphincter
defect could be seen upon endoanal ultrasound (EAUS) in
62% of patients, and clinical symptoms were related to the
size of these defects [12].
Recent technological advances in imaging techniques
allow for improved diagnostic evaluation. Ultrasound allow
for incorporating measurements of defects in the anal sphinc-
ters and the pubovisceral muscles [13].
37.2 Diagnostic Workup
The first step in evaluating patients suffering from FI includes
a careful history and physical examination. Questions should
be directed toward the type and degree of incontinence, as
well as changes in patients’ lifestyle.
473
474
A validated scoring system (Williams, Pescatori, Wexner,
AMS score, etc.) is often used to rate FI more accurately. A
distinct sphincter disruption can often be palpated upon
dynamic digital-rectal examination. Clinical evaluation and
endoscopy exclude structural disorders, such as polyps or
tumors. The basic clinical investigation frequently is compli-
mented with more specific testing.
Ultrasound has secured an important role in the assess-
ment of FI. Ultrasound provides an objective assessment of
the sphincter integrity and can readily diagnose injuries and
anatomic deficiencies of the internal and external anal
sphincters and the pelvic floor [14, 15]. Various preoperative
factors have been evaluated to determine the prognostic fac-
tors for successful sphincteroplasty. A preoperative volun-
tary contraction of the puborectal sling >8 mm convincingly
discriminates between patients with a good functional out-
come and those with an unsatisfactory outcome after sphinc-
ter repair for post-obstetric anal incontinence [16].
Defecography adds anatomic and functional imaging of
the rectum and other structures. Defecography can be helpful
in detecting a rectocele or internal rectal prolapse, which
may contribute to incontinence symptoms in some patients
[17]. Defecography can be performed with fluoroscopic or
MRI technique.
Anorectal manometry provides objective data regarding
anal canal pressures, sensation, and the rectoanal inhibitory
reflex (RAIR). This information can be helpful in the diagno-
sis of the etiology of incontinence; however, some argue that
it is of little clinical utility as decisions for treatment are
largely based on symptoms [18].
Nerve conduction studies have also been used in the
assessment of FI. Pudendal nerve testing can be used to eval-
uate nerve damage, but pudendal nerve testing can be diffi-
cult to perform accurately and the technique has a significant
learning curve. It is estimated that diagnostician must per-
form at least 40 exams to become efficient [19]. Pudendal
nerve terminal motor latency measurement has been shown
in some studies to have predictive value in patients who
undergo sphincteroplasty. This prognostic information may
be of value to patients in deciding whether to undergo such
an invasive procedure [20, 21]. Other authors have demon-
strated that pudendal nerve testing is normal or unilaterally
normal in 88% of the time and that only 12% of patients with
bilaterally prolonged pudendal nerve latency have signifi-
cantly poorer outcomes [22]. Recent data indicates that
pudendal nerve injury does not independently predict the
success of sphincteroplasty [23–25]. Nerve testing has slowly
faded away as a main diagnostic modality and today nerve
testing is only performed in certain indicated situations.
Needle electromyography (EMG) of the pelvic floor musles
involves direct testing of the external anal sphincter by placing a
needle electrode in the muscle. EMG is therefore associated with
significant discomfort and is nowadays infrequently used [20].
A. Studniarek et al.
37.3 Indications
If the patient has significant symptoms and conservative
treatment options (dietary modification, medications, bio-
feedback, etc.) have failed, patients may be considered for
a surgical sphincter repair if they have an isolated sphinc-
ter injury. Sphincteroplasty used to be the standard of care
for the management of FI related to anal sphincter injury
[26], but more recent studies demonstrate that sacral nerve
stimulation (SNS) is another viable alternative in these
patients. Some centers recommend SNS as a first-line
treatment, even in the presence of sphincter defects
[27–30].
Patients best suited for surgical corrections are usually
younger women with fecal incontinence secondary to an
obstetrical injury [31]. Anal sphincteroplasty has the ability
to also correct anatomical defects, such as a thinned perineal
body or a rectovaginal fistula.
37.4 Surgical Technique
The patient usually receives a full bowel preparation with
polyethylene glycol solution, perioperative antibiotics, and a
Foley catheter. The operation is performed under general
anesthesia with the patient in the prone jackknife position.
Some surgeons use the lithotomy position.
The operation starts with a curvilinear incision on the
perineum, and the dissection is carried until the edges of
external anal sphincter are identified and isolated. Care is
taken not to dissect too far laterally to avoid nerve injury.
Sometimes, a concomitant levatorplasty is performed.
Separate attention to the internal anal sphincter imbrica-
tion has not been demonstrated to add to the overall success
rate of sphincteroplasty [32–36]. The ends of anal sphincter
muscles are usually overlapped and repaired with mattress
sutures, providing new bulk to the sphincter complex. After
the muscle repair, a simple wound closure is performed with
the midportion left open for drainage. Postoperatively, daily
showers or sitz baths are recommended. The estimated time
for wound closure is approximately 4–6 weeks.
37.5 Technical Considerations at Surgery
37.5.1 Overlapping vs. End-to-End Repair
Historically, sphincter injuries were usually repaired with
an end-to-end technique.  Failure rates were however high
and in 1971 Sir Alan Parks introduced a new technique,
overlapping sphincter repair [34]. This type of repair became
widely accepted and has been the surgery of choice until
this day [35].
37  Sphincter Repair and Postanal Repair
A Cochrane review from 2006 showed that there was no
statistically significant difference in perineal pain, dyspareunia,
flatus incontinence, and FI between the two repair techniques
at 12 months. At the same time, the overlap group had, statisti-
cally significant lower incidence in fecal urgency and lower
anal incontinence score. The overlap technique was also asso-
ciated with a statistically significant lower risk that anal incon-
tinence symptoms will worsen over a 12-month period. There
was, however, no significant difference in quality of life [36].
The results of overlapping anal sphincter repair seem to
deteriorate with time. Patients should be counseled that a
majority will have improved FI  after the procedure, but
continence is rarely perfect, and function may deteriorate
with time [37]. A few studies have reported more promis-
ing results, with lasting improvement and satisfactory
long-term functional results [38].
In a comparison between the two techniques, Tjandra
et al. [39] found no significant difference in functional out-
come of overlapping vs. apposition of the sphincter ends.
This prospective, randomized controlled trial demonstrated
that the outcomes were similar. Although, the population
size was relatively small, there is little additional data pub-
lished comparing the two techniques.
Overlapping sphincteroplasty has remained the standard
at surgical repair, with supporting short-term and long-term
results. A direct relationship between the size of the tear and
the degree of dysfunction has not been confirmed [40].
37.5.2 Separate Suturing of External
and Internal Sphincters
A modified surgical approach, with separate suturing of the
external and internal anal sphincters, has been suggested by
Lindqvist et al. [41]. Separate suturing technique resulted in
significant improvement of anal incontinence symptoms at
1-year follow-up [42]. This has, however, not been replicated
in larger trials or with longer follow-up.
37.5.3 Scar Tissue
There seems to be an immediate benefit to overlap scar
over scar, which can be adequately evaluated and quanti-
fied with ultrasound. This may also facilitate repair of
larger defects [42].
37.5.4 Suture Material
Several different suture materials have been suggested by
authors, including monofilament nylon, pullout wire, cat-
475
gut, silk, and PDS. Evaluation of 40 case series of women
who underwent overlapping anal sphincteroplasty with the
use of either permanent or absorbable sutures demonstrated
decreased FI severity scores with permanent sutures, but
the overall patient-reported degree of FI symptoms was
similar [43].
37.5.5 Diverting Stoma
In patients with a severe trauma to the perineum other than
after delivery, a proximal diverting colostomy is often con-
structed to decrease the risk for infectious complications
and to facilitate nursing management. Patients undergoing
elective anal sphincteroplasty are, however, usually oper-
ated without diverting stoma. The presence of a stoma has
not proven to improve the rate of wound healing and a
diverting stoma also adds the risk for stoma-related compli-
cations [44].
37.6 Other Considerations
37.6.1 Primary Repair vs. Sphincteroplasty
A third- or fourth-degree perineal tear at child delivery is
usually repaired immediately with a “primary repair.” For
optimal outcomes, these injuries should be repaired under
optimal conditions. Persisting sphincter defects are reported
in up to 66% [45, 46], and up to 40% of these women eventu-
ally develop FI symptoms [47].
In situations when there is no available surgical specialist,
primary repair can be delayed 8–12  h without worse out-
comes at 1-year follow-up [48]. Delayed primary repair is
usually not recommended routinely, but can be an alternative
under special circumstances [49, 50].
For secondary repair with sphincteroplasty after obstet-
ric injury, a delay of at least 6 months to 1 year has been
recommended to allow the tissue to recover [50]. Soerensen
et  al. prospectively looked at sphincter repairs done as a
delayed primary (within 72  h postpartum) or as an early
secondary reconstruction (within 14 days after delivery)
without a diverting stoma in women who had sustained a
third-degree or fourth-degree obstetric tear. They found
equal results with acceptable long-term functional out-
come in both groups [51].
In acute emergency trauma situations, the recommended
initial treatment is usually debridement of nonviable tissue,
removal of foreign material, open drainage, and often proxi-
mal diversion with distal washout. Depending on the extent
of injury and the associated trauma, reconstructive surgery
may be deferred.
476
37.6.2 Failed Primary Repair
There seems to be no difference in outcome in patients who
had an unsuccessful primary repair and those who had an
occult injury (and thus no previous primary repair) [51].
Recent data evaluating risk factors for primary repair con-
clude that repairs performed during on-call hours, with inex-
perienced personnel, and often misdiagnosed at first, increase
the risk for a failed repair, while use of antibiotics and laxa-
tives may improve the outcome [52]. Patients undergoing
more than two previous repairs (including previous second-
ary sphincteroplasty) usually have poorer outcomes [52].
37.6.3 Age
Sphincteroplasty can be successfully performed in elderly
patients [53], but it has been debated whether their repair has
the same success rate as in younger patients. Simmang et al.
[53] found no difference in outcome in patients with a mean
age of 66 years (range 55–81 years) when compared to
younger patients. Other authors have reported similar results
[54, 55]. Nikiteas et al. [52] reported poorer results in patients
older than 50 years, especially with concomitant obesity and
perineal descent.
37.6.4 Pudendal Neuropathy
Pudendal neuropathy has been reported to be a predictive
factor of failure following anterior overlapping sphinctero-
plasty, while other studies have not seen a difference in
patients with or without pudendal neuropathy [56].
Sphincteroplasty is usually considered even if there is a doc-
umented pudendal neuropathy. The potential impact of this
should be discussed with the patient preoperatively.
Some patients have an inability to volontarily contract the
sphincter muscles at preoperative clinical examination. This
may indicate a severe neurological injury and this may be a
predictor of possible failure after surgical repair.
37.6.5 Biofeedback
Biofeedback is used as a first-line therapy for FI.  Several
studies demonstrate a positive effect of biofeedback in
patients with sphincter defects. In a follow-up study by
Sander et al. [57], 48 patients were followed up after third- or
fourth-degree sphincter lacerations. After 1 month, ten
patients (21%) complained of anal incontinence with major-
ity being incontinent only for gas. After 1 year, only three
patients (7%) had symptoms of incontinence. The authors
A. Studniarek et al.
concluded that pelvic floor exercises are appropriate first-­
line treatment options. Electrical stimulation was abandoned
in this study due to anal pain.
Some studies [58] use technological devices to improve
results of home treatment with biofeedback, and there are
smartphone applications used for the same purpose.
Patients who have undergone sphincteroplasty are usually
referred for postoperative pelvic floor exercises and biofeed-
back [59].
37.6.6 Concomitant Perineal Operations
Patients with FI and a sphincter defect sometimes have
other concomitant pelvic floor pathologies. Combining
the sphincteroplasty with levatorplasty, procedures for
urinary incontinence and/or pelvic organ prolapse are
sometimes performed [60, 61]. Sphincteroplasty some-
times need to be combined with a repair of a more exten-
sive perineal reconstruction of the pelvic floor for
cloaca-like deformities [62].
Some authors have recommended a simultaneous repair
with sphincteroplasty and a repair for rectal prolapse [63].
Usually, however, we would recommend to fix the prolapse
first (with appropriate repair) and subsequently consider
additional treatment with sphincter repair or SNS if the pro-
lapse repair fails to improve/correct the FI symptoms.
37.6.7 Alternative Surgical Options
Different types of muscle transpositions/flaps have been sug-
gested to treat FI.  Usually, the gracilis or gluteus muscles
have been used, but long-term results have not been encour-
aging. Dynamic graciloplasty, transposition of a gracilis
muscle that was stimulated with an electric stimulator, has
been tried but carried a high complication rate and is no lon-
ger available [64–66].
Artificial sphincters have also been tried [67]. An inflat-
able device has been used, but carries a rather high complica-
tion rate (mainly infections), and is no longer available on
the market. More recently, a magnetic sphincter has been
tried with promising results [68], but it is unfortunately cur-
rently not available.
Another option is SNS, first proposed by Dr. Matzel in
1995 [69]. SNS treats FI successfully in a majority of patients
[69, 70]. Though SNS and sphincteroplasty have not been
directly compared prospectively in the literature, numerous
studies have shown that patients with FI and sphincter defects
can have excellent outcomes with SNS [70–75]. The success
of SNS in these patients also does not appear to be correlated
to the degree of sphincter defect.
37  Sphincter Repair and Postanal Repair 477

37.6.8 Financial Aspects 37.8 Results of Sphincteroplasty

Sphincteroplasty is a relatively inexpensive operation com- 37.8.1 Short-Term Results

pared to more sophisticated procedures such as SNS. Successful
sphincteroplasty substantially improves FI patients’ quality of
life and reduces the overall cost of treatment [76].
37.7 M
 easurement of Outcomes After
Sphincteroplasty
Short-term results (<5 years) of sphincteroplasty are usually
quite good, with significant improvement rates of about
70–90% (Table  37.1). Unfortunately, few patients are
relieved of their symptoms completely, and results often
deteriorate with time (Fig.  37.1). It is therefore important
that patients are counseled about these issues (Fig. 37.2).

Measuring outcomes after treatment of FI can be done in

several different ways, and each modality has their own 37.8.2 Long-Term Results
advantages and disadvantages.
Unfortunately, the long-term results of sphincteroplasty are
not as successful as surgeons would like them to be
37.7.1 Descriptive Measures (Table  37.2). A systematic review by Glasgow and Lowry
demonstrated that although fecal continence deteriorates
Descriptive measure questionnaires do not provide summary over the long-term (more than 5 years) following anal
scores. Mayo Fecal Incontinence questionnaire was designed sphincterotomy, patient QOL and satisfaction remain rela-
to measure the prevalence of FI in the community and risk tively high [96] (Fig. 37.3).
factors associated with incontinence [77]. Other descriptive
questionnaires include Osterberg Assessment and Malouf Table 37.1  Results for overlapping sphincteroplasty: short term (<5
Postoperative Questionnaire, but they only have descriptive years)
value and are rarely used [78, 79]. Age (mean Success
Author Year N years (range)) (%)
Oliveira et al. [27] 1996 55 48 (27–72) 71
37.7.2 Severity Measures Pfeifer et al. [27] 2004 41 34 (19–71) 73
Tjandra et al. [39] 2003 23 45 (31–68) 74
Yoshioka and Keighley [84] 1989 27 34 (17–81) 74
Severity measures usually rate the type and frequency of
FI [80–83]. The disadvantage of these measurements is Fang et al. [85] 1984 79 (17–68) 89
that the impact on quality-of-life changes is not directly Fleshman et al. [86] 1991 28 38 (22–75) 75
addressed, though it is clear that a higher frequency of Morren et al. [87] 2001 55 39 (24–73) 56
incontinence episodes leads to a lower quality of life. A Elton and Stoodley [88] 2002 20 n.a. 80
Wexner score of 9 or higher indicates a significant impair-
Barisic et al. [89] 2006 65 n.a. 74
ment of quality of life [81]. Mevik et al. [90] 2009 29 45 (6–77) 86
n.a. not available

37.7.3 Impact Measures

1.00

The impact on quality of life can be evaluated with impact

measures. FI can significantly disrupt quality of life, and this 0.75
condition can be quite debilitating. General quality of life
questionnaires have a long history of use, with established
0.50
reliability, validity, and population norms (e.g., the Short
Form-36 (SF-36)). The disadvantage is that they are measur-
ing general quality of life and they are not specifically aimed 0.25
at quality of life issues related to FI. Lately, Fecal Incontinence
Quality of Life scale (FIQL) has been increasingly used [83].
0.00
The instrument is FI specific, and it is sensitive. FIQL is 0 20 40 60 80 100 120 140
composed of 29 items that form four scales: lifestyle (10 Time (months)
items), coping/behavior (9 items), depression/self-­perception
(7 items), and embarrassment (3 items). Fig. 37.1  Degradation of anal continence over time [91]
478 A. Studniarek et al.

100 37.9 S
 exual Function After
Sphincteroplasty
Patient’s rating of improvement

Sexual function after anal sphincteroplasty has been evalu-

in symptoms (%)

ated in several studies [97, 93]. In a study by Riss et al. [98],

50 sexual function was significantly diminished in patients who
underwent overlapping sphincteroplasty in comparison to
control group. No correlation with the severity of FI was
found. On the other hand, in a study by Pauls et al. [97], sex-
ual activity and function were similar following sphinctero-
plasty, despite more pronounced symptoms of FI.  They
0
15 months 77 months
found that solid stool FI and resulting depression were cor-
(n=31) (n=36) related with poorer sexual function. Similar results have
Median follow-up
been reported by Trowbridge et al. [93]. They found that anal
Patient’s ratings of improvement in symptoms from
continence rates 5 years after sphincteroplasty are disap-
preoperative state in 38 patients without stoma or further pointing and this adversely impacts quality of life, but not
surgery after sphincter repair sexual function (Fig. 37.4).
Bars show median values.

Fig. 37.2  Patients’ ratings of improvement in symptoms over time

[25] 37.10 Postanal Repair

Before the advent of EAUS, patients with FI were often

Table 37.2  Results for overlapping sphincteroplasty: long term (>5 categorized as having idiopathic or neurologic FI [99].
years) Patients were then frequently operated with postanal
Age (mean Success repair, described by Sir Alan Parks in the 1970s and pop-
Author Year N years (range)) (%) ularized in the 1980s.
Gilliland et al. [21] 1998 77 47 (25–80) 60 Postanal repair involves coaptation of the levator ani,
Malouf et al. [25] 2000 55 43 (26–67) 50 puborectalis, and external anal sphincter posterior to the anal
Karoui et al. [92] 2000 86 n.a. 49
canal and the anorectal junction by approximating these
Halverson and Hull [24] 2001 71 38.5 (22–80) 46
muscles with nonabsorbable sutures. The anatomical result
Bravo-Gutierrez et al. [23] 2001 191 37 (20–74) 62
Trowbridge et al. [93] 2006 86 n.a. 11 of this procedure is lengthening of the anal canal and a pos-
Barisic et al. [89] 2006 65 n.a. 48 sible reduction of the anorectal angle [102]. The procedure
Soerensen et al. [51] 2008 22 31 (22–38) 50 was performed to restore the anorectal angle, increase anal
Oom et al. [94] 2009 160 n.a. 37 pressure, and lengthen the anal canal [100].
Mevik et al. [90] 2009 17 45 (6–77) 53 The short- and long-term results of this procedure have
Johnson et al. [95] 2010 33 36 67 not been shown to be better than sphincteroplasty (Tables
Ratto et al. [70] 2010 24 47.6 (26–70) 85.7
37.3 and 37.4). Some speculate that success appears to be
n.a. not available

Fig. 37.3  Comparison of 100

long-term outcome with
90
length of follow-up as
described by Halverson and 80
Hull [24]
70
Incontinence to Stool
60
Percent

Incontinence to Gas/Mucous
50
Continent
40
30
20
10
0
3* 40 * 63 77†
Months of follow-up
37  Sphincter Repair and Postanal Repair 479

Fig. 37.4  Results from Patients with ´good´ outcome (%)

published series examining 100
anal sphincter repair
outcomes over time. “Good” 90
outcome determined using
definitions provided by the 80
authors of each article [101] Malouf6
70 Halverson/Zutshi13
60 Vaizey24
Bravo-Gutierrez16
50
Zorcolo25
40 Barisic15
30 Maslekar10
Mevik20
20
Johnson18
10

0 20 40 60 80 100 120 140

Months

Table 37.3  Results of postanal repair: short term (<5 years)

Author Year N Success (%) Take-Home Message
Womack et al. [102] 1988 16 68 Overlapping sphincteroplasty, despite sometimes sub-
Orrom et al. [101] 1988 17 59 optimal long-term results, is a viable treatment option
Braun et al. [103] 1991 31 84 for treatment of FI in patients with an isolated, prefer-
Briel and Schouten [104] 1995 37 46 ably anterior, sphincter defects. The surgery is usually
Athanasiadis et al. [105] 1995 31 52
performed in younger patients, and concomitant ana-
Matsuoka et al. [106] 2000 21 35
tomical problems can be repaired at the same time.
Physiological and other diagnostic tests are useful for
preoperative planning, but they do not predict the qual-
Table 37.4  Results of postanal repair: long term (>5 years)
ity of life in these patients postoperatively.
Author Year N Success (%) Various quality of life measures exist in order to
Yoshioka and Keighley [84] 1989 116 24
evaluate the resolution of symptoms after overlapping
Setti-Carraro et al. [107] 1994 54 52
Rieger et al. [108] 1997 22 58
sphincteroplasty, and patients’ satisfaction remains
Abbas et al. [109] 2005 47 68 high despite frequent deterioration of symptoms. Other
Mackey et al. [110] 2009 57 52 treatment modalities, including SNS, are increasingly
used in the treatment of this patient group.

related more to improve sphincter pressures and anal sensa-

tion. Others believe that the effect of postanal repair is due to
local scarring and anal stenosis than restoration of the ano-
rectal angle.
Postanal repair is rarely used, because of low success
rates in moderate-quality studies [110–113]. Postanal repair
should not be recommended for the treatment of anal sphinc-
ter defects.
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term results of overlapping anterior anal-sphincter repair for obstet-
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 Dynamic Graciloplasty
Piotr Walega and Maciej Walega
Learning Objectives
• Define typical indications for graciloplasty.
• Plan the preoperative evaluation before
graciloplasty.
• Describe the surgical steps of graciloplasty
procedure.
• Compare dynamic and adynamic graciloplasty in
the treatment of end-stage-fecal incontinence.
• Analyze the risks and benefits of graciloplasty in
patients with end-stage-fecal incontinence.
38.1 Introduction
Approximately 7–10% of working population suffer from
fecal incontinence; about 30% of them are affected by the
end-stage fecal incontinence [1, 2]. The number includes
patients with congenital absence of the anal sphincter,
patients after surgical treatment of the anus and rectum and
also after major perineal trauma, spinal injury or damage, or
peripheral innervation of the sphincters, who in the majority
of cases do not respond to conservative measures, such as
biofeedback training or electrical stimulation, and are not
eligible for surgical repair, for example, sphincteroplasty [3].
To improve quality of life and avoid the end-stoma, this
group requires “the last chance methods”: sphincter recon-
Electronic Supplementary Material  The online version of this chapter
(https://doi.org/10.1007/978-3-030-40862-6_38) contains supplementary
material, which is available to authorized users.
P. Walega (*)
3rd Department of Surgery, Jagiellonian University Collegium
Medicum, Krakow, Poland
e-mail: pwalega@mp.pl
M. Walega
Department of Anaesthesiology, University Hospital Düsseldorf,
Düsseldorf, Germany
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_38
38
struction employing procedures involving transposition of
autologous muscle or replacing the anal sphincter with an
artificial prosthesis [4].
In the 1930s of the last century, Devesa at el. proposed to
transplant the gluteal muscle to construct the anal sphincter [5].
This technique is still employed in some centers; however,
because of unsatisfactory long-term results, the method never
gained popularity. According to the research, the morphology
of the gracilis muscle most closely resembles the morphology
of anal sphincter muscles. The gracilis muscle also demon-
strates several features which favor its use in perineal recon-
struction as a pedicled flap: it arises from the pubic arch and is
long enough to be formed into a loop placed around the rectum,
and its proximal vasculonervous supply allows for full mobili-
zation of the muscle without dissection of its vascularization.
Graciloplasty employed to construct the anal sphincter
was initially introduced by Pickrell et  al. in 1952 to treat
children with anal incontinence secondary to neurological
disorders. The initially optimistic results of Pickrell’s study
[6] were changed by the later research studies performed by
Corman, which showed improvement only in 50% of cases.
These results were due to the fact of fast-twitch “fatigue-­
prone” type II muscle fibers in the gracilis muscle. For this
reason, Dixon supplemented the Pickrell method with a tem-
porary stimulation of the muscle with an implanted electrode
[7]. Similar but technically modified procedures were carried
out by Cavina and Seccia [7]. In 1981, Cor Baeten [8]
described a method of continuous stimulation of the gracilis
muscle aiming at transforming the gracilis fast-twitch fibers
into slow-twitch, “fatigue-resistant” fibers to achieve a sus-
tained tonic contraction. This procedure was called dynamic
graciloplasty (DGP). Promising results of those studies led
to the modification of stimulation systems in the following
years. Modern electrostimulators have been used, modeled
on pacemakers employed in electric stimulation of the heart.
Currently, there are already several hundred patients who
were treated with DGP in various modifications. In some
countries (the Netherlands, Austria), graciloplasty is covered
by insurance companies. Nowadays, electrodes are implanted
483
484
intramuscularly into the gracilis muscle around the neuro-
vascular bundle, and not—as suggested by Williams—the
epineural bundle.
Medtronic implanted stimulators with external stimula-
tion and extended battery life (up to 10 years) have come into
use. Although the price of such stimulators continues to be
high, the effectiveness of the therapeutic management, with
the patient returning to full social and professional activity,
causes the method to gain popularity [9, 10].
38.2 Perioperative Assessment
Preoperative evaluation plays an important role in selecting
patients for treatment with dynamic graciloplasty.
Before the surgery, the patient should be informed in
detail about how much the treatment can help him and about
a higher than average risk of complications. Insightful,
sometimes multiple conversations with a psychologist are
necessary to determine the patient’s expectations.
The medical history of the patient should clearly specify
the nature of incontinence, including duration, severity, type
of leakage, and acquired habits due to fecal incontinence
(wearing a pad, limitations of daily activities). Of equal
importance is information about previous pregnancies and
deliveries, as well as surgical procedures, comorbidities, and
currently taken medicines.
Severity of FI can be assessed using the Jorge-Wexner
grading score (the Wexner Cleveland Clinic Florida score).
The impact of FI on the patient’s quality of life can be mea-
sured using specific questionnaires, such as the Short Form-­
36 (SF36) or Rockwood Fecal Incontinence Quality of Life
Scale (FIQL), which contains a total of 29 different items
assessing social, emotional, occupational, and functional
aspects.
Physical examination aims at assessing sphincter function
and anatomy (characteristics of the anal canal: its length, the
tension of the sphincter at rest and in contraction).
Functional tests (manometry) and visualization (rectal
ultrasound and MRI) are essential in assessment of the
causes of FI.
Anorectal manometry allows for measurement of resting
sphincter pressure, squeeze sphincter pressure, and the func-
tional length of the anal canal, rectal sensation, anal sensa-
tion, and the presence or absence of rectoanal inhibitory
reflex. Defecography allows for the visualization of defeca-
tion in real time and can exclude concomitant some dysfunc-
tions (rectal prolapse, rectocele, enterocele, intussusception).
In the center where the author is employed, prior to the
procedure, the quality of nerve supply is evaluated along
with the location of nerve bundles connecting with the graci-
lis muscle; the assessment is performed using a multichannel
surface electromyography sensor [10, 11].
P. Walega and M. Walega
38.2.1 Indications for Graciloplasty
• End-stage fecal incontinence (>35 points FISI)
• Lack of sphincter or extensive sphincter defect (more than
1/3 of the circumference of the muscle based on transanal
ultrasound or MRI)
• Previous unsuccessful treatments (sacral nerve
stimulation)
• Sphincter innervation defect (verified by electrophysio-
logical examination)
38.2.2 Contraindications to Graciloplasty
Age below 18 years of life
Patient’s refusal to undergo the procedure
Peripheral neuropathy (diabetic, polyneuropathic)
Ischemic limb disorders
Severe heart, kidney, and liver conditions
Contraindications to electrical stimulation usage
38.3 Technique
The procedure is performed with the patient under general
anesthesia. The patient is placed in the position with an
abducted lower extremity allowing for its rotation and adduc-
tion during the operation. This position is necessary to allow
for transposing the muscle without any tension. Depending
on its length, the gracilis muscle is exposed employing two
or three incisions in the thigh along its anterior margin
(Fig. 38.1). When the muscle has been identified, it should be
dissected along its entire length (Figs. 38.2 and 38.3). While
dissecting the muscle, employing surgical scissors is recom-
mended, while electric instruments should be used for hemo-
stasis only. The proximal neurovascular bundle should
remain visible and preserved (Fig.  38.4). Of assistance in
precise location of the innervation is stimulation employing
a handheld electrostimulator needle (Neuro-pulse Aaron
Medical Industries Inc.®). Short vessels of the distal segment
should be ligated and divided. The tendon is divided from the
tubercle of the tibia employing a separate incision of the skin
(Fig. 38.1).
The majority of surgeons from various centers, including
the author of the present chapter, employ the classic tech-
nique developed by Baeten or its modification by Rosen—the
“split-sling” technique with the muscle forming an alpha or
gamma loop around the rectum, depending on the anatomical
conditions. The tendon is fixed to the tuber ischiadicum or to
the skin using a Prolene 2-0 suture. The extremity from which
the muscle is to be harvested is determined prior to the proce-
38  Dynamic Graciloplasty
Fig. 38.1  Thigh phase. Dissected gracilis muscle belly. Tendon tran-
sected from distal attachment
Fig. 38.2  Thigh phase. Critical point of gracilis muscle preparation—
location of the last neurovascular bundle. Intact proximal neurovascular
bundle is a condition to maintain the vitality and function of muscle
mass
dure, depending on its topical condition, neurological assess-
ment, and preferences of the patient. During the perineal
stage, two blunt incisions are made on both sides of the anus
(approximately 2–3 cm from its margin), thus forming a tun-
nel to which the gracilis muscle is transposed (Fig.  38.5).
Depending on the anatomical conditions and the preferences
of the operator, the incisions are horizontal or vertical. The
transposed muscle is fitted around the rectum, thus forming
the neosphincter [12, 13]. The preferred form is an alpha or
gamma loop, but other configurations have also been
described. In the “split-sling” technique, the free end of the
muscle is pulled through the approximately 1-cm-wide open-
ing formed by separating the muscle mass into layer [14]. The
485
Fig. 38.3  Intact proximal neurovascular bundle visible in the surgical
field. End of thigh phase. At this height the gracilis muscle is transposed
through a subcutaneous tunnel to create a loop around the anus
Fig. 38.4  Gracilis muscle has been transposed in perianal space. The
distal tendon is fixed with Prolene suture to the skin. It is important to
avoid any tension of muscle flap because the risk of ischemia
free tendon end should be sutured using nonabsorbable
sutures (monofilament 2/0) to the ischial tuberosity or skin.
The last stage of the procedure consists in implanting the
electrodes and stimulator (Fig.  38.6). In the region of the
identified major nerve bundle, two monopolar electrodes
(model 4300 manufactured by Medtronic®) are sutured to the
muscle mass. The needle of the first electrode (anode) is
inserted distally to the nerve bundle, while the cathode is
inserted as close as possible to the bundle, at the site of the
maximum response during stimulation (Fig. 38.7). Using an
external stimulator (Medtronic, type 3051E®), one should
select the best stimulation parameters (Fig. 38.7). Usually, the
said parameters are as follows: amplitude—0.5–1.0  V,
486
impulse width—0.210 ms, frequency from 10 to 20 Hz. In the
experience of the author, intraoperative manometric assess-
ment facilitates the selection of stimulation power [12, 14].
Following the dissection of the skin and subcutaneous
layer in the hypogastrium, a 4  ×  4  cm pocket should be
formed in order to place the stimulator (Fig. 38.8). Using the
guideways provided in the kit, the cables connecting the
electrodes with the IPG InterStim 3023 stimulator manufac-
Fig. 38.5  End of the thigh and perineal phase. (A) Dissection point of
the distal attachment of gracilis muscle. (B) Access to the distal tendon
of gracilis muscle to its safety removal. (C) Reverse gracilis muscle
with proximal neurovascular bundle. Two electrodes will be here
inserted into the muscle using external stimulator. (D) Tendon of graci-
lis muscle sutured to the skin. (E) Gracilis muscle wrapped around the
anus. In author’s center strength and tension of the muscle is adjusted
using intraoperative anorectal manometry
Fig. 38.7  Positioning of neurostimulation electrodes. (A) External
stimulator connected with the electrodes temporarily brought out
through the abdominal wall during parameter optimization. (B) Two
P. Walega and M. Walega
tured by Medtronic® are pulled through from the groin to the
formed pocket. After surgical wound closure and application
of dressing, one should check the stimulator operation using
the console of the 7432 Medtronic® Itrel Programmer. The
thigh wounds are suction-drained and a double-layer closure
Fig. 38.6  Neuromuscular pacemaker implantated by dynamic gracilo-
plasty. (a) A patient programmer. (b) Implantable pacemaker placed in
abdominall wall. (c) Intramuscular electrode implantated in gracillis
muscle near the proximal neurovascular bundle
electrodes inserted into the muscle near the neurovascular bundle. In
the next step, they will be passed through the subcutaneous tunnel to the
pacemaker in abdominal wall
38  Dynamic Graciloplasty
Fig. 38.8  The pacemaker connected with electrodes is placed in sub-
cutaneous space. Exact location is determined preoperatively together
with the patient
Fig. 38.9  Wounds are closed with Prolene 3-0 suture. In the author’s
center, a suction drain is placed in thigh incision
is employed—the fascia and subsequently the skin are closed
separately (Fig.  38.9). In the majority of centers where
graciloplasty procedures are performed, electrostimulation is
not activated in the first postoperative week. The thigh wound
drainage should be removed in the 2–3 postoperative day. In
the first day after surgery, the patient is immobilized, and the
extremity is maintained as non-weight bearing. It is recom-
mended to maintain a compression dressing on the thigh and
lower leg for 2–3 weeks. Starting on day 2 postoperatively,
the patient is on an oral non-residue diet. He is administered
loperamide (1 tablet 3 times a day for 3 days), diclophenac,
and fraxiparine [13–15].
If no local complications develop, starting from week 2
postoperatively, 2-week preliminary stimulation is intro-
duced; its parameters are as follows: voltage, 1.5 V; impulse
width, 0.210 ms; and frequency, 5.2 Hz. The objective of the
487
stimulation is to reorganize the gracilis muscle (fast to slow
muscle conversion). After 2 weeks of stimulation, its fre-
quency is increased to 16 Hz while monitoring the pressure
values in the anal canal. In the subsequent several months,
the parameters are modified as needed.
38.4 Outcomes and Complications
of Dynamic Graciloplasty
For more than 20 years, numerous European, American, and
Australian centers were employing various modifications of
replacing the patient’s sphincter with transposed autologous
muscles or artificial implanted devices. Clinical experience—
mainly from Dutch (Baeten), Italian (Cavina), British
(Williams), American (Wexner), and Austrian centers
(Rossen)—indicated that at that time it was the only procedure
of forming alternative sphincters using autologous muscles
that allowed for achieving satisfactory clinical results (60% of
patients claimed the effect of the procedure to be good and
very good, while another 15% to be satisfactory) [16, 17].
Nevertheless, reports that were published later were more
skeptical. In 2006, the Bochum team, Belyaev et al. reviewed
the literature addressing the implantation of the gracilis mus-
cle with implanting a stimulator and implantation of an artifi-
cial sphincter. In 20 centers, a total of 934 dynamic
graciloplasty procedures were performed. The mean follow-
­up was 2.7 years (1.0–5.0 years). Only 49.3% of the proce-
dures were surgical successes. In 378 patients (46.2%),
surgical revision was necessary, and in 259 subjects (32.5%),
the stimulator and electrodes had to be explanted. In as many
as 82.8% of patients, postoperative complications developed.
38.5 Adynamic Graciloplasty
The procedure is a less popular variant of graciloplasty.
Rosen et  al. demonstrated that almost one-half of patients
after DGP ceased to use stimulation within 1 year postopera-
tively [14]. In the literature review done by Rutman, explana-
tion of the stimulator and electrodes was necessary in as
many as 40% of patients after DGP. In consequence, the high
cost of the procedure became even higher [18]. For this rea-
son some centers achieve good results performing a signifi-
cantly less expensive and risk-bearing variant of the
procedure. Following muscle transposition, as in DGP, no
stimulator or electrodes are implanted. When the wounds
heal, transanal stimulation is employed using an endoanal
probe and hand stimulators available on the market. In the
center represented by the author, 12 months postoperatively,
comparable functional results and FIQL scores were achieved
in the dynamic graciloplasty and endoanal probe-stimulated
graciloplasty (Fig. 38.10). The implantation was character-
488
Fig. 38.10  Transanal electrostimulation. In author’s center applied by patients without permanent stimulator (adynamic graciloplasty)
ized by an absence of complications and significantly lower
costs. The above observations allow for recognizing gracilo-
plasty without stimulator implantation (adynamic
­graciloplasty) as an equally effective and efficient procedure
of treating extreme forms of FI; the prerequisite is simultane-
ous transanal stimulation [19].
38.6 Total Anorectal Reconstruction (TAR)
Cavina and Rullier [20, 21] proposed bilateral gracilo-
plasty as a part of total anorectal reconstruction (TAR)
after abdominoperineal resection of rectum (APR). This
multistage treatment consists of APR, bilateral gracilo-
plasty with protective ileostomy, stimulator implantation
in the second stage, and then—if the neosphincter function
is satisfactory—Ileostomy closure in the last stage. Despite
the higher than average risk of complications (infection
and necessity of implant removal, electrodes displace-
ment, and the high risk of a critical stenosis), satisfactory
functional results in approximately were obtained. This
technique finds application as a method of sphincter recon-
struction in a very small group of young and determined
patients after APR [22, 23].
P. Walega and M. Walega
38.7 Conclusion
Dynamic graciloplasty next to sacral nerve stimulation and
artificial bowel sphincter is the treatment of choice for end-­
stage fecal incontinence.
To achieve a higher success rate and to reduce the risk of
complications graciloplasty should be performed only in ref-
erence centers. Adynamic graciloplasty is also an acceptable
method of treatment with a significantly lower risk of com-
plications and lower treatment costs. Further multicenter
long-term studies are necessary [24].
Take-Home Message
• End-stage fecal incontinence is still a difficult
subject.
• Last chance treatment of fecal incontinence:
dynamic and adynamic graciloplasty are the only
way to improve the sphincter function despite sig-
nificant complication rates.
• Last chance treatment leads not only to objective
improvement of the anorectal function but also affect
the psychological impact of fecal incontinence.
38  Dynamic Graciloplasty 489

References 13. Madner JB, Williams NS. The electrically stimulated gracilis neo-­
anal sphincter. Eur J Gastroenterol Hepatol. 1997;9:435–41.
14. Rosen HR, Novi G, Zoech G, Feil W, Urbarz C, Schiessel

1. Nelson R, Norton N, Cautley E, Furner S. Community based preva-
R. Restoration of anal sphincter function by single-stage dynamic
lence of anal incontinence. JAMA. 1995;274:559–61.
graciloplasty with modified (split-sling) technique. Am J Surg.
2. Thomas TM, Egan M, Walgrove A, Meade TW. The prevalence of
1998;175:187–93.
faecal and double incontinence. Community Med. 1984;6:216–20.
15. Herman RM, Walega P, Nowakowski M, Gryglewski A, Richter
3. Jorge JMN, Wexner SD. Etiology and management of faecal incon-
P, Popiela T.  Dynamic gracilloplasty in Poland. Proktologia.
tinence. Dis Colon Rectum. 1993;36:77–97.
2001;2:179–85.
4. Muller C, Belyaev O, Deska T, et al. Fecal incontinence: an up-to-­
16. Williams NS, Hallan RI, Koeze TH, Pilot MA, Watkins

date critical overview of surgical treatment options. Langenbecks
S. Construction of a neoanal sphincter by transposition of the graci-
Arch Surg. 2005;390:544–52.
lis muscle and prolonged neuromuscular stimulation for the treat-
5. Devesa JM, Vicente E, Enríquez JM, Nuño J, Bucheli P, de Blas
ment of faecal incontinence. Ann R Coll Surg. 1990;72:108–13.
G.  Total fecal incontinence--a new method of gluteus maximus
17. Rosen HR, Urbarz C, Novi G, et  al. Long-term results of modi-
transposition: preliminary results and report of previous experience
fied graciloplasty for sphincter replacement after rectal excision.
with similar procedures. Dis Colon Rectum. 1992;35:339–49.
Colorectal Dis. 2002;4:266–9.
6. Pickrell KL, Broadbent TR, Masters FW.  Construction of a rec-
18.
Ruthmann O, Fischer A, Hopt UT, Schrag HJ.
tal sphincter and restoration of anal continence by transplant-
Schliessmuskelprothese vs. Ersatzmuskelplastik bei hochgradiger
ing the gracilis muscle in four cases of children. Ann Surg.
stuhlinkontinenz? Chirurg. 2006;77:926–38.
1952;135:853–62.
19. Walega P, Romaniszyn M, Siarkiewicz B, Zelazny D. Dynamic ver-
7. Cavina E, Seccia M, Banti P, Zocco G.  Anorectal reconstruction
sus adynamic graciloplasty in treatment of end-stage fecal incon-
after abdominoperineal resection. Experience with double-wrap
tinence: is the implantation of the pacemaker really necessary?
graciloplasty supported by low-frequency electrostimulation. Dis
12-Month follow-up in a clinical, physiological, and functional
Colon Rectum. 1998;4:1010–6.
study. Gastroenterol Res Pract. 2015;698516, 5p.
8. Baeten C, Spaans F, Fluks A. An implanted neuromuscular stimu-
20. Cavina E, Seccia M, Evangelista G, Buccianti P, Tortora A, Chirico
lator for faecal continence following previously implanted gracilis
A.  Perineal colostomy and electrostimulated gracilis “neosphinc-
muscle. Dis Colon Rectum. 1988;31:134–7.
ter” after abdominoperineal resection of the colon and anorectum: a
9. Chapman AE, Geerdes B, Hewett P, et  al. Systematic review of
surgical experience nad follow up study in 47 cases. Int J Colorectal
dynamic graciloplasty in the treatment of faecal incontinence. Br J
Dis. 1990;5:6–11.
Surg. 2002;89:138–53.
21. Rullier E, Zerbib F, Laurent C, Caudry M, Saric J. Morbidity and
10. Adang EMM, Engel GL, Rutten FFH, Geerdes BP, Baeten

functional outcome after double dynamic graciloplasty for anorec-
CG.  Cost-effectiveness of dynamic graciloplasty in patients with
tal reconstruction. Br J Surg. 2000;87:909–13.
faecal incontinence. Dis Colon Rectum. 1998;41:725–33.
22. Inglin RA, Eberli D, Brugger LE, Sulser T, Williams NS, Candinas
11. Romaniszyn M, Walega P, Nowakowski M, Nowak W. Can surface
D.  Curent aspects and future prospects of Total anorectal recon-
electromyography improve burgery planning? Electromyographic
struction-­a critical and comprehensive review of the literature. Int J
assessment and intraoperative verification of the nerve bundle entry
Colorectal Dis. 2015;30:293–302.
point location of the gracilis muscle. J Electromyogr Kinesiol.
23. Ho KS, Seow-Choen F. Dynamic graciloplasty for total anorectal
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12. Baeten CG, and the Dynamic Gracilloplasty Therapy Study Group.
Int J Colorectal Dis. 2005;20:38–41.
Safety and efficacy of dynamic graciloplasty for fecal incontinence.
24. Yokshioka K, Keighley MR. Clinical and manometric assessment
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of gracilis muscle transplant for faecal incontinence. Dis Colon
2000;43:743–51.
Rectum. 1988;31:767–9.
 Injectable and Implantable Biomaterials
for Anal Incontinence
Alex Hotouras and Pasquale Giordano
Learning Objectives
• To understand the technical aspects of injection and
implantation of biomaterials.
• To understand the role of injectable and implantable
biomaterial in the treatment algorithm of anal
incontinence.
39.1 Introduction
The internal anal sphincter (IAS) is a smooth muscle and
plays a fundamental role in the mechanism of continence. Its
action is entirely involuntary, and it is in a state of continuous
maximal contraction providing continuous closure of the
anal canal. Sympathetic fibres from the superior rectal and
hypogastric plexuses stimulate and maintain internal anal
sphincter contraction. Its contraction is inhibited by para-
sympathetic fibre stimulation. This sphincter is tonically
contracted most of the time to prevent leakage of fluid or gas
but is relaxed upon distention of the rectal ampulla (rectoanal
inhibitory reflex), requiring voluntary contraction of the
puborectalis and external anal sphincter (EAS) to prevent
defaecation.
The resting pressure of the anal canal is mostly deter-
mined by the IAS which is believed to be the main factor
responsible for the continuous closure of the anal canal. The
anal mucosal folds and haemorrhoidal cushions further con-
tribute to the prevention of leakage by providing up to 20%
A. Hotouras (*) · P. Giordano
Royal London Hospitals, Barts Health NHS Trust, London, UK
e-mail: alex007@doctors.org.uk;
p.giordano@londoncolorectal.org
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_39
39
of the anal resting tone and acting as a mechanical “seal”
providing the fine closure of the anus.
Passive faecal incontinence (FI) results normally from
dysfunction of the IAS although deficiency of the anal
cushions, deformity, and scarring of the anal contour and
an absent rectoanal inhibitory reflex can all contribute to
the passive loss of gas and bowel contents. IAS injury is
usually the result of childbirth or iatrogenic trauma. IAS
can also be structurally intact but weak following degen-
eration with age, in patients with rectal prolapse, follow-
ing pelvic irradiation or due to a connective tissue disorder
such as scleroderma.
The contemporary treatment of urge and mixed inconti-
nence involves repair of a structurely impaired EAS or
neuromodulation therapies (e.g. percutaneous tibial nerve
stimulation, sacral nerve stimulation) with relative suc-
cess, particularly in the absence of rectal evacuatory disor-
der. The management of passive FI, however, is more
challenging, as many patients do not appear to benefit
from conservatives measures or only experience tempo-
rary benefits. Furthermore, results of neuromodulation
treatments seem to be poor. Direct surgical repair of an
IAS defect is difficult as the muscle is very thin (2–3 mm)
and is held at constant base tension. Furthermore, opera-
tions such as dynamic graciloplasty and artificial bowel
sphincter implantation are technically demanding, have
the potential for significant morbidity and long-term
results are unsatisfactory.
For all these reasons, colorectal surgeons worldwide
have turned their attention to less invasive treatments that
appear to combine safety and feasibility with reasonable
functional results in the short and medium term. Evidence
from urological studies suggests that the use of injectable
biomaterials (e.g. autologous fat, muscle collagen, and
polytetrafluoroethylene) used to enhance the function of
the vesical neck may have a role to play in augmenting the
structure of an injured anal sphincter. Injectable bulking
agents offer the possibility of a minimally invasive and
simple procedure to treat internal sphincter dysfunction
491
492 A. Hotouras and P. Giordano

and can be considered for the treatment of FI refractory to
conservative therapy.
The aim of this chapter is to describe the most com-
monly used injectable and implantable biomaterials used
for incontinence and appraise the results of the various
studies (Table 39.1).
Table 39.1 Injectable and implantable biomaterials for faecal
incontinence
• Autologous fat
• Silicone biomaterial (PTQ, Bioplastique)
• Carbon-coated zirconium beads (Durasphere)
• Calcium hydroxylapatite microspheres (Coaptite)
• Hyaluronic acid (NASHA/Dx, Solesta, Zuidex)
• Glutaraldehyde cross-linked collagen (Contigen)
• Polyacrylamide hydrogel (Bulkamid)
• Porcine dermal collagen (Permacol)
• Ethylene vinyl alcohol copolymer (Enteryx)
• Expandable silicone microballoons
• Polyacrylonitrile (Hyexpan, Gatekeeper, SphinKeeper)
39.2 Types of Agents Used
Shafik was the first to describe the use of bulking agents in
1993 [1]. He used polytetrafluoroethylene (Teflon or Polytef)
or autologous fat to treat patients with “partial faecal incon-
tinence” [1, 2]. The agent was injected without anaesthesia,
in the rectal neck submucosa, above the dentate line at each
of the 3 and 9 o’clock positions. Since then many other
injectable biomaterials have been used including silicone
biomaterial (PTQ™), stabilized hyaluronic acid/dextrano-
mer (NASHA/Dx), ethylene vinyl alcohol (EVOH), porcine
dermal cross-­linked collagen (Permacol®), glutaraldehyde
bovine cross-­linked collagen (Contigen), pyrolytic carbon-
coated zirconium beads (Durasphere), polydimethylsiloxane
elastomer, dextranomer in nonanimal stabilized hyaluronic
acid, hydrogel cross-linked with polyacrylamide
(Bioplastique), synthetic calcium hydroxylapatite ceramic
microspheres, and polyacrylonitrile in cylinder form
(Hyexpan) (Gatekeeper™, SphinKeeper®) [Table 39.1].

a b

c d

Fig. 39.1 (a) Injectable silicone biomaterial (PTQ—Macroplastique); (b) schematic drawing of bulking agent injection into the submucosa; (c,
d) intraoperative images. Injections performed at 3 (left lateral) and 9 (right lateral) o’clock positions
39  Injectable and Implantable Biomaterials for Anal Incontinence 493

39.3 Technique
The technique may vary depending on the type of material
used. Injectable bulking materials are generally inserted
into the submucosa of the distal rectum, while implant-
able materials are normally placed into the proximal inter-
sphincteric space with the objective to increase the tissue
volume in the high-pressure zone, especially in the proxi-
mal portion of the anal canal, creating a tighter seal at rest
(Fig. 39.1). Currently the only injectable material placed
into the intersphincteric plane is EVOH, while both
implantable devices Gatekeeper™ and SphinKeeper® are
delivered into the intersphincteric plane (Fig. 39.2). The
number of injections and the volume of the injected bulk-
ing agent are variable depending on the material used and
the indication. Usually several injections in different parts
of the anal circumference are needed to optimize the
tightening of the anal canal. Bulking agents could also tar-
get defective areas of the IAS, if present, to create canal
symmetry and regular contour of the anus.
The procedure is usually performed in an outpatient set-
ting under local anaesthesia with or without some degree of
sedation or under general anaesthesia as day case procedure
depending on the type of material used. In many cases if the
response is not satisfactory or the improvement is lost over
time, a repeat injection can be administered. Although there
is no need for specific bowel preparation, a phosphate enema
is often used just before the procedure is carried out.
Antibiotic prophylaxis (e.g. metronidazole) at induction of
anaesthesia is recommended. Intraoperative endoanal ultra-
sound (EAUS) is not compulsory but is thought to facilitate
the correct placement of the bulking agent into the submu-
cosa space (Fig. 39.3) or the implant in the intersphincteric
plane (Fig. 39.4) [3].

a d

Dispenser

c Delivery system

e f

Fig. 39.2  Implantable Gatekeeper device. (a) Guide sheath assembly; (b) prosthesis in sheath; (c) prosthesis released from sheath; (d) delivery
system and dispenser; (e, f) intraoperative images
494 A. Hotouras and P. Giordano

a b

Fig. 39.3  Three-dimensional endoanal ultrasound performed by linear transducer (type 8838, BK Medical). Bulking agents (PTQ) are visualized
as hyperechoic volumes into the submucosa. (a) Axial plane; (b) coronal plane; (c) sagittal plane
39  Injectable and Implantable Biomaterials for Anal Incontinence 495

a b

Fig. 39.4  Three-dimensional endoanal ultrasound performed by linear transducer (type 8838, BK Medical). Polyacrylonitrile implants
(Gatekeeper) are visualized as hypoechoic cylinders (asterisks) into the intersphincteric plane. (a) axial plane; (b) coronal plane

39.4 Safety and Adverse Events
Injection and implantation of biomaterials for the manage-
ment of FI appear safe as the risk of complications is small,
and most adverse events are relatively minor that resolve
within the first 2 postoperative weeks. The most common
adverse event is perianal pain or discomfort. Others included
leakage of injected agents within the first few days, abscess
formation that may require surgical intervention, mucosal
erosion, hematoma, obstruction defecation, pruritus ani, and
urgency.
In a systematic review [4] of the 420 patients treated with
bulking agents for passive FI, there were 52 reported adverse
events. The most common adverse events were minor and
included pruritus ani (n = 16) and mild pain during injection
(n  =  13). Other common events included mild proctalgia
(n  =  8) and anal inflammation and swelling (n  =  6). More
serious events included persistent anal discomfort (n  =  1),
infection requiring drainage (n = 1), and pain during defeca-
tion (n  =  1). Furthermore, one patient reported significant
pain during the injection. Other events were anal bleeding
(n = 2), anal soiling (n = 1), leakage (n = 1), and dermatitis
(n  =  1). Migration of the injectable bulking agent was
reported in 14 patients, 2 patients were injected with
Durasphere, and 12 had a PTQ injection. Two patients had
leakage of Durasphere with stool.
In a small prospective RCT comparing silicone biomate-
rial (PTQ) to saline injection, Siproudhis et al. [5] reported
18 adverse effects in 9 participants of their trial. Six out of
22 people injected with silicone biomaterial (PTQ) experi-
enced pain at the implant site compared to 2 out of 22 in the
control group. Anal inflammation was found in two com-
pared to none in the control group. Overall the adverse
events were not considered “serious”; however, the duration
of events had not been reported in the outcome. In a study
reported by Graf et al. [6] in 2011, 128 patients treated with
NASHA/Dx experienced post-procedure adverse events
compared to 29 in the sham treatment group. The most com-
mon adverse event was proctalgia (19/136 vs. 2/70) fol-
lowed by injection site bleeding (7/136 vs. 12/70) and rectal
haemorrhage (10/136 vs. 1/70). Two serious events were
reported in the NASHA/Dx group: prostatic abscess treated
conservatively with antibiotics and a rectal abscess requir-
ing surgical drainage [6]. The trial comparing PTQ and
496
Durasphere [7] noted significantly more adverse events in
the Durasphere group compared to PTQ group. The main
post-procedural complaints in patients with PTQ were of
bruising. In contrast, participants injected with Durasphere
complained of rectal pain (1/20), erosions (2/20), and type
III hypersensitivity reaction (1/20) requiring hospital admis-
sion for management. A systematic review by Hong et  al.
[8] looking at outcomes from injectable bulking agents for
FI commented on adverse events following this procedure.
Twenty-three studies reported adverse events occurring in
219 patients. The rate of adverse events was 18% (95% CI
10.0–30.1). In majority of cases, adverse outcomes were
considered minor and resolved in a few weeks. Adverse
events included perianal pain or discomfort (most com-
mon), leakage of injected agents, abscess, mucosal erosion,
obstructed defecation, hypersensitivity reaction, hematoma,
diarrhoea, pruritus, and urgency. Fifteen patients experi-
enced leakage of the injected agent, which self-resolved in a
few days. Seven out of 219 patients developed a perianal
abscess, two of which required surgical drainage. Bartlett
et al. [9] performed a study looking at the efficacy of PTQ
for FI.  Nine complications were noted, all of which were
minor. Two patients needed antidiarrheal medication, and
two patients required treatment for constipation. One patient
developed a perianal abscess requiring removal of the
implant, surgical drainage of the abscess, and replacement
of the PTQ. The patient achieved full continence following
this. One perianal abscess was treated conservatively with
antibiotics alone. Three patients experienced anal irritation
and discomfort. Once the infection settled on antibiotics, the
patient had a replacement PTQ implant and achieved full
continence subsequently. Three patients had minor anal irri-
tation or discomfort; one patient had superficial mucosal.
Similarly, Morris et  al. [10] had one patient developing a
perianal abscess in the PTQ group, but no complications in
the Durasphere group. Dehli et al. [11] assessed the effec-
tiveness of NASHA/DX in the management of FI. Among
the ten patients who received the anal injection of NASHA/
DX, three were infected requiring treatment; one was treated
with oral antibiotics; and two required surgical drainage. All
three patients were treated effectively, and the incontinence
was unaffected. Due to the development of infection of
these patients, the remaining 54 patients in the trial were
given prophylactic antibiotics. No further post-procedural
infections were noted. Seven patients (11%) reported leak-
age of the injected agents, and three patients (5%) experi-
enced prolonged defecation. Pain was well controlled with
paracetamol alone in three patients.
Similarly, Mellgren et al. [12] assessed the long-term effi-
cacy of NASHA/Dx injection therapy for treatment of
A. Hotouras and P. Giordano
FI.  Adverse outcomes and complications were also noted.
During the first phase of the trial, 128 patients developed
treatment-related adverse events. The most common post-­
procedure complication was minor bleeding, pain, and dis-
comfort. Two serious complications post-injection were
noted: one patient developed a perianal abscess that required
surgical intervention and one patient developed a prostatic
abscess that resolved on antibiotic treatment. In the long-­
term follow-up phase, 20 further treatment-related adverse
events were recorded, the most common being proctalgia
and injection site nodule. Kenalog injection and xylocaine
ointment were used for this. None of these patients under-
went surgery, and proctalgia eventually resolved in all cases.
Stephens et al. [7] looked at the impact of implantation of
EVOH for incontinence management. Thirteen subjects had
at least one adverse event; 11 were classified as mild and 2 as
severe. Twenty-eight patients developed treatment-related
adverse events; 22/28 were classified as mild in nature. Two
serious complications were recorded. One patient developed
faecal impaction and injection site anal abscess and required
hospital admission. Another patient experienced severe chest
pain following the procedure; patient was admitted, observed,
and discharged with no further intervention. Overall compli-
cations post-procedures have been poorly reported. No stud-
ies available looking at adverse events alone following such
procedures, but adverse events that have come to the atten-
tion to the investigators during their trial have occasionally
been stated. Three studies have used biological material as a
bulking agent for a total of 122 patients [13–15]. Overall,
105 patients received cross-linked porcine dermal collagen
paste (Permacol™) and 17 received Glutaraldehyde cross-­
linked (GAX) collagen, a highly purified bovine dermal col-
lagen. There were no complications reported in any of these
three studies [13–15].
39.5 Efficacy
Evidence on the efficacy of bulking agents is weak, and most
studies conducted for this treatment have been of poor qual-
ity and included small number of patients. A Cochrane
review in 2016 found little evidence that perianal injection of
a bulking agent is effective in treating FI although patients
did report an improvement in symptoms in the short-term
[15]. Long-term benefit on symptoms of passive FI remains
still unclear.
Shafik [2] first described the use of Teflon for the manage-
ment of FI by injecting the substance into the rectal neck
mucosa above the pectinate line. The study including 11
patients noted a long-term cure in 45.4% after the first injec-
39  Injectable and Implantable Biomaterials for Anal Incontinence
tion and in 63.6% after the second injection. 36.4% showed
partial improvement, and therefore no failures were found.
According to Shafik, improvement is secondary to an
increase in rectal neck pressures produced by the cushion-­
effect of the injection [2].
In a more recent analysis, with 637 patients from 19 stud-
ies that used the CCF-FIS score, the improvement rate was
close to 40% [8]. A univariate meta-regression analysis based
in change in CCF-FIS showed that the transphincteric or
intersphincteric route was associated with greater improve-
ment in continence compared to submucosal injection through
the transanal route. Similarly, a lower percentage of study
patients with missing or migrated implants was significantly
associated with greater improvement in continence. Patient
age, severity of incontinence, number of injections or volume
of material, use of EAUS, and repeated injection were not
found to be impacting on the efficacy of the therapy [8].
Two small similarly sized RCTs compared PTQ versus
Durasphere [10, 16]. The first, with 40 patients, showed that
at 12 months after injection, significantly more PTQ patients
achieved greater than 50% improvement in CCF-FIS.  In
comparison to the Durasphere group, PTQ was shown to
have better outcome; with improved symptoms at 6 and
12 months (at 12 months, RR 0.15, 95% CI 0.04–0.60 and
better quality of life at 6 months (MD −0.56, 95% CI −1.01
to −0.011) [10]. There was also a significant improvement in
FI quality of life scale and the 12-month physical health
scale of Short Form-12 health survey in the PTQ group but
not in the Durasphere group [16].
In the second RCT by Morris et  al. [10] including 34
patients, the efficacy of PTQ and Durasphere were also com-
pared. A significant improvement in mean continence scores
in both the PTQ and Durasphere was demonstrated. These
effects persisted at all three points of follow-up; 6  weeks,
6 months, and 12 months. In participants randomized to the
PTQ group, the CCF-FIS was reduced by 4.3 (P < 0.001),
4.2 (P < 0.001), and 1.1 (P = 0.24) at 6 weeks, 6 months, and
12 months, respectively [10]. These differences were found
to be statistically significant (P = 0.001). In participants ran-
domized to the Durasphere group, the CCF-FIS score was
reduced by 5.3 (P  =  0.003), 4.1 (P  =  0.002), and 1.8
(P = 0.19). These differences were again statistically signifi-
cant (P  =  0.001) [10]. When the two groups (PTQ vs.
Durasphere) were compared, no significant differences in the
magnitude of effects were demonstrated at all three follow-
up points. Calculated differences in the CCF-FIS scores
­ period of 9 months. Response to treatment was recorded as
between PTQ and Durasphere groups were 1.0 (P = 0.52) at
6-week follow-up (mean 4.3, SD  ±  3.7 vs. 5.3  ±  5.1), 0.1
(P  =  0.92) at 6  months (4.2  ±  3.5 vs. 4.1  ±  3.8), and 0.4
(P = 0.72) at 12 months (1.4 ± 2.6 vs. 1.8 ± 3.0) [10]. One
497
patient experienced a postoperative complication of a peri-
anal abscess requiring surgical drainage (PTQ group).
Furthermore a large prospective study [9] recruited 74
patients who received PTQ implants in the intersphincteric
plane. At a median follow-up of 28  months, 52 patients
(70%) were continent and extremely satisfied with the result.
The CCF-FIS in participants who remained incontinent was
reduced significantly from 12 before implant to 3.5 at
follow-up.
NASH/Dx or stabilized hyaluronic acid/dextranomer is an
alternative bulking agent to PTQ and Durasphere, also injected
into the intersphincteric plane. A large RCT by Graf et al. [6]
compared injection of NASH/Dx to the injection of a sham
agent. Two hundred and six patients were selected of which
136 were randomized to receive NASHA/Dx (n = 136) versus
70 who were randomized to sham treatment. Success was con-
sidered in patients with a 50% or more reduction in the num-
ber of incontinence episodes experienced. This study noted a
statistically significant difference between the treatment and
control groups. Participants in the treatment group had consid-
erably more incontinence free days at 6 months (3.1 days vs.
1.7  in the sham group, MD 1.40  days, 95% CI 0.33–2.47).
However secondary endpoints including the number of FI epi-
sodes, CCF-FIS at 3 and 6  months, and Fecal Incontinence
Quality of Life (FIQOL) at 12 months did not show any statis-
tical difference. In another RCT, with 60 patients in each arm,
comparing stabilized hyaluronic acid (NASHA/Dx) versus
biofeedback, there was no statistical difference in the inconti-
nence improvement rate after 24 months [11].
In the largest prospective study with 136 patients that
received NASHA/Dx submucosally, Mellgren et  al. [12]
reported a >50% reduction in incontinence episodes at 52%
of patients after 36  months. The improvement in the pri-
mary endpoint was accompanied by improved quality of
life scores for all domains of the FIQOL scale with minor,
transient adverse events. In the second largest study [13]
with 100 patients that received intersphincteric injection of
collagen (Permacol®), 68% reported a subjective improve-
ment in symptoms with 56 reporting improved CCF-FIS
from a mean of 14 (range 9–18) to a mean of 8 (range 5–14)
after 36  months. Thirty-eight patients (38%) required a
repeat injection of collagen, and a further 15 patients
required a third injection. Similarly Hussain et  al. [14]
investigated the efficacy of Permacol for the management
of FI. Thirty-eight patients were followed up for a median
excellent, good, fair, and poor in 12, 5, 4, and 17 patients,
respectively; St. Mark’s score improved in 72% and 63% of
patients at 1 and 2 years, respectively [14]. All four domains
of Rockwood Quality of Life Score improved on first and
498
Fig. 39.5 Gatekeeper
consists of a thin and solid a b
cylindrical prosthesis (a) that
within 24 h of implantation in
contact with human tissue, it
expands and changes shape
and volume, becoming thicker
and shorter (b)
second year follow-up; however, only two domains, coping
and embarrassment, were statistically significant. Maeda
et al. [17] compared injection of Bulkamid (hydrogel cross-
linked with polyacrylamide) and Permacol (porcine dermal
collagen). The hydrogel group incontinence scores
improved from a median of 15–12 at 6 weeks, and this was
maintained at 6 months. Nonetheless there was an improve-
ment in the collagen group as well with a median score
improvement from 16 to 14 over 6 weeks but deteriorated
to 15 at 6 months. The numbers for the trial were too small
to demonstrate a significant different in the two groups. In
a study by Kenefick et al. [18], six patients were injected
with silicone biomaterial for FI. Despite the small numbers
in the study, there was a marked improvement in symptoms
and patient satisfaction in five out of six patients. Median
incontinence scores improved significantly from 14 before
the procedure to 8 after the procedure (P = 0.04). There was
a significant improvement in the FIQOL reported by
patients as demonstrated by the change in the SF-36 scores
(worst score = 0, best score = 100). A marked improvement
in physical function score was noted from a median of 26
(range 5–33) pre-procedure to 79 (range 25–100) post-pro-
cedure (P = 0.02) and social function score from 10 (range
5–37) to 100 (range 50–100) (P = 0.02). No post-procedure
complications were reported.
Gatekeeper (polyacrylonitrile cylinder), is a relatively
novel material initially introduced as bulking agent in the
management for FI. It consists of a thin and solid cylindrical
prosthesis that is implanted into the proximal portion of the
intersphincteric space of the anal canal (Fig. 39.2). Within
24 h of implantation in contact with human tissue, it expands
and changes shape and volume, becoming thicker, shorter,
and softer consistency providing extrinsic compression of
the anal canal (Fig. 39.5). In the initial series of 14 patients
[19], 4 prostheses were injected in each patient. At a mean
follow-up of 33 months, there were no complications, and
there was a significant decrease in major FI episodes per
A. Hotouras and P. Giordano
week with an improvement of CCF-FIS from 12.7 to 5.1
(P < 0.001). More recently, Trenti et al. [20] have investi-
gated the use of the Gatekeeper in treatment of FI as part of
a multicentre, retrospective, and longitudinal study of 49
patients with incontinence. In this study six implants were
inserted. The Vaizey score was used as a means of analysing
improvement in symptoms over a period of time. Twenty-­
three patients (48%) were classified as responders and 25
(52%) as nonresponders. The mean Vaizey score at baseline,
6  months, 12  months, and last visit post-surgery in the
responder group was 13.3 (SD 3.8), 4.3 (SD 2.1), 4.2 (SD
3.6), and 5.7 (SD 5.3), respectively. There were statistically
significant differences noted in the mean baseline Vaizey
score and scores at 6 and 12 months and last follow-up post-­
procedure (P  <  0.001). When considering long-term
improvement in symptoms, follow-up at 2.7 years noted that
the initial responders maintained an improvement of more
than 50% of the baseline Vaizey score. A higher percentage
of prosthesis migration was found in the nonresponder
group compared to the responders (2.4 SD 2.5 vs. 1.0 SD
1.6; P = 0.040) [20]. Similarly, Ratto et al. [21] led a multi-
centre, observational study on the efficacy of the Gatekeeper
[20]. In this study, 54 patients were implanted with six
Gatekeeper implants positioned into the intersphincteric
place. At baseline and 1, 3, and 12 months after implanta-
tion, the number of FI episodes and CCF-FIS, Vaizey,
FIQOL Scale, and SF-36 Health Survey scores were mea-
sured. All FI severity scores were significantly reduced fol-
lowing implantation, and patients’ quality of life improved.
At 12  months, 30 patients (56%) showed at least 75%
improvement in all FI parameters, and 7 (13%) became fully
continent. At the final follow-­up appointment at 1 year, 30
patients (56%) had improvement of at least 75% in all
incontinence parameters; however 24 patients have a less
than 75% improvement. All scores measuring FI severity
reduced significantly during follow-up. Median CCF-FIS
varied from 12 to 5 (P < 0.001), median Vaizey from 14 to
39  Injectable and Implantable Biomaterials for Anal Incontinence 499

a SphinKeeper
prostheses

Mucosa/
Submucosa
Internal
shincter

Intersphincteric
space

External
sphincter

Fig. 39.6  Ten SphinKeeper implants can be placed into the inter- formed by mechanical rotating transducer (type 2052, BK Medical,
sphincteric plane to achieve a better encirclement of the anal canal. (a) frequency 13 MHz). Ten polyacrylonitrile implants (SphinKeeper) are
Schematic drawing; (b) three-dimensional endoanal ultrasound per- visualized as hypoechoic cylinders into the intersphincteric plane

6.5 (P < 0.001), and median AMS from 87 to 43.5 (P < 0.001)
[21]. The Gatekeeper implant has now been replaced with a
new-generation implant, the SphinKeeper, made of the same
material but just larger in size (Fig.  39.6) [22]. Up to ten
SphinKeeper implants can be placed in each patients with
the idea to achieve a better encirclement of the anal canal
and optimize the functional outcome. With the evolution of
the prosthesis and the technique, the SphinKeeper is now
used as a permanent implantable device rather than a bulk-
ing agent with the rational to introduce a kind of artificial
neosphincter rather than simply augmenting the IAS as the
injectable materials.
Ethylene vinyl alcohol (EVOH) is another alternative to
treatment for FI. A prospective study by Stephens et al. [7]
looking at 21 patients showed a statistically significant
decrease in CCF-FIS (P = 0.0005) and the FI Severity Index
score (P = 0.005) after treatment. Twelve months following
treatment, the mean CCF-FIS had decreased by 37%
(P = 0.0021), and 47% of subjects had >50% improvement
in CCF-FIS.  There was also a notable improvement in
embarrassment (P  =  0.0455) and coping/behaviour
(P = 0.0056). In a study [23] with the longest follow-up of
7  years, 19 patients who received various bulking agents
(Durasphere, PTQTM, Solesta®) did not sustain the initial
500
a b
Fig. 39.7 Three-dimensional endoanal ultrasound performed by
mechanical rotating transducer (type 2052, BK Medical, frequency
13  MHz). Migration of the prostheses into the supralevator space
short-term improvements, and EAUS showed complete
resorption of the implants, which correlated with the clini-
cal outcome. Interestingly, no patient received repeated
injections during the study period. Two other studies with
follow-up of 47 and 34 months reported that intersphincteric
injection of collagen in 11 patients and Gatekeeper in 14
patients resulted in 25% and 39%, respectively, improve-
ment in the incontinence score [19, 24].
39.6 A
 norectal Physiology and Endoanal
Ultrasound
Anorectal physiology was not routinely performed postop-
eratively. Furthermore, it was not performed in a standard-
ized and uniform way, thus making data interpretation
difficult. Nevertheless, mean anal resting (MRP) and squeeze
(MSP) pressures were the most commonly reported param-
eters. No obvious trend was seen in MSP. MRP appeared to
increase in the short-term (e.g. over 3  months), but the
increase was not sustained in the long-term. This may be
related to implant reabsorption and the need for repeated
injections. The repeat injection rate is widely variable and
depends on the implant used. Endoanal ultrasound was also
not routinely performed postoperatively, and, when it was
performed, the timing of the ultrasound assessment was not
standardized. Nevertheless, it showed implant migration or
loss of implant in up to 20% of patients at 3 years follow-up
(Fig. 39.7).
A. Hotouras and P. Giordano
(arrow) (a) and into the subcutaneous space (arrows) (b). PR puborec-
talis muscle, ScEAS subcutaneous external anal sphincter
39.7 Discussion
Many different materials have been used as bulking agents
for the management of passive FI, and more recently new
generations of implantable materials have also been intro-
duced. The studies used to evaluate the clinical outcomes of
these techniques have been overall of poor quality, including
relatively small numbers of patients. Long-term follow-up
data are also scarce. Nevertheless, the use of these materials
to treat patients with passive incontinence appears to be safe
with minor, temporary complications. Overall these treat-
ments also seem to produce an improvement in symptoms
although their actual efficacy is still unclear. Some of the
problems with the current evidence on the use of bulking
agents relates to the heterogeneity of the studies in terms of
patient selection, injection method, and outcomes. There are
significant differences in methodology, variation in injection
methods, volume of injections and number of injections, and
outcome measures used in each study. The m ­ ajority of stud-
ies also have failed to mention their selection criteria,
whether patients had been selected consecutively or whether
they had been controlled for other treatment options includ-
ing antidiarrheal medications. Another interesting point
regards the method of action for bulking agents. It has been
postulated the method of action through a mechanical bulk-
ing effect on the anal sphincter creating a mechanical barrier
and/or improving closure of the anal canal. However, the use
of these materials is rarely followed by an increase in mean
resting pressure, this casting doubt on their mechanism of
39  Injectable and Implantable Biomaterials for Anal Incontinence
action. Although misplacement of the agent and/or reabsorp-
tion with time may partially explain that, it has also been
suggested that the improvement in FI in these patients could
be related to a placebo effect [24, 25].
As far as safety, the reported adverse events are minor
from which patients made a good recovery. Adverse events
included perianal pain or discomfort (most common), leak-
age of injected agents, abscess, mucosal erosion, obstructed
defecation, hypersensitivity reaction, hematoma, diarrhoea,
pruritus, and urgency. In rare instances, patients developed a
perianal abscess, requiring antibiotics or surgical drainage.
In a large systematic review paper including 420 patients,
Luo et al. [4] reported migration of the bulking agent in 14
patients, 2 with Durasphere and 12 with PTQ injection.
39.8 Conclusions
Despite the significant result variations related to the differ-
ent materials used over the years and the lack of long-term
data, current evidence suggests that many patients suffering
with passive FI report improved symptoms following their
use of without significant serious adverse events. The posi-
tion of bulking agents in the treatment algorithm for incon-
tinence is still difficult to define. However, they may be
used as first-line therapy to treat patients with passive
incontinence or as part of a multimodal treatment regime in
patients with mixed incontinence once conservative mea-
sures alone have proved unsuccessful. New-­ generation
implantable materials may evolve the concept of bulking
agent moving in the direction of artificial bowel sphincter
implant with the potential of better improving functional
outcomes.
Take-Home Messages
• Injectable bulking agents offer the possibility of a
minimally invasive and simple procedure to treat
IAS dysfunction and can be considered for the
treatment of FI refractory to conservative therapy.
• Injectable bulking materials are generally inserted
into the submucosa of the distal rectum, while
implantable materials are normally placed into the
proximal intersphincteric space. The number of
injections and the volume of the injected bulking
agent depend on the material used.
• The use of injectable or implantable materials to
treat patients with passive incontinence appears to
be safe with minor, temporary complications.
Overall these treatments seem to produce an
improvement in symptoms although their actual
efficacy is still unclear long-term.
501
References
1. Shafik A. Polytetrafluoroethylene injection for the treatment of par-
tial fecal incontinence. Int Surg. 1993;78:159–61.
2. Shafik A.  Perianal injection of autologous fat for treatment of
sphincteric incontinence. Dis Colon Rectum. 1995;38:583–7.
3. Leo CA, Leeuwenburgh M, Orlando A, Corr A, Scott M, Murphy
J, Knowles CH, Vaizey CJ, Giordano P. Initial experience with
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on the efficacy and safety of injectable bulking agents for passive
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M, NASHA Dx Study Group. Efficacy of dextranomer in stabilised
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7. Stephens JH, Rieger NA, Farmer KC, Bell SW, Hooper JE, Hewett
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Y, Lindsetmo RO, Vonen B. Sphincter training or anal injections of
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 Sacral Neuromodulation for Fecal
Incontinence 40
Klaus E. Matzel and Birgit Bittorf

40.2 Technique and Its Evolution

Learning Objectives
• Understand the technique of sacral neuromodula-
tion for the treatment of fecal incontinence
• Understand the indication and patient selection of
SNM for FI
• Understand the outcome of SNM for FI
• Understand the role of SNM for FI in the current
treatment algorithm of FI
40.1 Introduction
Sacral neuromodulation (SNM)/neurostimulation (SNS) is a
minimally invasive treatment for functional disorders of the
pelvic floor, particularly urinary and fecal incontinence. By
stimulating sacral spinal nerves, central and peripheral neu-
ral control of these functions is affected, and residual anorec-
tal function is recruited.
The introduction of SNM into clinical practice in colo-
proctology [1] represents a paradigm shift in the treatment of
fecal incontinence: before this, any attempt to correct fecal
incontinence aimed to modify sphincter function by narrow-
ing the anal canal or reinforcing the anal sphincters. There
was no possibility of affecting other physiological functions
influencing continence. Also, SNM has the unique advantage
over other techniques in that it offers a reliable trial stimula-
tion that can identify patients who will respond to permanent
stimulation therapy.
The procedure has evolved since its introduction. The origi-
nal technique entailed a presacral incision to identify the
sacral foramen for insertion of the electrode implant and
suture fixation of the electrode to the periosteum under gen-
eral anesthesia. The technique became less invasive with the
introduction of a percutaneous Seldinger-like positioning for
electrode placement, performed under fluoroscopy. This
modified technique can be performed under either general or
local anesthesia.
Recently the technique has been revisited, modified, and
standardized with the objective of reducing the risk of subop-
timal implants [2]. The current technique involves intraop-
erative imaging and the use of a curved stylet for electrode
placement (Fig. 40.1). Fluoroscopy clarifies the location of
electrode insertion by identifying the medial edges of the
sacral foramina and the distal edges of the sacroiliac joint
(H-sign) (Fig. 40.2). It helps to determine the depth of elec-
trode insertion (Fig. 40.3) and the direction of placement. A
curved, less rigid stylet adds another degree of electrode

K. E. Matzel (*) · B. Bittorf

Sektion Koloproktologie, Chirurgische Klinik der Universität
Erlangen-Nürnberg, Erlangen, Germany
e-mail: Klaus.Matzel@uk-erlangen.de Fig. 40.1  Tined lead electrode with curved tip

© Springer Nature Switzerland AG 2021 503

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_40
504
reach and facilitates placement along the natural path of the
sacral spinal nerves in the pelvis. The positioning of the elec-
trode is always determined by the pattern and intensity of a
motor or sensory response to stimulation, the intensity of
applied stimulation, and the radiographic appearance of the
implanted electrode. Ideally, all four contacts of the elec-
trode should be positioned close to and parallel with the tar-
get nerve, which runs in a caudolateral direction after exiting
the ventral opening of the foramen. This offers the greatest
Fig. 40.2  Intraoperative use of fluoroscopy with lateral imaging of
sacrum after a.p. marking of distal edge of ileosacral junction and
medial edges of sacral foramina: “H“-sign foramen needle electrode
inserted into S3 left
Fig. 40.3  Intraoperative imaging: (a) electrode introducer placement, (b) tined lead electrode placement
K. E. Matzel and B. Bittorf
number of programming options for permanent stimulation
with the least energy consumption—and thus battery longev-
ity and the lowest likelihood of negative side effects [2].
The SNM procedure consists of a test phase to determine
clinical effectiveness and, in case of a successful test, chronic
therapeutic stimulation. The test phase entails percutaneous
nerve evaluation (PNE) with either temporary electrodes
(one or more easily placed monopolar flexible electrodes
(Medtronic InterStim® 3059, Medtronic Inc., Minneapolis,
MN, USA)) or the so-called quadripolar tined lead [2]
(Medtronic InterStim® 3889, Medtronic Inc., Minneapolis,
MN, USA). The first option offers the possibility of testing
more than one sacral spinal nerve and is less invasive and
expensive. These electrodes are easily removable; however,
if test stimulation is successful, insertion of a tined lead is
required for chronic stimulation. The latter option, the tined
lead, is less prone to dislodgement [3] and can remain and be
connected to the fully implantable pulse generator (Medtronic
InterStim® II, 3058, Medtronic Inc., Minneapolis, MN,
USA), which will be implanted if during the test phase a
50% symptom improvement is achieved. For the test stimu-
lation phase (typically 2 weeks), both types of electrode are
connected to an external pulse generator (Fig. 40.4), and the
patient documents bowel habits and incontinence frequency
by diary. The indication for chronic therapeutic stimulation
is based on the degree of symptom improvement.
For both test and chronic stimulation with the fully
implanted system (Fig. 40.5), the parameters are set in coop-
eration with the awake patient. They are determined by the
perception of stimulation, the required intensity, and the
40  Sacral Neuromodulation for Fecal Incontinence
Fig. 40.4  Test stimulation phase: electrode connected to external pulse
generator for continuous low-frequency stimulation (Medtronic)
Fig. 40.5  Sacral neuromodulation system (electrode and pulse genera-
tor) implanted
presence of side effects. The temporary electrodes allow
only unipolar stimulation and the tined lead electrode only
bipolar stimulation; chronic stimulation with an implanted
tined lead and pulse generator can be uni- or bipolar. The
stimulation setting should be comfortable and free of side
effects. Most commonly, suprasensory threshold stimulation
is used, although a subsensory threshold can also be effective
[4]. Patients are able to adjust the parameters within a preset
range with a handheld programmer. Adjustments to the pro-
gramming parameters may be required.
505
Over time the implantable pulse generator has been
reduced in size and its features improved, resulting in greater
comfort and safer implantation, especially in underweight
patients with thin subcutaneous tissue. The programmer has
also improved in performance and ease of use.
40.3 Mechanism of Action
The mechanism of action of SNM is not yet entirely under-
stood. It appears to modulate peripheral and central nervous
functions. The original concept—that it worked predomi-
nately by improving anal sphincter function [5]—has not
been confirmed [6]. A sphincter contraction can be induced
by SNS during electrode placement, but this has been shown
to be the result of a polysynaptic reflex rather than a direct
activation of the alpha-motoneurons [7] and, when present,
is not sufficient to fully explain the restored continence.
Improved anorectal sensation seems to play a major role in
the control of continence. An intact ascending neural path-
way to the central nervous system (CNS) is also needed, as
one of the contraindications for SNM is complete spinal cord
injury [8]. To what extent colonic motor function is affected
remains controversial, as the lack of consistent data does not
permit a firm conclusion. Increasing evidence indicates that
SNM’s effect is not limited to the anorectum per se but that
it appears to modulate areas of the CNS associated with stor-
age and evacuation, most likely via stimulation of the affer-
ent sensory nerve fibers [9]. The effects on the CNS have
been investigated mostly in patients with urinary inconti-
nence; positron emission tomography (PET) [10] has dem-
onstrated that, via the spinal cord, SNS influences some
brain areas involved in alertness and awareness, leading to a
reduced excitability of some areas of the cortex [11].The
effect of temporary stimulation on the CNS appears to differ
from that of chronic stimulation [12].
40.4 Indications
No physiological predictors of outcome exist. Thus, the indi-
cations for implantation of the permanent device are based
on the clinical outcome of test stimulation. Initially, SNM
was limited to fecal incontinence in the presence of a mor-
phologically intact anal sphincter. However, based both on
the awareness that stimulation’s effect is not limited to the
sphincters and on the experience of a highly predictive posi-
tive test, a progressive broadening of the indications has
occurred. Today a wide spectrum of causes of fecal inconti-
nence is successfully treated with SNM. The procedure has
also been extended to other pelvic organ/floor disorders,
such as constipation [13]. A pragmatic trial and error con-
cept—in which the indication for test stimulation is not
506 K. E. Matzel and B. Bittorf

based solely on specific pathophysiological or pathomorpho-
logical criteria—has demonstrated that SNM may be effec-
tive for fecal incontinence caused by external anal sphincter
damage [14–16], radiation [17], rectal prolapse repair [18],
Crohn’s disease [19], partial spinal lesions [20], and cauda
equina [21], several neurological diseases (such as muscular
dystrophy and systemic sclerosis) [22, 23], and also low
anterior resection syndrome (LARS) [24, 25]. The associa-
tion of fecal incontinence with other pelvic floor dysfunc-
tions such as urinary incontinence or retention is a further
area for application [26, 27].
A placebo effect has been addressed in a double-blind
randomized crossover trial [28].
Multiple guidelines and recommendations (National
Institute for Health and Care Excellence [NICE] [29],
American Society of Colon and Rectal Surgeons [ASCRS]
[30], International Consultation on Incontinence [ICI]
[31], French [32] and Italian [33]) confirm the clinical effi-
cacy of SNM and consider it to be one of the first-line sur-
gical interventions for fecal incontinence of varied
etiology. The positioning of SNM in the treatment algo-
rithm is central (Fig. 40.5 ICI Algo). A limited number of
surgical alternatives such as sphincteroplasty exist, but
they are suitable for a far more limited spectrum of etiolo-
gies (Fig. 40.6).
The list of specific contraindications for SNM is limited
to conditions not allowing adequate electrode placement,
such as anorectal/sacral malformations, complete spinal cord
transection, septic conditions in the field of operation (pilo-
nidal sinus), pregnancy, mental or physical inability to adhere
to treatment, and the need for MRT (the current version of
the implant is only conditionally safe for 1.5 T MRT head
coil).
40.5 Prognostic Factors of Outcome
Any attempt to identify factors statistically predictive of a
successful outcome to temporary and chronic stimulation
has failed. At present no clinical factors (patient features, eti-
ology of incontinence, motor or sensory response to test
stimulation) or preoperative laboratory investigations (anal
manometry, electrophysiological tests, etc.) have convinc-
ingly demonstrated prognostic value [34–37], either for the
test phase or for chronic stimulation [38]. Recently, a retro-
spective study reported that patients with fecal incontinence
and concomitant high-grade internal rectal prolapse (Oxford
Grade 3 and 4) have a poorer clinical outcome to chronic
SNM [39].
40.6 Outcome
Since the introduction of SNM in coloproctology [1], out-
come reports have accumulated (Tables 40.1 and 40.2), some
focusing on its long-term efficacy [40–44, 50, 61–63]. Most

Review Repeat
clinical, radiological and evaluation
physiological data

Severe Rectal prolapse Correction

ACE
spinal cord Rectovaginal fistula of anatomic
Colostomy
impairment Cloacal deformity abnormality

Rectal evacuation Sphincter defect > 180º or Sphincter defect Sphincter defect No sphincter
disorder significant perineal tissue loss 120º – 180º < 120º defect

• Rectocele repair • Sphincteroplasty +/- vaginal and • Sphincteroplasty • SNS • SNS

• Ventral rectopexy perineal reconstruction • SNS • Sphincteroplasty • BI
• SNS • BI • Colostomy
• Colostomy
• Colostomy • Colostomy
• Stimulated graciloplasty*
• Artificial anal sphincter*

Yes Symptom no
Follow up
improvement
Novel therapies:
• Magnetic anal sphincter
• Puborectal sling
ACE: antegrade continence enema, BI: biomaterial injection, • Radiofrequency energy treatment
SNS: sacral nerve stimulation; *not widely available • Stem cell therapy
• Vaginal pessary - EclipseTM

Fig. 40.6  Algorithm International Consultation on Incontinence (ICI): surgical treatment for fecal incontinence [31]
40  Sacral Neuromodulation for Fecal Incontinence 507

Table 40.1  Chronic sacral nerve stimulation (SNS) for fecal incontinence (FI): incontinence episodes, studies with at least 50 patients

Median Incontinence episodes/week

Patients (n) Patients (n) Patients (n) follow-up median (range)
Author Year PNE (implants) (follow-up) (months) Baseline Last follow-up P value
Uludag et al. [40] 2004 63 50 (79%) 6 24a 8 (n.a.) 1 (n.a.) n.a.
Melenhorst et al. [41] 2007 134 100 (75%) 6 60a 10 (n.a.)b 2 (n.a.)b <0.001
Dudding et al. [42] 2008 60 51 (85%) 48 24 6 (0–81) 1 (0–59) n.a.
Tjandra et al. [43] 2008 60 53 (88%) 53 12a 10 (13)b 3 (10)b <0.001
Altomare et al. [44] 2009 94 60 (64%) 52 74b 4 (n.a.)b 1 (n.a.)b 0.004
Michelsen et al. [45] 2010 167 126 (74%) 49 12a 8 (n.a.) 1 (n.a.) <0.001
Hollingshead et al. [46] 2011 113 86 (76%) 86 33 9 (7)b 1 (2)b <0.001
Uludag et al. [47] 2011 n.a. 50 n.a. 60 8 (n.a.) 0 (n.a.) <0.002
Duelund-Jakobsen et al. [48] 2012 n.a. 147 147 46 6 (n.a.) 1 (n.a.) <0.001
Hull et al. [49] 2013 133 120 (90%) 76 >60 9 (n.a.) 2 (n.a.) <0.0001
Altomare et al. [50] 2015 407 272 (67%) 228 84 7 (4–11) 0.3 (0–3) <0.001
Janssen et al. [51] 2017 374 325 (87%) ? 7.1 years 5 (n.a.)b 1(n.a.)b <0.001
Modified after Thin et al. [52]
n.a. not available
a
Values at specific time point
b
Mean

Table 40.2  Chronic sacral nerve stimulation (SNS) for fecal incontinence (FI): Cleveland Clinic Incontinence Score, studies with at least 50
patients
Patients Median Median score
(n) Patients (n) follow-up Median score follow-up
Author Year (baseline) (follow-up) (months) baseline (range) (range) P-value
Tjandra et al. [43] 2008 53 53 12a 16 (1)b 1 (2)b <0.001
Altomare et al. [44] 2009 60 52 74b 15 (4)b 5 (5)b <0.001
Brouwer et al. [53] 2010 55 13 48a 15 (13–18) 6 (2–8) 0.008
Faucheron et al. [54] 2010 87 87 45 13 (6–19)b 8 (1–17)b n.a.
Michelsen et al. [45] 2010 126 10 72a 20 (12–20) 7 (2–11) <0.001
Gallas et al. [34] 2011 200 54 24a 14 (2–20) 7 (0–19) 0.001
Lim et al. [55] 2011 53 41 51§ 12 (9–15) 8 (5–11) 0.001
Wong et al. [56] 2011 61 61 31 14 (n.a.) 8 (n.a.) n.a.
Faucheron et al. [57] 2012 57 42 63 14 (4–19) 7 (1–16) <0.001
Damon et al. [58] 2013 102 101 48b 14 (3) 9 (1) <0.0001
Maeda et al. [59] 2014 108 101 60a 16 (6–20) 8 (0–19) <0.0001
Altomare et al. [50] 2015 272 228 84 16 (13–18) 7 (4–12) <0.001
Duelund-­Jakobsen et al. 2016 164 n.a. 22 15 (3–20) 9 (0–20) <0.001
[60]
Modified after Thin et al. [56]
n.a. not available
a
Values at specific time point
b
Mean

patients treated with chronic SNM experience a sustained
clinical improvement regardless of the underlying etiology
[50], with reported follow-up of up to 18  years [61]. The
long-term results are favorable when compared with those of
other surgical techniques such as sphincteroplasty. The clini-
cal benefit is not limited to symptom reduction or relief but
also to quality of life: a significant improvement has been
repeatedly demonstrated in short-, mid-, and long-term out-
come studies that used both general health (SF-36) and
disease-­specific questionnaires such as the Fecal Incontinence
Quality of Life Scale (FIQLS) [41, 44–46, 63–65].
40.7 Future Directions
SNM is a well-established treatment option for fecal inconti-
nence. Its role in the current treatment is central. Future
development will most likely include a modifications of the
applied stimulation device (miniaturization) and its handling
(programming, interface). With the availability of a test stim-
ulation phase, which is highly predictive of the clinical effec-
tiveness if it leads to a positive clinical outcome during the
test phase, the spectrum will of application will expand
further.
508
Take-Home Messages
SNM develop to be the central treatment modality for
surgical therapy of fecal incontinence. A broad spectrum
of etiologies leading to fecal incontinence can be treated
successfully. The patient selection is pragmatic and
based on the outcome of a timely limited test stimulation
phase. The chronic stimulation results in long-­ term
symptom improvement and improved quality of life.
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 Posterior Tibial Nerve Stimulation
for Faecal Incontinence 41
Gregory P. Thomas, Carolynne J. Vaizey,
and Yasuko Maeda

41.2 Percutaneous PTNS

Learning Objectives
To understand: This is the more commonly used version of PTNS. It requires
• The different ways of delivering PTNS. a needle electrode to access the tibial nerve at the ankle
• How effective is PTNS. (Fig. 41.1). The ground pad is placed on the sole of the foot.
• How PTNS is thought to work and its anatomical Stimulation is applied for 20–30 min at a time to one side.
rationale. This is typically performed on a weekly or twice-weekly
• How PTNS compares to other treatments. basis. Stimulation parameters of a frequency of 10–20  Hz
and a pulse width of 200 μs are applied. The amplitude is set
to a level just below or at sensory threshold. After around 12
sessions, the patient is discharged. They return when symp-

41.1 Introduction

Posterior tibial nerve stimulation (PTNS) or tibial nerve

stimulation was first reported for urinary incontinence by
Nakamura in 1983 [1] and McGuire in 1983 [2]. It was first
described for faecal incontinence by Shafik in 2003 [3], who
used percutaneous stimulation. This was followed by the less
invasive transcutaneous stimulation introduced by Queralto
[4]. Since then, further studies have investigated the effec-
tiveness of PTNS for faecal incontinence.
The posterior tibial nerve is a distal branch of the tibial
nerve, which originates from the sciatic nerve (L4,5 S1,2,3).
The posterior tibial nerve lies superficial and posterior to the
medial malleolus. This is the point where it may be accessed
for PTNS. Percutaneous PTNS (Fig. 41.1) involves use of a
needle electrode, whereas transcutaneous PTNS (Fig. 41.2)
requires an electrode pad. Its proposed mechanism of action
is described below.

G. P. Thomas · C. J. Vaizey · Y. Maeda (*)

St Mark’s Hospital and Academic Institute, Harrow, London, UK
e-mail: ymaeda@nhs.net; yazmeda@gmail.com Fig. 41.1  Percutaneous PTNS

© Springer Nature Switzerland AG 2021 511

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_41
512 G. P. Thomas et al.

toms begin to deteriorate. At this point “top-up” treatments (p < 0.0001) after 12 sessions. After most recent top-up ther-
are given. This can then be continued in the longer term. This apy, the mean score was 10 (4.3) (p < 0.0001). The median
is usually administered in the outpatient clinic, although deferral time also improved significantly after 12 sessions (1
recent work has explored its use by the patient from home. (0–45) to 5 (0–60) min p < 0.0001). This improvement per-
Percutaneous PTNS has been described in a number of sisted after most recent top-up therapy (4 (0–60)  min
single series. Shafik, in 2003 [3], described 32 patients, all p < 0.0001). The median FI episodes per week improved sig-
with idiopathic faecal incontinence, who had received percu- nificantly after 12 sessions (5 (0–35) to 1 (0–27) p < 0.0001).
taneous PTNS.  All had an intactanal sphincter, had failed Again, this improvement was maintained at most recent top-
biofeedback and other conservative treatments. They ­up session (1 (0–24) p < 0.0001). The median (range) time
received 30 min of stimulation on alternate days for a period from completion of the 12 initial sessions of PTNS to top-up
of 4 weeks. This group was compared with 20 untreated con- therapy was 12 (1–40) months. Uni- and multivariate analy-
trol patients. The primary endpoint was >50% improvement sis showed that type of FI (urge or passive) and sphincter
in a faecal incontinence score, similar to the Cleveland Clinic morphology had no significant impact on outcome.
FI score [5]. A >50% improvement in the continence score
occurred in 27 (84%) of patients treated, 9 (29%) of whom
experienced a relapse during a mean period of 22.3  ±  4.6 41.3 Transcutaneous PTNS
[SD] months. Six of these patients benefitted from further
“top-up” therapy. It is unclear whether randomisation or This is less commonly used. It requires an electrode pad to
matching of the two groups were attempted, or how the con- stimulate the posterior tibial nerve (Fig. 41.2). Like the per-
trol group was managed or how they compared with the cutaneous version, a ground pad is placed nearby. The treat-
treatment group. The follow-up period ranged from 16 to ment regimen is similar to that used for percutaneous
30 months. PTNS. It is also more amenable to use by the patient from
De la Portilla [6] described 16 subjects treated by PTNS home. Stimulation of both left and right sides simultaneously
for 30 min once a week for 3 months. All had failed conser- [9] and the use of bespoke devices [10] have been described.
vative therapy, and all had an intact sphincter. A statistically
significant reduction in the Cleveland Clinic FI score [5] was
seen immediately after treatment, which was maintained at a
3-month assessment. The reduction in the number of incon-
tinent episodes was not statistically significant.
In a prospective multicentre study by Govaert and col-
leagues, 22 patients received twice-weekly 30-min PTNS for
6 weeks [7]. All had failed conservative treatment, and none
had a significant sphincter defect. Treatment was continued
weekly, then biweekly and finally monthly. At 6  weeks 14
(63%) had a greater than 50% reduction in incontinent epi-
sodes, but this was not statistically significant. If symptoms
reappeared or worsened, then treatment reverted to the last
effective treatment schedule and was continued for 1 year. At
1-year assessment, there was a significant reduction in incon-
tinence episodes in the 14 patients, who remained in the
study. There was a statistically significant reduction in the
Cleveland Clinic FI score [5] at 6 weeks, 3 months and 1 year
after PTNS. A significant improvement in the SF-36 health-­
related quality of life score at 1 year was also seen. Anorectal
physiological parameters were not assessed.
The largest series to date is from The Royal London
Hospital, UK. Hotouras and colleagues [8] reported the out-
come of 150 patients who had undergone percutaneous
PTNS. 115 were available for analysis. The patients under-
went a course of 12 sessions of PTNS followed by “top-up”
sessions when required. A median (range) total of 26 (12–42)
months of follow-up was recorded. The mean Cleveland
Clinic FI score [5] improved from 12 (3.9) to 9.4 (4.6) Fig. 41.2  Transcutaneous PTNS
41  Posterior Tibial Nerve Stimulation for Faecal Incontinence
A significant improvement in symptoms has been reported in
around 60% of patients.
In a prospective uncontrolled study by Queralto [4], ten
patients received daily treatment for 20 min for 4 weeks. All
had an intact sphincter and had failed biofeedback. A statisti-
cally significant improvement of more than 60% in the
Cleveland Clinic FI score was reported, which was main-
tained at a 12-week assessment. It is unclear whether this
was statistically significant. There was no statistically sig-
nificant change in anal canal pressures.
Vitton reported the outcome of 24 patients [11] who
received 20-min daily sessions for 3 months. All had failed
conservative therapy, but no data on the integrity of the anal
sphincter were given. There was no statistically significant
difference in the Cleveland Clinic FI score before and after
treatment. Those with evidence of improvement were offered
further treatment. On assessment at a mean of 15  months,
this improvement was maintained. Anorectal manometry
was not performed.
Eleouet reported on 32 patients, who were treated twice
daily for 1 month [12]. The primary endpoint was a visual
analogue score simply to assess percieved overall benefit.
Secondary endpoints included the Cleveland Clinic FI score
and a faecal incontinence quality of life score [13]. Twenty
(62.5%) recorded a greater than 10% improvement in the
visual analogue score. There was also a statistically signifi-
cant improvement in the mean Cleveland Clinic FI score
(14.5 to 11), which was maintained at 3 and 6 months, fol-
lowing further top-up treatment.
Thomas and colleagues [14] randomised 30 patients to
receive either daily or twice-weekly transcutaneous PTNS
for 6 weeks. Three of the daily group achieved complete con-
tinence at 6  weeks. None of the twice-weekly group man-
aged this. Only the daily group showed a significant
improvement in median (IQR) FI episodes per week (5
(11.1) to 3.5 (4.3) p = 0.025). Deferral and Vaizey FI scores
[15] were not affected significantly in either group. A further
study by the same authors [9] looked at bilateral stimulation,
or stimulation to both left and right posterior tibial nerves
simultaneously. Here, a total of 20 patients underwent
6  weeks of daily bilateral transcutaneous PTNS.  Two
achieved complete continence. Ten (59%) achieved a greater
than 50% reduction in FI episodes per week. The median
(IQR) FI per week improved significantly from 6 (8.3) to 2
(7.3) (p  =  0.03). The ability to defer defecation improved
significantly too from 3 (4) to 5 (8) min (p = 0.03).
Rimmer [10] reported the outcome of a bespoke device
called the Geko (Firstkind Ltd., UK). This was a wearable
device which provided electrical transcutaneous stimulation
to the posterior tibial nerve. It allowed ambulatory treatment.
The authors compared 1 h with 4-h unilateral treatment twice
weekly for a total of 6 weeks. Twenty-two were randomised
to the 1-h group and 21 to the 4-h group. Improvement in the
513
median (range) FI episodes per week was seen in both
groups, 1 hour (2 (0–16) to 0.5 (0–12)) and 4 h (4 (0–16) to
1 (0–8)). Improvement was seen in the ability to defer defe-
cation, 1 h (2 (0.5–5) to 2 (0.5–10) min), and more signifi-
cantly in the 4-h group (0.5 (0.5–5) to 5 (0.5–15) min). No
detailed statistical analysis of the data was performed.
41.4 Mechanism of Action
It is uncertain how PTNS works. It is thought to neuromodu-
late the sacral nerve plexus remotely via the posterior tibial
nerve through to the sciatic nerve. This implies a similar
mechanism of action to sacral nerve stimulation (SNS). The
exact mechanism of action of SNS is uncertain. It is likely to
be the result of multiple different physiological effects [16,
17], leading to alteration of local somato-visceral reflexes
with subsequent changes in colonic motility, rectal sensitiv-
ity and modulation of higher perception of afferent informa-
tion [18, 19]. One study attempted to determine if there are
any changes in anal sphincter function with PTNS. Lopez-­
Delgado and colleagues [20] assessed anal resting and maxi-
mum squeeze pressures in a group of patients who had
received PTNS.  They reported statistically significant
increases in these measures in 24 patients after a 3-month
follow-up. Marti and colleagues [21] assessed rectal capacity
in 46 patients who underwent PTNS. At follow-up, no sig-
nificant change in rectal capacity was seen. It should be
noted that there are no consistent changes in anorectal func-
tion seen from SNS [22].
The acupuncture point, “Sanyinjiao” or “spleen 6”, over-
lies the posterior tibial nerve near the ankle. Chang et al. [23]
reported the effects of acupuncture stimulation of this point
in patients with lower urinary tract dysfunction. An improve-
ment was seen in the majority of the patients. A small study
by Scaglia et al. [24] reported improvement in faecal conti-
nence using acupuncture. One of the acupuncture points
used here corresponded to the position of the posterior tibial
nerve. No work published to date has directly compared acu-
puncture with PTNS for FI.
PTNS is usually delivered unilaterally, at the nerve’s most
superficial position above and behind the medial malleolus.
It does not matter which leg is used. There has been no sug-
gestion of dominance of either the left or right tibial nerve,
although work has been done in relation to dominance of the
pudendal nerve and its effect on anal sphincter activity [25].
A frequency of 10–20 Hz and a pulse width of 200 μs are
usually used for PTNS; these are similar to the settings used
for SNS. It has been [26] suggested that a shorter pulse width
and a higher frequency may improve faecal incontinence in
patients receiving SNS. There is no published work investi-
gating the effect of altering these parameters in PTNS. The
optimum duration and frequency of treatment have yet to be
514 G. P. Thomas et al.

determined. The published literature describes a diverse
range of treatment and “top-up” schedules. The therapeutic
effects of SNS are short-lived once treatment has stopped.
Much of the literature suggests that there is a residual thera-
peutic effect after PTNS treatment finished. It is unclear how
long this can last for and how this is related to the initial
treatment regimen or modality of PTNS used.
this, and only one of the sham group achieved this outcome.
The percutaneous group achieved statistically significant
superiority when compared to the others (p  =  0.035). The
percutaneous group also showed an improvement in mean
deferral time from 1.9 to 6.7 min. The authors concluded that
percutaneous PTNS was superior to transcutaneous PTNS.

41.7 PTNS vs. Sham

41.5 P
 ercutaneous PTNS vs. Sacral Nerve
Stimulation The single series studies described above suggest that PTNS
is an effective treatment. However, many are non-­
There is limited evidence to show how PTNS compares to comparative, and none compared PTNS to sham. The fol-
SNS. Thin and colleagues [27] compared these treatments in lowing three trials have attempted to address this last point.
a prospective randomised single-blinded pilot study. Twenty-­ In 2012 Leroi and colleagues [30] reported the outcome
three underwent peripheral nerve evaluation for SNS. Of of a large multicentre prospective blinded randomised trial to
these, 15 underwent SNS.  Sixteen patients underwent compare transcutaneous PTNS with a sham treatment. 144
PTNS.  At 6  month’s follow-up, the following was seen. patients were randomised to either active treatment or sham.
Those who had SNS showed a change in mean (S.D.) faecal At 3 months their response was assessed. No statistically sig-
incontinent episodes per week of 11.4 (12) to 4.9 (6.9) and nificant difference was seen in frequency of incontinent epi-
change in Cleveland Clinic FI score of 16.2 (3) to 10.4 (5.6), sodes per week or urgency between the two groups. However,
and 11 had a greater than 50% improvement in faecal incon- 47% of the active group achieved a greater than 30%
tinent episodes per week. Those who had PTNS showed a improvement in the Cleveland Clinic FI score compared to
change in faecal incontinent episodes per week of 10.6 (11.2) 27% of the sham group. This difference achieved statistical
to 6.3 (6.9) and change in Cleveland Clinic FI score of 15.1 significance (p = 0.02). No difference in anorectal physiol-
(3) to 12.1 (5.2), and seven had a greater than 50% improve- ogy assessment was noted. The authors concluded that trans-
ment in faecal incontinent episodes per week. Because this cutaneous PTNS offered no clinically significant benefit.
was a pilot study, very limited analysis of the data was per- Knowles and colleagues [31] compared percutaneous
formed. However, the authors concluded that both treatment PTNS with a sham. This was a multicentre prospective
modalities offered benefit. blinded randomised trial. One-hundred and three patients
Hotouras [28] reported the outcome of 37 who had under- were allocated to active treatment and 102 to sham. They
gone SNS and 146 who had PTNS in a non-randomised received treatment on a weekly basis for 12 weeks. Thirty-­
cohort study. They looked at the cost of these treatments after nine of the active group achieved a greater than 50% improve-
the first year and found that the mean cost of SNS was ment in FI episodes per week compared to 32 of the sham
£11,374 and £1740 for PTNS. It is uncertain how the costs group (p = 0.96). This was a non-significant difference. This
compare in the longer term, when factors such as repeated was the primary outcome measure. However, significant
clinic visits for PTNS and replacement of SNS components improvements were seen in urge FI per week in the active
are taken into account. Despite this, it is likely that PTNS group (6–3.5 vs. 6.9–4.8) and also in total FI episodes per
would remain as the cheaper treatment option. week (3–1.5 vs. 2.5–1.25). The authors concluded that PTNS
was no more effective than sham.
Van der Wilt and colleagues [32] compared percutaneous
41.6 Percutaneous PTNS vs. PTNS to a sham in a smaller study. This was a multicentre
Transcutaneous PTNS blinded randomised trial. Twenty-nine received active treat-
ment, and 30 received sham. Forty-five percentage of the
George and colleagues [29] attempted to compare percutane- active group achieved a greater than 50% improvement in FI
ous PTNS with the transcutaneous modality in a prospective episodes per week compared to 20% of the sham group. This
partially blinded randomised trial. Eleven received percuta- achieved statistical significance (p = 0.028). The active group
neous PTNS, 11 received transcutaneous PTNS, and 8 achieved a significant greater improvement in median FI epi-
received sham over a 6-week period. Nine of the percutane- sodes per week. In contrast to the work of Knowles’ group,
ous group achieved a greater than 50% improvement in FI the authors concluded that percutaneous PTNS may offer
episodes per week, five of the transcutaneous group achieved some benefit.
41  Posterior Tibial Nerve Stimulation for Faecal Incontinence
Take-Home Messages
• PTNS is a minimally invasive and safe treatment for
faecal incontinence. It is likely to offer some bene-
fit. However, how much benefit is uncertain, given
its poor performance when compared to sham treat-
10. Rimmer CJ, Knowles CH, Lamparelli M, Durdey P, Lindsey I,
ment. Percutaneous PTNS is probably more effec-
tive than transcutaneous PTNS.  The latter may
demand a more intensive treatment regimen if any
benefit is to be gained.
• It should be offered to those who have failed con-
servative treatments such as pelvic floor physiother-
apy, biofeedback and basic pharmaceutical
measures such as loperamide. It may also be con-
sidered for those who do not wish to proceed with,
or are unable to receive, more invasive treatments.
• With regard to the different subtypes of faecal
incontinence, it is uncertain which patients are
likely to benefit the most from PTNS. Recent small
studies have reported its use in patients with low
anterior resection syndrome. Success rates in up to
50% of patients have been reported [33, 34]. This
deserves further investigation.
• Its mechanism of action and optimum treatment
regimen are uncertain. Further work in this area
may allow improvements to be achieved in its
efficacy.
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 Radiofrequency
Luanne Force, Mariana Berho, and Steven D. Wexner
Learning Objectives
• To identify patients who qualify for
radiofrequency.
• Understand the technique of radiofrequency.
• Learn the short- and long-term patient outcomes of
radiofrequency.
42.1 Introduction
Fecal incontinence is defined as an uncontrolled leakage of
stool for greater than 1 month’s duration [1, 2]. The etiology
of fecal incontinence is multifactorial and patient-specific,
including sphincter defects, congenital abnormalities, puden-
dal neuropathies, and medical comorbidities [1]. Regardless
of the etiology, fecal incontinence is highly distressing to the
patient, often leading to a significant compromise in quality
of life. The true incidence of fecal incontinence is difficult to
determine since embarrassment usually precludes reporting
of this condition. Mostly affecting women, it is estimated
that up to 20% of women experience some form of fecal
incontinence [3, 4]. Treatment of fecal continence starts with
medical modalities. The application of radiofrequency
sphincter augmentation has been used as a minimally inva-
sive treatment for fecal incontinence for patients with mild
incontinence who have failed less invasive treatments such
as medications and fiber.
The application of radiofrequency energy to the anal
canal was first used in 1999. The proposed mechanism of
L. Force · S. D. Wexner (*)
Department of Colorectal Surgery, Digestive Disease Center,
Cleveland Clinic Florida, Weston, FL, USA
e-mail: wexners@ccf.org
M. Berho
Department of Pathology and Laboratory Medicine, Cleveland
Clinic Florida, Weston, FL, USA
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_42
42
action includes improvement of rectal sensation through C
and A delta afferent fiber neuromodulation, smooth muscle
remodeling, and modulation of interstitial Cajal cell function
[3]. Fibrosis of the internal anal sphincter may also provide
some improvement in continence [5], although radiofre-
quency augmentation was not shown to produce fibrosis in
an animal model, but was shown to induce hyperplasia and
hypetrophy of smooth muscle fibers [6]. Application of this
technique was extrapolated from a similar radiofrequency
application to the lower esophageal sphincter for gastro-
esophageal reflux [5].
42.2 Recommendations for Practice
42.2.1 Technique (Fig. 42.1)
The procedure can be undertaken in the outpatient setting.
The preoperative preparation is two disposable phosphate
enemas and a single dose of parenteral antibiotics [4]. The
procedure can be performed under sedation or general anes-
thesia, depending on surgeon and patient preference. A
grounding pad is placed on the patient and connected to the
radiofrequency generator. The SECCA handpiece is then
connected to the generator as well as to the tubing connected
to a bag of sterile water and to suction [4, 7].
The handpiece is designed like an anoscope, which con-
tains four curved needle electrodes. The handpiece is trans-
parent, which allows visualization of the entire area being
treated. After the needles are deployed into the muscle, irri-
gation of the mucosa is undertaken through the coolant ports
on the handpiece, and the muscle is heated to 85 °C for 60 s,
and the water cools the mucosa to 33 °C. The treatments are
undertaken in four quadrants, starting at the dentate line and
extending every 5  mm up to 4  cm above the dentate for a
total of five treatments per quadrant. A three-quadrant chev-
ron distribution including right anterolateral, left anterolat-
eral, and posterior quadrants avoids anterior energy
application [4, 7, 8].
517
518
a b
Fig. 42.1  The SECCA procedure. (a) Anoscope wires are deployed in
three to four quadrants circumferentially and are meant to enter the
internal anal sphincter. (b) Radiofrequency treatment is performed at
42.2.2 Complications
Complications are minor and infrequent, the most common
complication being mucosal bleeding, which is usually mini-
mal and resolves with conservative treatment [1]. In rare
cases, a suture ligature may be required [9]. Some patients
may develop mucosal ulceration, which generally improves
over several weeks [9]. Some patients have experienced tran-
sient worsening of their incontinence [9].
L. Force et al.
four levels within anal canal, both above and below the dentate line. (c)
The procedure leads to internal anal sphincter thickening (With permis-
sion © Springer 2016 [2])
42.2.3 Results
The earliest studies on radiofrequency augmentation were
done by Takahashi et al. The first study by this group dem-
onstrated an improvement in the Cleveland Clinic Florida-
Fecal Incontinence Score (CCF-FIS) from 13.5 to 5 [1].
They also found a significant improvement in quality of
life scores over 6 months. Improvement in initial and max-
imal rectal distention volumes was demonstrated by
42 Radiofrequency
manometry [1]. The same group was able to demonstrate a
>50% improvement in Wexner incontinence scores from
an average of 13.5 to 8.26 on 5-year follow-up [10]. These
promising results were not reproduced in subsequent
series. Two early series by Efron et al. also demonstrated
some improvement in Wexner incontinence scores, from
an average of 14 to 11  in 46 patients [9, 11]. They also
found significant improvement in quality of life scores, but
they did not demonstrate any measurable effects on physi-
ologic testing such as ultrasound or manometry [9, 11].
Later series have not shown the same promising results
as early series. One study by Felt-Bersma et al. in 2007 of
11 patients showed a modest improvement of the Vaizey
incontinence score from 18 to 15 [7]. Another small series
of 15 patients in 2008 showed an improvement of the
Wexner incontinence score of 14–11, with minimal
improvement of quality of life [8]. Kim et al. failed to dem-
onstrate any benefit from radiofrequency treatment in eight
patients after 8 months [12]. A multicenter study in 2010 of
24 patients showed a modest improvement in fecal inconti-
nence score of 15.6–12 after 1 year [12]. One study evaluat-
ing 3-year outcomes in 31 patients demonstrated that
efficacy of the procedure diminished over the course of the
study, with only 6% of patients maintaining a clinical
response [13]. Abbas et al. were able to demonstrate a bet-
ter 3-year response, with 22% of the patients in that series
having a sustained clinical effect over 3 years [14]. A recent
sham-controlled clinical trial of 40 patients demonstrated a
mild improvement of the Vaizey incontinence score by 2.5
points, but did not in quality of life scores when compared
to the sham group [15]. Finally, a recent analysis of ten
studies concluded that radiofrequency treatment of the anal
canal provided a modest improvement in patients with mild
fecal incontinence, with minimal complications [16]. No
study was able to demonstrate any change in physiologic
testing such as ultrasound or manometry [16]. A recent
guideline for the treatment of fecal incontinence from 2014
stated the efficacy of radiofrequency augmentation is low
to intermediate based on some quality evidence [17].
42.3 Future Directions
Further study should be done to identify patients who may
have potentially benefit from radiofrequency treatment to the
anal canal for fecal incontinence.
519
Take-Home Messages
Radiofrequency augmentation of the anal sphincter
muscles can be moderately effective for mild-to-
moderate fecal incontinence. A discussion should be
had with the patient regarding expectations after this
procedure, since improvements are at best modest.
After other treatable causes for fecal incontinence have
been excluded, radiofrequency may be attempted.
References
1. Takahashi T, Garcia-Osogobio S, Valdovinos MA, Mass W, Jimenez
R, Jauregui LA, et al. Radio-frequency energy delivery to the anal
canal for the treatment of fecal incontinence. Dis Colon Rectum.
2002;45(7):915–22.
2. Paquette IM, Bordeianou L.  Evaluation and treatment of FI.  In:
Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow
CB, editors. The ASCRS textbook. 3rd ed. New York, NY: Springer;
2017. p. 1091–105.
3. Frascio M, Mandolfino F, Imperatore M, Stabilini C, Fornaro R,
Gianetta E, et al. The SECCA procedure for faecal incontinence: a
review. Colorectal Dis. 2014;16(3):167–72.
4. Brown HW, Wexner SD, Segall MM, Brezoczky KL, Lukacz
ES. Accidental bowel leakage in the mature women’s health study:
prevalence and predictors. Int J Clin Pract. 2012;66(11):1101–8.
5. Arts J, Bisschops R, Blondeau K, Farré R, Vos R, Holvoet L, et al. A
double-blind sham-controlled study of the effect of radiofrequency
energy on symptoms and distensibility of the gastro-esophageal
junction in GERD. Am J Gastroenterol. 2012;107(2):222–30.
6. Herman RM, Berho M, Murawski M, Nowakowski M, Ryś J,
Schwarz T, et  al. Defining the histopathological changes induced
by nonablative radiofrequency treatment of faecal inconti-
nence – a blinded assessment in an animal model. Colorectal Dis.
2015;17(5):433–40.
7. Felt-Bersma RJ, Szojda MM, Mulder CJ. Temperature-controlled
radiofrequency energy (SECCA) to the anal canal for the treat-
ment of faecal incontinence offers moderate improvement. Eur J
Gastroenterol Hepatol. 2007;19(7):575–80.
8. Lefebure B, Tuech JJ, Bridoux V, Gallas S, Leroi AM, Denis P,
et  al. Temperature-controlled radio frequency energy delivery
(Secca procedure) for the treatment of fecal incontinence: results of
a prospective study. Int J Colorectal Dis. 2008;23(10):993–7.
9. Efron JE, Corman ML, Fleshman J, Barnett J, Nagle D, Birnbaum
E, et  al. Safety and effectiveness of temperature-controlled
radio-frequency energy delivery to the anal canal (Secca proce-
dure) for the treatment of fecal incontinence. Dis Colon Rectum.
2003;46(12):1606–16.
10. Takahashi-Monroy T, Morales M, Garcia-Osogobio S, Valdovinos
MA, Belmonte C, Barreto C, et al. SECCA procedure for the treat-
ment of fecal incontinence: results of five-year follow-up. Dis
Colon Rectum. 2008;51(3):355–9.
520
11. Efron JE. The SECCA procedure: a new therapy for treatment of
fecal incontinence. Surg Technol Int. 2004;13:107–10.
12. Kim DW, Yoon HM, Park JS, Kim YH, Kang SB. Radiofrequency
energy delivery to the anal canal: is it a promising new approach to
the treatment of fecal incontinence? Am J Surg. 2009;197(1):14–8.
13. Lam TJ, Visscher AP, Meurs-Szojda MM, Felt-Bersma RJ. Clinical
response and sustainability of treatment with temperature-­controlled
radiofrequency energy (Secca) in patients with faecal incontinence:
3 years follow-up. Int J Colorectal Dis. 2014;29(6):755–61.
14. Abbas MA, Tam MS, Chun LJ.  Radiofrequency treatment for
fecal incontinence: is it effective long-term? Dis Colon Rectum.
2012;55(5):605–10.
L. Force et al.
15.
Visscher AP, Lam TJ, Meurs-Szojda MM, Felt-Bersma
RJF. Temperature-controlled delivery of radiofrequency energy in
fecal incontinence: a randomized sham-controlled clinical trial. Dis
Colon Rectum. 2017;60(8):860–5.
16. Felt-Bersma RJ. Temperature-controlled radiofrequency energy in
patients with anal incontinence: an interim analysis of worldwide
data. Gastroenterol Rep (Oxf). 2014;2(2):121–5.
17. Kaiser AM, Orangio GR, Zutshi M, Alva S, Hull TL, Marcello PW,
et al. Current status: new technologies for the treatment of patients
with fecal incontinence. Surg Endosc. 2014;28(8):2277–301.
 Other Surgical Options for Anal
Incontinence: From End Stoma
to Stem Cell
Zoran Krivokapić and Barišić Goran
Learning Objectives
• In this chapter, less frequently used and novel tech-
niques under investigation for the treatment of fecal
incontinence will be discussed.
43.1 Introduction
Fecal incontinence is a socially incapacitating condition. It is
quite distressing for patients and has negative effects on
social interactions and mental health and severely affects
quality of life. It seems that the incidence of fecal inconti-
nence has been rising by time. A study published at the end
of the last century reported that fecal incontinence affected
2% of the general population [1]. Meta-analysis published
10 years later reported quite higher rates, ranging from 11%
to 15% [2]. A more recent study reported the prevalence of
fecal incontinence of 6% in women younger than 40 years
old, 15% in women older than 40 years, and 6–10% in men
[3]. However, these differences may be the consequence of
various definitions of fecal incontinence used in studies per-
formed in diverse time periods and may not reflect the accu-
rate increase.
The most common cause of fecal incontinence is injury of
the anal sphincter during vaginal delivery, followed by iatro-
genic injuries caused by surgical procedures such as fistu-
lotomy, hemorrhoidectomy, and sphincterotomy. Direct
perineal trauma as a consequence of traffic accidents as well
as war injuries and/or post-pelvic irradiation may also play
Z. Krivokapić (*) · B. Goran
Clinical Center of Serbia, Clinic for Digestive Surgery, First
Surgical Clinic, Belgrade School of Medicine, University of
Belgrade, Belgrade, Serbia
e-mail: scpy@beotel.rs
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_43
43
an important role. Conservative treatment is usually a first
choice but is ineffective in most cases, especially in trau-
matic fecal incontinence. In these cases, only surgical treat-
ment may give satisfactory results. In most cases, the decision
as to which surgical procedure should be used depends on
the severity of anal sphincter injury, experience of surgical
team, and funds, because some procedures are quite expen-
sive. Patients who have limited sphincter defects (less than
50% of the circumference revealed by endorectal ultrasound)
may be offered sphincteroplasty as a first choice, because
this is a relatively cheap procedure with satisfactory results
in around 50% of patients in the long term. At the same time,
perineal anatomy can be restored with excellent aesthetic
results. Patients with more extensive injuries, not amenable
to sphincteroplasty, may be offered artificial sphincter
implantation, muscle transposition, etc. Patients with ana-
tomically intact, but not functional sphincters, may benefit
from sacral nerve stimulation, biofeedback, bulking agents,
etc., but these procedures may be beneficial even in patients
with sphincter defects. In some cases multiple procedures
may be combined. New and emerging techniques such as
stem cell therapy may change the treatment algorithm in the
near future. However, in cases when all treatments fail, the
only reasonable solution may be the permanent stoma.
In this chapter, we will focus on less frequent and investi-
gational techniques for fecal incontinence treatment.
43.2 Sphincter Replacing Procedures
Sphincter replacing therapy is indicated in patients with
large sphincter defects, more than 50% of the muscle miss-
ing, or completely destroyed sphincters. It may also be indi-
cated in case of sacral nerve stimulation (SNS) failure in
patients who would like to avoid colostomy. In practice, the
sphincter replacement procedures are divided in muscle
transposition techniques or the artificial bowel sphincter
(ABS) implantation. Although frequently used in the past,
the indications for sphincter replacement surgery are decreas-
521
522
ing since the introduction of SNS. In modern surgery indica-
tions include end stage severe fecal incontinence associated
with extensive anal sphincter loss or congenital anorectal
malformation, as imperforate anus or spina bifida, or peri-
anal colostomy after abdominoperineal resection where the
only other option is a stoma [4, 5].
43.3 Muscle Transposition Techniques
Muscle transposition techniques are usually used in the man-
agement of end-stage incontinence where previous, less
aggressive treatments have failed. Various skeletal muscles
were used in the past as neosphincters in order to maintain
fecal continence [6]. These muscles were typically in close
proximity to the anus and were harvested and encircled
around the anus in order to substitute anal sphincters [6]. The
earliest successful report ensued when Chetwood [7] per-
formed transposition of the gluteus muscle to restore conti-
nence in a patient who developed fecal incontinence after
trauma.
Gracilis muscle transposition (without electrical stimula-
tion) was first described by Pickrell et al. in 1952 [8] in order
to restore continence in four children. Fedorov et al. [9] used
adductor longus muscle, while Hakelius et al. [10] utilized
free autogenous muscle transplant for the treatment of anal
incontinence in children. Some advocated smooth muscle
transplants [11], while Hallan [12] used electrically stimu-
lated sartorius neosphincter in a canine model. Sartorius
neosphincter showed excellent results in animal model but
was not successful in humans. The main downside of all pas-
sive muscle transposition techniques was the inability of
patients to voluntarily contract the transposed muscle in an
effective manner to maintain continence. Another problem
was the inability of the transposed muscle to maintain tonic
contraction over prolonged periods of time. In practice, only
two muscles were used for this purpose: the gluteus and the
gracilis muscle.
43.4 G
 luteoplasty (Gluteus Maximus
Plasty)
Since Chetwood reported the first transposition of the glu-
teus maximus muscle in order to treat fecal incontinence,
various modifications of the original technique were
described. In 1930, Chittenden [13] used gluteal muscle
flaps for anal reconstruction after abdominoperineal resec-
tion, while Bistrom [14] transposed gluteus muscle and
pulled the rectal stump through a previously created hole in
the muscle for treatment of fecal incontinence. After the
Z. Krivokapić and B. Goran
World War II, this technique was almost abandoned until in
1981 Bruining [15] reported modified technique of gluteus
muscle transposition in a 17-year-old female injured in a
traffic accident. He detached gluteus muscles from the femur
and wrapped them around the anus to create a “scissorlike”
mechanism. In 1982 Hentz [16] modified the technique by
detaching gluteus muscles from the sacral and coccygeal ori-
gin and wrapped them around the anus in order to stabilize
spitted muscle slings at a proper resting tension and fiber
length. In order to minimize donor site morbidity (hip desta-
bilization), Orgel [17] proposed the technique of a double-­
split gluteus maximus muscle flap, where he mobilized only
the inferior part of one muscle (usually the right side) at its
insertion at the iliotibial band and femur. A number of case
reports or small series were reported since 1980, using dif-
ferent techniques with a proximally or distally based muscle
flaps [18–23]. In 1996, Guelinckx et al. [24], encouraged by
reported results of dynamic cardiomyoplasty and dynamic
graciloplasty, presented results in seven patients treated by
conventional and four patients treated by dynamic
gluteoplasty.
Theoretically, the use of the gluteus maximus muscle as a
substitute for anal sphincters has advantages because it is
normally used as an auxiliary muscle to maintain fecal con-
tinence and patients can be easily trained to use it. At the
same time, it is a well-vascularized, large, and powerful mus-
cle, supplied by the superior and inferior gluteal artery, capa-
ble for forceful contraction. It is innervated by the inferior
gluteal nerve originating from the L5 and S1 nerve roots
which makes it functional even in cases of fecal incontinence
due to the pudendal neuropathy. Active contraction and high
tonus of the muscle can be maintained for longer periods
compared to the gracilis muscle which is of paramount
importance for maintaining continence. Furthermore, its
neurovascular structures can easily be preserved during dis-
section and detachment from the sacrum, and neurovascular
pedicle has less traction compared to graciloplasty. In most
cases muscle wraps have sufficient length to reach the anal
canal without excessive tension. Several wrap configurations
are possible because the amount of the transferred muscle far
exceeds the amount of muscle tissue of a normal anal sphinc-
ter. It enables enough of healthy and contractile muscle to
completely encircle the anus and form a muscle cuff even in
cases when muscle atrophy occur, which is not uncommon
after transposition. The best functional results were obtained
with a technique that uses caudal parts of both gluteus mus-
cles to encircle the anus [25]. Unfortunately, there are impor-
tant drawbacks regarding to this technique. Gluteus maximus
contains predominantly type II striated muscle fibers which
make it prone to fatigue. It is not capable to sustain continu-
ous contraction for a longer period of time. Furthermore, the
43  Other Surgical Options for Anal Incontinence: From End Stoma to Stem Cell
muscle after dissection is bulky, making it technically
demanding to tunnel and wrap around the anus especially in
patients with deficient perineal body or excessive scarring of
the rectovaginal septum. There is also a problem with a
higher donor site morbidity compared to gracilis muscle
transposition. In gluteoplasty, in most cases, muscles from
both sides should be harvested, while in graciloplasty only
one muscle is taken. Gluteus maximus is a hip extensor,
important for walking, running, standing up from sitting
position, and walking upstairs, so patient may experience
some difficulties in everyday life. In most cases, sport
­activities are dramatically reduced after muscle transposi-
tion. At the same time, this natural function of the muscle
can make continence difficult to maintain when patient is
running or climbing stairs [26]. Finally, surgical technique
for gluteoplasty is more complex and challenging because
the access to its neurovascular bundle is less familiar com-
pared to graciloplasty. Those may be the reasons why it never
gained the same popularity as the graciloplasty, even though
results of non-stimulated gluteoplasty were shown to be
superior [27] or at least equal [21] to the results of non-stim-
ulated graciloplasty. The best candidate for this procedure is
a young patient with severe sphincter defects or destroyed
sphincters not amenable to sphincteroplasty. It may be a
good option for patients who may benefit from transposition
of substantial muscle bulk but without excessive rectovagi-
nal scarring. The primary contraindication for this procedure
is the presence of injured or nonfunctioning gluteus maxi-
mus muscles. Patients with fecal incontinence secondary to a
spina bifida or myelomeningocele should not be treated with
gluteoplasty because the nerve supply of the muscle is
derived from the inferior gluteal nerve, originating from L5
to S1. Conversely, patients with Leriche syndrome are not
candidates for this procedure, since vascular supply for the
muscle originates from the superior and inferior gluteal
artery. Complications after gluteoplasty are not uncommon.
The most frequent complication is wound infection occur-
ring in almost one quarter of patients [28]. Other, less fre-
quent complications include skin necrosis, anal canal
necrosis, anal canal stricture, fecal impaction, obstructive
defecation, chronic pain, and donor site morbidity such as
posterior thigh numbness, dysesthesia, and severe chronic
pain. Christiansen [21] reported wound infection in three out
of seven patients after bilateral gluteoplasty. Hultman [23]
reported donor site morbidity and perirectal complications in
64% of patients in a retrospective analysis of 25 consecutive
patients undergoing gluteoplasty for fecal incontinence.
Puerta [29] reported a success rate of 70% using the gluteus
transposition technique in 22 patients with fecal inconti-
nence. Madoff [30] reported wound infection in 27% and
anal stricture in 9% out of 11 patients treated with dynamic
523
gluteoplasty. In most reports, continence improved after glu-
teoplasty. There are a limited number of studies with objec-
tive assessment of long-term results. Guelinckx reported
continence for stool in 9 out of the 11 patients, while seven
patients were also continent for liquids [24]. Christiansen
found improvement in continence in three out of seven
patients, while in four it remained unchanged [21]. Hultman
found that gluteoplasty was successful in restoring fecal con-
tinence in 72% and partially successful in 16% of patients
[23]. According to a review of the literature by Fleshner,
complete continence was achieved in 60% and partial conti-
nence in 36%, while total failure was observed in 4% of
patients [28]. Combined data from 17 studies including 149
patients with gluteoplasty showed successful or partially
successful outcome in 73% of patients with an overall com-
plication rate of 38%. Since the first report by Chittenden,
anorectal reconstruction after abdominoperineal resection
(APR) by gluteoplasty has received little attention, so only
few reports were published [20, 29, 31] (Fig. 43.1).
43.5 Dynamic Gluteoplasty
Madoff [30] reported results of the prospective multicenter
study where electrostimulation of the transposed gluteus
muscle was performed in order to improve results. He
achieved good results in all patients initially but maintained
successful outcome in only 5 (45%) out of the 11 patients
and concluded that this procedure should be limited to inves-
tigational purposes. Guelinckx [24] treated 11 patients, 7
with conventional and 4 patients with dynamic gluteoplasty.
All patients who had satisfactory results and were continent
for both solid and liquid stool were in dynamic gluteoplasty
group. However, dynamic gluteoplasty newer gained such a
popularity as dynamic graciloplasty. It was probably because
the gracilis was technically easier to use, had less variations
in the nerve and blood supply, and had less donor site mor-
bidity. Finally, electrostimulation threshold is much higher
in gluteoplasty resulting in shorter device battery life.
43.6 Graciloplasty
Passive gracilis muscle transposition (without electrical
stimulation) was first described by Pickrell et al. in 1952
[8] after an attempt to restore continence function in four
children. More than 30 years after, Corman [32] reported
good results with this technique, while Faucheron et  al.
[33] confirmed that significant proportion of patients
may have satisfactory continence after passive gracilis
transposition.
524
a b
Fig. 43.1 (a–c) Gluteoplasty. (a) Marks in the operative field. (b)
Identifying the inferior gluteal nerve and vascular pedicle. (c)
Transposition of the muscle. (Reprinted with permission from McPhail
The gracilis muscle is the most superficial adductor of
the thigh and has little impact on motion of the lower
extremity. Its natural function is to assist the legs in adduc-
tion and internal rotation, so when this muscle is used for a
neosphincter procedure, adjacent muscles take over its func-
tion. As a result, there is minimal donor site morbidity, and
patients can perform most of everyday activities including
sports [34]. This superficial muscle has constant and proxi-
mal neurovascular supply, which enables effortless dissec-
tion and in most cases sufficient muscle length to overlap
around the anus. Unfortunately, like all skeletal muscles,
gracilis has a majority of type II, fatigue prone, fast-twitch
muscle fibers and is incapable to sustain prolonged, forceful
contraction. At the same time, natural function of this mus-
cle has nothing in common with muscles responsible for
Z. Krivokapić and B. Goran
L.E., Hultman C.S. Gluteoplasty for the Treatment of Fecal
Incontinence. In: Ratto C., Doglietto G.B., Lowry A.C., Påhlman L.,
Romano G. (eds) Fecal Incontinence. Springer, Milano 2007)
continence making it very difficult for a patient to learn how
to contract and use the gracilis muscle as a neosphincter.
Muscle fatigue and the inability of patients to voluntarily
contract the transposed muscle were the main reasons why
successful results of non-­ stimulated graciloplasty were
achieved in less than 50% of patients. Moreover, most of the
patients had severe constipation due to outlet obstruction
produced by overtightening of the anus with the transposed
muscle [35].
Finally, in many cases of fecal incontinence, there is an
adjacent pudendal nerve damage, which precludes this tech-
nique. Results of non-stimulated graciloplasty were success-
ful in less than 50% of cases, although some claimed that
continence rate was improved in more than 80% [32, 35–37]
(Fig. 43.2).
43  Other Surgical Options for Anal Incontinence: From End Stoma to Stem Cell 525

a b

c
d

Fig. 43.2 (a) Dissection of the gracilis muscle. (b) Preserving of the neurovascular bundle. (c) Muscle transposition. (d) Muscle wrapped around
the anal canal

43.7 Dynamic Graciloplasty prone muscle fibers to a slow, fatigue-resistant fibers by con-
tinuous electrical stimulation. In Italy, Cavina [43] et al. used
A physiologic base for dynamic graciloplasty was the results graciloplasty for anal sphincter reconstruction after abdomi-
from experimental studies in muscle physiology in animals. noperineal resection. In England, group around N. Williams
They found that low-frequency electrical stimulation of the stimulated directly the nerve trunk using external device
muscle can change normal muscle fiber pattern and trans- periodically. In Maastricht, Beaten et  al. used permanent
form fiber type II, fatigue prone muscles into fiber I, fatigue-­ implantable stimulator for electrostimulation of the muscle.
resistant muscles [12, 38]. This process can change skeletal Direct nerve stimulation is more physiological and requires
muscle-like gracilis into a muscle with properties of a lower stimulation level thus maximizing battery life, while
sphincter muscle. muscle electrodes are more secure, and there is less chance
Introduction of muscle electrostimulation techniques, of lead displacement. This procedure became the most popu-
based on research in using the latissimus dorsi muscle to lar form of a muscle neosphincter because of its simplicity,
assist a failing heart in dynamic cardiomyoplasty [39], the nature of neurovascular supply of the gracilis muscle,
renewed the interest in the gracilis muscle transposition. and minor donor site morbidity.
Although the first electrical stimulation for treatment of fecal Dynamic graciloplasty is a major procedure, and many
incontinence after operation for anorectal agenesis was complications have been reported. The most frequent were
reported by Dickson in 1968 [40], it was C.  Beaten from wound complications. In a prospective multicenter study
Maastricht who in 1986 implanted the first neurostimulator including 139 patients from 12 centers, Madoff [30] reported
in a patient who already had conventional graciloplasty major wound complications in 32% of patients and minor
10 years earlier for anal atresia. wound complications in 29%. Tendon detachment was
The new technique, named dynamic graciloplasty, was recorded in 3%, pain in 22%, and device/stimulation prob-
attributed to Beaten [41] and Williams [42] who indepen- lems in 11% of patients. Necrosis of the neoanus as well as
dently developed the concept of transforming fast, fatigue the gracilis muscle was also reported. Moreover, 48% of the
526
138 reported complications in this study required one or more
reoperations [30]. Functional failure, which was not related to
some specific complication, was recorded in 40% of all fail-
ures [30]. Constipation was reported after graciloplasty in
approximately 16% of patients, and in some cases it was due
to overtightening of the anus with the gracilis. Insufficient
contraction of the gracilis muscle is complication caused by
muscular or stimulation problems. Dynamic graciloplasty is a
very complex procedure, and experience is very important in
order to reduce complication rate and improve results. It
should be performed only in high-volume centers. Madoff
[30] reported significant differences in complication rate and
outcome comparing high- and low-volume centers. The over-
all major wound complication rate was 17.4% in high-volume
centers compared to 33.1% in low-­volume centers.
In the literature, the success rates of dynamic graciloplasty
in treatment of fecal incontinence vary from 45% to 80%
[44–49]. Most studies reported a small number of patients
with an overall improvement of continence in about 50% of
cases with follow-up ranging from 7  months to 4  years.
Again, high-volume centers did better than inexperienced
ones. The reported overall success rate was 80% in experi-
enced centers compared to only 47% in inexperienced centers
[30]. Large differences in success rates may be related to the
learning curve associated with this complex procedure. It
may also be related to the length of the follow-­up and differ-
ent tools and definitions used to measure outcomes.
Although the results of dynamic graciloplasty are satis-
factory in general, the problem is very high complication
rate, mostly wound infections, high rates of reoperation, and
complications related to the implanted devices. There are
also issues with obstructive defecation. In addition, the long-­
term consequences of chronic electrostimulation may cause
the problem because there are concerns that chronic electro-
stimulation may decrease muscle fiber diameter and lead to
muscle degeneration and atrophy by affecting the collateral
blood supply [50, 51]. Another important disadvantage is the
high cost of the procedure. However, studies showed that
there is a considerable cost benefit of graciloplasty compared
to the costs of the colostomy in the long term [52].
Muscle transposition techniques continue to have its role
in treatment of fecal incontinence although results are not
always predictable. Since they are major surgical procedures
with lots of complications, they should be reserved only for
selected cases, when all other options are not possible and
when permanent colostomy is the only alternative.
43.8 Artificial Bowel Sphincter (ABS)
The ABS manages incontinence by imitating the natural
action of the sphincter muscle. The device consists of an
Z. Krivokapić and B. Goran
inflatable cuff that occludes the anal canal, a pressure-­
regulating balloon located in the retroperitoneal space, and
a control pump placed in the scrotum or labia. It was
designed as a sphincter replacement procedure for treat-
ment of an end-stage fecal incontinence in cases when all
previous treatments failed in patients who wanted to avoid
colostomy. The first artificial bowel sphincter for fecal
incontinence was implanted by Christiansen in 1987 [53].
He used urinary sphincter (AMS 800), while Lehur [54]
designed it specifically for fecal incontinence treatment in
1996. Since that time, the artificial bowel sphincter has
been used mostly in specialized centers. However, most
studies had a small number of patients, and it was difficult
to assess the effectiveness of this device. One meta-analy-
sis included 21 studies with 541 patients and revealed that
ABS was implanted only in patients with severe end-stage
fecal incontinence [55]. The most common indication was
sphincter destruction followed by congenital malforma-
tions, while one study included perineal colostomy after
abdominoperineal resection. There was no mortality, but
complication rate was high. The pooled rate of surgical
revision was 49%, and the most common reason was
device malfunction, such as cuff rupture or balloon and
pump leak and cuff unbuttoning. However, device mal-
function did not appear to be a major cause of definite fail-
ure. The pooled rate of permanent device removal was
24%. The most common reasons were device infection and
erosion (pooled rates 56%). The pooled rate of retaining a
functional device was 69%. Evacuatory difficulty was
common, but it was severe in only 8% of patients. In cases
when the artificial bowel sphincter is operational, without
serious complications, patients might experience a signifi-
cant improvement in continence and even in quality of life.
The pooled improvement rate of continence was between
55% and 75% depending on the method/scale used for
evaluating continence function. All studies revealed sig-
nificant improvements in QOL after implantation, includ-
ing at long-term follow-up.
ABS is successful method for treating severe fecal incon-
tinence, but at the price of a very high complication rate,
frequently leading to subsequent explantation of the device.
The most frequent complication is infection which was
reported to be around 26% (in some series up to 76%) [56],
followed by constipation that occurs in approximately 29%
of patients. Pain and technical failure are also common com-
plications, in some cases necessitating device removal.
Patients should be well informed about the high rate of com-
plications before accepting this procedure.
As a result of technical challenges, device malfunctions
and high infection rates, followed by high rates of further
surgery for complications, this device never became widely
accepted (Fig. 43.3).
43  Other Surgical Options for Anal Incontinence: From End Stoma to Stem Cell
43.9 Magnetic Anal Ring
Magnetic anal ring was first used for anal incontinence treat-
ment by Lehur and colleagues in 2010 [57] although it was
originally developed for the treatment of gastroesophageal
reflux disease (LINX® Reflux Management System, Torax
“Sphincter”
Balloon
Pump
Fig. 43.3  Artificial bowel sphincter (Reprinted with permission from
Herold A. Incontinence. In: Herold A, Lehur PA, Matzel KE, O Connell
PR.  European manual of medicine, Coloproctology. Springer-­Verlag
Berlin Heidelberg 2008)
a b
Fig. 43.4 (a, b) FENIX® Continence Restoration System. (a) Fenix glamor closed. (b) Fenix glamor opened (Reprinted with permission from
Torax Medical)
527
Medical). This device was considered to add support of a
weakened anal sphincter through the magnetism of beads
placed around the anal canal (FENIX® Continence
Restoration System, Torax Medical). Several small studies
revealed that surgical procedure is straightforward, and the
safety profile is acceptable. They reported promising short-­
term outcomes with this technique, but long-term outcomes
still remain unknown. In general, therapeutic success rates
ranged between 53% and 66% at short-term follow-up. In
one study, long-term results with the median follow-up of
5 years were published [58]. This study included 35 patients
with severe fecal incontinence for ≥6 months, who had pre-
viously failed conservative therapy. During follow-up, device
had to be removed in seven patients due to complications.
Therapeutic success rates, including treatment failures
(device explantation or stoma creation), were 63% at year 1,
66% at year 3, and 53% at year 5 [58]. The most frequent
adverse events included defecatory dysfunction (20%),
implant site pain (14%), device erosion (11%), implant site
infection (11%), and bleeding (9%) [58]. Authors concluded
that magnetic anal sphincter augmentation may provide
excellent outcomes in patients with functioning device. This
technique may develop into a promising new treatment
option for fecal incontinence. The perfect indication has yet
to be determined, and more studies with larger numbers of
patients with a longer follow-up are necessary to determine
the role of magnetic anal ring in surgical treatment of fecal
incontinence. However, in 2017, Torax Medical announced
the discontinuation of sales and clinical studies of the
FENIX® Continence Restoration System (Fig. 43.4).
528 Z. Krivokapić and B. Goran

43.10 Stem Cell Transposition

The concept of full regeneration of the damaged tissue is not

a new one, but, until recently, it was mostly seen in futuristic
movies and revealed human aspiration and thoughts toward
noninvasive and perfect healing. Today, we are able to inves-
tigate these processes in vitro and in vivo thus making regen-
eration of the tissue possible. Mesenchymal stem cells have
remarkable pluripotent abilities to differentiate into different
types of cells like myocytes, osteocytes, adipocytes, etc. In
addition, in many tissues, they serve as internal repair sys-
tem, dividing essentially without limit to replenish other
cells during the whole life. They are regarded to have poten-
tial to improve muscle contractile function by replacing
fibrous tissue of the injured muscle with a new muscle cells.
There are two kinds of stem cells: embryonic stem cells and Fig. 43.5 Liposuction
somatic or “adult” stem cells (present in blood, bone mar-
row, and fat tissue). The adipose tissue is the richest source
of adult stem and other regenerative cells, so-called adipose-­
derived regenerative cells (ADRCs). It is estimated that
ADRC accounts to approximately 1% of all nucleated cells
in the lipoaspirate, which is more than 100-fold the yield
obtained from bone marrow aspiration and much easier to
harvest [59, 60].The reparative mechanism of ADRCs
includes the modulation of inflammation and trophic factors
to improve engraftment. It also improves the endogenous
regenerative potential without risks of rejection. Most
authors agree that many different growth factors and other
mediators are involved in this process of tissue regeneration.
Furthermore, secretion of high levels of angiogenic factors
and production of multiple growth factors make them a suit-
able option for muscle repair [61, 62]. The ability of ADRCs
to differentiate into muscle cells has been clearly shown in
both in vitro [63, 64] and in vivo [65, 66] studies. Thus, the
concept of regeneration of the injured anal sphincter muscle
tissue and improvement of its function using stem cells might
be promising alternative treatment strategy. So far, stem cell
transplantation is mostly an experimental method, studied
mainly in animal models, but there are also studies per-
formed in humans. These studies have confirmed the long-­
term safety of application of mesenchyme and muscle-derived
stem cells in treatment of urinary and fecal incontinence,
perianal fistula repair, and graft material enhancement [67–
72]. Others reported satisfactory results in chronic anal fis-
sure treatment with ADRCs [73] (Figs. 43.5 and 43.6). Fig. 43.6  Injection of adipose-derived regenerative cells into the exter-
According to the results of an experimental model in rats nal anal sphincter
[74], bone marrow-derived mesenchymal stem cell injection
improved muscle regeneration and contractility function of nence in patients with external anal sphincter defects treated
the anal sphincter. Kang [75] reported that autologous muscle-­ with sphincteroplasty. Although the number of patients was
derived stem cells enhanced contractility of the anal sphincter small and follow-up was short, this study showed that injec-
and differentiation of muscle masses at the stem cell injection tion of ADSCs in the anal sphincter during sphincter repair
sites. Recently, randomized double-blind clinical trial was surgery may cause replacement of fibrous tissue with muscle
performed in humans in order to evaluate the efficacy of allo- tissue, which exhibits contractile function [76]. Another ran-
geneic transplantation of ADSCs for relieving fecal inconti- domized, prospective, placebo-controlled trial in humans is
43  Other Surgical Options for Anal Incontinence: From End Stoma to Stem Cell
ongoing in order to assess the safety of adipose-derived
mesenchymal stem cells after the injection into the anal
sphincter. The secondary end point is to compare the efficacy
of ADRCs in patients with fecal incontinence [77].
Another strategy is to harvest stem cells directly from the
striated skeletal muscle and culture them in  vitro into the
myoblasts. The advantage of this procedure is that after
implantation these cells only differentiate into muscle cell
lines, regardless of the type of tissues in the vicinity. Skeletal
muscles have the capability to regenerate (at least partially)
and to repair damage. Special stem cells, called satellite cells,
located among the muscle fibers, became activated in response
to muscle damage and transform into myoblasts, which are
then capable of intense proliferation in order to repair dam-
age. The technology of in vitro myoblast culturing is already
available and is continuously improving. The first study,
involving ten women with obstetric external anal sphincter
disruption treated by injection of adult stem cells, autologous
myoblasts (AM), was published by Frudinger [78]. No
adverse events were observed. At 12  months the Wexner
incontinence score had decreased by a mean of 13.7  units,
anal squeeze pressures were unchanged, and overall quality
of life scores improved by a median of 30 points. Authors
concluded that treatment with autologous myoblasts was safe
and well tolerated and significantly improved symptoms of
anal incontinence due to obstetric anal sphincter trauma.
Recently, first randomized, placebo-­controlled study of intra-
sphincteric injections of autologous myoblasts in 24 patients
with fecal incontinence was published [79]. This was a phase
2, double-blind, placebo-­controlled study where administra-
tion of AM or placebo was performed with eight injections in
the existing residual external anal sphincter under endoanal
ultrasound guidance. At follow-up visits (6 and 12 months),
CCI and FIQL scores, anorectal manometry, perineal electro-
physiological tests, anal ultrasound, and MRI were per-
formed. Myoblast injection resulted in a significant reduction
in CCI scores and improvement in quality of life. The CCI
score at 6 and 12 months decreased from a median of 15 at
baseline to 9 and 6.5, respectively. After 12 months there was
a >30% reduction in the CCI score in 58% of patients in the
AM arm compared with 8% in the placebo arm. Excellent
results obtained in this and two other studies [78, 80] revealed
that the injection of AM in the anal sphincter may become a
standard treatment for FI and may change the treatment para-
digm of fecal incontinence in the near future.
43.11 Anal Plugs
The anal plug is a special intra-anal device that acts as a
physical barrier and prevents fecal leakage, thus enabling
continence. This is a simple and low-cost treatment, capa-
529
ble of reducing fecal incontinence-related problems.
Different types of anal plugs are commercially available.
Plugs are made of different materials (polyurethane, poly-
vinyl alcohol) and come in different designs, shapes, and
sizes. First they were used in patients with fecal inconti-
nence due to major neurological problems, such as spina
bifida. A limited data regarding this procedure exist in the
literature. One prospective, randomized, controlled study
evaluated the use of the anal plugs in children and adults
with fecal incontinence [81]. This study showed that the
majority of patients gained some benefits, reflected in
reduced soiling, and the small but quantifiable improve-
ments in the quality of life. The conclusion of this study
was that anal plug may be a good solution for selected
patients. In a Cochrane review that included four studies
with a total of 136 patients, they found that plugs may be
helpful in alleviating problems caused by incontinence
[82]. However, the available data suggest that anal plugs
can be difficult to tolerate because 48 participants (35%)
were excluded before the end of the study, suggesting poor
compliance. Satisfying results were obtained in 77% of
users that achieved a ≥50% reduction in incontinence fre-
quency [82]. Selection of the type of plug can be very
important for its performance. Intolerance of the device
and failure of retention are the most frequently reported
adverse events. So far, anal plugs can be considered as
relatively efficient, cheap, and acceptable symptomatic
fecal incontinence treatment option in a selected group of
people, either as a substitute for other forms of manage-
ment or as an adjuvant treatment option (Fig. 43.7).
Fig. 43.7  Anal plug
530
43.12 Colostomy
Although fecal diversion is usually the last choice in treat-
ment of severe fecal incontinence, it has a 100% cure rate,
but it is still unknown whether it truly improves QOL in
these patients in whom all previous treatments have failed.
The first study that addressed this issue was published by
Colquhoun [83]. It was a cross-sectional postal survey of
110 patients with fecal incontinence or an end colostomy.
QOL measures used in this study included the Short Form
36 General Quality of Life Assessment (SF-36) and the
Fecal Incontinence Quality of Life (FIQOL) score. Analysis
of the SF-36 revealed higher social function score in the
colostomy group, and analysis of the FIQOL revealed higher
scores in the coping, embarrassment, lifestyle, and depres-
sion scales in the colostomy group compared to the FI
group. The conclusion of this study was that colostomy
improves QOL in patients who suffer moderate-to-severe
fecal incontinence. Finally, colostomy formation has accept-
able complication rate, offers 100% cure with no relapse,
results in better QOL, and may be a good option when all
previous treatments fail. However, creation of a permanent
stoma is a radical option and has a distinctive form of physi-
cal impairment and QOL adjustment. One retrospective
study [84] has examined patients’ views of a colostomy in
fecal incontinence and included 11 males and 58 females
with a median age of 64 years. The majority of patients had
experienced a variety of problems with the stoma, while
only ten patients reported no problems with their stoma. On
the other hand, the majority (83%) felt that the stoma did not
restrict their life, and nearly all felt that the stoma had
improved their quality of life. The overwhelming majority
of patients in this study were positive about the stoma and
the difference it had made to their life. Although the litera-
ture is sparse regarding colostomy in fecal incontinence
treatment, based on available studies, we can conclude that
colostomy may be a viable option in patients with an end-
stage, severe fecal incontinence, where all previous treat-
ment attempts have failed.
43.13 Conclusion
In summary, surgical treatment of fecal incontinence is often
quite challenging. In most cases, the decision regarding sur-
gical procedure depends on severity of anal sphincter injury,
experience of surgical team, and funds, because some proce-
dures are quite expensive. Muscle transposition techniques
still have a role in the treatment of fecal incontinence, but
with a price of high morbidity, complications, wound infec-
tions, high rates of reoperation, and frequently unpredictable
results. Graciloplasty appears to be superior to gluteoplasty,
as it has less donor site morbidity. These techniques should
only be considered in cases with a severely deficient sphinc-
Z. Krivokapić and B. Goran
ter, when a permanent colostomy is the only other viable
alternative. ABS is successful method for treating severe
fecal incontinence, but at the price of a very high complica-
tion rate, frequently leading to subsequent explantation of
the device. Magnetic anal sphincter augmentation may pro-
vide satisfactory outcomes in patients with functioning
device, but Torax Medical announced the discontinuation of
sales of the FENIX® Continence Restoration System.
Promising initial results with different cell therapy options
may change the treatment paradigm of fecal incontinence in
the near future, but further research is needed in this area.
Anal plugs can be considered as a relatively efficient, cheap,
and acceptable symptomatic fecal incontinence treatment
option in a selected group of patients, either as a substitute
for other forms of management or as an adjuvant treatment
option. At the end, colostomy may be a decent option in
patients with an end-stage, severe fecal incontinence, where
all previous treatment attempts have failed.
Take-Home Messages
• Surgical treatment of fecal incontinence is often
complex and should be performed only in special-
ized centers.
• Patients with limited sphincter defects (less than
50% of the circumference) may be offered sphinc-
teroplasty as a first choice.
• Sphincter replacing therapy is indicated in patients
with large sphincter defects or completely destroyed
sphincters but with a price of high morbidity, com-
plications, high rates of reoperation, and frequently
unpredictable results.
• New and under investigation techniques such as
stem cell therapy may change the treatment para-
digm of fecal incontinence in the near future, but
further research is needed.
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 Treatment of Anal Incontinence: Which
Outcome Should We Measure?
Alison J. Hainsworth, Alexis M. P. Schizas,
and Andrew B. Williams
Learning Objectives
• To understand symptom assessment with patient
questionnaires, stool diaries and patient interviews.
• To understand which questionnaires can be used for
assessment of severity, bother of symptoms and
quality of life. To understand the advantages and
drawbacks of difference questionnaires and that a
combination of tools may be required for a thor-
ough and complete evaluation.
• To understand why and when is it also useful to
assess anorectal structure and function.
• To understand why and how to assess outcomes
after treatment for anal incontinence.
44.1 Introduction
Faecal incontinence is a common condition which adversely
affects quality of life and has substantial economic costs
worldwide [1]. Outcome measures may be subjective mea-
surements (i.e. symptom assessment) or objective measure-
ments (i.e. assessment of the structure and function of the
anorectum). The impact of faecal incontinence is dependent
upon patient perception as well as cultural and psychosocial
factors.
Subjective assessment of symptoms includes how symp-
toms have changed following an intervention, impact upon
quality of life and patient satisfaction. This can be achieved
with patient questionnaires (Table  44.1), stool diaries and
patient interviews. Objective assessment of the anorectal
structure and anorectal function includes how measurements
A. J. Hainsworth (*) · A. M. P. Schizas · A. B. Williams
Colorectal Surgery, Guy’s and St Thomas’ Hospital, London, UK
e-mail: allyhainsworth@gmail.com; aschizas@hotmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_44
44
have changed following treatment and the identification of
persistent abnormalities in patients whose symptoms have
failed to improve despite treatment (e.g. a persistent sphinc-
ter defect following attempted surgical repair). This can be
achieved with anorectal physiology, saline or porridge conti-
nence tests or imaging with endoanal ultrasound or MRI.
(Tables 44.2 and 44.3 summarise the outcome measures
which can be used.)
44.2 Symptom Assessment
The underlying pathophysiology of faecal incontinence is
multifactorial and so symptoms alone cannot be used to
determine treatment [2]. However, the assessment of symp-
toms and how they have changed following treatment is an
important indicator of how ‘successful’ any interventions
are. The aim of any intervention should be to reduce severity
of symptoms and improve a patient’s quality of life.
Patient questionnaires aim to assess faecal incontinence
in terms of:
• The severity of symptoms (four main aspects (the fre-
quency and type of incontinence, faecal leakage, faecal
urgency) and reliance upon behaviour such as avoidance
techniques and the use of adjuncts such as pads, plugs and
antidiarrhoeal medications to control symptoms).
• The amount of bother inflicted upon the patient.
• The effects on quality of life (impact on factors such as
self-esteem, confidence, anxiety and depression).
Bowel function diaries can also be used to assess severity.
Qualitative analysis with interview data can be used to assess
patients’ perception, their satisfaction with treatments and
the acceptability of treatments [3].
There may be difficulty in comparing the results from
questionnaires between different populations as the concepts
of faecal incontinence are affected by different cultural and
533
534 A. J. Hainsworth et al.

Table 44.1  The questionnaires which can be used to assess faecal incontinence
Questionnaire Quality of Life
(authors) Type Purpose (QoL) Validation Pros Cons
Symptom severity scores
Pescatori score Self-­assessment Diagnostic tool No Simple to use. Limited to a score
(Pescatori et al.) (frequency to for frequency and Sensitive to of only 6 points.
[57] flatus/mucous, type of anal frequency Does not take
liquid or solid incontinence amount in account
stool)
American Medical Self-­assessment Designed to assess No Includes stool lost, Complex
Systems score [58] (retrospective outcomes after frequency and
review of artificial bowel effect on lifestyle
symptoms over sphincter
past 4 weeks)
Jorge and Wexner Designed to be Diagnostic tool, Yes Valid, responsive, Simple to use, Subtle assessment
Faecal Incontinence filled in by grade severity reproducible [26] easily understood of QoL. Does not
score/Cleveland physicians but by patients [6] include urgency,
Clinic Score (Jorge also used as leakage amount or
and Wexner) [5] self-assessment volume
(type and
frequency, pad
usage, lifestyle
alteration)
St Mark’s faecal Interview-based or Diagnostic tool, Yes Responsive [26], Includes urgency, Subtle assessment
incontinence score/ self-administered grade severity reproducible, high antidiarrhoeal of QoL
Vaizey score questionnaire clinical validity medication
(Vaizey et al.) [6] (about past and utility [6]
4 weeks)
The Revised Faecal Short 5-item For use in No Responsive, Short, reliable
Incontinence Scale assessment tool outcome and reliable
(Sansoni et al.) [9] epidemiological
research and
clinical practice
Faecal Incontinence Self-­assessment Diagnostic tool No Criterion validity, Simple tool to Does not include
Severity Index (weighted scores test-retest assess severity urgency, leakage
(FISI) (Rockwood for four types of reliability and amount or volume
et al.) [10] leakage and five responsiveness to
frequencies) change have been
partly or
adequately
validated [7]
Cancer specific
LARS score Self-­assessment Diagnostic tool No Valid, reliable Simple, quick Correlates to QoL
(Emmersten et al). evaluation
[15]
MSKCC bowel Self-­assessment Diagnostic tool to No Reliable, valid Not routinely used Broad scope
function instrument survey (41 points) prospectively (length and
(Temple et al.) [12] which can be used evaluate scoring influence
via email/paper/by symptoms after its practicality)
interview in the sphincter
phone [16] preserving cancer
surgery
Quality of life scores
The Rockwood Self-­assessment Assessment of Yes Reliable, valid, Does not measure
scale (FIQL) (29 items in 4 QoL specific to responsive [25, leakage. No single
(Rockwood et al.) domains: lifestyle anal incontinence 26] summary measure
[24] behaviour,
depression,
embarrassment)
44  Treatment of Anal Incontinence: Which Outcome Should We Measure? 535

Table 44.1 (continued)
Questionnaire Quality of Life
(authors) Type Purpose (QoL) Validation Pros Cons
Combined severity and quality of life
ICIQ-BS [29, 31] Self-­assessment Assessment of Yes Robust, valid, Assessment of the Does not report on
(17 questions in 3 symptom severity, reliable, severity, the leakage amount or
scored domains: the bother of reasonable bother and volume. More
bowel pattern, symptoms and response to QoL. Can be work needed to
bowel control and QoL changes in applied across assess
quality of life) symptoms and international responsiveness to
QoL following populations change [7]
intervention
Rapid assessment Self-­assessment Rapid assessment Yes Significant Fast assessment of Superficial
faecal incontinence (includes visual of both severity correlation both severity and assessment of
score (RAFIS) (De analogue scale) and QoL between RAFIS QoL both aspects.
La Portilla et al.) and Jorge-Wexner Sensitivity to
[27] score and change in
Rockwood scale. symptoms/QoL
Reliable after treatment
and test-retest has
not been assessed
Visual analogue scores
Visual analogue Self-­assessment Rapid assessment No Not concordant Fast assessment Cannot replace
score severity of severity with other
(Devesa et al.) [33] Jorge-Wexner questionnaires
Visual analogue Self-­assessment Rapid assessment Yes Only correlation Fast assessment Cannot replace
score QoL (Devesa of QoL with Rockwood other
et al.) [33] scale was for questionnaires
embarrassment
subscale

Table 44.2  Possible outcome measures for the treatment of anal incontinence
Outcome measure Assessment tools Importance Limitations
Symptom severity Questionnaires The aim of treatment is to improve – There may be poor correlation between
Bowel diaries symptoms and so these should be symptom severity and quality of life
Patient interviews assessed – As anal incontinence is multifactorial
symptoms may persist despite an
intervention which has solved one
aspect; this will not be apparent on
assessment of symptoms only
Bother Questionnaires The aim of treatment is to improve the – As above
Patient interviews bother of anal incontinence and so this
should be assessed
Quality of life Questionnaires The aim of treatment is to improve – Multiple contributing factors which are
Patient interviews quality of life and so this should be complex to assess
assessed
Patients’ perception Patient interviews Treatments must be acceptable to
and acceptability of patients
treatment
Anal sphincter Anorectal physiology Objective parameters useful to assess – Changes in function may not be
function change for research reflected in patient symptoms
Anal sphincter Endoanal ultrasound Useful in research – Changes in structure may not be
structure MRI Useful in clinical practice if symptoms reflected in patient symptoms
Volume vector manometry have failed to improve despite
treatment or if symptoms deteriorate
despite an initial improvement
536
Table 44.3  A summary of the tools which can be used to measure outcomes after treatment of anal incontinence
Tool Advantages
Questionnaires – Assess the patients’ symptoms, amount of bother
inflicted and quality of life which are the main outcome – Severity may be underestimated by patients due to
measures for any intervention
Bowel diaries – Avoid recall bias for symptom severity
Patient interviews – Allow qualitative assessment (e.g. patient perception
and the acceptability of treatments)
Anorectal physiology – Objective measure of change in anorectal function after – May not correlate with change in symptoms
treatment
Imaging (endoanal – Objective measure of change in anorectal structure after – May not correlate with change in symptoms
ultrasound/MRI) treatment
psychosocial factors [4]. There are also few questionnaires
which are used to evaluate severity and treatment outcomes
that address all four aspects of severity simultaneously.
Moreover, some assess severity of symptoms of anal inconti-
nence and others assess quality of life in relation to anal
incontinence, but few assess both. There have also been
questionnaires designed to assess cancer-specific outcomes
following the surgical treatment of rectal cancer.
44.2.1 Symptom Severity Questionnaires
Table 44.1 summarises the symptom questionnaires which
assess faecal incontinence. The International Consultation
on Incontinence (ICI) has recommended the Jorge-Wexner,
St Mark’s incontinence score and Revised Faecal
Incontinence Scale for use in both research and clinical prac-
tice and the Faecal Incontinence Severity Index (FISI) for
use in research (optional in clinical practice).
44.2.1.1  The Jorge-Wexner Score
The Jorge-Wexner score (also known as the Wexner score or the
Cleveland Clinic Score) may be filled in by physicians or patients
as a self-assessment tool [5]. It is simple to use and easily under-
stood by patients [6]. It is used to grade severity of faecal incon-
tinence and to assess its impact upon lifestyle; it was the first
score to include usage of pads and lifestyle alteration as well as
frequency and severity of episodes. However, it only allows a
subtle assessment of quality of life and does not include urgency,
leakage or volume. The International Consultation on Continence
(ICI) has examined the score and found that construct and crite-
rion validity, internal consistency, test-retest reliability and
responsiveness are partly or adequately validated [7].
A. J. Hainsworth et al.
Disadvantages
– Not all are responsive to change after intervention
avoidance behaviour or recall bias
– Few questionnaires assess all aspects of severity and
quality of life; multiple questionnaires may be required
– Although recommended by some societies, there are few
published examples of those which can be used in clinical
practice
– Time consuming
44.2.1.2  The St Mark’s Incontinence Score
The St Mark’s incontinence score (also known as the Vaizey
score) is widely used to assess severity of anal incontinence
[6]. It combines elements of the Pescatori score, the Wexner
score and the American Medical Systems score with the
addition of questions about urgency and the use of antidiar-
rhoeal medications. (The Pescatori score was one of the first
scores designed to assess anal incontinence and simply diag-
noses the frequency and type of anal incontinence. The
American Medical Systems score was designed to assess
outcomes after an artificial bowel sphincter.)
The St Mark’s incontinence score was developed after cli-
nicians noticed that patients used avoidance behaviour
(remaining close to the toilet) to control their symptoms such
that severity may be underestimated if urgency is not
accounted for. It also reduces the emphasis placed on pad
usage (compared to the Jorge-Wexner score) as pad usage
may simply reflect the fastidiousness of the patient or co-­
existing urinary incontinence rather than anal incontinence
severity. The St Mark’s incontinence score has shown the
greatest change after treatment compared to the Pescatori
score, the Jorge-Wexner and the American Medical Systems
score and is a useful score for comparison of patients and
treatments.
A recent study of 390 patients by the team at St Mark’s hos-
pital compared patients’ subjective perception of bowel control
(scale 0–10) with the St Mark’s incontinence score (a change in
the score was documented in 131 patients who underwent bio-
feedback). The St Mark’s incontinence score correlated moder-
ately well with patients’ subjective perception of their symptoms
and was reliable regardless of type of incontinence, age and
gender. The authors reaffirmed that the St Mark’s score is suit-
able for the evaluation of treatment outcomes [8].
44  Treatment of Anal Incontinence: Which Outcome Should We Measure?
44.2.1.3  The Revised Faecal Incontinence Scale
The Revised Faecal Incontinence Scale was developed to
provide a short, psychometrically sound tool to assess sever-
ity of faecal incontinence before and after treatment [9]. The
authors examined 61 people with faecal incontinence at
baseline and 38 at follow-up and found the score was able to
discriminate between different levels of incontinence
severity, had superior internal consistency and test-retest
­ (score 21–29) and major LARS (score 30–42). It is highly
reliability to the Wexner and St Mark’s scores and was at
least as responsive to detecting a change in incontinence
after treatment as the Wexner and St Mark’s scores.
44.2.1.4  T  he Faecal Incontinence Severity
Index (FISI)
The Faecal Incontinence Severity Index is a diagnostic tool
based on a type x frequency matrix which includes four types
of leakage (gas, mucus, liquid and solid) and five frequencies
(1–3 times per month, once per week, twice per week, once
per day and twice per day). It was developed by surgeons
(who suggested which aspects to include) and patients (who
ranked each aspect) to assess severity of symptoms [10]. It
can be used to assess treatment outcomes in research; for
example, Zutshi used it to assess 10-year outcomes after anal
sphincter repair for faecal incontinence and found that conti-
nence deteriorates in the long term following surgical repair
[11]. Further work is needed for evaluating construct validity
and internal consistency [7].
44.2.2 Symptom Severity Questionnaires
Designed to Assess Outcomes
for Rectal Cancer Treatment
Sphincter preserving surgery for rectal cancer is often possi-
ble, but functional results are not well understood [12], and
many patients suffer with low anterior resection syndrome
(LARS). Questionnaires have been developed to assess symp-
toms and their contributing factors and to consolidate the treat-
ment of LARS and assess treatment outcomes [13]. The LARS
score and MSKCC bowel function instrument (both discussed
below) are suitable for the comprehensive and in-depth assess-
ment of LARS although focused assessment with the Wexner
score, St Mark’s score or FISI may also be used.
Experts recommend that the consistent use of the same
questionnaires in order that different institutions can compare
outcomes and interventions [13]. A systematic review in 2017
found that there is still substantial variation in reporting of
functional outcomes following low anterior resection and a
consensus is still needed to improve and standardise research
into low anterior resection syndrome and its treatment [14].
537
44.2.2.1  T  he Low Anterior Resection Syndrome
Score (LARS Score)
The low anterior resection syndrome (LARS) score has been
specifically developed to assess bowel dysfunction after low
anterior resection and is the most useful tool for rapid assess-
ment. It is a simple tool for quick evaluation, and the results
can be categorised as no LARS (score 0–20), minor LARS
sensitive and specific to ‘major’ LARS [15]. The authors
who developed this questionnaire invited all 1143 low ante-
rior resection patients identified in a national Colorectal
Cancer Database to complete the questionnaire, 961 partici-
pated. There were significant differences in groups with and
without radiotherapy, tumour height above or below 5  cm
and total mesorectal excision/partial mesorectal excision.
The LARS score correlates with quality of life though qual-
ity of life is not assessed by the questionnaire.
44.2.2.2  T  he Memorial Sloan Kettering Cancer
Center (MSKCC) Bowel Function
Instrument
The MSKCC instrument was developed to prospectively
evaluate bowel function following sphincter preserving sur-
gery for rectal cancer [12]. The authors developed a 41-point
bowel function survey after a literature review, expert opin-
ion and patient interviews. They asked 184 patients to com-
plete the survey (70.1% response rate) and found that the
instrument was reliable and valid (radiation, coloanal anasto-
moses and handsewn anastomoses had significantly worse
function).
This bowel function instrument can be used via the web/
email, with paper or on the phone via interview [16]. The
scope of the MSKCC bowel function instrument is broader
than the LARS score as it covers the consequences of the
symptoms as well as their severity reliable and is valid for
assessment of outcomes after rectal cancer surgery. However,
it is not routinely used as it is lengthy and its’ scoring system
(which involves re-coding, three subscale scores, a global
score and a total score) may make it less practical [13].
44.2.3 Diary Monitoring
Symptom questionnaires may be misleading, only provide a
snapshot of bowel habits and fail to reflect day-to-day varia-
tions or the relationship between bowel symptoms and stool
form [17]. Bowel diaries are recordings of bowel habits
which are widely used in diagnostic and interventional stud-
ies [18]. They may be more accurate than interviews or ques-
tionnaires with less recall bias [17, 19, 20]. For example,
538
Manning examined 150 patients and found a discrepancy
between recalled and recorded figures for bowel frequency
of three or more bowel actions per week in 16% of patients
[20]. Diary monitoring provides an objective assessment of
severity if filled out correctly by patients.
Although some societies advocate bowel diaries to
assess bowel dysfunction and guide treatment, there are
few published examples which can be used in clinical
practice. The International Continence Society suggests
the following are included: urgency, flatus and faecal
incontinence (amount, consistency), passive staining/
soiling, pads (changes, degree of soiling), straining/dif-
ficulty/time in the toilet, unsuccessful attempts to defe-
cate, assistive measures (e.g. digital stimulation, manual
evacuation, irrigation, laxative or rectal evacuant use),
diet and fluids (type and/or timing) [18].
Daily stool diaries have been frequently used to assess
outcomes after treatment of faecal incontinence with
sacral nerve stimulation. Improvements in both the num-
ber of episodes of faecal incontinence per week (as
recorded in the diary) and summative symptom scores
(Cleveland score, St Mark’s score) have been seen in both
the short and the long term [21].
44.2.4 Quality of Life Questionnaires
There may be poor correlation between symptom severity
and quality of life [22, 23]. Symptom scores alone do not
allow satisfactory evaluation of the impact of faecal inconti-
nence on quality of life, and therefore both aspects of faecal
incontinence should be assessed [22]. Quality of life can be
assessed using generic scales such as the SF36 questionnaire
or specific scales such as the Rockwood scale.
44.2.4.1  The Rockwood Scale (FIQL)
The Rockwood scale (the Rockwood faecal incontinence
quality of life scale (FIQL)) is a widely used tool to spe-
cifically assess the impact of faecal incontinence on qual-
ity of life [24] (it has also been translated into Spanish)
[25]. It contains 29 different items to form four scales for
the assessment of lifestyle, coping/behaviour, depression/
self-­perception and embarrassment, but there is no single
summary measure. It was suggested by experts and then
proposed to patients for ranking. Psychometric evaluation
has shown that this is a reliable and valid measurement
with significant correlations with the subscales in the
SF-36 [24]. The International Consultation on Continence
recommend its use in research but as an optional tool in
clinical practice [18].
A. J. Hainsworth et al.
44.2.5 The Combined Assessment of Symptom
Severity and Quality of Life
There are different scores to measure the severity of and
impact on quality of life, of faecal incontinence but often not
together, and some authors recommend a combination of
scores to allow thorough assessment [26]. Minguez (who
translated the Rockwood scale into Spanish) compared the
Rockwood scale to the Jorge-Wexner score and found a
strong correlation between the two [25]. They also found that
pad usage is an independent factor which worsens quality of
life scores. Bols examined the Vaizey score (St Mark’s faecal
incontinence score), the Jorge-Wexner score and Rockwood
scale and concluded that although all total scores had ade-
quate to excellent responsiveness and longitudinal construct
validity, there were psychometric limitations for each. They
also found a strong correlation between some items (particu-
larly between embarrassment and coping/behaviour sub-
scales). However, they still suggested a combination of the
Wexner score for severity assessment with the Rockwood
score for quality of life is required to enable a thorough and
complete evaluation [26]. Bordeianou performed a prospec-
tive analysis in 502 consecutive patients to examine the rela-
tionship between the Faecal Incontinence Severity Index
(FISI) and the Rockwood scale and SF-36. There was only
moderate correlation with embarrassment and coping/behav-
iour and no correlation with lifestyle/depression, stressing
the need to measure both variables (severity and quality of
life) to determine the true impact of treatment [23].
44.2.5.1  T  he Rapid Assessment Faecal
Incontinence Score (RAFIS)
The rapid assessment faecal incontinence score (RAFIS) was
developed to quickly assess faecal incontinence in both its
severity and impact upon quality of life. It consists of a visual
analogue scale combined with the frequency of episodes of fae-
cal incontinence within the last month. The authors examined
261 consecutive subjects and found a significant correlation
between RAFIS and the Jorge-Wexner score and the Rockwood
scale. They concluded that RAFIS is a valid and reliable tool to
assess both aspects of faecal incontinence [27] (severity and
quality of life) although only superficially and has not been
routinely adopted for clinical or research practice.
44.2.5.2  ICIQ-BS
The modular international consultation on incontinence
questionnaire for bowel symptoms (ICIQ-BS) has been
developed as a comprehensive, robust, condition-specific
self-completion questionnaire to assess bowel symptoms, the
amount of bother they cause and their impact on quality of
44  Treatment of Anal Incontinence: Which Outcome Should We Measure?
life [28, 29]. It is the top-rated questionnaire for evaluation
of symptoms severity and impact on health-related quality of
life [30]. It can be applied across international populations in
clinical practice and research and enables comparison of
findings from different settings and studies [31]. Online ver-
sions are also psychometrically robust, in men and women,
including Veterans [32]. It shows a reasonable response to
changes in symptoms and quality of life following an inter-
vention [29], but more work is needed in this domain [7].
44.2.6 Visual Analogue Scores
Visual analogue scores have also been developed to assess
the severity of faecal incontinence and its impact upon qual-
ity of life but have not been shown to be a suitable substitute
for other scoring systems. Devesa examined 103 consecutive
patients affected by faecal incontinence to determine if a
single score represented in a visual analogue scale (VAS)
could replace the Jorge-Wexner score and Rockwood faecal
incontinence quality of life scale. A VAS for quality of life
could not substitute all four subscales of the Rockwood
score. A VAS for severity was not concordant with the Jorge-­
Wexner score. The authors concluded that a VAS does not
assess the same issues for severity of symptoms and impact
upon quality of life for faecal incontinence as the Jorge-­
Wexner score and Rockwood scale. The only significant cor-
relation was between the VAS for faecal incontinence and
the embarrassment subscale of the Rockwood scale [33].
44.2.7 Interview Assessment
Interviews can be used for qualitative assessment and to
assess patient acceptability of treatments and patient percep-
tion of their symptoms and how they have changed following
an intervention. For example, Thin performed a randomised
clinical trial of sacral versus percutaneous tibial nerve stimu-
lation in patients with faecal incontinence and qualitative
interview data suggested both treatments had high accept-
ability amongst patients [3].
Symptom severity questionnaires can also be used in an
interview scenario. For example, the St Mark’s score can be
used as both an interview-based and a self-administered
incontinence score [34].
44.3 Anorectal Structure and Function
Patients’ symptoms, the amount of bother experienced by
the symptoms and their impact upon quality of life may be
considered the most important and relevant outcome mea-
539
sures in the treatment of anal incontinence. However, ano-
rectal structure and function are also useful outcome
measures, particularly in the context of therapeutic trials for
faecal incontinence. This is because:
1. Symptom severity may be underestimated by day-to-day
variation in symptoms and patient avoidance of certain
activities to reduce incontinent episodes.
2. The pathophysiology of faecal incontinence is multifacto-
rial, and therefore there may be several contributing fac-
tors towards symptoms which may not all be solved with
a single intervention.
3. Objective parameters may be useful to determine out-
comes in uncontrolled studies.
4. If faecal incontinence initially responds to treatment and
then symptoms deteriorate, there may be failure of treat-
ment or another contributing factor (e.g. recurrent incon-
tinence after sacral nerve stimulation due to device
malfunction) [35].
Tests of anorectal structure and function include anal
manometry, rectal compliance and sensation with either
balloon studies or Barostat, saline continence tests, por-
ridge enema, pudendal nerve terminal motor latency, nee-
dle EMG of the external sphincter, endoanal ultrasound
and endoanal MRI.
Tests of anorectal structure and function in a research
context can help to strengthen the argument for implementa-
tion of certain therapies and ensure treatments are more
widely available. Previously, although biofeedback treat-
ment was known to ameliorate symptoms in patients with
faecal incontinence, it was not known if it also caused an
improvement in anorectal function. Rao examined anorectal
manometry, saline continence tests, prospective stool dia-
ries and bowel satisfaction scores before and after biofeed-
back for faecal incontinence and found a significant
improvement in all parameters in both the short and long
term [36, 37]. The examination of anorectal function as well
as patient symptoms in these studies helped to highlight the
effectiveness of biofeedback therapy for faecal inconti-
nence. Norton performed a randomised control study which
examined conservative treatment in 171 patients. All ver-
sions of conservative treatment (from standard advice to
hospital biofeedback plus a home electromyogram biofeed-
back device) improved continence, quality of life, psycho-
logical well-being and anal sphincter function (measured
with a diary, symptom questionnaire, continence score,
patient’s rating of change, quality of life, hospital anxiety
and depression score and anorectal manometry). The assess-
ment of anorectal manometry showed subjective and objec-
tive improvement in faecal incontinence following all types
of conservative measures.
540
44.3.1 Anorectal Physiology
Anorectal physiology includes anorectal manometry, sen-
sory measurements and neurophysiology.
44.3.1.1  Anorectal Manometry
Anorectal manometry includes conventional anal manome-
try, high-resolution manometry, high-definition manometry,
vector volume manometry and ambulatory manometry.
Anorectal manometry measurements include functional anal
canal length, maximum resting pressure, maximum squeeze
pressure, involuntary squeeze pressure, endurance squeeze
pressure and resting pressures.
Manometry may be useful to evaluate treatment outcomes
[38]. For example, in patients with low anterior resection
syndrome (LARS), there is reduced anal pressure after sur-
gery which can be treated with biofeedback. The level of
incontinence correlates with reduced resting pressure levels
[39, 40], and a recovery in anorectal function can be moni-
tored with anorectal manometry [41]. Improvements in fae-
cal incontinence and quality of life are also associated with a
significant increase in maximal anal resting pressure follow-
ing artificial sphincter reimplantation for faecal incontinence
[42], and some have observed reduced anal pressures in
patients with persistent incontinence despite surgical repair
obstetric anal sphincter injury [43].
However, some have found no association between
improvement of symptoms and anal manometry pressures
following treatment of faecal incontinence. Sorensen
found no correlation between anal pressures and severity
of symptoms after primary obstetric injury repair [44].
Grey examined 85 patients following anal sphincter
repair, and whilst there were significant improvements in
quality of life, there were no changes in anal manometry
[45]. This may be explained by a systematic review of
long-term outcomes after anal sphincter repair for faecal
incontinence which analysed data from 16 studies com-
prising nearly 900 repairs. There was poor correlation
between severity of symptoms and quality of life, and the
authors concluded that despite worsening results over
time, most patients remain satisfied with their sphinctero-
plasty [46]. This may be due to the variety of techniques
used; as more advanced manometric techniques are used
more widely (e.g. high-definition anal manometry) and as
a consensus emerges regarding normal values, changes in
anal manometry may reflect changes in symptoms more
frequently.
44.3.1.2  Sensory Measurements
Sensory measurements are made with rectal balloon distention,
Barostat and rectal impedance studies. Measurements include
rectal sensation (first and urge sensation and maximal tolerated
A. J. Hainsworth et al.
volume) and compliance. Progress after treatment with either
pelvic floor rehabilitation or rectal sensitivity training with bal-
loon distension (the subject is trained to feel the distension and
to tolerate progressively lower or larger volumes depending on
if there is rectal hyper- or hyposensitivity present) can be docu-
mented according to the volumes tolerated. However, although
there may be an improvement in rectal capacity, this may not be
reflected by patients’ symptoms. For example, Terra examined
281 patients and found a moderate improvement in maximal
tolerated volume and severity of faecal incontinence, but only a
few patients had a substantial improvement in the St Mark’s
faecal incontinence score [47]. The authors have done further
work which concludes that additional tests (including anal sen-
sitivity testing, anal manometry and endoanal ultrasound) only
have a limited role in assessing treatment outcomes after pelvic
floor retraining and will not necessarily predict any improve-
ment in symptoms [48].
44.3.1.3  Neurophysiology
Neurophysiology includes EMG (electromyography) and
pudendal nerve terminal motor latency. Measurements
include assessment of activity in the external sphincter and
puborectalis. EMG can be used for strength training during
biofeedback and be used to quantify the reinnervation of the
external anal sphincter by detecting a prolongation in the
motor unit potential [18].
44.3.2 Saline Continence Tests or Porridge
Enema
Following a sphincter repair with defunctioning colostomy or
low anterior resection with a defunctioning loop ileostomy, a
water holding procedure provides a simple examination for
the evaluation of the anal sphincter function prior to stoma
reversal. Saline or another liquid (e.g. porridge) is inserted into
the rectum via a catheter and the patient asked to walk around
with a pad in for 20 min to assess continence [38, 49].
44.3.3 Imaging
44.3.3.1  Endoanal Ultrasound
Endoanal ultrasound may be used pre- and post-surgical
sphincter repair to assess the effect of the operation on the
sphincter defect and to investigate unsatisfactory results after
surgery [50] (Fig. 44.1).
Some have found a good correlation between patient
symptoms and post-operative appearances on endoanal
ultrasound. Felt-Bersma examined 18 patients before
and after anal sphincter repair. There was not only good
correlation between the clinical effect of sphincter repair
and changes on endoanal ultrasound and anal manome-
44  Treatment of Anal Incontinence: Which Outcome Should We Measure? 541

44.4 Future Directions

Questionnaires which incorporate both severity of symptoms

and quality of life should be further developed and routinely
used [57].
A consensus on assessment of low anterior resection syn-
drome and which tool used to assess how patient symptoms
change after treatment is needed.
More work is needed to assess and improve responsive-
ness to change after treatment for symptom questionnaires.
Further work will be done on how changes in anorectal
structure and function relate to patient symptoms.

Take-Home Messages
1. Treatment of anal incontinence may be assessed by
2. It is important to assess outcomes to:
Fig. 44.1  Endoanal ultrasound. A sagittal view of the anal sphincter
complex. The white arrow shows the internal anal sphincter, the dashed
arrow shows the longitudinal muscle and the black arrow the external
sphincter
try, but post-operative persistent incontinence could be
attributed to remaining sphincter defects [51]. Norderval
found improved St Mark’s scores correlated with the
length of the external anal sphincter defect following
primary repair of obstetric anal sphincter tears in 63
women (61 controls) (the integrity of the internal anal
sphincter did not differ) [52]. Sorensen examined 59
women (29 cases after primary obstetric injury repair
and 30 controls) and found that anterior sphincter length
correlated with severity of incontinence (though there
was no correlation between anal pressures and severity
of incontinence) [44].
Endoanal ultrasound can also be used to assess the safety
of new treatments, for example, to ensure that there is no
migration of an artificial bowel sphincter [53] or inter-­
sphincteric bulking agents such as the Gatekeeper™ [54].
44.3.3.2  MRI
MRI is equivalent to endoanal ultrasound for the assessment
of external sphincter defects but not internal sphincter defects
[55]. Research has shown that external anal sphincter atro-
phy following sphincteroplasty (for obstetric injury causing
incontinence) can only be visualised on endoanal MRI but
not ultrasound and that atrophy affects continence post-­
operatively [56]. However, the quality of ultrasound has
improved since this study, and although imaging the sphinc-
ter post-operatively may be useful for research purposes, it is
often not available for routine post-operative assessment in
clinical practice.
subjective or objective outcomes.
–– Check that treatments are successful in the short,
medium and long term.
–– Understand why a treatment has or has not
worked.
–– Allow improvement in treatments.
–– Increase the adoption of treatments by multiple
units.
–– Check patient acceptability of treatments.
3. Subjective outcomes:
Symptoms (severity, bother and quality of life) may
be assessed with patient questionnaires, stool dia-
ries and patient interviews.
Often a combination of questionnaires is
required for the complete evaluation of both symp-
tom severity and impact upon quality of life. The
ICIQ-BS is the only questionnaire at present which
assesses symptoms, quality of life and bother of
symptoms simultaneously.
Patients may use avoidance behaviour which
leads to underestimation by the clinician of symp-
tom severity.
4. Objective outcomes:
Anorectal structure and function may be assessed
with anorectal physiology, saline or porridge conti-
nence tests, endoanal ultrasound and endoanal MRI.
The pathophysiology of anal incontinence is
multifactorial and so the assessment of the anorec-
tal structure and function may explain why symp-
toms are not solved with a single intervention.
Assessment of anorectal structure and function
may explain a recurrence of symptoms despite initial
success (e.g. recurrent incontinence after sacral nerve
stimulation due to device malfunction) and may be
useful to determine outcomes in uncontrolled studies.
542 A. J. Hainsworth et al.

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 Part VI
Pelvic Organ Prolapse
 Epidemiology and Etiology of Pelvic
Organ Prolapse
Stefano Salvatore, Sarah De Bastiani, and Fabio Del Deo
Learning Objectives
• This chapter aims to provide to the reader the actual
knowledge on epidemiological data based on differ-
ent classification systems, different definitions, and
the concomitance of symptoms related to POP with
or without functional disorders.
• This chapter also illustrates the evidence of risk fac-
tors and pathophysiological mechanisms based on
the most recent literature, making the reader aware
regarding all the multifactorial elements related to
POP.
45.1 Definition and Classification
Prolapse (Latin: Prolapsus—“a slipping forth”) refers to a
falling, slipping, or downward displacement of a part or
organ. Pelvic organ refers most commonly to the uterus and/
or the different vaginal compartments and their neighboring
organs such as bladder, rectum, or bowel. Different sites of
female genital prolapse are described according to the organ
involved. The anterior compartment prolapse is character-
ized by herniation of anterior vaginal wall often associated
with descent of the bladder (also called cystocele). Hernia of
the posterior vaginal segment, or posterior compartment pro-
lapse, is often associated with descent of the rectum (or rec-
tocele). Apical compartment prolapse (uterine prolapse,
vaginal vault prolapse) is characterized by the descent of the
S. Salvatore (*) · S. De Bastiani · F. Del Deo
IRCCS San Raffaele Scientific Institute, Milan, Italy
e-mail: stefanosalvatore@hotmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_45
45
apex of the vagina into the lower vagina, to the hymen, or
beyond the vaginal introitus. The apex can be either the
uterus and cervix, cervix alone, or vaginal vault, depending
upon whether the woman has undergone hysterectomy.
Apical prolapse is often associated with enterocele, the her-
niation of the intestines to or through the vaginal wall. The
uterine procidentia is instead, the herniation of all three com-
partments through the vaginal introitus. Division of the
vagina into separate compartments is somewhat arbitrary,
because the vagina is a continuous organ, and prolapse of
one compartment is often associated with prolapse of another
[1]. About 50% of parous women are affected. Prolapse of
pelvic organ (POPs) can cause pelvic, urinary, bowel, and
sexual symptoms [2].
A system of three integrated levels of vaginal support has
been described by DeLancey [3]. All levels of vaginal sup-
port are connected through a continuous endopelvic fascia
support network:
–– Level 1—Uterosacral/cardinal ligament complex, which
suspends the uterus and upper vagina to the sacrum and lat-
eral pelvic side wall. Level 1 support represents vertical
fibers of the paracolpium that are a continuation of the
uterosacral/cardinal ligament complex which inserts vari-
ably into the cervix and vagina. Loss of level 1 support con-
tributes to the prolapse of the uterus and/or vaginal apex.
–– Level 2—Paravaginal attachments along the length of the
vagina to the superior fascia of the levator ani muscle and
the arcus tendineus fascia pelvis (also referred to as the
“white line”). Loss of level 2 support contributes to ante-
rior vaginal wall prolapse (cystocele).
547
548 S. Salvatore et al.

–– Level 3—Perineal body, perineal membrane, and superfi-

cial and deep perineal muscles, which support the distal D
one third of the vagina. Anteriorly, loss of level 3 support
can result in urethral hypermobility. Posteriorly, loss of C
3 cm Ba
level 3 support can result in a distal rectocele or perineal
descent [4, 5].

A second classification system was introduced in 1996, Aa

the Pelvic Organ Prolapse Quantification (POP-Q) system,

and it has become the standard classification system [6]. Bp
The POP-Q system is the POP classification system of Ap
choice of the International Continence Society (ICS), the

tvl
American Urogynecologic Society (AUGS), and the
Society of Gynecologic Surgeons (SGS) [6]. The American gh
pb
College of Obstetricians and Gynecologists has also rec-
ommended its use [7]. It has proven interobserver and
intraobserver reliability [8] and is the system used most POP-Q PROLAPSED
COMPARTMENT SITE ORGAN VAGINAL WALL SITE
commonly in the medical literature [9]. The POP-Q is an
Anterior Aa Urethra Distal anterior vaginal
objective, site-­specific system for describing and staging (urethrocele) wall
POP in women [10]. In the POP-Q system, the topography Ab Bladder Proximal and distal
of the vagina is described using six points (two on the ante- (cystocele) anterior vaginal wall
Middle C Cervix Cervix
rior vaginal wall, two on the superior vagina, and two on D Small bowel Uterosacral scar
the posterior vaginal wall) and several other measurements (enterocele)
Posterior Ap Small bowel Proximal posterior
[10]. Taken together, these measurements can be used to vaginal wall
(enterocele)
produce a sagittal ­diagram of the prolapse and a detailed Bp Rectum Proximal and distal
description of vaginal anatomy. For the purposes of simple (rectocele) posterior vaginal
wall
clinical communication or grouping patients for research Perineal body Perineal body
purposes, an ordinal staging system using the POP-Q mea-
surements was developed:
A simplified version of the POP-Q system, which was
–– Stage 0—No prolapse. developed by an international group of investigators, has
–– Stage I—The requirements for stage 0 are not met, but the been proposed [11, 12]. Like the standard POP-Q examina-
most distal portion of the prolapse is >1 cm distal to the tion, the Simple POPQ (S-POPQ) measures the anterior,
level of the hymenal plane. posterior, and up to two measurements of the apex, including
–– Stage II—The most distal portion of the prolapse is both the cervix and posterior cul-de-sac. The S-POPQ
between ≤1 cm proximal to the hymenal plane and ≥1 cm records the ordinal stage of the four measurements by esti-
distal to the hymenal plane. mating the distances involved.
–– Stage III—The most distal portion of the prolapse is While not recommended by leading societies, the Baden-­
between >1 cm distal to the hymenal plane, but no further Walker Halfway Scoring System is another commonly used
than 2  cm less than the total vaginal length in. In other POP staging system. The degree, or grade, of each prolapsed
words, the maximum prolapse is more than 1 cm outside structure is described individually (e.g., grade 1 anterior
the hymenal plane, but it is 2 cm less than the maximum vaginal wall prolapse or grade 3 uterine prolapse). The
possible protrusion. grade/degree is defined as the extent of prolapse for each
–– Stage IV—Eversion of the total length of the vagina. structure noted on examination while the patient is strain-
45  Epidemiology and Etiology of Pelvic Organ Prolapse
ing. Because there are no clear demarcations among the cut-
off stages, the Baden-Walker system lacks the precision and
reproducibility of the POP-Q system. The system has five
degrees/grades [13].
45.2 Prevalence and Incidence
Pelvic organ prolapse is one of the most frequent disorders
connected with age that makes women visit their gynecolo-
gist. The worldwide prevalence of POP has recently been
reported to be around 9% [14]. If the diagnosis is based on
clinical evaluation, the prevalence ranges from 41% to 56%
as compared to 3–7% when the diagnosis is based on symp-
toms or complaints from women [15, 16]. In a study done in
the United States, the prevalence of POP was lower in
African American women 1.9% as compared to Caucasian
women 2.8% and Hispanic women 5.1% [17]. The differ-
ence in prevalence of POP between Africans residing in the
United States and those living in Africa could be explained
by a comparatively higher number of deliveries, difficult
access to skilled delivery attendance, and heavier physical
workload among African living in sub-Saharan Africa. In the
United States, this problem may affect even 24% of the
women’s population, whereby the percentage depends
mainly on age. Among women between 20 and 39 years of
age, it concerns 10% of the population, whereas it involves
up to 50% of women in their 80s [18]. With regard to the
aging process of the society, this problem will involve a
higher rate of the total women’s population. One estimates
that in 2050 it will concern over 30% of women over 20 years
old [19]. In the United States, the incidence of women sub-
mitted to surgical procedures connected with one of the types
of prolapse is 11.8%, which constitutes the most common
indication for surgical procedure. There are approximately
300,000 POP surgeries each year in the United States [20,
21]. In developed countries, approximately 20% of surgical
procedures among women are carried out due to pelvic organ
prolapse [22–24]. It is also worth mentioning that the prob-
lem is probably more frequent, because only 10% of the
population struggling with pelvic organ prolapse in their
everyday life seeks help from a gynecologist and the major-
ity never ask for it [25]. Population-based studies report an
11–19% lifetime risk in women undergoing surgery for pro-
lapse or incontinence [26, 27].
The exact prevalence of POP is difficult to ascertain, for
several reasons: (1) different classification systems have
been used for diagnosis; (2) studies vary by whether the rate
of prolapse reported is for women who are symptomatic or
asymptomatic; and (3) it is unknown how many women with
549
POP do not seek medical attention. The distinction between
symptomatic and asymptomatic POP is clinically relevant,
since treatment is generally indicated only for women with
symptoms. However, there are few high-quality data regard-
ing the prevalence of symptomatic POP.
Rates of asymptomatic POP are probably even higher.
Several studies have used clinical examination to assess the
prevalence of POP in a community-based setting. One study
included 497 women who were seen in an outpatient clinic
for routine gynecologic care and were assessed using the
Pelvic Organ Prolapse Quantification (POP-Q) system. The
overall distribution of POP-Q system stages was as follows:
stage 0, 6.4%; stage 1, 43.3%; stage 2, 47.7%; and stage 3,
2.6%. No subjects examined had POP-Q system stage 4 pro-
lapse. The distribution of the POP-Q system stages in the
population revealed a bell-shaped curve, with most subjects
having stage 1 or 2 support. Few subjects had either stage 0
(excellent support) or stage 3 (moderate to severe pelvic sup-
port defects) [28].
If we analyze a Sliwa et al. work, we found that the most
frequent pelvic disorder reported in their group of patients
was the defect connected with both cystocele and rectocele.
This may lead to the conclusion that cystocele is the most
common type of dysfunction throughout the whole group of
women with pelvic organ disorders [24]. Similar results were
obtained by Hendrix et al. on a large group where the most
frequently observed disorder was also cystocele [29].
45.3 R
 isk Factors and Pathophysiological
Mechanisms
45.3.1 Ethnicity
Several studies showed that Hispanic and European women
seem to have a higher risk of developing POP compared to
Asian or African women [30–34]. In Zacharin’s cadaveric
study, pubourethral ligaments, endopelvic fascia, and endo-
pelvic attachment to the obturator fascia were reported to be
stronger and thicker in Chinese compared to Caucasian
women [35]. A significantly less pelvic organ mobility in
Asian women was shown also by Dietz et al. using perineal
ultrasound [34]. The reasons for these ethnic discrepancies
are still unclear.
45.3.2 Familiarity and Other Genetic Risk Factors
It is generally recognized that POP has an inheritable predis-
position. In a case-control study, Chiaffarino et  al. showed
550
that the risk of urogenital prolapse was higher in women with
mother or sister reporting this condition: the odds ratios
(ORs) were 3.2 (95% CI 1.1–7.6) and 2.4 (95% CI 1.0–5.6),
respectively, in comparison with women whose mother or sis-
ters reported no prolapse [36]. The reason why some females
with little to no risk factors develop POP while other females
with multiple risk factors do not is clearly that some women
have a genetic predisposition to prolapse. Analyzing young
women with stage III and IV POP, Jack et al. showed that the
risk of prolapse among their siblings was five times higher
than that of the risk for the general population [37]. The
authors concluded that POP has a dominant pattern of inheri-
tance with incomplete penetrance. Buchsbaum et al. found a
high concordance in the POP stage between nulliparous
women and their parous sisters, thus supporting the hypothe-
sis of a familial basis for this condition [38]. Nevertheless,
they highlighted the importance of vaginal delivery that
appeared to confer a risk for more advanced prolapse.
Some genetic variants have been found in families with an
increased incidence of POP. In the genome-wide association
study conducted by Allen-Brady et al., results from associa-
tion analysis identified five single-nucleotide polymorphisms
significantly associated with POP [39]. More recently the
same authors performed a genome-wide linkage analysis
using a resource of high-risk POP pedigrees and results
showed that loci on chromosomes 10q and 17q may predis-
pose to POP development [40].
Further studies investigated the role of specific genetic
polymorphisms in increasing the susceptibility to early onset
of POP, such as polymorphism in the promoter of LAMC1
gene or of COL1A1 gene [41, 42]. Although results were
encouraging, their clinical application cannot be recom-
mended based on current evidence.
Women with genetic disorders of the connective tissue,
such as Marfan or Ehlers-Danlos syndrome, have high rates
of POP [43–47]. It is well-known that the vaginal wall is
composed of connective tissue in its subepithelial layer and
adventitia and also vaginal and uterine supportive tissues are
mainly made of collagen and elastin. Therefore in these
women, the connective tissue disorder may occur also in
terms of pelvic organ descent.
Apart from these genetic diseases, numerous data show
that women with POP have an abnormal pelvic extracellular
matrix metabolism with an increased collagen turnover.
Connective tissue remodeling throughout the body is con-
trolled by matrix metalloproteinases (MMP), a family of
calcium-dependent zinc-containing endopeptidases. An
overexpression of MMP-1 and 2 has been observed in women
with prolapse with a concurrent decrease in their inhibitor
TIMPs [48, 49]. The consequences are an excessive tendency
toward connective tissue degradation and a decrease in the
amount of collagen in pelvic tissue that has been reported
from women with POP.
S. Salvatore et al.
45.3.3 Obstetric Factors
Pelvic floor tissue trauma that occurs during childbirth is
universally considered the main risk factor for developing
POP later in life [50–56]. Pregnancy itself has been widely
accepted as a risk factor for pelvic floor dysfunction. This
association is strongest for stress urinary incontinence
(SUI), whereas for POP it has been less well established. In
the study by O’Boyle et al., all 21 nulliparous nonpregnant
women had a POP-Q stage 0–I, while out of 21 nulliparous
pregnant women, 47.6% had a stage II POP (p  <  0.001)
with POP-Q stage increasing from the first to the third tri-
mester [57].
As confirmed by several studies, a woman’s parity is
strongly associated with her risk of developing POP.  The
Women’s Health Initiative showed that having one childbirth
determined a twofold risk increase for prolapse compared to
nulliparity, and each additional childbirth added a 10–20%
risk increase [32]. Another case-control study found that in
women with a parity of four, the risk for symptomatic POP
was 3.3 times higher compared to those with a parity of one
[53]. In a population-based study by Rortveit et al., authors
found that the risk of prolapse progressively increased from
one to three or more vaginal deliveries [31].
The potential protective effect of caesarean section still
remains controversial. However, nowadays it has been well
demonstrated that elective caesarean section has a protective
role on the pelvic floor, and therefore it may decrease the risk
of developing POP [36, 50–56, 58–60]. Comparing women
who delivered by caesarean section only with vaginal deliv-
eries only, the incidence rate for prolapse surgery was sig-
nificantly lower in the first group, whereas in the vaginal
delivery cohort, it progressively increased reaching its peak
about three decades after first childbirth. This interesting
result was shown in a register-based cohort study [59] in
which authors included 33,167 women having all their preg-
nancies terminated by caesarean section and an age-matched
sample of 63,229 women only having spontaneous births in
the decade 1973–1983. Gyhagen et al. reported that the prev-
alence of POP was not significantly different comparing
women who had undergone emergency or elective caesarean
section [55].
Controversy remains with regard to the risk of developing
POP related to specific obstetrical events and interventions.
Several studies found that instrumental delivery significantly
increase the risk of prolapse when compared with non-­
operative vaginal birth, with no differences between forceps
and vacuum delivery [60, 61]. On the other hand, a case-­
control study observed no significant association between
instrumental delivery, maternal age, length of delivery, and
POP [53]. Similar results were found by Uma et  al. with
regard to forceps delivery, episiotomy, infant birthweight,
and prolonged labor [52].
45  Epidemiology and Etiology of Pelvic Organ Prolapse
45.3.4 Age and Hormonal Status
It is well-known that both incidence and prevalence of
POP increase with increasing age. Through a large cross-
sectional study in menopausal clinics in Italy, members of
Progetto Menopausa Italia Study Group showed that in
comparison with women aged ≤51 years, the OR of uter-
ine prolapse was 1.3 and 1.7, respectively, for women
aged 52–55 and ≥56 years [62]. Similar findings came out
from a cross-­ sectional analysis of American women
enrolled in the Women’s Health Initiative [32]. The life-
time risk of undergoing a single operation for prolapse or
incontinence by age 80 is 11.1% according to Olsen et al.
[63]. This surgery is uncommon in people younger than
30 years.
Although it would seem intuitive that the decrease of
estrogen levels observed with menopause might predispose
to POP, current evidence on this topic is controversial. Some
studies support the role of estrogen in the development of
pelvic floor disorders. In a cross-sectional study by Lara
et  al., postmenopausal women with POP were reported to
have a lower expression of estrogen receptor α on the vaginal
wall and a smaller number of vessels in the lamina propria of
the vagina compared to premenopausal controls [64]. On the
other hand, according to Trutnovsky et al. the pelvic organ
support and levator ani function do not appear to be substan-
tially influenced by hormone deficiency following meno-
pause. The same applies for local or systemic hormone
replacement therapy [65].
45.3.5 Socioeconomic Factors
A low socioeconomic status, intended as low educational
level and yearly income, is a demographic factor associated
with an increased risk of developing POP [66, 67].
Considering the 21,449 non-hysterectomized women around
menopause analyzed by the Progetto Menopausa Italia Study
Group, the OR of uterine prolapse was 0.8 (95% CI 0.7–0.9)
and 0.8 (95% CI 0.6–0.9), respectively, for women with
intermediate or high school/university degree compared to
women with none/primary education [62].
In a review study on prevalence and risk factors for pelvic
floor dysfunction in 16 developing countries, Walker et  al.
observed that the mean prevalence of POP was 19.7% (range
3.4–56.4%) but risk factors were similar to those in industri-
alized countries, particularly increased age and parity. In
low-income countries additional risk factors for pelvic floor
disorders were poor nutrition and heavy work [68].
Jobs involving heavy lifting have been reported to increase
the risk for POP.  In a multicenter cross-sectional study,
Woodman et al. showed that the prevalence of severe POP
was significantly higher among women who were laborers/
551
factory workers compared to other job categories (p < 0.001).
They also showed that an annual household income of
Dollars 10,000 or less was associated with severe POP [67].
According to Chiaffarino et al., housewives had an OR of
urogenital prolapse of 3.1 (95% CI 1.6–8.8) in comparison
with professional/managerial women [36].
45.3.6 General Medical Conditions
Through a chronic increase of the pressure on the pelvic
floor, obesity may be intuitively associated to global pelvic
floor dysfunction and therefore to more severe prolapse [69,
70]. However, this association is not as strong for prolapse as
for stress urinary incontinence [71, 72].
According to Swift et al., the OR for developing POP is
2.51 and 2.56 for overweight and obese women, respec-
tively [30]. Similarly, women with a body mass index of
more than 26 kg/m2 are more likely (OR 3.0 95% CI 1.6–
5.7) to undergo surgery for prolapse compared to those with
a lower value [73].
Kudish et al. evaluated the relationship between change in
weight and POP progression/regression in women during a
5-year period [74]. Analyzing 16,608 postmenopausal
women with an intact uterus, aged 50–79  years, they
observed that the risk of prolapse progression in overweight
and obese women as compared with participants with healthy
BMIs increased by 32% and 48% for cystocele, by 37% and
58% for rectocele, and by 43% and 69% for uterine prolapse,
respectively. The authors also showed that weight loss does
not appear to be significantly associated with regression of
POP, suggesting that damage to the pelvic floor related to
weight gain might be irreversible.
Although not convincingly, chronic obstructive pulmo-
nary disease has been associated with the development of
POP causing increased intra-abdominal pressure during
chronic cough [75].
The same pathophysiological mechanism might be the
basis of an increased risk for prolapse among patients with
chronic constipation implying repetitive straining at stool.
Spence-Jones et al. reported that the presence of this condi-
tion already in the youth was significantly more common in
women who then developed uterovaginal prolapse (61% vs.
4%, p < 0.001) compared with controls [76]. At the time of
consultation, 95% of the women with prolapse were consti-
pated, compared with only 11% of control women. Many of
these women also needed to digitate to achieve rectal
evacuation.
In a recent study, Rogowski et al. showed that the diagno-
sis of metabolic syndrome and the presence of elevated tri-
glycerides increased with the overall POP-Q stage and
therefore they may be associated with the severity of POP in
urogynecological patients [77].
552
45.3.7 Previous Pelvic Surgery
It is widely accepted that hysterectomy increases the risk for
POP, as confirmed by several cross-sectional and retrospec-
tive studies. However, considering that prolapse symptoms
generally develop many years after this procedure, studies
with larger population samples and an adequate long-term
follow-up would be required to determine a definite
association.
The Oxford-Family Planning Association study on over
17,000 women reported that the incidence of prolapse which
required surgical correction following hysterectomy was 3.6
per 1000 person-years of risk [78]. The cumulative risk rises
from 1% 3 years after a hysterectomy to 5% 15 years after
hysterectomy. The risk of prolapse following hysterectomy
is 5.5 times higher (95% CI 3.1–9.7) in women whose initial
hysterectomy was for genital prolapse as opposed to other
reasons.
In a case-control study, Dällenbach et al. determined that
among hysterectomies performed for prolapse, the risk of
undergoing a second prolapse repair was particularly
increased (8.0 times higher) if preoperative prolapse grade 2
or more was present. Other risk factors included previous
POP or urinary incontinence surgery, history of vaginal
delivery, and sexual activity [79].
According to Forsgren et al., having a vaginal hysterec-
tomy for reasons other than POP also significantly increase
the risk of POP and SUI surgery compared to other modes of
hysterectomy [80].
Apart from hysterectomy, previous gynecological surgery
in general or rectopexy for rectal prolapse or retropubic col-
posuspension procedure predisposes to a near 30% risk of
subsequent vaginal vault and posterior vaginal prolapse at
long-term follow-up [73, 81–83].
Take-Home Messages
POP is a common condition with a prevalence
increasing with age but with a great range of reported
data in relation to the anatomical finding with or
without symptoms. Multiple risk factors and patho-
physiological mechanism are involved in the devel-
opment and/or progression of POP.  Some are not
preventable, such as ethnicity, familiar or genetic
factors, and aging. The increasing awareness and
knowledge of other factors such as obstetric, socio-
economic, or the ones related to some medical con-
ditions might be minimized and being an interesting
field for future research.
S. Salvatore et al.
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 Patient-Reported Outcomes and Pelvic
Organ Prolapse
Stavros Athanasiou
Learning Objectives
• The assessment of POP should involve objective
and subjective measures.
• Subjective measurements of POP are the patient-­
reported outcomes (PROs).
• PROs should be used in the day-to-day clinical
practice as they provide a better understanding of
patients’ perceptions regarding their situation and
their thoughts for the therapeutic management.
• PROs should be used in research for the assessment
of therapeutic outcomes and comparison of the var-
ious therapeutic modalities.
46.1 Introduction
Pelvic organ prolapse (POP) is “primarily a definition of
anatomical change” [1]. It refers to a falling, slipping, or
downward displacement of the uterus and/or vaginal com-
partments and neighboring organs such as the bladder, rec-
tum, or bowel [1]. Thus, POP along with urinary incontinence,
voiding dysfunction, fecal incontinence, and defecatory dys-
function belongs in an interrelated group of conditions
named pelvic floor disorders (PFD) [2].
The diagnosis of POP includes clinical evidence of POP
and symptoms related to the “downward displacement” of a
pelvic organ [1]. The clinical evidence of POP is evaluated
using the Pelvic Organ Prolapse Quantification (POP-Q)
System [3]. POP-Q includes four stages (stage 0 to stage IV).
Stages 0 and IV define the absence of POP and the complete
eversion, respectively. Stages I, II, and III define the distance
between the most distal portion of the prolapse from the level
of hymen (≥1 cm above the level of hymen, between 1 cm
S. Athanasiou (*)
National and Kapodistrian University of Athens, Athens, Greece
e-mail: stavros.athanasiou@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_46
46
above and 1 cm below, and ≤1 cm below but at least 2 cm
less than the total vaginal length, respectively).
Clinical evidence of POP does not always correlate with
the presence of POP symptoms, as up to 80% of women may
be asymptomatic [4]. The level of hymen has been estimated
to be an important “cutoff point” for symptom manifestation,
as women with POP below the hymen are more likely to
have bulging symptoms and more PFD symptoms, as well
[2, 5–7]. However, the symptoms of POP are diverse and
often non-condition specific as they may be the result of a
coexisting PFD and not directly attributing to the POP itself.
Thus, it is of importance to acknowledge which symptoms
reflect the POP and which is a coexisting PFD before choos-
ing the best therapeutic approach. Additionally, the latter
allows a thorough patients’ counselling aiming to provide
information of what to expect (i.e., which symptoms may
disappear or persist, etc.) after an intervention. POP in par-
ticular and PFD in general rarely result in severe morbidity
or mortality but can influence negatively women’s quality of
life (QOL) and their daily (physical and social) activities and
sexual function.
Furthermore, management of PFD involves conservative
treatment including vaginal pessaries, behavioral therapy
(such as lifestyle modification, bladder training, etc.), phar-
macotherapy, and surgical interventions. Definition of treat-
ments’ success rates has not been standardized yet. Surgical
interventions aim to restore the anatomical changes to an
optimum or at least satisfactory result. Objective measures
such as “optimal anatomic outcome” (stage 0 according to
the Pelvic Organ Prolapse Quantification (POP-Q) System
[8]) used to define “cure” which was the priority of surgeons
[3]. However, anatomy does not always correlate with the
severity or presence of symptoms. POP symptoms may not
be present in 75% of patients without an optimum postsurgi-
cal anatomic result and in 40% of patients with a satisfactory
one [9]. As a step forward, recommendations of reporting
surgical outcomes suggest evaluation not only of objective
but also of subjective and quality of life measures [10].
555
556 S. Athanasiou

This chapter reviews the currently available patient-­
reported outcome (PRO) measures that can be used by clini-
cians and researchers in patients with POP. Specifically, PROs
assessing pelvic floor symptoms, their effect on patient’s qual-
ity of life and sexual function, and what the patients actually
think and feel for their condition and what they expect from
their therapy will be presented. The aim of this chapter is to
present available evidence of research studies and to provide
an appropriate patient-oriented clinical practice and a repro-
duction of comparable results for the research studies.
46.2 Recommendations for Practice
46.2.1 POP Symptomatology
All symptoms that may be directly or potentially associated
to POP as described by the International Urogynecological
Association (IUGA) and the International Continence
Society (ICS) are presented in Table 46.1 [1]. The most com-
monly described symptoms are the bulge sensation/visual-
ization, feeling of pelvic pressure, bladder storage symptoms
(i.e., frequency, urgency, and nocturia), urinary incontinence
(UI), recurrent UTIs, and incomplete defecation [1]. Other
common symptoms are the low backache, incomplete emp-
tying/urinary retention, slow urine stream, rectal urgency,
digitation/splinting, dyspareunia, and vaginal laxity [1].
The presence of POP symptoms may increase from an
average of 0.5 symptoms in stage I prolapse to 2.1 symptoms
in women with the leading edge of prolapse extending
beyond the level of hymen [11]. However, weak correlations
have been found between prolapse and individual symptoms
[12, 13]. Although bladder, bowel, and sexual symptoms are
more common in women experiencing POP than those with-
out, there is a weak correlation between specific prolapsed
compartments and individual symptoms [13, 14]. The only
symptom that is consistently reported by the patients with
severe POP is the vaginal bulge that can be seen or felt [2].
Furthermore, women with mild prolapse may have stress uri-
nary incontinence (SUI) [15], while those with an advanced
one may experience voiding difficulties due to obstruction,
needing a manual assistance to urine [13]. Nevertheless, in
some cases, SUI may be occult, appearing only after reduc-
tion of prolapse, and a combined prolapse and anti-­
incontinence surgical procedure should be considered [16].
In addition, data regarding the appearance of urgency and
urge incontinence (UUI) in relation to POP stage are in dis-
cordance [13, 15]. Specifically, Romanzi et  al. found that
urgency and UUI may occur in patients with advanced POP
[15], while Burrows et  al. demonstrated that patients with

Table 46.1  Prolapse symptoms as defined by the International Urogynecological Association (IUGA) and the International Continence Society
(ICS) [1]
Prolapse symptoms
Vaginal prolapse symptoms Urinary tract prolapse symptoms Anorectal prolapse symptoms
Vaginal bulging (complaint of a” bulge,” “lump,” Urethral prolapse (complaint of a (a) Anorectal prolapse (complaint of a “bulge” or
or “something coming down” or “falling out”) “lump” at the external urethral “something coming down”)
Pelvic pressure meatus) (b) Rectal prolapse (complaint of external protrusion
Bleeding, discharge, infection of the rectum)
Splinting/digitation
Low backache
Potential prolapse symptoms
Related to lower urinary tract symptoms Related to anorectal dysfunction Related to sexual dysfunction symptoms
symptoms
Hesitancy Constipation Dyspareunia
Slow stream Feeling of incomplete bowel Obstructed intercourse
Intermittency evacuation Vaginal laxity
Straining to void Straining to defecate Libido loss or decrease
Spraying (splitting) of urinary stream Sensation of anorectal blockage
Feeling of incomplete (bladder) emptying Splinting/digitation
Need to immediately re-void Fecal (rectal) urgency
Post-micturition leakage Post-defecatory soiling
Position-dependent micturition
Splinting to micturate
Dysuria
Urinary retention
Urinary frequency
Urgency
Other possible associated symptoms
Urinary incontinence symptoms
Bladder storage symptoms
Bladder sensory symptoms
Lower urinary tract infection
46  Patient-Reported Outcomes and Pelvic Organ Prolapse
less advanced POP are more likely to experience urgency
and UUI than those with an advanced one [13].
All the above indicate that the presence or severity of POP
may not attribute to specific POP symptoms, while POP
symptoms may be experienced by women with adequate pel-
vic support. Therefore, a detailed documentation of the
symptomatology is essential prior to the initiation of any
therapy in order to assess its efficacy.
46.2.2 Patient-Reported Outcome
Questionnaires
The PFD symptoms can be assessed during the clinical inter-
view. However, the clinical interview relies on the physi-
cian’s time and knowledge. Usually, there is not enough time
to review all problems that may affect patients, while clinical
histories do not assess patients’ perception regarding their
condition neither how their quality of life is impaired by their
condition.
Subjective and quality of life measures can be assessed by
psychometrically robust, preferably self-administered ques-
tionnaires known as patient-reported outcomes (PRO). PRO
“is any report of the status of a patient’s health condition that
comes directly from the patient, without interpretation of the
patient’s response by a clinician or anyone else” [11]. They
represent the most important clinical review of patient’s
experience, disease, or set of symptoms. Thus, PROs are
used to assess effectiveness and quality of treatment, as they
evaluate presence and severity of symptoms and their impact
in the everyday life [17, 18].
46.2.3 Selecting PRO Instruments
The choice of which PRO instrument to use should be based
on three steps: (1) seeking its relativity and consistency to
the clinical purpose and objectives of the study, (2) determi-
nation of the length and construct of the questionnaire
because long questionnaires may be difficult to be completed
by the patients, and (3) assessment of the reliability (ability
to reproduce similar results after repeated assessments),
validity (ability to measure of what it is expected to), and
responsiveness of the questionnaire (ability to detect
changes) [2, 19].
The smallest change in PROs that patients perceive as
important defines the minimum clinically important differ-
ence (MCID). The statistically important differences do not
always correlate to what is clinically important. Thus, MCID
helps physicians to interpret the outcome measures and to
decide of whether to continue or modify their management.
In addition, it helps researchers to calculate the sample size
of clinical trials [20]. However, MCID can vary depending
557
Table 46.2  Grade of recommendations according to the International
Consultation on Incontinence [23]
Grade Criteria
A. Highly Valid and reliable and responsive to change on
recommended psychometric testing (published data)
B. Recommended Valid and reliable to change on psychometric
testing (published data)
C. With potential Valid or reliable or responsive to change on
psychometric testing (published data or
abstracts)
on certain factors such as population, culture, the baseline
from which the patients start, etc. [21]. Thus, it should not be
overestimated but applied judiciously to clinical practice or
research [21].
46.2.4 Categories of PROs
PRO measures are divided into two large categories [22]: (1)
Generic measures are multidimensional and have been
designed to attribute to a broad range of populations as they
tend to assess physical, social, and emotional dimensions of
life. However, they may not detect MIDs as they do not focus
on specific effects of the evaluated therapeutic approach.
And (2) condition-specific measures are more specific to a
certain disease or population and thus may be more precise
at evaluating the efficacy of the treatment. Grade of recom-
mendations and their criteria according to the International
Consultation on Incontinence [22, 23] are presented in
Table 46.2.
In addition, PRO questionnaires may be divided into five
other categories: (1) screeners, (2) symptom questionnaires
(measure the presence, intensity, discomfort, and impact of
specific symptoms), (3) quality of life questionnaires, (4)
sexual function questionnaires, and (5) measures of patient’s
satisfaction, expectations, and goal achievements [2, 22].
Some questionnaires may be mixed assessing symptoms,
quality of life, and sexual function of the patients.
46.3 PRO Instruments for POP
Many PRO instruments for POP are used, aiming to cover all
POP symptoms (directly, potentially, or possibly associated
to POP), their impact on patient’s quality of life and sexual
function, as well as patients’ expectations and satisfaction
(Table 46.3, Further Reading). Patients initially may not be
able to recognize issues associated with bladder or bowel or
sexual function. Thus, in research and in clinical practice,
these issues should be acknowledged before proceeding to
therapy and medical counselling.
PROs for POP may be administered by mail in order to be
completed prior the patient’s visit or online or via phone or by
558 S. Athanasiou

Table 46.3  Summary of PRO instruments for POP

Patients’ expectations and
Screeners Symptoms Quality of life Sexual function satisfaction
7-item Q [28] POP-SS [54, 55] HUI-3 [91–95] ICIQ-VS [67] GAS [135–141]
5-item Q [29] 10-cm VAS [56, 57] EQ-D5 [91, 92, 96] Australian Pelvic Floor SAGA [141]
Questionnaire [68]
Single-Q [30] UDI [58–61] SF-36, SF-12, SF-6 [91, ePAQ-PF [69–72] EGGS [138, 143]
93, 94, 97, 98]
POPSSI [31] UDI-6 [62] AAS [98] ICIQ-FLUTS [78] PGI scales (PGI-S, PGI-B,
PGI-I, PGI-C) [144–148]
EPIQ [32] PFDI, PFDI-20 [63–66] ICIQ-VS [67] Golombok Rust Inventory of SSQ-8 [149, 150]
Sexual Satisfaction [115]
B-SAQ [33, 34] POPDI long and short Australian Pelvic Floor BISF-W [116, 117] GPI [61, 151]
form [63, 65] Questionnaire [68]
ICISI [35–37] ICIQ-VS [67] ePAQ-PF [69–72] CSFQ, CSFQ-14 [118, 119] PSQ [151]
MESA [38] Australian Pelvic Floor ICIQ-FLUTS [78] FSFI [120, 121] EPI [151]
Questionnaire [68]
3IQ [39] ePAQ-PF [69–72] OAB-q [81–83] MSFQ [122] PPTBQ [130, 152]
OAB-V8/OAB BBUS-Q [73, 74] PFIQ, PFIQ-7 [60, 63–66, SPEQ [108, 123–126] PPBC [153, 154]
Awareness Tool ISI [75] 84, 91, 99]
[40, 41]
PUF [42, 43] BLUTS [76, 77] P-QOL [100–104] PISQ, PISQ-12 [127–131] BSW [130, 155]
BPIC-SS [44] ICIQ-FLUTS [78] IIQ, IIQ-7 [63, 99, PISQ-IR [132, 133] SATMED-Q [156, 157]
105–107]
QUID [45–47] ICIQ-UI SF [79, 80] I-QOL [108–110] BIPOP [134] TSQM [158, 159]
3 questions [48] QUID [45–47] KHQ [111, 112] OAB-S [160, 161]
SFQ [49, 50] OAB-q [81–83] ICIQ-LUTSqol [111]
SFQ28 [49–51] CRADI [63, 84] FIQL [113, 114]
SFQ15 [49, 50] ICIQ-B [85]
HSDD [52] Wexner [86, 87]
B-PFSF [53] RAFIS [88]
FISI [89]
Cleveland Clinic
Incontinence Score [90]
AAS Activities Assessment Scale, BBUS-Q Birmingham Bowel and Urinary Symptoms Questionnaire, BFLUTS Bristol Female Lower Urinary
Tract Symptoms Questionnaire, BIPOP Body Image in the Pelvic Organ Prolapse Questionnaire, BISF-W Brief Index of Sexual Functioning for
Women, B-PFSF Brief Profile of Female Sexual Function, BPIC-SS Bladder Pain/Interstitial Cystitis Symptom Score, B-SAQ Bladder Control
Self-Assessment Questionnaires, BSW Benefit, Satisfaction, and Willingness, CRADI Colorectal-Anal Distress Inventory, CSFQ Changes in
Sexual Functioning Questionnaire, EGGS Expectations, Goal Setting, Goal Achievement, and Satisfaction, ePAQ-PF Electronic Personal
Assessment Questionnaire-Pelvic Floor, EPIQ Epidemiology of Prolapse and Incontinence Questionnaire, FIQL Fecal Incontinence Quality of
Life Scale, FISI Fecal Incontinence Severity Index, FSFI Female Sexual Function Index, GAS Goal Attainment Scaling, HSDD hypoactive sexual
desire disorder, HUI Health Utilities Index Mark, ICIQ-FLUTS International Consultation Modular Questionnaire-Female Lower Urinary Tract
Symptoms, ICIQ-LUTSqol ICIQ-Lower Urinary Tract Symptoms quality of life, ICIQ-UI SF ICIQ-Urinary Incontinence Short Form, ICIQ-VS
International Consultation on Incontinence Questionnaire-Vaginal Symptoms, ICSI Interstitial Cystitis Symptom Index, 3IQ 3-Incontinence
Questionnaire, IIQ Incontinence Impact Questionnaire, I-QOL Incontinence Quality of Life Questionnaire, ISI Incontinence Severity Index, KHQ
King’s Health Questionnaire, MESA Medical, Epidemiological, and Social Aspects of Aging Questionnaire, MSFQ McCoy Female Sexuality
Questionnaire, OAB-S OAB-Satisfaction, OAB-V8/OAB overactive bladder, OAB-q Overactive Bladder Questionnaire, PFDI Pelvic Floor Distress
Inventory, PFIQ Pelvic Floor Impact Questionnaire, PGI scales Patient Global Impression scales, PISQ Pelvic Organ Prolapse/Urinary Incontinence
Sexual Function Questionnaire, PISQ-IR PISQ-International Urogynecological Association Revised, POPDI Pelvic Organ Prolapse Distress
Inventory, POP-SS Pelvic Organ Prolapse Symptom Score, POPSSI Pelvic Organ Prolapse Simple Screening Inventory, PPTBQ Patient Perception
of Treatment Benefit Questionnaire, P-QOL Prolapse Quality of Life Questionnaire, PUF pelvic pain and urgency/frequency, Q Questionnaire,
QUID Questionnaire for Urinary Incontinence Diagnosis, RAFIS Rapid Assessment Fecal Incontinence Score, SAGA Self-Assessment Goal
Achievement, SATMED-Q Treatment Satisfaction with Medicines Questionnaire, SFQ Sexual Function Questionnaire, SPEQ Short Personal
Experiences Questionnaire, SSQ-8 Surgical Satisfaction Questionnaire, TSQM Treatment Satisfaction Questionnaire for Medication, UDI
Urogenital Distress Inventory, VAS Visual Analogue Scale.

a member of the medical team or self-administered in the
healthcare setting. The method of administration will affect
both the response rate and the accuracy of the response. Self-­
administered questionnaires are the most robust and accurate
for assessing patients’ perspectives as they are not affected by
an inter-observer variability. Computerized questionnaires
were also suggested and were found to be comparable to paper
questionnaires in reliability and validity with superior response
rates, efficiency, and economic advantages [24–27]. In addi-
tion, patients may find them easier and more enjoyable to
46  Patient-Reported Outcomes and Pelvic Organ Prolapse
complete [27] provided they have technological skills. When
patients are elderly, as many POP patients, such skills are
doubtful resulting in no completion of the questionnaires or
needing help from outer observers that may introduce biases.
All PROs for POP are presented in Table 46.3 [28–161]
and extensively reviewed in Further Reading. Below, some
PROs for POP, as well as considerations and tips for their
selection and interpretation, will be discussed.
46.3.1 Screeners
The beginning of screeners in POP lies in 1989 when WHO
conducted a meeting to establish specific questions about
chronic obstetric comorbidities [28]. Seven questions were
chosen that could identify 80–90% of moderate to severe
prolapses. Since then many screening tools have been devel-
oped [28]. Screeners may be used to detect patients who
might have POP or PFD before a clinical examination.
Nevertheless, they should not be misinterpreted as diagnostic
tools even when cutoff scores have been determined. They
usually include few and specific-oriented questions (i.e.,
“feeling or seeing a bulge in vagina?” etc.). Responsiveness
of screeners has not been assessed. However, sensitivity and
specificity are extremely important for their interpretation
[22]. Sensitivity provides information regarding how likely a
patient with a certain condition is to score positive in screen-
ers, while specificity is how likely a patient without a certain
condition is to score negative [22].
46.3.2 Symptom Questionnaires
Symptom questionnaires aim to assess the presence, severity,
and bothering of particular POP symptoms or groups of POP
symptoms. Ideally, they should be valid, reliable, and respon-
sive, with the MCID being of importance especially for the
studies assessing surgical strategies. Questionnaires with a
wide coverage of POP symptoms are preferable, but when
specific symptoms are indicative (such as UI), specific condi-
tion questionnaires may be used. Nevertheless, before decid-
ing which or how many questionnaires to use, it should be
kept in mind that the goal is to obtain accurate answers from
the patients without making it difficult or confusing for them.
In addition, the administration of longer questionnaires may
result in more missing data than the short ones. Usually for
research studies, many features have to be evaluated; thus the
long ones may be more appropriate, whereas for the everyday
clinical practice, the short ones are considered more user-
friendly. Furthermore, the most frequently used PROs are not
always the most reliable ones [22]. Another aspect that should
be considered before deciding which questionnaire to use is
the recall period that allows factors to affect patients’ mem-
559
ory. Thus, recall bias may be introduced [22]. Furthermore,
parts or certain questions from PROs should not be used alone
or in modification or changing the order or content because
the psychometric properties may alter, and the scoring is
invalidated [22]. If someone wishes to modify, a validated
questionnaire should perform a new validation. In addition,
some questionnaires are considered companion to others (i.e.,
PROs evaluating symptoms with PROs evaluating QoL and
PROs evaluating sexual function). The advantage of compan-
ion questionnaires is that they add the one to another without
duplicating questions.
Urogenital Distress Inventory (UDI-6), Pelvic Floor
Distress Inventory-20 (PFDI-20, respectively), and Pelvic
Organ Prolapse Distress Inventory long and short form
(POPDI and POPDI-6, respectively) are PROs for POP with
Grade A recommendation and wide coverage of symptoms
[22, 23]. The International Consultation on Incontinence
Modular Questionnaire on Female Lower Urinary Tract
Symptoms (ICIQ-FLUTS) and ICIQ-UI SF, as well as the
Colorectal-Anal Distress Inventory long and short form
(CRADI and CRADI-8, respectively), are Grade A PROs
focusing on LUTS and bowel function, respectively [22, 23].
PFDI-20 is the synthesis of the UDI-6, POPDI-6, and
CRADI-8. It has been derived from the PFDI (its long form
that consists of 46 questions) a questionnaire designed spe-
cifically for women with POP.  PFDI-20 is the most com-
monly used questionnaire in studies assessing therapies
(surgical or conservatives) for POP as it includes urinary,
colorectal, and POP scales and is reliable, valid, and respon-
sive to change. Its flexibility due to the wide coverage of
symptoms allows the postsurgical evaluation of POP inter-
ventions with subgroup comparisons of POP women with
and without UI or with and without bowel dysfunction. This
is of importance because postsurgical complications (i.e., de
novo appearance of UI) can be assessed, while modifications
of certain types of surgical techniques may be introduced
when POP coexist with UI or bowel dysfunction.
Furthermore, its recall period of 3  months is considered
appropriate for the recollection of symptoms and events [63,
65]. UDI-6, POPDI-6, and CRADI-8 they all can be used
separately because they have been validated and designed to
be used individually. However, their synthesis forbids possi-
ble duplication of concepts or items, offers less patient bur-
den, and takes less time to be administered.
46.3.3 Quality of Life Questionnaires or
Health-Related Quality of Life
Questionnaires
“Quality of Life is defined as an individual’s perception of
their position in life in the context of the culture and value
systems in which they live in relation to their goals,
560
expectations, standards and concerns” [162]. “Health-
Related Quality of Life (HRQOL) is defined as an indi-
vidual’s or a group’s perceived physical and mental health
over time” [163].
Usually, QoL or HRQOL is evaluated with multi-item
questionnaires aiming to assess various aspects of patients’
life such as sleep, energy, physical health, emotions, work
life, sex life, and social life. The terms QoL questionnaires or
HRQoL questionnaires are used interchangeably in the lit-
erature. However, the QoL questionnaires include domains
such as personal safety, community connectedness, and
future security that usually are not found in HRQoL ques-
tionnaires, although these domains may be affected by ill-
nesses [164]. HRQoL measures a broad description of
self-perceived health status using functioning and well-being
and not of QoL as it is widely known [164].
QoL or HRQoL questionnaires may be interpreted differ-
ently by the patients depending on their personality, social
and economic status, psychology, etc. In addition, individual
symptoms have distinct impact on QoL. For example, women
with POP may stop participating in physical or social activi-
ties, while women with UI, even though still participating in
such activities, usually declare less satisfied than they used to
before the condition occurred [7]. In addition, improvements
of objective measurements following a POP surgery do not
always reflect improvements in the patients QoL. Thus, QoL
questionnaires are important outcomes for urogynecological
interventions.
As mentioned above PROs assessing QoL or HRQoL
are divided into two categories, the generic and condition
specific. The condition-specific PROs are preferable, as
they allow to estimate the impact of the specific condition
in patient’s life and to address changes following an
intervention.
Short Form Survey (SF) long and short form (SF-36 and
SF-12, respectively), Pelvic Floor Impact Questionnaire
long and short form (PFIQ and PFIQ-7, respectively),
Incontinence Impact Questionnaire long and short form (IIQ
and IIQ-7, respectively), King’s Health Questionnaire, and
International Consultation on Incontinence Questionnaire-­
Lower Urinary Tract Symptoms quality of life (ICIQ-­
LUTSqol) are the most commonly used HRQOL with Grade
A level of recommendation [22, 23]. The SF is a generic
questionnaire that measures concepts such as physical and
social functioning, role limitations due to physical or emo-
tional problems, bodily pain, vitality, and mental health and
general health perception. The SF short form is frequently
used as a gold standard for health-related QoL question-
naires [165, 166]. However, apart from its social functioning
scale, it is not responsive to change in women with POP
undergoing surgery.
PFIQ is prolapse specific with excellent validity, reliabil-
ity, and responsiveness that assesses the impact of urinary,
prolapse, and bowel function in the everyday life of women
S. Athanasiou
with POP [63–66]. Thus, it can be used by researchers and
clinicians. It encompasses the Incontinence Impact
Questionnaire (IIQ), the Pelvic Organ Prolapse Impact
Questionnaire (POPIQ), and the Colorectal-Anal Impact
Questionnaire (CRAIQ) [63–66]. It has a 3-month recall
period that is considered appropriate to recollection of symp-
toms’ impact in the quality of life [63, 65]. The PFIQ-7
includes the IIQ-7, POPIQ-7, and CRAIQ-7 and is a com-
panion questionnaire to the PFDI-20 [22]. PFIQ-7 and PFDI-­
20 have been translated and validated in many languages
reproducing its reliability and validity [165–171].
Moreover, many mixed questionnaires have been devel-
oped aiming to offer evaluation of symptom bothering and
simultaneously how this bothering interfere with the
patient’s everyday life. Such questionnaires are the follow-
ing: the Australian Pelvic Floor Questionnaire, Electronic
Personal Assessment Questionnaire-Pelvic Floor (ePAQ-
PF), ICIQ-VS, ICIQ-FLUTS, and Overactive Bladder
Questionnaire (OAB-q) are mixed questionnaires. The
Australian Pelvic Floor Questionnaire and the ePAQ-PF also
include a sexual function domain, while ePAQ-PF is the only
electronic prolapse specific questionnaire. Moreover,
ICIQ-VS and ICIQ-FLUTS include a 10-cm VAS for the
determination of patients’ QoL. However, VAS for measur-
ing HRQOL in POP patients has not found to be valid [91].
46.3.4 Sexual Function
Female sexuality is complex, as various aspects, such as psy-
chological, social, and physiological, are involved. Therefore,
female sexual dysfunction (FSD) is difficult to diagnose.
However, it is very important to be identified and treated
appropriately, for establishing women’s well-being and qual-
ity of life. Two systems are considered “sanctioned with
international fluence” for the definition of sexual dysfunc-
tion the ICD-10 and DSM-5 [172]. The combination of these
two produced the ICD-11 which is currently in the process of
modification. The ICD-10 includes sexual dysfunction not
caused by an organic disorder or disease, while DSM-5
includes the female sexual interest/arousal disorder, female
orgasmic disorder, and genito-pelvic pain/penetration disor-
der [172]. These systems are not familiar to gynecologists,
and screening for FSD in women with PFDs is not consis-
tently performed [173].
However, 50–60% of women with PFD are sexually
active [13, 174]. Data regarding the presence of dyspareu-
nia, decreased orgasmic capacity, and libido in women with
POP are controversial. Studies have demonstrated that
symptomatic POP and UI increase the risk of FSD (due to
reduced sexual arousal, infrequent orgasm, and dyspareu-
nia) while UI women are more likely to avoid sexual inti-
macy due to their fear of urine leakage [123, 129]. In
addition, the negative impact of POP in sexual functioning
46  Patient-Reported Outcomes and Pelvic Organ Prolapse
may be improved or remained unchanged following a PFD
surgery [175]. Nevertheless, measures of sexual function
have been found to be similar between women with and
those without POP [129]. Moreover, FSD was found to be
related to the presence of POP and not the grade of POP and
can be explained only partly by the presence of POP [176].
Other factors such as aging/menopause or problems with the
partner may be involved.
As sexuality is a multi-complex issue, it is essential for
the gynecologists to screen and accurately evaluate the pres-
ence of FSD in POP patients taking into account all sexuality
aspects in order to provide a better patient counselling. The
PROs evaluating women’s sexuality and its deviations may
help them identify the problem without embarrassing neither
the gynecologist nor the patients. PROs for sexual function,
as PROs for quality of life, are divided into two large catego-
ries: the generic and the condition specific.
The Golombok Rust Inventory of Sexual Satisfaction and
the Brief Index of Sexual Functioning for Women are generic
questionnaires with Grade A level of recommendation [22,
23]. Condition-specific questionnaires with Grade A level of
recommendation are not available. However, the most com-
monly used condition-specific PROs for sexual function in
women with POP are the Pelvic Organ Prolapse/Urinary
Incontinence Sexual Function Questionnaire short form
(PISQ-12), with a Grade B level of recommendation, and the
Female Sexual Function Index (FSFI) with a Grade C level
[22, 23]. In particular, the PISQ-12 is a companion question-
naire to the PFDI-20 and the PFIQ-7 [127–131]. It was
designed to evaluate the sexual function of heterosexual
women with POP or UI. It is a valid, reliable, and responsive
to change questionnaire. However, it cannot assess the part-
ner perception of POP and cannot identify the post-surgery-­
specific negative effects on sexual function. Recently, IUGA
revised PISQ-12 to PISQ-IR aiming to attribute in both sexu-
ally and nonsexually active women [132, 133]. PISQ-IR cor-
relates with PFDI-20 and FSFI [132, 133].
FSFI, although with Grade C level of recommendation, is
often used in the assessment of POP patients, especially
when undergoing surgical approaches. It may detect patients
with hypoactive sexual desire disorder (HSDD), female
orgasmic disorder (FOD), and female sexual arousal disor-
der (FSAD) [120]. It has also a particular threshold discrimi-
nating patients with from those without FSD [121]. Thus, it
may help clinicians and researchers understand whether POP
or another factor contributes to the FSD and identify sexual
problems arising de novo postsurgical.
46.3.5 Patients’ Expectations and Satisfaction
PROs for patients’ expectations and satisfactions have been
developed to evaluate directly the patients’ perceptions
regarding the effectiveness of their therapy and whether their
561
therapeutic goal has been fulfilled. Patient’s perceptions of
outcomes associated with urogynecologic health are greatly
influenced by their personal beliefs about their condition and
their understanding of the availability of various treatments.
Patients’ expectations and satisfaction are two separate sub-
jective instruments. Specifically, patients’ expectations may
be positive (goals) or negative (fears) [177]. Important goals
prior to POP surgery are symptom release and improved life-
style (including physical capabilities and improved sexual
life), while the most important fears are de novo symptoms,
POP recurrence, and surgical complications [177]. However,
goals are not always in alignment within what reasonably
expected in terms of efficacy. For example, disagreement
between the patients’ goals and the objectively demonstrated
success of the surgical procedure may cause patient’s dis-
satisfaction. Thus, it is of great importance for the clinicians
during the pretreatment counselling to identify and under-
stand what the patient regard as the main problem and what
they actually expect as a feedback from their therapy in order
to suggest the optimum therapy for them.
The Goal Attainment Scaling (GAS) is the oldest PRO that
is widely used in the medicine aiming to identify the therapeu-
tically goals of each patient. In urogynecology it can be used
to evaluate treatment outcomes following surgery for PFD
[139, 140]. The Goal Attainment Scaling (GAS) is a PRO
evaluating the extent to which patient’s individual goals are
met by thepeutic interventions. (1) It augments information
received from standardized outcomes. A disadvantage of stan-
dardized outcomes is that patients answer questions that are
not adjusted for the individual or a particular situation. In con-
trast, GAS is specifically tailored for individuals and evaluates
only what is important to the patient. (2) Patients’ expectations
are central for GAS, providing all the information needed for
the physician to know what is regarded as treatment benefit to
the patients. Thus, unrealistic goals may be separated from the
realistic ones, and physicians can explain to the patients what
their treatment can actually achieve. In this way, patients may
understand that their goals are unrealistic and determine new
ones, more realistic, while physicians may select an alternative
therapeutic option instead of their initial plan. (3) It may be
used in clinical trials. Its individualized approach may be over-
come using a summary score of all goals of patients utilizing
standardized z-based scoring.
Disadvantages of GAS may include [178] the following:
(1) risk of bias at setting goals because physicians may lead
the patients to easy achievable goals; (2) success depends on
physician to select appropriate goals and accurately predict
outcomes, while observable changes may not correspond to
the pre-defined outcomes; (3) it’s time-consuming, espe-
cially the initial step; (4) difficulties performing double-
blind trials; and (5) unresolved statistical issues regarding
the calculation of the summary score. Thus, some research-
ers suggest being a complementary outcome and not a pri-
mary one [179].
562
Patients’ satisfaction is achieved when the results of the
therapeutic interventions are in alignment with patients’
expectations. As an outcome measure, patients’ satisfaction
allows healthcare providers to assess the appropriateness of
treatment according to patients’ expectations. Patients’ sat-
isfaction is a complicated issue because various aspects
such as treatment’s efficacy, side effects, accessibility, and
convenience, availability of resources, continuity of care,
cost, availability of information on the disease, information
giving, pleasantness of surroundings, and facilities may
play an important role, on patients’ thoughts leading them
to over- or underestimate the therapeutic results. The
assessment of patients’ satisfaction has many advantages
[22]: (1) may be the only distinguishing outcome between
treatments in chronic diseases, where realistic objective is
not the cure but living with the treatments, (2) may be the
distinguishing outcome for therapies with the same mecha-
nism of actions, (3) has better sensitivity to changes than
QoL PROs, and (4) helps in defining MIDs for other types
of PROs.
Patient Global Impression (PGI) scales are valid and reli-
able measures for patients’ satisfaction. Specifically, the
PGI-Improvement (PGI-I) is a single-question PRO, respon-
sive to change, that can be used to evaluate the satisfaction of
patients following a pelvic floor surgery. Moreover, all
patient-centered outcomes are combined in Expectations,
Goal Setting, Goal Achievement, and Satisfaction (EGGS)
PRO [138]. Specifically, EGGS has been suggested to
become the fourth dimension for the assessment of PFD
along with the physical findings, symptoms, and QoL out-
comes [143].
46.4 Future Directions
As we move to a more patient-centered approach, PROs
provide a better understanding of what is mostly important
to the patients. Taking into account patients’ expectations,
goals, and satisfaction with the treatments, clinicians have
an enhanced understanding of the needs and treatment
results of the patients. They also help to organize a thera-
peutic plan better catered to the individual needs of the
patient. On the curator side, PROs help clinicians to com-
municate better with the patients and facilitate sharing clin-
ical information and outcomes between researchers. There
is ongoing research on the field, and hence guidelines on
the use of specific PROs are not available. Recommendations
exist and should be applied on the everyday clinical prac-
tice and in clinical studies but are in an ever-changing pro-
cess due to the continuous research on the field. New
studies regarding the use, application, and content of PROs
are always in need in the modern approach to the patient
with POP.
S. Athanasiou
Take-Home Messages
• Patient-reported outcomes (PROs) are objective
measures for subjective phenomenon such as symp-
tom presence and bothering, quality of life, sexual
function, and patients’ expectations and
satisfactions.
• Before deciding which PRO to use, validity, reli-
ability, responsiveness, and interpretability should
be taken into account.
• PROs are of critical value for the everyday clinical
practice as they help physicians decide the best
therapeutic option for each patient individually and
perform a better patient counselling.
• PROs are also of critical value for the research stud-
ies as “treatment’s success rates” have not been
standardized and the optimum anatomic result does
not correspond to the patients’ satisfaction or per-
ception of symptom presence. In addition, they pro-
vide comparable results for evaluating therapeutic
approaches especially the surgical reconstructive
procedures.
Further Reading
Screeners
 etection of Patients with POP Symptoms
D
Before a Clinical Examination
A 7-item questionnaire by the World Health Organization
(WHO) [28]: In 1989 WHO conducted a meeting to develop
specific questions about chronic obstetric morbidities. Thus,
seven questions were selected for POP that could identify
80–90% of moderate to severe prolapses. These questions
were the following:
• “Do you feel anything coming out of your vagina?”
• “Do you have pain or difficulty in urinating?”
• “Is it uncomfortable down below?”
• “Do you have a feeling of heaviness?”
• “Do you feel any swelling down below when you urinate
or move your bowels?”
• “Do you need to manipulate it to urinate or defecate?”
• “Do you have any difficulty with intercourse?”
Short form questionnaire of five items for genital pro-
lapse [29]: It has 92.5% sensitivity with 94.5% specificity
when POP was confirmed and 66.5% sensitivity with 94.2%
46  Patient-Reported Outcomes and Pelvic Organ Prolapse
specificity when objective signs of prolapse in clinical exam-
ination were not present.
Single-question screening [30]: The question is: “Do
you usually have a bulge or something falling out that you
can see or feel in your vaginal area?” Affirmative answer to
this question has 96% sensitivity and 79% specificity for
prolapse beyond the level of hymen.
Pelvic Organ Prolapse Simple Screening Inventory
(POPSSI) [31]: It is based on Pelvic Floor Disorder Inventory
(PFDI) and includes the following four questions:
• “Urinary incontinence following laughing, sneezing or
coughing?”
• “Urinary urgency?”
• “Feeling pain during defecation?”
• “Feeling or seeing bulge in vagina?”
• In the general population, POPSSI has 45.5% sensitivity
and 87.4% specificity.
Epidemiology of Prolapse and Incontinence
Questionnaire (EPIQ) [32]: It is a validated screener that
may detect women at high risk to develop PFD (POP, SUI,
OAB, and anal incontinence). Its positive and negative pre-
dictive value for POP is 76% and 97%, respectively, while
for SUI 88% and 87%, respectively, for OAB 77% and 90%,
respectively, and for AI 61% and 91%, respectively.
Detection of Patients with LUTS
Bladder Control Self-Assessment Questionnaires
(B-SAQ) [33, 34]: It has been developed to identify patients
with general LUTS and not solely symptoms of specific con-
dition. Thus, it assesses presence and bothering of urgency,
frequency, nocturia, and incontinence. Bothering scoring has
a range between 0 (not at all) and 3 (a great deal). The final
score is calculated by the sum of scoring of each symptom. It
is quick and easy to complete, with 98% sensitivity and 79%
specificity for bothersome LUTS.
Interstitial Cystitis Symptom Index (ICSI) [35–37]: It
includes four questions assessing the severity of day-time
frequency, nocturia, urgency, and bladder pain over the past
month. Severity scoring ranges from 0 to 20. A score of 0–6,
7–14, and 15–20 are indicative for mild, moderate, and
severe symptoms, respectively. It has a good test-retest reli-
ability, internal consistency, validity, and responsiveness. It
may be used to distinguish which patients should be further
examined for interstitial cystitis, as it has not a sufficient
specificity to be used as a diagnostic tool.
Medical, Epidemiological, and Social Aspects of Aging
Questionnaire (MESA) [38]: It includes 15 questions with
four possible answers: “rare,” “rarely,” “sometimes,” and
“often,” applying to “0,” “1,” “2,” and “3” scoring, respec-
563
tively. Questions 1–9 are targeted to stress urinary inconti-
nence (SUI) with a maximum total score of 27, while
questions 10–15 to urge incontinence with a maximum total
score of 18 (UUI). However, data regarding its sensitivity
and specificity are not available.
3-Incontinence Questionnaire (3IQ) [39]: It has been
designed to distinguish patients with SUI and UUI. It includes
three questions, with the first one being “During the last 3
months, have you leaked urine (even a small amount)?”
Affirmative answer leads to the other two questions. The type
of UI is defined based on the third question. The classification
of UUI has a 75% sensitivity and 77% specificity, while the
classification of SUI has 86% sensitivity and 60% specificity.
However, due to low specificities the 3IQ should not be used
as a diagnostic tool, as many as 23% and 40% of women may
be treated inappropriately for UUI and SUI, respectively.
OAB-V8/OAB Awareness Tool [40, 41]: It includes eight
questions, based on OAB Questionnaire (OAB-q), involving
frequency, nocturia, urgency, and UUI with bothering scores
ranging from 0 to 5. A score greater of 8 may indicate pres-
ence of bothersome OAB symptoms. It has a 98% sensitivity
and an 82.7% specificity. However, OAB-V8 in comparison
to B-SAQ is worst in detecting SUI symptoms.
Pelvic Pain and Urgency/Frequency (PUF) [42, 43]: It
includes eight questions addressing to frequency, nocturia,
symptoms related to sexual intercourse, and pain in the blad-
der or the pelvis. Each answer may receive a score from 0 to
4. A cutoff score ≥13 has been found to provide the best
sensitivity-specificity ratio for PUF.  The sum of scores
defines the total score. It correlates directly with the likeli-
hood of the intravesical positive potassium results that have
been estimated in about 80% of patients with bladder pain
syndrome and interstitial cystitis. However, it should not be
used as a diagnostic tool. In addition, it has been designed by
clinicians without patient input. It includes medical terms
that may not be adequately comprehended by the patients.
Thus, its validity as a PRO instrument is questionable.
Bladder Pain/Interstitial Cystitis Symptom Score
(BPIC-SS) [44]: It is an eight-item questionnaire designed to
select BPS/IC patients for clinical trials. A cutoff score ≥19
has a 72% sensitivity and 86% specificity for clinical trial
inclusion. However, it should not be used as a diagnostic tool.
Questionnaire for Urinary Incontinence Diagnosis
(QUID) [45–47]: It may distinguish accurately patients with
SUI or UUI with only six questions, and it is considered as one
of the few available questionnaires that may add to office diagno-
sis of UI type. Each item may receive scores from 0 to 5. Items
1–3 and 4–6 correspond to stress and urge score, respectively.
Thus, the minimum and maximum scores for both stress and
urge are 0 and 15, respectively. The diagnosis of SUI or UUI is
proposed when stress score is ≥4 or urge score ≥6, respectively.
Its sensitivity and specificity for SUI are 85% and 71%, respec-
tively. For UUI both sensitivity and specificity are 79%.
564 S. Athanasiou

Detection of Patients with Sexual Dysfunction Visual Analogue Scale [56, 57]: It is a valid, repeatable,
single-item continuous scale, usually with a length from 0 to
Three questions [48]: The following specific questions have 10 cm, that assesses bothering of each POP symptom using a
been found to be as effective as detailed interview: sliding indicator. The highest the score, the more intense are
the symptoms. Initially, it was validated for the assessment
• “Are you sexually active?” of quality of life in urogynecologic research. Lately, an asso-
• “Are there any problems?” ciation between VAS and POP grade on clinical and ultra-
• “Do you have any pain with intercourse?” sound examination was found. However, studies performing
comparisons between VAS and other standard validated POP
Sexual Function Questionnaire (SFQ) [49, 50]: It con- questionnaires, or studies evaluating its sensitivity to change
sists of 34 questions detecting the presence or absence of following therapeutic interventions, currently are not avail-
hypoactive sexual desire disorder (HSDD), female sexual able. Additionally, MID has not yet been determined.
arousal disorder (FSAD), female orgasmic disorder (FOD), Urogenital Distress Inventory (UDI) (Grade B) [58–
and dyspareunia. It has an excellent internal consistency and 61]: It is a reliable, valid, and sensitive 19-item questionnaire
validity (discriminant and longitudinal) and moderate to including irritative symptoms, obstructive/discomfort symp-
good reliability. toms, and stress symptoms. Answers assess the presence of
Sexual Function Questionnaire 28 [49–51]: It includes symptoms and the degree of bother on a four-point scale
six domains and 28 questions for recognition of HSDD, (“not at all,” “a little bit,” “moderately,” and “greatly” apply-
FSAD, FOD, dyspareunia, enjoyment, and partner issues ing to 0, 1, 2, and 3, respectively). Initially, it was designed
using a five-point Likert scale. It has a good test-retest reli- to assess women with UI but has also been used for the
ability and validity and excellent internal consistency. A cut- assessment of lower urinary tract function in women with
off score of 5 determines the arousal cognitive domain. POP. However, the validity in women with UI without uro-
Sexual Function Questionnaire 15 [49, 50]: It includes dynamic diagnosis is questionable. MID for the UDI and
four domains and 15 questions for recognition of HSDD, UDI-stress, in women with stress-predominant UI, is consid-
FSAD, FOD, and dyspareunia using a five-point Likert scale. ered reasonable at −11 and −8 points, respectively. MID for
HSDD [52]: It is a four-item questionnaire with a five-­ the UDI and UDI-irritative, in women with urge-­predominant
point Likert scale designed to detect presence or absence of UI, is −35 and −15, respectively.
HSDD. Urogenital Distress Inventory-6 (UDI-6) (Grade A)
Brief Profile of Female Sexual Function (B-PFSF) [62]: It is the short form of UDI.  It has a high correlation
[53]: It is a seven-item instrument based on the Profile of with the long form, but it is patient friendlier as it includes
Female Sexual Function and Personal Distress Scale. Each only six questions. The total score is calculated using the fol-
item has a six-point Likert scale (“always” to “never”). Sum lowing algorithm: sum of scores/6  ×  25. As with the long
of scores results in a final score ranging from 0 to 35. A cut- form, UDI-6 has a questionable validity for women with UI
off score ≤20 defines the presence of HSDD with 97% sen- without a urodynamic diagnosis.
sitivity and 96% specificity. Pelvic Floor Distress Inventory (PFDI) (Grade B) [63]:
It is based on two validated questionnaires the UDI and the
Incontinence Impact Questionnaire (IIQ) and assesses symp-
Symptom Questionnaires tom distress in women with PFD.  Overall it includes 52
items (19, 17, and 16 for UDI, Colorectal-Anal Distress
PROs with Wide Coverage of POP Symptoms Inventory (CRADI), and Pelvic Organ Prolapse Distress
Inventory (POPDI), respectively). It is reliable, valid, and
Pelvic Organ Prolapse Symptom Score (POP-SS) [54, condition-specific. However, it is time-consuming as it takes
55]: It is a seven-item questionnaire that patients report how an average of 23 min to be completed. It may be used to pre-
often they experience POP symptoms. Possible answers dict the outcome of pelvic reconstructive surgery [64]. In
apply to a five-point Likert scale: “never,” “occasionally,” particular, a cutoff value of 62/300 pre-surgery, in women
“sometimes,” “most of the time,” and “all the time” receiving with pelvic organ prolapse that was repaired with synthetic
scores of 0, 1, 2, 3, and 4, respectively. Thus, the total score mesh, may predict a failure to improve quality of life at 36
ranges from 0 to 28. It has a good internal consistency, con- months post-surgery. The positive predictive value and spec-
struct validity, and sensitivity to change. In particular, it was ificity of the latter cutoff value were 83.6% and 62.1%,
able to detect changes when surgical or pelvic floor muscle respectively.
training (PFMT) was applied, with a different magnitude of PFDI-20 (Grade A) [63]: It is the short-form of PFDI
changes depending on intervention. An MID of 1.5 has been with 20 items and three scales (UDI-6, POPDI-6, and
considered to correspond better to patients’ satisfaction. CRADI-8). It is reliable and responsive to change and has an
46  Patient-Reported Outcomes and Pelvic Organ Prolapse
excellent correlation with the long form of PFDI. Total score
is calculated by adding the scores of the three scales with a
possible range from 0 to 300. Each scale item could receive
values from 0 to 4 applying to a score ranging from 0 to
100  for each scale. The higher the score, the more intense
are  the symptoms. A change of ≥45 points (15%) was
­determined as MID. PFDI-20 correlates well with the PFDI
[66]. Additionally, PFDI-20 can be converted using a certain
formula to PFDI [66].
Pelvic Organ Prolapse Distress Inventory (POPDI)
long and short form (Grade A) [63, 65]: It is a specific
condition questionnaire and has been included in PFDI. Its
short version has six questions and it is part of PFDI-20: “Do
you usually experience pressure in the lower abdomen?”,
“Do you usually experience heaviness or dullness in the pel-
vic area?”, “Do you usually have a bulge or something fall-
ing out that you can see or feel in your vaginal area?”, “Do
you ever have to push on the vagina or around the rectum to
have or complete a bowel movement?”, “Do you usually
­experience a feeling of incomplete bladder emptying?”, and
“Do you ever have to push up on a bulge in the vaginal area
with your fingers to start or complete urination?”. Negative
answers receive 0 score, while affirmative ones’ score ranges
from 1 to 4 depending on degree of bothering. Each scale
score ranges from 0 to 100.
International Consultation on Incontinence
Questionnaire-Vaginal Symptoms (ICIQ-VS) (Grade C)
[67]: It is a valid, reliable, consistent, and responsive
PRO. Initially it included 27 items for vaginal symptoms (14
items and 13 subquestions (corresponding to the degree of
bother)), sexual matters (ten items and nine subquestions
corresponding to the degree of bother)), and quality of life
(one item). Responses of vaginal symptoms and sexual mat-
ters have 4–5 points, while the quality of life question and
the subsequent questions of vaginal symptom and sexual
matters a 10 VAS. The short form includes 14 items corre-
sponding to the evaluation of vaginal symptoms, sexual mat-
ters, and quality of life. Vaginal symptoms and sexual matters
are calculated separately using specific algorithms.
Australian Pelvic Floor Questionnaire [68]: It is a
reproducible and valid questionnaire with a wide coverage,
as it assesses presence, bothering, and impact on quality of
life of all pelvic floor symptoms (bladder, bowel, and sexual
function) and prolapse symptoms. It has 42 items and four
sections (bladder, bowel, prolapse, and sexual function cor-
responding to questions 1–15, 16–27, 28–32, and 33–42,
respectively). Scores are calculated separately for each sec-
tion giving values from 0 to 10 for each section. Thus, the
maximum global dysfunction score is 40. The bladder,
bowel, prolapse, and sexual function domains correlate with
the UDI-6, established bowel questionnaire, International
Continence Society Prolapse Quantification, and McCoy
Female Sexuality Questionnaire, respectively.
565
Electronic Personal Assessment Questionnaire-Pelvic
Floor (ePAQ-PF) [69–72]: It is reliable, valid, and web-­
based questionnaire consisting of urinary (12 questions),
bowel (20 questions), vaginal (11 questions), and sexual (15
questions) domains. All domains evaluate quality of patients’
life. Moreover, urinary domain assesses pain, overactive
bladder and SUI, bowel domain constipation, evacuation,
and incontinence, while vaginal domain sensation and pro-
lapse. Sexual domain includes aspects of urinary, bowel, and
vaginal symptoms in relation to sex. The time for its comple-
tion has been estimated between 12–103  min providing
medians of 26 and 33 for the “non-interactive” version and
primary care, respectively. Additionally, its responsiveness
to change has been indicated in the relative domains of pro-
lapse and quality of life, in women undergoing POP surgery.
The electronic over paper administration of PROs is consid-
ered to offer many advantages. However, patients should
have technological skills, but the vast majority of POP
patients are elderly, and such skills are doubtful.
Birmingham Bowel and Urinary Symptoms
Questionnaire (BBUS-Q) (Grade B) [73, 74]: It is a valid,
reliable, and responsive, 22-item questionnaire assessing
constipation (Q1 and 2), evacuation (Q7–13 and 15), incon-
tinence (Q3–6), and urinary symptoms (Q16–22). Question
14 is not encompassed in any domain. Responses apply to a
four-level scale, while scores range from 0 to 100 for each
domain. Cutoff scores to define abnormal domains are
≥64%, ≥17%, ≥17%, and ≥20%, for constipation, evacua-
tion, incontinence, and urinary symptoms score,
respectively.
PROs Focusing on LUTS
Incontinence Severity Index (ISI) [75]: It is a valid, reli-
able, sensitive measure with only two questions (“how often
do you experience urine leakage” and “how much urine do
you lose each time”). The total score is calculated by multi-
plying the score of the first question (from 0 to 4) by the
score of the second question (from 1 to 2). It can be used in
routine clinical practice.
Bristol Female Lower Urinary Tract Symptoms
Questionnaire (BFLUTS) [76, 77]: It is a valid and reliable
questionnaire that includes 6 domains involving frequency,
voiding, incontinence, sex, and quality of life with scores
ranging from 0 to 15, 0 to 12, 0 to 20, 0 to 6, and 0 to 18,
respectively. However, it has been found that women may
score higher on self-completion than interview [65].
International Consultation on Incontinence Modular
Questionnaire-Female Lower Urinary Tract Symptoms
(ICIQ-FLUTS) (Grade A) [78]: It is the short form of
BLUTS. It is a valid, reliable, and responsive, 12-item ques-
tionnaire evaluating nocturia, urgency, bladder pain, fre-
566
quency, hesitancy, straining, intermittency, UI (urge, stress,
and unexplained), frequency of urinary incontinence, and
nocturnal enuresis. Filling, voiding, and incontinence symp-
tom subscales range from 0 to 15, 0 to 12, and 0 to 20,
respectively. Additionally, it evaluates impact of individual
symptoms with bothering scales that are not incorporated in
the overall scores.
ICIQ-UI SF (Grade A) [79, 80]: It is a valid, reliable,
responsive questionnaire with four items, including fre-
quency, prevalence and cause of UI, and impact on everyday
life. The cause of UI is not included in the total score calcula-
tion. The total score ranges from 0 to 21. The recommended
MIDs for women undergoing surgery due to SUI are −5 and
−4 at 12 and 24 months postoperatively, respectively.
Questionnaire for Urinary Incontinence Diagnosis
(QUID) [45–47]: It is a valid, reliable, and responsive to
change with 6-item UI symptom questionnaire. It may dis-
tinguish accurately the type of UI and may be offered as a
screener, as presented above. It correlates strongly with the
UDI as it assesses symptoms’ intensity and bothering. In
addition, it may detect differences following a non-surgical
intervention. Thus, it may be used in research as UI outcome
measure of clinical trials.
Overactive Bladder Questionnaire (OAB-q) [81–83]: It
is a valid, reliable, and responsive symptom bother and qual-
ity of life questionnaire attributable in both continent and
incontinent patients. Initially, 62 items (13 symptom items, 4
general, and 44 health-related quality of life (HRQL)) were
included, while a reduction to 33 items (8 symptom items
and 25 HRQL) was performed in order to become user-­
friendlier and more accurate. It includes scales of symptom
bother (frequency, nocturia, urgency, and urge incontinence),
coping, concern/worry, sleep, social interaction, and
HRQL.  Each question corresponds to a six-point Likert
scale, from “none of the time” to “all the time,” applying to
1–6, respectively. The total score for each domain ranges
from 0 to 100, with MID recommended at ≥10 points. In
addition, two versions of 4- and 1-week recall period with
similar factor structures are available.
PROs Focusing on Bowel Function
Colorectal-Anal Distress Inventory (CRADI) long and
short (CRADI-8) form (Grade A) [63, 84]: The long form
has 17 items and is included in the PFDI, while CRADI-8
has eight items and is included in the PFDI-20. However,
they can be used apart from the PFDI and PFDI-20 as inde-
pendent questionnaires for women with fecal incontinence.
MIDs for the long and short form are 11 and 5, respectively.
International Continence Consultation-Bowels
(ICIQ-B) [85]: It is a valid, reliable, and responsive 35-item
questionnaire (25 symptom items and 10 HRQL items). It
S. Athanasiou
has three scored domains involving bowel pattern, bowel
control, and quality of life with scores ranging from 1 to 21,
0 to 28, and 0 to 26, respectively. Additionally, it includes
four unscored items for the assessment of clinical or patient
perspective.
Wexner Scores (Grade C) [86, 87]: It is a scoring system
for both fecal incontinence and constipation. The inconti-
nence score ranges from 0 to 20, while the constipation score
from 0 to 30 with values >15 defining constipation’s pres-
ence. Zero defines absence of symptoms while 20 and 30
severe ones.
Rapid Assessment Fecal Incontinence Score (RAFIS)
[88]: It is a valid and reliable two-item tool for assessing
fecal incontinence. The total score ranges from 0 to 20.
Fecal Incontinence Severity Index (FISI) [89]: It
includes four items involving incontinence to gas, mucus,
liquid stool, and solid stool with scores ranging from 0 to 12,
0 to 12, 0 to 19, and 0 to 18, respectively.
Cleveland Clinic Fecal Incontinence Score [90]: It is a
five-item questionnaire assessing leakage of solid, liquid,
and gas, the use of pads, and the lifestyle restriction.
Responses apply to “never,” “rarely,” “sometimes,” “usu-
ally,” and “always.”
Quality of Life Questionnaires
Generic Questionnaires
Health Utilities Index (HUI)-3 [91–95]: It includes eight
attributes (vision, hearing, speech, ambulation, dexterity,
emotion, cognition, and pain) with five or six levels. The
scoring attribute to morbidity scale is from 0.00 (worst level)
to 1.00 (best level). It can receive negative scores represent-
ing health states worse than death. Difference in mean HUI
total score ≥0.03 has been suggested as MID.  It is a valid
tool of HRQOL in women with POP or other PFDs (i.e., UI).
EuroQol (EQ-5D) [91, 92, 96]: It includes five attributes
(mobility, self-care, usual activities, pain/discomfort, and
pain) with five or six levels. The score of EQ-5D ranges from
−0.59 to 1.00. Difference in utility score of 0.03 has been
suggested as MID. It is a valid measure of HRQOL in women
with POP and UI (urge, stress, and mixed).
Sort Form Survey (Grade A) [91, 93, 94, 97, 98]: It has
various versions including 36 (SF-36), 12 (SF-12), and 6
(SF-6) items. SF-36 measures eight concepts: physical and
social functioning, role limitations due to physical or emo-
tional problems, bodily pain, vitality, mental health (psycho-
logical distress and well-being), and general health
perception. The number of response levels varies between 4
and 21, depending on domain. The MID for the physical
functioning scale is 2 and 3 points for functioning scores <40
and >40, respectively. SF-12 also includes eight concepts,
46  Patient-Reported Outcomes and Pelvic Organ Prolapse 567

while SF-6 is derived from SF-12 with six concepts (physical study evaluating these long forms of PFIQ in women under-
and social functioning, role limitation, pain, mental health going pelvic floor reconstructive surgery (PFR) or receiving
and vitality). SF-6 is scored on a scale from 0.29 to 1.00, andvaginal pessary resulted in different MIDs in the respective
each of the six attributes has five or six levels of responses.subscales depending on type of intervention. In particular,
In addition, SF-6, as with HUI-3 and EQ-5D, is valid and MID for POPIQ is −40 to −27 and −29 for PFR and vaginal
reliable for women with POP or UI of any type, with MID of pessary, respectively. MID for CRAIQ is −34 to −6 and −29
0.03. for PFR and vaginal pessary, respectively.
Activities Assessment Scale (AAS) [98]: It is a valid, Prolapse Quality of Life Questionnaire (P-QOL) [100–
reliable, and responsive measure for the assessment of physi- 104]: It is a simple, valid, and reliable measurement that
cal activities following vaginal reconstructive surgery for includes nine domains (general health perceptions; prolapse
POP and SUI. It includes 13 items for the evaluation of the impact; role; physical, social, and personal limitations; emo-
ability regarding lying in bed, sitting, getting in or out of bed
tions; sleep/energy; and severity measures) with responses
or chair, reaching or stretching, lifting 3–5 pounds, walking having a four-point scoring system. This scoring attributes to
around inside, climbing up or down stairs, walking outside how much the POP symptoms are affecting women’s life
or at work, engaging in sedentary activities (i.e., typing, talk-
ranging from “none/not at all” to “a lot.” Each domain ranges
ing on the phone, playing cards, watching TV), engaging in from 0 to 100. Higher score indicates greater negative impact
light physical activities (i.e., cooking, dusting, clerical work,
on women’s life. Thus, it is a reliable and valid tool for the
visiting friends), engaging in moderate physical activities recognition of women who need a therapeutic intervention,
(i.e., sweeping, washing the car, dancing, playing golf, hik- as symptom severity and their impact on quality of women’s
ing), engaging in vigorous physical activities (i.e., construc-life can be defined. Additionally, P-QOL has been used in
tion work, shoveling, playing tennis or basketball, weight surgical studies, detecting significant improvement of the
lifting), and engaging in sexual intercourse. Responses may quality of life of women undergoing a pelvic reconstructive
receive scores from 1 “no difficulty” to 6 “did not do it for surgery, such as vaginal mesh implantation. In particular,
other reasons.” The total score is calculated using a transfor-MID difference was met in all domains. Nevertheless, the
mation algorithm to produce a range from 0 to 100. Higher latter MID was defined only by a statistical model using the
total score indicates greater physical functioning. “half standard deviation,” as studies with the recommended
methods for determining MID have not been published [94].
Incontinence Impact Questionnaire long (IIQ) and
Condition Specific short form (IIQ-7) (Grade A) [63, 99, 105–107]: The long
form includes 30 items with 4 subscales (physical activity,
Pelvic Floor Impact Questionnaire (PFIQ) long and short travel, social relationships, and emotional health) and a pos-
form (PFIQ-7) (Grade A) [60, 63–66, 84, 91, 99]: It is a sible score of 0–400. Mild, moderate, and severe levels of UI
valid, reliable, and responsive measurement assessing the are defined when IIQ is <50, 50–70, and >70, respectively. In
impact in HRQOL of related, possibly related, and poten- addition, MID for women undergoing continence surgery or
tially related POP symptoms. The short form correlates well PFR or receiving vaginal pessary is −28 to −14 or −37 to
with the long one, while a conversion formula from the short −31 or −17, respectively [88]. IIQ-7 consists of seven ques-
to the long form, with an excellent goodness of fit, has been tions and a possible score of 0–100. Good, moderate, and
published. The long form includes three domains poor QoL is indicated when IIQ-7 is <50, 50–70, and >70,
(Incontinence Impact Questionnaire (IIQ), Pelvic Organ respectively.
Prolapse Impact Questionnaire (POPIQ), and Colorectal-­ Incontinence Quality of Life Questionnaire (I-QOL)
Anal Impact Questionnaire (CRAIQ)) with 93 items (31 [108–110]: It is a valid and reproducible measure of UI that
items in each domain). The PFIQ-7 includes three domains is more closely related to overall well-being of patients than
(IIQ-7, POPIQ-7, and CRAIQ-7) with 21 items (seven items bodily pain. Initially, it was designed for use in clinical trials
in each domain). The total score of PFIQ-7 ranges from 0 to and in-patient care centers. It has 22 items with three sub-
300 (each domain may receive scores from 0 to 100). A scales (avoidance and limiting behavior, psychosocial
change of ≥36 points (12%) has been suggested as MID for impact, and social embarrassment). MID for patients with
PFIQ-7. In addition, the generic questionnaires of HUI-3, SUI has been proposed to be 2.5 and 6.3 points for between
EQ-5D, and SF-6D correlated significantly but moderately and within treatment, respectively. MID for patients with
with the prolapse subscale of PFIQ-7. The long and short neurogenic bladder ranges from 4 to 11 points.
forms of IIQ, POPIQ, and CRAIQ can also be used individu- King’s Health Questionnaire (KHQ) (Grade A) [101,
ally from the PFDI long and short form, respectively. MID 102]: It is a valid, reliable, and responsive measure of UI
for IIQ has been estimated at −16 points. MID for CRAIQ regardless of type. It has three sections: (1) general health
long and short form is −18 and −8, respectively. However, a and overall health related to urinary symptoms with two
568
questions; (2) incontinence impact, role limitations, physical
limitations, social limitations, personal limitations, emo-
tions, sleep and energy, and severity coping measures with
19 questions; and (3) bother or impact of urinary symptoms
with 11 questions. MID is indicative when change from
baseline to posttreatment is ≥5 in each domain.
International Consultation on Incontinence
Questionnaire-Lower Urinary Tract Symptoms quality
of life (ICIQ-LUTSqol) (Grade A) [111, 112]: It is a valid,
reliable, and responsive measurement that has been derived
from KHQ, with 22 items. The total score of all items ranges
from 0 to 76, and the overall impact on everyday life sub-
scale from 0 to 10 that is not incorporated in the overall
score. The MID has been suggested to be 3.71.
Fecal Incontinence Quality of Life Scale (FIQL)
(Grade B) [113, 114]: It includes 29 items with four scales
(lifestyle, coping/behavior, depression/self-perception, and
embarrassment). It may distinguish patients with fecal incon-
tinence from patients with other gastrointestinal problems.
Additionally, it has significant correlations with the SF-36
subscales. However, limitations have been found, and
­suggestions for revisions have been made. In particular, there
is a lack of contrast validity, a highest reliability in patients
with low QoL, and a minimal differential functioning. Thus,
it has been suggested formatting, scoring, and instructions to
be simplified, items with higher difficulty to be developed,
and embarrassment domain to be revised. Furthermore, it has
not been tested in asymptomatic controls. Thus, its capability
as a screening tool is unknown.
Sexual Function
Generic PROs
Golombok Rust Inventory of sexual satisfaction (Grade
A) [115]: It is a valid, reliable, and responsive measure that
has 56 items (28 for women and 28 for men) for the assess-
ment of heterosexual couples’ sexual relationship and indi-
vidual’s functioning, as well. It includes 12 domains that are
divided in five domains for women (anorgasmia, vaginismus,
avoidance, nonsexuality, and dissatisfaction), five for men,
and two non-gender oriented (frequency of sexual contact
and non-communication).
Brief Index of Sexual Functioning for Women
(BISF-W) (Grade A) [116, 117]: It includes 22 items ini-
tially covering levels of sexual functioning (interest/desire
and sexual activity) and satisfaction suitable for both clinical
and nonclinical samples. However, a new scoring algorithm
was created for clinical trial use, encompassing seven domains
(thought/desire, arousal, frequency of sexual activity, recep-
tivity/initiation, relationship satisfaction, pleasure/orgasm,
and problems affecting sexual function). This scoring was
compared between normative and surgically menopausal
S. Athanasiou
women, and it was able to quantify the nature and degree of
impaired sexual function in surgically menopausal women.
Changes in Sexual Functioning Questionnaire long
form (CSFQ) and short form (CSFQ-14) (Grade C) [118,
119]: It is a 35-item questionnaire that evaluates changes
related to sexual function with an underlying cause (such as
medications for illness). It encompasses five domains (sex-
ual desire/frequency, sexual desire/interest, sexual plea-
sure, sexual arousal, and orgasm) with scoring of
individuals’ domains and an overall CSFQ score. It may be
used in both clinical and nonclinical patients (i.e.,
depressed ones) with responsiveness. A short form with 14
items and three scales has been suggested as a global mea-
sure of sexual dysfunction. It addresses desire, arousal,
and orgasm but also the scales of the long form with a
strong internal reliability.
Condition-Specific PROs
Female Sexual Function Index (FSFI) (Grade C) [120,
121]: It is a valid and reliable 29-item questionnaire with six
domains (desire, arousal, lubrication, orgasm, satisfaction, and
pain). It may detect patients with HSDD, FOD, and FSAD. In
addition, a cutoff value of 26.55 may distinguish patients with
sexual dysfunction from those without. However, a possible
disadvantage is that the evaluation refers in the last 4 weeks.
Cases where sexual intercourse has not been performed for
reasons other than sexual dysfunction cannot be detected, as
the response of “not having sexual intercourse” does not
include the possible reasons. Furthermore, the partner’s sexual
problems cannot be addressed.
McCoy Female Sexuality Questionnaire (MFSQ)
(Grade C) [122]: Various versions have been tested using 7,
9, 10, or 17 items that were all valid, reliable, and consistent.
Responses are retrieved with seven-point Likert scales. It is
able to identify levels of sexual interest and response in rela-
tion to levels of estrogens and androgens. In particular, a dif-
ferentiation of sexual response between women with
hormone replacement therapy (HRT), oral contraceptives,
and presence or absence of ovaries may be detected by cer-
tain items of MSFQ.
Short Personal Experiences Questionnaire (SPEQ)
[108, 123–126]: It includes nine items with eight of them
being adapted from the MSFQ. The first half attributes to all
women irrespectively to partner status, while the second one
to women with partners (females or males). Sexual desire
(one item), arousal (two items), orgasm (one item), dyspa-
reunia (one item), passion for the partner (1 item), and diffi-
culties of partner in sexual performance (one item) are
evaluated. A cutoff score of ≤7 detects women with sexual
dysfunction (79% sensitivity and specificity). In addition,
SPEQ scores correlate with estradiol levels and, thus, meno-
pausal status, indicating that from early to late menopause,
46  Patient-Reported Outcomes and Pelvic Organ Prolapse
sexual dysfunction may rise from 42% to 88%. Furthermore,
SPEQ may detect the arousal, orgasm, and dyspareunia
changes in relation to PFDI scores. Thus, it has been found
that POP is associated with decreased sexual arousal, infre-
quent orgasm, and dyspareunia.
Pelvic Organ Prolapse/Urinary Incontinence Sexual
Function Questionnaire long (PISQ) and short form
(PISQ-­12) (Grade B) [127–131]: It has been developed to
evaluate sexual functioning in heterosexual women with UI
or POP and discriminate patients with sexual dysfunction
from those without. Two versions (long form and short form)
have been published. The long form measures 31 items,
while the short one (PISQ-12) only 12 items. PISQ-12 scores
may predict the PISQ-31 scores. For both versions the items
correspond to behavioral-emotive, physical, and partner-
related. Likert scale ranging from always (0 score) to never
(4 score) is encompassed. Scores are obtained for all domains
individually. The sum of all scores creates a total PISQ score.
PISQ total score ranges from 0 to 125. Higher values indi-
cate better sexual functioning, while MID is set at 6 points.
Furthermore, it has a sensitivity of 78% and specificity of
72% for the detection of women with depression. However,
PISQ has defaults. The partner-related domain does not eval-
uate the response of partners to POP and UI but the women’s
perception regarding her partners’ response. In addition, its
capability to address sexual function following a pelvic sur-
gery is inadequate, because it cannot identify most surgery-­
specific negative effects on sexual function.
PISQ-International Urogynecological Association
(IUGA) Revised (PISQ-IR) [132, 133]: It is a valid, reli-
able, and responsive measure of sexual function that devel-
oped from the PISQ-12 and attributes to both sexually and
nonsexually active women. It includes 42 items evaluating
both sexual activity status and sexual function. It is the only
PRO for sexual function that has been validated not only in
women with POP and/or UI but also in women with anal
incontinence (AI). It has been found to correlate with the
PFDI-20, ISI, and EPIQ question 35, for both sexually and
nonsexually active women, and for the sexually active ones
additionally correlate with FSFI and POPQ. Results of the
PISQ-IR may be calculated using the transformed summa-
tion or the mean calculation. Guidelines for both methods
have been published. In addition, a summary score is not rec-
ommended, as explaining or understanding relationships
between items is not feasible.
Body Image in the Pelvic Organ Prolapse Questionnaire
(BIPOP) [134]: It is a valid, consistent, and reliable 21-item
questionnaire developed to identify the impact of POP on
body image. It has two versions, one for women with a sex-
ual partner and one for those without. In particular, this mea-
surement aims to identify how women feel or might have felt
regarding their attractiveness, confidence, femininity, and
sexual intimacy due to their anatomical changes when they
have or have not a sexual partner, respectively. It is calcu-
569
lated using a mean value with the intention to automatically
account of missing data. Better body image is indicated
when BIPOP is scored higher.
ICIQ-VS [67], Australian Pelvic Floor Questionnaire
[68], and Electronic Personal Assessment Questionnaire-­
Pelvic Floor (ePAQ-PF) [69–72]: They are mixed question-
naires as they address symptoms, sexual functioning, and
quality of life of women with POP, as presented above.
Patients’ Expectations PROs
Goal Attainment Scaling (GAS) [135–141]: GAS is a mul-
tistep approach which begins with the identification of goals
by the patients. Initially, patients list their goals and the
importance of each goal to them (fairly important, very
important, and extremely important). Afterward, anticipated
or expected outcome levels are discussed with the urogyne-
cologist. Thus, unrealistic goals may be eliminated. After the
completion of therapy, assessment of goal attainment is
rated. The scores may be “0” when the goal is achieved as
predicted, “+1” or “+2” when achievement is above the level
predicted (“somewhat better than expected or predicted” or
“much better than expected or predicted,” respectively),
“−1” when achievement is below the expected level, and
“−2” when there is worsening of the target function.
Self-Assessment Goal Achievement (SAGA) [141]: It is
a patient-completed questionnaire designed to assess goal
attainment in behavioral or pharmacologic treatment of
LUTS/OAB.  It is a comprehensive and easy-to-understand
questionnaire. At baseline, SAGA includes nine fixed treat-
ment goals and up to five additional treatment goals specified
by the patients. The five most important goals are ranked,
and the criteria for successful achievement of the most
important goals are identified. At follow-up, the degree of
achievement of each individual (fixed and additional) goal,
as well as the overall goal, is rated.
Expectations, Goal Setting, Goal Achievement, and
Satisfaction (EGGS) [138, 143]: It combines all patient-­
centered outcomes (expectations, goal setting, goal achieve-
ment, and satisfaction). It has been suggested to become the
fourth dimension for the assessment of PFD along with the
physical findings, symptoms, and QoL outcomes. Specifically,
it was found that women who did not chose surgical interven-
tion had as primary goal information seeking, while patients
with a primary goal other than the symptom goal were more
likely to choose alternative to surgery interventions.
Patients’ Satisfaction PROs
Patient Global Impression (PGI) Scales [144–148]: Valid and
reliable measurements for LUTS and POP that include a single
item aiming to evaluate a certain condition overall and not sepa-
570
rately its components. Thus, patients may rate the severity (PGI-
S) or bothering (PGI-B) of their condition and the change
(PGI-C) or improvement (PGI-I) following a therapeutic inter-
vention. Depending on type of PGI, responses may involve
four- to seven-point scales. PGI-S and PGI-I correlate signifi-
cantly with number of UI episodes, stress pad test, and QoL
questionnaires. Moreover, PGI-C and PGI-I are valid, reliable,
and sensitive to change measures that can be used following a
prolapse surgery. Furthermore, PGI-I is a single question that is
answered post-surgery with an excellent positive correlation
with POP-Q and pQoL and a negative correlation with self-­
documentation in goal achievement. Thus, it may be ­considered
a tool for the definition of surgery “success” for POP, as it
reflects the objective, subjective, QoL, and patients’ goal.
However, it may score higher than ICIQ in women undergoing
surgery for UI or POP, overestimating the surgical results.
Surgical Satisfaction Questionnaire (SSQ-8) [149,
150]: It is a valid and reliable tool for the patient satisfaction
following pelvic surgery. It includes eight items with five- or
six-point scale responses (from “very satisfied” to “very
unsatisfied” or “very satisfied” to “N/A” or “yes” to “never”).
In women with advanced POP that underwent reconstructive
or obliterative surgery, the postoperative answers of SSQ-8
are comparable with the improvements from preoperative to
postoperative IIQ and UDI.
Global Perception of Improvement (GPI) [61, 151],
Patient Satisfaction Questionnaire (PSQ) [151], and
Estimated Percent Improvement (EPI) [151]: GPI is simi-
lar to the PGI-I, but it includes five-point scale responses
(from “much better” to “much worse”) instead of seven-point
scale responses. PSQ is a single-item questionnaire that eval-
uates the level of satisfaction following a therapeutic inter-
vention. It may receive responses using a five-point scale
(from “very satisfied” to “very dissatisfied”). GPI, PSQ, and
EPI are valid measurements for outcomes of behavioral treat-
ment for UI. They all correlate positively with the reduction
of the number of UI episodes in the bladder diary and the
change in the IIQ.  They all correlate negatively with the
desire of another treatment. In addition, GPI along with the
PSQ and the incontinence episodes (IE) has been used for the
determination of the MID of UDI and OAB-q.
Patient Perception of Treatment Benefit Questionnaire
(PPTBQ) [130, 152]: It evaluates whether patients perceive
a benefit from the treatment. Responses vary from “no ben-
efit,” “little benefit,” and “much benefit”). PPTBQ along
with bladder diaries, PPBC, OAB-q, and IIQ-7 has been used
for the definition of the MID of PISQ. PPTBQ, bladder diary,
and PPBC all set the MID at five points. Finally, the six-point
MID for PISQ was derived taking into account the nine and
seven points of OAB-q and IIQ-7, respectively.
Patient Perception of Bladder Condition [153, 154]: It
is a valid and responsive to change measurement that may be
used as a global assessment of bladder condition of patients
S. Athanasiou
with UI and/or OAB. It is a single-item questionnaire with
six possible responses evaluating the problems (from “none”
to “many severe”) due to the bladder condition. PPBC cor-
relates with the bladder diaries, OAB-q, and KHQ.
Specifically, higher PPBC improvement indicates greater
reductions in frequency, urgency episodes, and symptom
bother and significantly greater improvement in HRQL in
comparison to a minor PPBC improvement.
Benefit, Satisfaction, and Willingness (BSW) [130,
155]: It is a three-item questionnaire designed to evaluate the
perception of patients regarding the benefit, satisfaction, and
willingness to continue with the therapy. It was validated by
three randomized controlled trials for the assessment of tolt-
erodine in OAB patients. In these studies correlations
between BSW and the improvements of OAB-q, KHQ, and
bladder diaries were evident.
Treatment Satisfaction with Medicines Questionnaire
(SATMED-Q) [156, 158]: It is a valid, reliable, and respon-
sive 17-item questionnaire with six domains (treatment
effectiveness, convenience of use, impact on daily activities,
medical care, global satisfaction, and undesirable side effects
that have been evaluated in chronically ill patients). The
MID has been suggested at 13.4 for total score. For domains
the MID ranges from 10.3 (medical care) to 20.6 (impact on
daily living/activities) points.
Treatment Satisfaction Questionnaire for Medication
(TSQM) [158, 159]: It is a sound and valid measure for
patients’ satisfaction with two versions, an initial long with
55 items and a second shorter with 31 items. Both versions
include four scales: side effects, effectiveness, convenience,
and global satisfaction.
Overactive Bladder Satisfaction (OAB-S)
Questionnaire [160, 161]: It is a valid questionnaire with
five scales involving OAB Control Expectations (ten items),
Impact on Daily Living with OAB (10 items), OAB Control
(ten items), OAB Medication Tolerability (six items), and
Satisfaction with Control (ten items). In addition, it includes
five single-item overall assessments of patient’s fulfillment
of OAB medication expectations, interruption of day-to-day
life due to OAB, overall satisfaction with OAB medication,
willingness to continue OAB medication, and improvement
in day-to-day life due to OAB. OAB-S has better test reli-
ability than TSQM, discriminating patients by severity level
and detecting change in satisfaction levels in OAB patients.
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 Integrated Imaging Approach to Pelvic
Organ Prolapse
Giulio A. Santoro, Andrzej P. Wieczorek,
Magdalena Maria Woźniak, Jonia Alshiek,
Abbas Shoebeiri, and Abdul H. Sultan
Learning Objectives
• To understand the combination and integration of
various imaging modalities for a global and unitary
assessment of pelvic floor disorders.
• To understand the role and place of pelvic floor
imaging in current guidelines.
• To understand the advantage of using a combina-
tion of more modalities to overcome the limitations
of each method.
47.1 Introduction
Pelvic floor (PF) is one of the most complex anatomical and
functional areas of the human body [1, 2], and the manage-
ment of PF disorders (PFD) involves different disciplines
(urologists, gynecologists, colorectal surgeons, gastroenter-
G. A. Santoro (*)
Tertiary Referral Pelvic Floor Center, IV Division of
General Surgery, Regional Hospital, Treviso,
University of Padua, Padua, Italy
e-mail: giulioasantoro@yahoo.com
A. P. Wieczorek · M. M. Woźniak
Department of Pediatric Radiology, Medical University of Lublin,
Children’s University Hospital, Lublin, Poland
e-mail: wieczornyp@interia.pl; mwozniak@hoga.pl
J. Alshiek
Department of Obstetrics and Gynecology, INOVA Health,
Falls Church, VA, USA
A. Shoebeiri
University of Virginia INOVA Campus, Department of Obstetrics
and Gynecology, INOVA Women’s Hospital,
Falls Church, VA, USA
e-mail: Abbas.shobeiri@inova.org
A. H. Sultan
Department of Obstetrics and Gynaecology, Croydon University
Hospital, Surrey, UK
e-mail: asultan29@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_47
47
ologists, radiologists). Pelvic floor acts as a unit rather than
as three compartments (anterior, middle, and posterior)
working separately and therefore should be approached with
a holistic vision. Pelvic floor abnormalities as a consequence
of obstetric trauma, pelvic surgery, aging, and hormonal sta-
tus lead to a variety of disorders, such as vaginal bulge, pel-
vic organs prolapse, voiding or defecatory dysfunctions,
urinary or anal incontinences, chronic pelvic pain, and sex-
ual dysfunction, that frequently coexist (multicompartmental
disorders), severely affecting quality of life [3–10].
Pelvic organs prolapse (POP) represents a significant
social and economic problem. It is estimated that 25% of
women older than 60 years suffer from some degree of POP,
and more than 300,000 operations for POP are performed
annually in the United States only [1, 2]. Women in the
United States have a 13% lifetime risk of undergoing sur-
gery for POP [3]. Although POP can occur in younger
women, the peak incidence of POP symptoms is in women
aged 70–79  years [4]. Given the aging population in the
United States, it is anticipated that by 2050, the number of
women experiencing POP will increase by approximately
50% [5]. The prevalence of POP based on reported symp-
toms is only 3–6% being much lower than the prevalence
identified by clinical examination (41–50%) [6]. The high
discrepancy between symptomatic and asymptomatic
patients may result from anatomical disorders which may
have additional influence to the prolapse itself; incidental
urinary tract abnormalities are common, for example, being
reported in 15% of bone scans [7, 8]. Reliable assessment of
the anatomy of the pelvis in POP is frequently difficult by
physical examination alone. Anterior or posterior vaginal
wall prolapse may be identified clinically and described by
using POP quantification system (POP-Q); however, the
organs prolapsed into the “sac” (bladder, uterus, rectum,
sigmoid colon, small bowel) or the coexisting damages of
the anatomical structures of support (levator ani muscle,
endopelvic fascia, pubocervical fascia, rectovaginal fascia,
uterosacral or cardinal ligaments, perineal body, and peri-
neal membrane) are very challenging to be detected by the
577
578 G. A. Santoro et al.

The surgical ship Sea level

96

68
Evident

66

Occult
13

Functional 44 Organic
10

Rectal intussusception
Innternal mucosal prolapse
Anxiety, depression

Rectocele
28
15
33

Hystero - vaginal prolapse

17
Anismus

Cystocele - prostatism
Pudendal neuropathy

28

Peritoneo-entero-sigmoidocele
Rectal hyposensation

13
Slow transit, IBS

Solitary rectal ulcer

Fig. 47.1  The Pescatori Iceberg [1]

urogynecologist or the colorectal surgeon [9, 10]. Moreover, imaging as magnetic resonance imaging (MRI) or evacua-
a single symptom such as obstructed defecation can be due tion proctography (EP) may be indicated.
to a variety of “occult” conditions often underestimated, This chapter aims to review the various imaging tech-
rather than to what is clinically evident, as reported in the niques and to demonstrate why and how they should be used
“iceberg diagram” by Pescatori et al. [11] (Fig. 47.1). These in combination to overcome the fractured unidisciplinary
causes, if present, are not uppermost in patients’ conscious- approach, providing a comprehensive assessment of the ana-
ness and must be searched for by the clinician, before rec- tomic damages and dysfunctions of the PF.
ommendation for treatment.
Imaging plays an important role to visualize abnormali-
ties undetected by the clinicians and/or to confirm clinical 47.2 Review of Imaging Techniques
findings to correlate with symptoms [12–15]. Although, in
recent years, new techniques have dramatically improved the 47.2.1 Evacuation Proctography (EP)
diagnostic accuracy in patients with POP, there is still no
single modality that can provide a comprehensive overview Evacuation proctography is the traditional modality used by
of the PF. In order to obtain as much information as possible, colorectal surgeons to assess the causes of obstructed defeca-
it is therefore fundamental an integration of different tech- tion syndrome (ODS): rectal prolapse, rectocele, intussus-
niques to overcome the limitations of each method. Routine ception, and anismus. It is also used by urogynecologists to
use of ultrasound techniques is a useful adjunct to clinical evaluate posterior compartment prolapse and to confirm or to
investigation and allows to assess multicompartmental disor- exclude an enterocele. This examination requires meticulous
ders. In most cases ultrasound imaging is adequate to select preparation of the patient consisting of laxatives and enemas,
a correct management, reducing the number of unnecessary with subsequent rectal administration of various contrast
surgeries and thus minimizing the risk of failures, as well as mediums, most often a combination of barite suspension
faster and more effective treatment of postoperative compli- with an appropriate proportion of potato paste, similar to the
cations. In difficult cases or when there is no agreement stool consistency. In the urogynecology setting, it is fre-
between clinical and ultrasound findings, the second level of quently used in a modification called cysto-urethro-colpo-­
47  Integrated Imaging Approach to Pelvic Organ Prolapse
defecography, and it requires the administration of contrast
medium per os and in the bladder, vaginal lumen, and distal
colon. The movement of pelvis organs at rest, during evacu-
ation phase, and squeezing is referred to the pubococcygeal
line (PCL).
Evacuation proctography has the following disadvan-
tages: embarrassing for the patient, difficult to perform, low
availability, and X-ray exposure in young females.
47.2.2 Ultrasonography (US)
In a recent document to standardize the terminology for PF
ultrasound (PFUS), a joint committee of international scien-
tific societies (AIUM/AUGS/IUGA/ACR/AUA) proposed
the practice parameter for the performance of urogyneco-
logic US examinations [16]. The terminology for PFUS was
standardized as “perineal PFUS,” “introital PFUS,” “endo-
vaginal US” (EVUS), and “endoanal US” (EAUS). For the
purposes of this chapter, the perineal PFUS and the introital
PFUS are grouped together under the old term of transperi-
neal US (TPUS).
47.2.2.1 Two-Dimensional Transperineal
Ultrasound (2D TPUS)
The most frequently used US technique in urogynecology is
TPUS. This term is synonymous with different applications
of the US transducer: introital, translabial, or transperineal.
This access enables visualization of the pelvic organs in the
sagittal, oblique, and transverse section [12, 17]. It is usually
performed by convex transducers with 2–6 MHz frequency
range routinely used for abdominal US or by endovaginal
end-fire transducers with 6–10  MHz frequency range used
for endovaginal and endorectal examinations or also by lin-
ear transducers. Examination is performed in a lying posi-
tion, no gynecological chair is required, no special
preparation for the patient is needed, and no contrast medium
is used.
In the midsagittal section, 2D TPUS shows the anatomi-
cal relationships of the three PF compartments at rest and
during dynamic maneuvers. Its main aim is to assess the
contraction and relaxation of the levator ani/puborectalis
muscle, the dimension of the levator hiatus, the mobility of
the urethra and bladder neck, and the displacement of the
pelvic organs during maximal squeezing and straining [12,
17]. The reference line to evaluate the position and mutual
relations of these organs is a plane/line running parallel to
the lower edge of the pubic bones in the caudal, dorsal
direction (H line). The distance between the bladder neck
and the H line is termed bladder symphysis distance (BSD)
[18]. The position and mobility of the urethra are also
assessed by measuring the γ angle (the angle between the
line running through the pubic symphysis and the line con-
necting the bladder neck and the lower edge of the pubic
579
symphysis) and the β angle/retrovesical angle (RVA: the
angle between the line extending through the lumen of the
proximal urethra and the line extending across the surface
of the bladder base). Normal values for ​​ bladder neck
descent (BND) have not been established; however, 20 mm
is considered as the limit value, above which urethral
hypermobility is defined. It has been shown that this mea-
surement strongly correlates with symptoms of stress uri-
nary incontinence (SUI) [17–20]. According to Al-Saadi
et al. [21], urethral hyper-rotation is more often observed in
SUI. Cystocele severity is usually evaluated by determining
the maximal descent of the bladder (MDB) relative to the
symphysis pubis during Valsalva maneuver [12]. Ni et al.
[22] proposed an automatic cystocele severity grading by
spatiotemporal regression. 2D TPUS also allows to assess
the position of implanted tapes or meshes, as described by
Wlazlak et al. [23].
For the middle compartment, the distance of the cervix
from the lower edge of the pubic symphysis [17] is mea-
sured, and for the posterior compartment, measured the ano-
rectal angle (ARA: it is formed by the line running along the
posterior wall of the rectum and the central axis of the anal
canal) is measured. An additional tool enabling the assess-
ment of biomechanical properties of pelvic structures is the
“motion tracking” technique (vectors reflecting the displace-
ment of pelvic organs and muscles). It proved to be effective
in evaluating the functionality of the puborectal muscle dur-
ing contraction and relaxation [24].
Limitations of 2D TPUS are the low frequencies
(2–6 MHz) used that may result in poor resolution and lack
of detailed information of the examined structures. An addi-
tional limitation is the difficulty to perform correct measure-
ments in patients with IV° degrees prolapse, because of the
displacement of transducer from the perineum. Hence the
translabial approach should be preferred to the introital
approach.
47.2.2.2 Three-Dimensional Transperineal
Ultrasound (3D TPUS)
Three-dimensional US was introduced at the end of the
1990s. Supplementing the 2D images with the third plane
allows a very accurate evaluation of the PF. By using trans-
ducers with a higher frequency than 2D probes (3–8 MHz),
it is possible to assess more accurately the morphology of
pelvic structures.
Volumetric 3D data can be stored and analyzed after the
examination (off-line), also performing post-processing
analysis such as surface and volume render mode (SRM,
VRM), multiplanar reconstructions (MPR), or tomographic
ultrasound imaging (TUI). 3D TPUS allows accurate visual-
ization of the pelvis at selected levels after prior definition of
the region of interest (ROI). Assessment includes position of
the urethra, vagina, and anus in the axial plane, symmetry
between each other and compared to pubic symphysis, eval-
580 G. A. Santoro et al.

uation of levator ani muscle and its attachment to the inferior anal canal provide excellent resolution. Automatic 3D acqui-
pubic rami, and measurement of biometric indices of levator sition reduces to a minimum the probability of artifacts com-
hiatus [18, 25, 26]. This modality is mainly used to visualize pared to “freehand” modality.
defects of the levator muscle components and to measure the EAUS has become the first step of imaging in proctology
urogenital hiatus in both nulliparous and multiparous women for the assessment of perianal fistulas and for the preopera-
with pelvic floor disorders. 3D TPUS has high repeatability tive staging of anorectal cancers [33]. In urogynecology, the
and reproducibility between operators [27, 28], and it is con- main indication of EAUS is the evaluation of obstetric anal
sistent with MRI [29]. Multiplanar and tomographic TPUS sphincter injuries (OASIS) [34]. According to the latest rec-
give access to the axial plane and allow to assess both levator ommendations of the International Consultation on
ani avulsion and hiatal ballooning which are correlated to Incontinence (ICI), the International Continence Society
organ prolapse severity and are risk factors for recurrence (ICS), and the International Urogynecological Association
after surgery [30–32]. Dietz et al. [31] described the minimal (IUGA), it has been defined as the “gold standard” investiga-
criteria for the diagnosis of avulsion of the puborectalis mus- tion of anal sphincter integrity [35–37]. Ultrasound anatomy
cle by TUI. of the anal canal and differences in its morphology between
The limits of 3D TPUS are similar to 2D TPUS: low reso- males and females are well known [12]. The anal canal is
lution and low penetration and difficulty to assess patients divided into three levels: in the upper part, there is the
with IV° degrees prolapse. Moreover, the position of the puborectal muscle; in the middle part, the external (EAS)
volumetric transducer at the introitus does not allow to visu- and internal anal sphincters (IAS); and in the lower part, only
alize the perineal body and the perineal muscles (e.g., bulbo- the subcutaneous EAS [12]. High-frequency EAUS allows
spongiosus, ischiocavernosus, and superficial transverse accurate measurements of anal sphincters and differentiation
perinei muscles) [18]. of abnormalities (thickening, thinning, atrophy, scars,
defects) [12]. 3D dynamic endorectal US may also be used to
47.2.2.3 Four-Dimensional Transperineal perform echodefecography [38]. This method allows to iden-
Ultrasound (4D TPUS) tify dysfunctions of the posterior compartment such as recto-
The simultaneous assessment of three perpendicular planes celes, intussusception, mucosal prolapse, and paradoxical
can also be performed real time (4D US). This technique can contraction (anismus) as well as of the middle compartment
be used for live 3D evaluation of pelvic organs, levator ani, (enterocele/sigmoidocele). The advantage of echodefecogra-
and levator hiatus during Valsalva maneuver and maximal PF phy is the ability to visualize causes of ODS without irradiat-
contraction (MPFC). However, in patients with IV° degrees ing the patient [39].
prolapse, accurate assessment of anatomical structures is
very difficult, as confirmed by Majida et al. [25] who reported 47.2.2.5 Three-Dimensional Endovaginal
that the visualization of the anterior and posterior borders of Ultrasound (3D EVUS)
the urogenital hiatus was possible only in 29% of cases. Axial images of the pelvis with high-frequency 3D EVUS
These results show that the 4D TPUS requires further (9–16 MHz) are similar to those with 3D TPUS; however, the
improvements before routinely use in clinical practice [25]. higher frequency provides better resolution of the examined
structures. EVUS examination is performed with the same
47.2.2.4 Three-Dimensional Endoanal 360° rotational transducers used for 3D EAUS. Patient is in
Ultrasound (3D EAUS) the lying position with the pelvis raised on her fists. No spe-
At the end of the 1990s, technological progress in the field of cial preparation is required, and no contrast medium is used.
endosonographic transducers resulted in the introduction of The probe must be inserted into the vagina in a neutral posi-
high multifrequency 360° rotational probes allowing high-­ tion so that it does not cause pressure on the surrounding tis-
resolution US. They were initially used to perform 2D EAUS sues, which could distort the anatomy [40]. In axial cross
and then replaced with new probes with 3D automatic acqui- section, pelvic structures are assessed in four levels: Level 1,
sition. These transducers (radial electronic transducer, at the highest level, the bladder base can be visualized on the
Hitachi Medical Systems, Japan, and mechanical rotating screen at 12 o’clock position and the inferior third of the rec-
transducer, types 2052, 8838, 20R3, BK Medical Herlev, tum at 6 o’clock position; Level 2, corresponds to the bladder
Denmark) differ in acquisition of 3D data (freehand or auto- neck, the intramural region of the urethra and the anorectal
matic). When using a mechanical transducer (type 2052), 3D junction; Level 3, corresponds to the midurethra and to the
is collected in the axial plane for a maximum of 60 mm in upper third of the anal canal; and Level 4, at the outer level,
60 s and consists of 300 consecutive images, where the num- the superficial perineal muscles, the perineal body, the distal
ber and thickness of layers can be individually selected by urethra, and the middle and inferior third of the anal canal can
the operator during the examination [33]. The 3D volume be evaluated [40]. High-resolution 3D EVUS allows an accu-
can be archived for off-line analysis. The high frequency of rate evaluation of the symmetry urethra/anal canal, the mor-
the transducer (9–16  MHz) and the direct contact with the phology of the urethra (rhabdosphincter, lisosphincter) and of
47  Integrated Imaging Approach to Pelvic Organ Prolapse
the supporting ligaments and fascia [41], the levator ani mus-
cle subdivisions [42] and the indices of levator hiatus (area,
length, and width) [43], and the integrity of the perineal body
and the rectovaginal fascia [44]. 3D EVUS showed high
interobserver reproducibility [43], which is important from
the perspective of using this modality on a larger scale in
clinical practice. 3D EVUS with automatic volumetric acqui-
sition provides high-resolution images in all reconstructed
planes. This technique is also helpful in the postoperative
evaluation of tapes and meshes. MPR allows to visualize
implanted elements and to identify displacement, shrinkage,
fluid collections, abscesses, or hematomas.
47.2.2.6 Dynamic Endovaginal Ultrasound
EVUS performed with electronic biplane transducer (type
8848 BK Medical) or linear electronic transducer (type 8838
BK Medical) allows a dynamic assessment of the anterior
and posterior compartment [12]. The biplane probe has both
convex and linear arrays which provide acquisition in the
longitudinal and axial cross sections. it allows precise visual-
ization of the urethra (intramural part, mid-urethra, and dis-
tal urethra) and the rectum (anorectal junction, ARA, perineal
body). It also provides information of urehtral vascularity by
using the color Doppler [45–47]. It is also possible a dynamic
assessment by asking the patient to squeeze and to strain, in
order to detect urethral hypermobility, cystocele, rectal pro-
lapse, rectocele, intussusception, enterocele, and anismus
[12]. The linear electronic transducer type 8838 also enables
automatic 3D data acquisition, providing accurate assess-
ment of urethral pathology, congenital abnormalities, and
postoperative complications.
47.2.3 Magnetic Resonance Imaging (MRI)
Magnetic resonance allows simultaneous imaging of all pel-
vic compartments, making them visible in a very compre-
hensive way. Static MRI assesses the anatomy, morphology,
and relationships between organs as well as their abnormali-
ties. A limit of this technique is the difficulty to visualize
tapes and meshes and to evaluate postoperative results [48].
In urogynecology, MRI can also be performed using the vag-
inal coil to obtain better resolution in the assessment of the
urethra and periurethral structures. However, the invasive-
ness of this examination results in low compliance and very
limited application [49]. Recently, dynamic studies [50–53]
and diffusion and tractography MRI techniques [54, 55] have
been introduced in the diagnosis of PFD.  Dynamic pelvic
MRI is a helpful adjunct to physical examination and urody-
namic testing, particularly when patient’s symptoms do not
correspond to physical examination findings. It can guide
preoperative and postoperative surgical management in most
patients, especially in the setting of multicompartmental dis-
orders [56]. In highly specialized urogynecological centers,
581
dynamic MRI defecography replaced EP, enabling not only
to reduce exposure to radiation but also to obtain a much
larger dose of information compared to the traditional X-ray
study [57–59]. There are also reports on 3.0 T resonance for
defecographic tests, which provides images of such high
resolution that it is possible to identify undiagnosed clini-
cally silent abnormalities [60]. Diffusion and tractographic
techniques allow to assess in great details the distribution of
levator ani fibers and their damages [51, 52].
The reference line used for the evaluation of pelvic organs
at rest and during MPFC and maximal Valsalva maneuver is
the PCL [50], which is defined on midsagittal images as the
line joining the inferior border of the symphysis pubis to the
last or second last coccygeal joint. The anorectal junction
(ARJ) is defined as the cross point between a line along the
posterior wall of the distal part of the rectum and a line along
the central axis of the anal canal. ARA is defined as the angle
between the posterior wall of the distal part of the rectum and
the central axis of the anal canal and can be measured at rest,
during squeezing and straining. In normal condition, the
upper edge of the levator plate should run parallel to the PCL
line. The H line measures the distance between the lower part
of the pubic symphysis and the posterior part of the ARA. The
M line is perpendicular to the P line to the farthest point of
the H line, indicating the degree of PF descent [61]. Comiter
et  al. [62] described the correct values for​​ H and M lines,
which are approximately 5 and 2  cm, respectively. Nardos
et  al. [63] showed that the measurements of the urogenital
hiatus obtained in the sagittal plane with MRI were signifi-
cantly higher compared to the measurements obtained with
TPUS in nulliparas, both at rest, Valsalva, and squeeze.
According to the authors, this can be due to a different inter-
pretation of the reference anatomical points.
47.3 Review of the Literature
and Recommendations
In 2010, an IUGA/ICS joint report on the terminology for
female pelvic floor dysfunction [36] stated that US has
become an increasingly frequent adjunct investigation in
urogynecology and female urology both in the office and in
the urodynamic laboratory allowing assessment of postvoid
residuals, intercurrent pelvic pathology, uterine version, and
bladder or urethral abnormalities. Six years later, an IUGA/
ICS joint report on the terminology for female POP [37]
stated that imaging may assist the clinical assessment of POP
or intercurrent PFD. The use of any of the different imaging
modalities is, however, entirely optional. MRI provides the
opportunity to examine the supporting structures of the PF
and evaluate POP, levator ani defects, and postoperative
results [36]. In 2017, an IUGA/ICS joint report on the termi-
nology for female anorectal dysfunction defined the role of
imaging in the diagnosis and management of posterior
582 G. A. Santoro et al.

c­ ompartment disorders [64]. Ultrasound has been increas-
ingly incorporated as a useful investigation in patients with
anal incontinence, anal pain, and ODS. The sixth ICI, based
on the concept that pelvic organ dysfunction includes multi-
ple conditions, proposed integrated PFUS with a combina-
tion of different modalities (2D, 3D, 4D, dynamic, as well as
EVUS, EAUS, TPUS) for a global and multicompartmental
perspective (Fig. 47.2). However, the values of this approach
in routine assessment of PFD are yet to be evaluated [65].
Ultrasound has several advantages (low cost, wide acces-
sibility and availability, office procedure performed by clini-
cians, intraoperative technique, less time-consuming, good
compliance) and should be performed as first-line assess-
ment in PFD [66]. Dynamic US (TPUS/EVUS/echodefecog-
raphy) has the potentiality to replace EP in the evaluation of
ODS, allowing to differentiate enterocele, rectocele, internal
intussusception, mucosal rectal prolapse, and paradoxical
anal sphincter and puborectalis contraction (anismus) [12].
Electronic transducers with Color Doppler mode provide
information on the vascularity of the urethra, which is char-
acterized by different flow parameters [46, 67–69]. Vascular
abnormalities may be related to urinary incontinence.
Ultrasound has also been demonstrated useful in the postop-
erative assessment of the position of mesh and sling.
Transobturator (TOT) or transvaginal (TVT) tapes posi-
tioned between 50 and 80 percentile of urethra length
resulted in a success rate of 91% in patients with SUI [70].
Clinicians are increasingly adopting a more holistic
approach with a combination of different US modalities for
a multicompartmental assessment of PFD [12] (Fig.  47.2).
Lone et al. [71] found a good to excellent agreement between
two examiners in the evaluation of all three compartments
and suggested that multicompartment PFUS should be con-
sidered as a systematic integrated approach to assess the PF.
Static MRI provides a comprehensive visualization of all
pelvic structures. It is performed at a magnetic field strength
of 1.5 T, using pelvic or phased-array coils and T2-weighted
fast-spin echo (FSE) sequences. The spatial resolution can
be enhanced by using endoluminal (endorectal, endovaginal)
coils. In combination with T2-weighted FSE sequences,
endoluminal coils provide improved signal-to-noise ratio
(SNR) and high-resolution images. The prominent pelvic
floor structures of the posterior compartment visualized at
MRI are the perineal body, the superficial perineal muscles,
the anal sphincters, the puborectalis muscle and levator ani,
the rectum, and the rectal support. With the development of
fast multi-slice sequences, MRI has gained increasing accep-
tance for dynamic imaging of the posterior compartment
(MR defecography) [64]. Piloni et  al. [59] described the
methodology of this technique, the diagnostic criteria, and
grading for ODS.  The proposed system in five grades of
combination of abnormalities seen at MR defecography was
correlated to therapeutic options.
MRI provides a comprehensive evaluation of the pelvic
floor; however it still has limited accessibility and high cost
and requires highly specialized equipment and qualified
medical staff. It should be considered as a second-line assess-
ment tool after ultrasound.
Van Gruting et al. [72] evaluated the diagnostic accuracy
of EP, MRI, TPUS, and EVUS for detecting posterior com-

Characteristics of ultrasonographic modalities for pelvic floor assessment

Modality Probe Frequency Imaging Dynamic Urethra LA/PR UGH Anterior Central Posterior
planes study vascularity LH Perineal compart compart. compart.
measure muscles

2D-TPUS Convex 3–6 MHz Sagittal

Coronal

3D-TPUS Convex 3–8 MHz Axial

Tomographic
4D-TPUS Convex 3–8 MHz Axial
Tomographic
2D-EVUS Biplane 5–12 MHz Sagittal
Axial
3D-EVUS Biplane 5–12 MHz Multiplanar
180°
rotational
3D-EVUS 360° 9–16 MHz Multiplanar
rotational
3D-EAUS 360° 9–16 MHz Multiplanar Anal
rotational sphincters

2D: Two-dimensional; 3D: Three-dimensional; EAUS: Endoanal ultrasound; EVUS: Endovaginal ultrasound; LA: Levator ani; LH: Levator
hiatus; PR: puborectalis mucle; TPUS: Transperineal ultrasound; UGH: urogenital hiatus

Fig. 47.2  Combination of different US modalities for the integrated, multicompartmental assessment of PFD [12]
47  Integrated Imaging Approach to Pelvic Organ Prolapse
partment disorders in patients with ODS. There was no opti-
mal test; however, all imaging modalities showed similar
accuracies. Because TPUS and EVUS had good accuracy and
the best patient acceptability, the authors proposed that these
techniques should be used as initial screening tools in ODS. In
another study, Van Gruting et al. [73] compared 2D and 4D
TPUS in order to assess if 4D technique has additional value
in the diagnosis of ODS.  They found no superiority of 4D
over dynamic 2D US and concluded that these two techniques
could be used interchangeably to screen women with
ODS. Hainsworth et al. [14] compared the accuracy of inte-
grated total PFUS (transperineal, transvaginal, endoanal) to
defecatory MRI. The results supported the use of integrated
US as a screening tool for defecatory dysfunction. When nor-
mal, defecatory MRI can be avoided, as rectocoele, intussus-
ception, and enterocoele are unlikely to be present.
47.4 Summary and Conclusions
History, use of questionnaires, and physical examination
based on POP-Q system to define the grade of anterior and/
or posterior vaginal prolapse are still considered exhaustive
to select surgical treatment of POP [74]. However, rather
than to what it is clinically evident, a variety of coexisting
occult conditions are often underestimated [11] and must be
searched for by the clinician before recommendation for sur-
gery. Imaging plays an important role to provide detailed
structural and dynamic information of the PF which can be
correlated with clinical examination. Integration and combi-
nation of different imaging modalities allows a comprehen-
sive assessment of the anatomic damages and dysfunctions
of the PF and overcomes the fractured uni-disciplinary
approach, guiding to an adequate management.
Standardization of techniques and unified multidisciplinary
diagnostic and therapeutic algorithms will lead to a wider
acceptability of imaging in the routine clinical practice.
Take-Home Messages
• Integrated imaging consists in a combination of dif-
ferent modalities (evacuation proctography,
2D/3D/4D TPUS, 3D EVUS, 3D EAUS, dynamic
US, static MRI, MR defecography) for a compre-
hensive assessment of the anatomy and functional-
ity of the pelvic floor.
• Ultrasound represents the first-line imaging technique
due to accessibility, compliance, accuracy, cost, less
time-consuming, office or intraoperative procedures.
• Evacuation proctography, static MRI, or MR defe-
cography should be considered in selected cases
when ultrasound findings are not exhaustive.
583
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 Transperineal Ultrasound: Practical
Applications
Hans Peter Dietz
Learning Objectives
• To appreciate the utility of translabial/perineal
ultrasound in the investigation of lower urinary tract
dysfunction, prolapse, obstructed defecation and
anal incontinence.
• To understand basic anatomical abnormalities of
the female pelvic floor.
• To recognize abnormal functional anatomy in the
midsagittal and axial plane.
• To be able to identify synthetic implants in the mid-
sagittal plane and on multiplanar imaging.
• To be able to identify levator ani avulsion and anal
sphincter trauma.
48.1 Introduction
Chapter 6 introduced normal pelvic floor anatomy as imaged
by translabial/ transperineal or ‘pelvic floor’ ultrasound. This
chapter will cover the use of this modality in clinical prac-
tice. To date, urogynaecology as taught in textbooks remains
largely uninformed by imaging; as a result it is permeated by
multiple misconceptions and misunderstandings. Even most
recent publications and teaching materials produced by
learned societies contain information that is contradicted by
functional anatomy as seen on simple 2D translabial ultra-
sound since the mid- eighties.
The growing interest in pelvic floor imaging in recent
years is attributable to several distinct factors. Pelvic floor
dysfunction includes a number of conditions that are increas-
ingly prevalent in our ageing populations. The estimated life-
time risk for prolapse or urinary incontinence surgery is
H. P. Dietz (*)
Sydney Medical School Nepean, University of Sydney,
Sydney, NSW, Australia
e-mail: hpdietz2@bigpond.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_48
48
10–20% in developed societies [1, 2]. Our understanding of
those conditions, however, is rather limited, resulting in sub-
optimal rates of failure, with about 1/3 of all prolapse proce-
dures being reoperations.
The recent rediscovery of the link between childbirth-­
related trauma to the levator ani muscle and female pelvic
organ prolapse (POP) [3–5] shows very clearly that imag-
ing will be of central importance if we want to improve
outcomes, develop preventative strategies [6, 7] and indi-
vidualize and optimize treatment [8]. Our clinical exami-
nation skills are simply not good enough as they focus on
surface anatomy rather than actual structural abnormali-
ties. As explained in Chap. 6, clinical assessment for POP
is confounded by a number of factors that are not com-
monly accounted for, such as bladder [9] and rectal filling,
levator co-activation [10] and the duration of a Valsalva
manoeuvre [11].
48.2 Instrumentation and Indications
Instrumentation and basic examination technique are cov-
ered in Chap. 6 which also provides information on the tech-
nique of 3D ultrasound. Figure  48.1 shows the standard
orientation for 3D/4D pelvic floor ultrasound, obtained by
placing an abdominal 3D/4D transducer on the perineum.
The A plane on the left conventionally shows the midsagittal
plane, with the symphysis pubis in the top left-hand corner of
that image as traditionally seen on 2D translabial imaging
since 1986. B and C planes are often omitted for convenience
but are available at the touch of a button. The right-hand
image shows a rotated, semitransparent representation of all
pixels contained in a ‘region of interest’, that is, the ‘box’
seen in Image A. This method of representing volume ultra-
sound data was originally developed to enable visualization
of the foetal face, but, rather fortuitously, it is eminently suit-
able for imaging of the entire levator hiatus, including the
symphysis pubis, urethra, bladder base, vagina, anorectum
and levator plate.
587
588
a b
Fig. 48.1  Standard orientation of translabial 4D pelvic floor ultrasound. The transducer is placed midsagittally. The midsagittal plane is repre-
sented in (a), a rendered volume in the axial plane in (b). The images represent findings on maximal Valsalva in a patient with stress urinary
incontinence and mild anterior compartment descent. A anus, B bladder, L levator ani, R rectal ampulla, S symphysis pubis, U urethra
Table 48.1  Indications for pelvic floor ultrasound imaging
Clinical indications for pelvic floor ultrasound
(a) Anal incontinence
(b) Assessment of synthetic implants (slings, meshes and bulking
agents)
(c) Defecatory dysfunction
(d) Levator ani muscle assessment after childbirth
(e) Obstructed defecation
(f) Obstetric perineal injury
(g) Obstetric anal sphincter injury
(h) Pelvic or vaginal pain after pelvic floor surgery
(i) Pelvic organ prolapse
(j) Pelvic pain and dyspareunia
(k) Perineal cyst or mass
(l) Symptoms of voiding dysfunction
(m) Urinary incontinence
(n) Vaginal cyst or mass such as a urethral diverticulum
(o) Vaginal discharge or bleeding after pelvic floor surgery
(p) Voiding dysfunction
Indications for pelvic floor ultrasound include virtually
all conditions seen in an urogynaecological clinic and are
listed in Table 48.1.
48.3 Anterior Compartment Pathology
48.3.1 Residual Urine and Bladder Wall
Ultrasound is commonly utilized to determine postvoid
residual urine. Using the transperineal route, the residual
volume in millilitres may be estimated by using the formula
X cm × Y cm × 5.6 [12], with X and Y denoting the largest
dimensions of the bladder, obtained perpendicular to each
other, in the midsagittal plane. Volumes over 50  ml are
H. P. Dietz
regarded as abnormal, although both lower and higher cut-
offs have been proposed. Abnormal volume measurements
should be confirmed after at least one more void. Occasionally,
incidental foreign bodies or bladder tumours may be detected
(Fig. 48.2). Detrusor wall thickness of > = 5 mm (detrusor
hypertrophy) seems associated with urge urinary inconti-
nence and detrusor overactivity [13]. Detrusor hypertrophy
can be variable depending on location, with the dome often
thicker than the posterior bladder base beyond the trigone,
especially in women with cystocele (Fig. 48.3). As a result,
DWT is not in fact a good test [14, 15]. Unlike the situation
in the male bladder, DWT may not be predictive of voiding
difficulty in women [16, 17]. Occasionally, a trigonal cystic
structure may be observed, the differential diagnosis being
ureterocele and Nabothian follicle (Fig. 48.4).
48.3.1.1 T  he Anatomy of Stress Urinary
Incontinence
In women suffering from stress urinary incontinence or uro-
dynamic stress incontinence, the proximal urethra commonly
rotates postero-inferiorly on Valsalva manoeuvre as the ure-
thra and anterior vaginal wall are tethered to the symphysis
pubis and the pelvic sidewall. In essence, the symphysis acts
as a fulcrum around which the entire anterior compartment
rotates. Points of reference for measurements of bladder neck
mobility are either the central axis of the symphysis pubis
[18] or its inferior-posterior margin [19]. The former may be
more accurate, providing measurements that are independent
of transducer position or movement. However, obtaining the
central axis of the pubis can be difficult in postmenopausal
women due to calcification of the interpubic disc, and visual-
ization of the entire interpubic disc makes inclusion of the
posterior compartment and anorectal angle in the resulting
image or volume difficult to impossible.
48  Transperineal Ultrasound: Practical Applications
a b
Fig. 48.2  Bladder stone (long arrow, left) and transitional cell carcinoma (TCC; short arrow, right). (a) The stone is hyperechogenic and shows
distal acoustic shadowing; (b) the TCC is iso-echoic and produces no shadowing
Fig. 48.3  Asymmetrical detrusor hypertrophy in a patient with symp-
toms of the overactive bladder and urodynamic detrusor overactivity
Bladder neck mobility can be determined in a highly
repeatable fashion (Fig. 48.5) [20]. The difference between
values at rest and on maximal Valsalva yields a numerical
value for bladder neck descent (BND). The same method can
be used for the mobility of any given point, which is espe-
cially useful for quantifying segmental urethral mobility. It is
the mobility of the mid-urethra rather than that of the bladder
neck which is most strongly associated with stress inconti-
nence [21]. In addition, urethral rotation may be quantified
by comparing the angle of inclination between proximal ure-
thra and any other fixed axis. Another parameter commonly
obtained is the urethrovesical (or retrovesical) angle between
proximal urethra and trigone and/or the angle γ between the
central symphyseal axis and a line from the inferior symphy-
seal margin to the bladder neck [22]. Unfortunately, none of
589
these measures have good test characteristics for the diagno-
sis of urodynamic stress incontinence [23, 24], similar to
DWT and the diagnosis of detrusor overactivity, underscor-
ing the continuing need for urodynamic testing in the assess-
ment of urinary incontinence.
Funnelling of the internal urethral meatus (Figs. 48.1 and
48.6) is often observed on Valsalva in women suffering from
stress urinary incontinence. Funnelling is commonly, but not
necessarily, seen at the time of urine leakage. Marked fun-
nelling as shown in Fig. 48.6 is associated with poor maxi-
mum urethral closure pressures [25, 26]. Other (indirect)
signs of urine leakage on Valsalva are greyscale echoes
(‘streaming’) within the usually invisible urethral lumen and
the appearance of two linear or ‘specular’ echoes indicating
the lumen of a fluid-filled urethra.
48.3.1.2 Anterior Compartment Prolapse
Clinicians use the word ‘cystocele’ and ‘anterior vaginal
wall descent’ interchangeably, and descent of the anterior
vaginal wall does indeed usually mean ‘cystocele’, that is,
descent or ‘prolapse’ of the bladder. However, such clinical
appearances may occasionally be due to a urethral diverticu-
lum or other cystic structures of the anterior vaginal wall
such as Gartner’s duct cysts, remnants of the Wolffian ducts
of embryological development (Fig.  48.7). Urethral diver-
ticula are commonly overlooked in women with lower uri-
nary tract symptoms and are a correctable cause of lower
urinary tract symptoms. Small diverticula may appear as a
mostly hyperechogenic irregularity of the urethra, although
they show a clearly cystic or solid-cystic appearance. Any
spatially circumscribed para-urethral abnormality is better
appreciated in the sectional planes, which are useful in dif-
ferentiating other cystic or mixed solid-cystic structures
from a urethral diverticulum. Figure 48.8 shows typical
appearances of four very different, urethroscopically con-
590 H. P. Dietz

a b

Fig. 48.4  Cystic structures in the anterior compartment, seen in the vesico-ureteric junction. Ureteroceles fill and empty with ureteric peri-
midsagittal or parasagittal planes. (a) Ureterocele, i.e. a sacculation of stalsis. (b) Nabothian follicle which is part of the cervix and moves with
the intravesical part of the ureter, which is due to a stenosis of the it on Valsalva

a b

c d

Fig. 48.5  Determination of bladder neck descent and retrovesical demonstrate the measurement of distances between inferior symphy-
angle: ultrasound images show the midsagittal plane at rest (a, c) and on seal margin and bladder neck (vertical, x and horizontal, y) and the ret-
Valsalva (b, d). A anal canal, B bladder, L levator ani, R rectal ampulla, rovesical angle at rest (rva-r) and on Valsalva (From [19], with
S symphysis pubis, U urethra, Ut uterus, V vagina. The lower images permission)
48  Transperineal Ultrasound: Practical Applications 591

a b

Fig. 48.6  Marked funnelling of the bladder neck (arrows) on Valsalva in the midsagittal plane (a) and a rendered volume (b). Such appearances
are suggestive of a low-pressure urethra (‘intrinsic sphincter deficiency’) and urodynamic stress incontinence

a b

c d

Fig. 48.7  Gartner cyst (Mullerian remnant; large arrows) as seen in the the circular urethral rhabdosphincter, confirming the diagnosis. The pri-
midsagittal plane (a), coronal plane (b), axial plane (c) and axial ren- mary differential diagnosis, a urethral diverticulum, grows from inside
dered volume (d). The small arrows in the bottom right panel indicate the rhabdosphincter and tends to destroy its ring structure
592 H. P. Dietz

a b

d
c

e f

h
g

Fig. 48.8  Varying appearances of urethral diverticula. Images of the mid- (a, b) Hyperechogenic foci and distortion; (c, d) Small cystic structure; (e,
sagitta (a, c, e, g) and coronal plane (b, d, f, h) obtained from 4 different f) Simple posterior urethral diverticulum; (g, h) Circumferential complex
patients with a confirmed urethral diverticulum on urethroscopy are shown. urethral diverticulum. Arrows indicate the diverticulum
48  Transperineal Ultrasound: Practical Applications 593

a b c

Aa

Ba

Bp D

Ap tvl

Fig. 48.9  Cystocele on clinical examination (a). ICS POPQ diagram and coordinates (b) and pelvic floor ultrasound in the midsagittal plane (c).
A anus, B bladder, L levator ani, S symphysis pubis, U uterus

a b

Fig. 48.10  Cystocele types as seen on maximal Valsalva in the midsagittal plane. (a) Cystocele with open retrovesical angle of over 180° (RVA,
indicated by lines placed through the trigone and the proximal urethra). (b) Typical large cystocele with intact retrovesical angle of about 110°.
A anus, B bladder, L levator ani, S symphysis pubis

firmed urethral diverticula. A urethral diverticulum usually
arises dorsal to the urethra and may develop by surrounding
the organ, initially within the confines of the fascia of the
urethral rhabdosphincter, explaining the horseshoe shape of
larger diverticula (Fig. 48.8d). Occasionally, they may also
be found ventral to the urethra, i.e. in the space of Retzius.
Most often, however, excessive descent of the anterior
vaginal wall is indeed a ‘cystocele’ or prolapse of the bladder
as shown in Fig. 48.9. Historically, two types of cystoceles
have been described, and they seem to have rather different
functional implications (Fig. 48.10) [27]. A cystourethrocele
or Green type II cystocele is associated with stress urinary
incontinence and normal voiding, while a cystocele with
intact retrovesical angle or Green type III cystocele tends to
be found in women with voiding dysfunction and symptoms
of prolapse rather than stress incontinence. The former is not
associated with avulsion of the levator ani, as opposed to the
Green type III cystocele, which argues against a traumatic
pathogenesis for cystourethrocele [28]. Occasionally, a
severe cystocele may result in inversion of the bladder neck,
that is, rotation of the bladder neck up to 180° on Valsalva
and marked urethral kinking. Fig. 48.11 shows quantification
of pelvic organ descent in a patient with three-compartment
prolapse.
48.3.1.3 Central Compartment
The uterus can be difficult to identify because of its iso-­
echoic nature, similar in echotexture to the vagina, especially
in women with small, atrophic uteri. In women with signifi-
cant uterine descent, a specular (mirror-like) echo indicates
the leading edge of the cervix. Nabothian follicles may help
distinguish the cervix from vaginal wall (Figs.  48.4 and
48.12). Occasionally, imaging will show a retroverted uterus
compressing the urethra and/or bladder neck, explaining
symptoms of voiding difficulties. Even more impressively, a
low anteverted uterus may result in rectal intussusception in
594
women with symptoms of obstructed defecation, which is
termed a ‘colpocele’ on defecation proctography (Fig. 48.13).
48.3.1.4 Posterior Compartment
Descent of the posterior vaginal wall can be due to a number
of different anatomical abnormalities with different patho-
Fig. 48.11  On Valsalva in the midsagittal plane, prolapse is quantified
against a horizontal line placed through the inferoposterior symphyseal
margin, as in this patient with three-compartment prolapse. There is
descent of the bladder neck to 16 mm below the symphysis, of the blad-
der to 19 mm below, of the uterus to 21 mm below, of an enterocoele to
26 mm below and of the rectal ampulla to 31 mm below the reference
line. B bladder, E enterocoele, R rectal ampulla, S symphysis pubis,
U uterus
a b
Fig. 48.12  A Nabothian follicle (arrow) can provide a convenient
marker of the cervix, as in this patient with third-degree cystocele and
second-degree uterine prolapse. The green line of the region of interest
(the ‘box’ in a) serves as the line of reference here; however, the result-
H. P. Dietz
physiological and therapeutic implications, even if, on clini-
cal assessment of surface anatomy, those conditions are
generally subsumed under the term ‘rectocele’. Many gynae-
cologists are unaware of this fact since they never see any-
thing but surface anatomy. Even digital rectal examination
(which needs to be performed on Valsalva to demonstrate
true rectocele and intussusception) is not routinely employed.
The link between anatomical abnormalities and defeca-
tory dysfunction, mostly in the sense of obstructed defeca-
tion (incomplete bowel emptying, straining at stool and
digitation) [29], is frequently not fully appreciated by both
gynaecologists and colorectal surgeons. The ‘gold stan-
dard’ diagnostic method, defecation proctography, is inva-
sive, expensive and not commonly available. Pelvic floor
ultrasound is cheaper, non-invasive and much better
accepted by the patient and seems to yield similar findings
[30–32], even without 3D/4D imaging. It is poised to
replace defecation proctography for the initial investigation
for women with posterior compartment prolapse and
obstructed defecation [33].
Clinical posterior compartment descent is most com-
monly found to be due to a ‘true’ or radiological rectocele on
imaging: a defect of the rectovaginal septum that results in
herniation of the anterior wall of the rectal ampulla into the
vagina [34]. On translabial ultrasound the rectovaginal sep-
tum (RVS) is often not easy to visualize (see Fig. 6.15, for an
exception) unless one uses endovaginal imaging, but direct
assessment of the RVS on static ultrasound seems to be of
very limited clinical utility [35].
ing axial plane rendered volume in (b) is not suitable for hiatal mea-
surement since the line of minimal dimensions (oblique line in a) lies
partly outside the box. This manifests in an overestimate of hiatal depth
posteriorly. A anal canal, B bladder, S symphysis pubis, U uterus
48  Transperineal Ultrasound: Practical Applications 595

a b

Fig. 48.13  A colpocele, i.e. a rectal intussusception propelled by the wall are shown by the dotted line, (a) with the cervix inverting the ante-
cervix of a prolapsing uterus. This usually is due to the cervix (as in this rior wall of the rectal ampulla. A anal canal, B bladder, Cx cervix,
patient), but very occasionally an acutely retroverted uterus can result in S symphysis pubis, Ut uterus. The dotted line in (b) shows hiatal area
a colpocele caused by the fundus. The anal canal and anterior rectal

a b c

Aa

Ba

Bp D

Ap tvl

Fig. 48.14  Rectocele on clinical photograph (a), representation on POP-Q (b; Ba = −3, C = −4, Bp = +1) and appearances on imaging (c; A anal
canal, B bladder, L levator ani, R rectocele, S symphysis pubis) (From [109], with permission)

Diagnosis of a ‘true’ rectocele does not rely on identifica-
tion of the RVS itself but rather on demonstration of a pocket
or diverticulum, i.e. a discontinuity of the anterior anal mus-
cularis on Valsalva (Fig. 48.14). A rectocele is defined by its
depth and descent relative to the symphysis pubis (Fig. 48.15).
Another manifestation of posterior compartment descent is
perineal hypermobility where the RVS is intact but may be
abnormally distensible (Fig.  48.16), synonymous with
‘descending perineum syndrome’ and associated with exces-
sive distensibility of the levator hiatus [36]. The latter is not
surprising since the levator plate distends not just laterally
but downwards as well.
Both rectocele and perineal hypermobility are associated
with symptoms of prolapse, i.e. of a vaginal lump or a drag-
ging sensation, but obstructed defecation is more likely with
a true, radiological rectocele, that is, a defect of the RVS
[37]. Other causes of posterior compartment prolapse
include a combined rectoenterocele, an isolated enterocele,
rectal intussusception or a deficient perineum giving the
impression of a ‘bulge’ [38, 39]. Rectal intussusception is
an early stage of rectal prolapse where rectal mucosa and
muscularis enter the proximal anal canal, changing it to a
‘martini glass’ configuration. This condition, not uncom-
mon but rarely diagnosed by gynaecologists, is strongly
596 H. P. Dietz

a b

c d

Fig. 48.15  Translabial ultrasound images in the midsagittal plane. (a) reference line placed through the ventral aspect of the internal anal
and (c) are images at rest; (b) and (d) are obtained on maximal Valsalva. sphincter. A anal canal, B bladder, R rectal ampulla, S symphysis pubis,
(b) Rectocele descent against a reference line placed through the infero- V vagina (From [110], with permission)
posterior symphyseal margin; (d) Rectocele depth measured against a

a b c

Fig. 48.16  Anatomical abnormalities of the posterior vaginal compart- of the rectal ampulla without rectocoele (‘perineal hypermobility’) and
ment associated with symptoms of obstructed defecation, showing a (c) rectal intussusception (From [111], with permission)
‘true rectocoele’, i.e. (a) defect of the rectovaginal septum, (b) descent
48  Transperineal Ultrasound: Practical Applications
associated with abnormalities of the levator ani muscle and
hiatus [40].
Current ultrasound data do not support the ­classification
of defects originally described by Cullen Richardson [34],
suggesting that some of the defects described were artefac-
tual, i.e. produced on dissection. This is plausible given the
technical challenges inherent in separating the vaginal mus-
cularis from the RVS proper.
A competent assessment of posterior compartment pro-
lapse by imaging can have substantial therapeutic conse-
quences. The overwhelming majority of women with
posterior compartment descent are treated with a simple pos-
terior colporrhaphy, a procedure that creates a scar plate
a b
Fig. 48.17  Posterior mesh repair (a, small arrows) usually ‘cures’ the
vaginal manifestation of rectocele. However, sometimes the rectocele
itself, i.e. the diverticulum of the rectal ampulla, is still sufficiently
a b
Fig. 48.18  Sonographic appearances on Valsalva, before (a) and 6  months after (b) defect-specific rectocele repair. A anal canal, B bladder,
R rectocele/rectal ampulla, S symphysis pubis (From [112], with permission)
597
between the vagina and anorectum, distorting and compress-
ing a true rectocele, enterocoele or intussusception, without
addressing the actual underlying abnormality. Even the use
of posterior compartment mesh may not be truly curative as
shown in Fig. 48.17 where a true rectocele is prevented from
developing into the vagina by an Apogee mesh. While the
posterior vagina now looks normal, neither the patient’s
symptoms of obstructed defecation nor the anatomical
abnormality are cured, since her rectocele now develops into
the perineum.
If a patient suffers from a symptomatic true rectocele,
then clearly a defect-specific rectocele repair should be the
surgical treatment of choice [41]. Figure 48.18 shows find-
large to cause symptoms, developing into the perineum rather than the
vagina (b, big arrow outlined by dots)
598 H. P. Dietz

ings before and 3  months after repair of a transverse RVS
defect. On the other hand, if posterior compartment descent
is due to a hyper-distensible fascia or perineal descent, plica-
tion of this fascia or even a levatorplasty may be a better
surgical option. Needless to say, it seems to make little sense
to remove portions of rectal wall as in the STARR (stapled
transanal rectal resection) procedure in someone who has a
herniation of the rectal wall due to a defect of the RVS, since
one would expect neither the rectocele nor the patient’s
symptoms to be cured.
Figure 48.19 demonstrates typical appearances of an iso-
lated enterocoele which tends to manifest clinically as post-­
hysterectomy vault prolapse. This is less common than a
combination of recto- and enterocoele. Both may also occur
in women with intact uterus. The contents of an enterocoele
are usually the small bowel and/or omentum which appears
iso-echoic and homogeneous, less often the sigmoid colon
which tends to be more inhomogeneous with hypo-­echogenic
aspects indicating bowel wall. Peristalsis is commonly
observed on real-time scanning.
The treatment of rectal intussusception (Fig. 48.20) is even
more controversial, although this is a controversy that gynae-
cologists are rarely exposed to since they are unlikely to diag-
nose the condition. Intussusception is even more strongly
associated with symptoms of obstructed defecation than recto-
cele [42] and is often associated with other manifestations of
prolapse. In the author’s unit, it has a prevalence of about 1:25.
A further complication may be the development of a lateral or
posterior rectocele due to severe damage to the levator plate;
this may also be considered a buttock hernia and is palpable on
digital rectal examination during Valsalva manoeuvre.
The standard approach to rectal intussusception is a recto-
pexy, either via a laparotomy or laparoscopically. This usu-
ally involves mesh and can be combined with a vault
suspension procedure. Another approach implemented in the
unit of the author is to utilize the RVS for an anterior vaginal

a b c

Aa

Ba

Bp D

Ap tvl

Fig. 48.19  Vault prolapse/enterocele on clinical photograph (a), representation on POP-Q (b; Ba = −3, D = +2.5, Bp = −1) and appearances on
imaging (c; B bladder, E enterocele, R rectal ampulla, S symphysis pubis) (From [109], with permission)

a b

Fig. 48.20  Intussusception with unusual posterior rectocele (arrow) in patient with severe obstructed defecation, bilateral avulsion and severe
ballooning. The distended ampulla with posterior sacculation is outlined in all three orthogonal planes in the midsagittal plane (a) and a rendered
volume showing the axial plane (b)
48  Transperineal Ultrasound: Practical Applications
rectopexy to the sacrospinous ligaments. This can conve-
niently be combined with a vault suspension and avoids
denervation of the rectum, a common consequence of open
or laparoscopic rectopexy procedures.
48.3.1.5 The Anal Sphincter
The external and internal anal sphincters are usually imaged
with endo-anal ultrasound [43] and MRI [44], which is particu-
larly useful in women with faecal incontinence and after obstet-
ric anal sphincter injury (OASI). These techniques are intrusive,
involving endo-anal placement of an ultrasound probe or
endocoil. Distortion of the anatomy is inevitable, which may be
one explanation why our textbook illustrations often seem so
different from observed anatomy on real-time ultrasound.
For different reasons, neither MRI nor endo-anal ultra-
sound allow dynamic assessment on manoeuvres, e.g. on
sphincter contraction. Exo-anal ultrasound imaging on the
other hand does not have these disadvantages. It was first
described by Peschers et al. in 1997 [44] and is now widely
used to image the anal sphincter using either endo-­vaginal or
transabdominal probe [45–48]. This method has been shown
to have good correlation with 2D endo-anal imaging [48] and
recently has been developed further using modern 4D trans-
ducers [49–53]. For a detailed overview of this novel tech-
nique, see [52].
For imaging of the anal canal, we use a standard curved
array volume transducer in the transverse or coronal plane,
i.e. perpendicular to the anal canal. The probe is inclined
quite steeply from ventrocaudal to dorsocranial to obtain a
coronal view of the anal canal (Fig. 6.3). Additional appli-
cation of gel in the midline is often beneficial to fill the
­gluteal fold. Imaging is performed on sphincter contraction
which seems to enhance the definition of muscular defects.
Figures 6.15–6.18 describe the basic methodology.
Fig. 48.21  Tomographic imaging of the anal sphincters. This is a comparison of (a) antenatal and (b) postnatal imaging, showing a 3b perineal
tear (asterisk) that was overlooked in the delivery suite
599
Figure 48.21 contrasts tomographic imaging (TUI) of a
normal anal sphincter on the left with the same sphincter
3 months after a vaginal delivery when it showed a signifi-
cant defect that had been overlooked immediately postpar-
tum; in the delivery suite, a second-degree perineal tear
had been diagnosed by the attending midwife. Even after
accurate diagnosis and primary repair of a major perineal
tear, a significant defect of the external anal sphincter
remains visible in 30–40% of patients [50], both in the
short term and many years later when over 50% of patients
are symptomatic [53].
Sonographically detected defects are associated with anal
incontinence, both after OASI repair [50, 53] and later in life
[51]. To quantify the extent of trauma, we determine the
number of abnormal slices, with > = 4/6 slices required for
the diagnosis of a ‘residual defect’ [52]. Another method is
to measure the defect angle as in Fig.  48.22; a cut-off has
empirically been set at 30°, although attempts at validating
defect angle have not been successful to date [54].
Translabial ultrasound of the anal sphincter is increasingly
used in research. Its simplicity and superior acceptance by
patients [55] will, much more so than in the case of more intru-
sive methods, allow incorporation into clinical practice. While
pain, oedema and the presence of suture material make imag-
ing difficult shortly after childbirth, exo-anal imaging is emi-
nently feasible within a very few days. Follow-up after
2–3 months, once the effect of potential neuropathy has sub-
sided, allows a final assessment of the quality of both diagno-
sis and treatment in the delivery suite. Establishment of
postnatal imaging services in the context of ‘perineal clinics’
is overdue as third-degree tears are ­frequently overlooked after
childbirth, with the experience of the personnel involved being
one of the main factors in the diagnosis [56], and as primary
repair is clearly insufficient in many cases [50, 53].
600
Fig. 48.22  Overlooked, unrepaired 3b tear with well-repaired episiotomy. The angle measurements illustrate quantification of this tear which
measures well over 30° in 5/6 slices
Figures 48.21–48.25 show different forms of residual
anal sphincter defects after vaginal delivery. In Fig. 48.22
there is evidence of a 3b tear that was not recognized at the
time of postnatal suturing of an episiotomy (see arrow).
Figure  48.23 demonstrates a poor result after end-to-end
repair, while Fig. 48.24 shows equally poorly reconstructive
results after an overlap repair. Even worse, Fig. 48.25 repre-
sents a rectovaginal fistula after a poorly repaired fourth-
degree tear. Due to increasing medicolegal and public
pressure, maternal trauma will likely become a key perfor-
mance indicator of obstetric services [57]. As regards ante-
natal and intrapartum research, future perinatal intervention
trials should include imaging of maternal trauma as an out-
come measure since maternal trauma is a common adverse
consequence of vaginal childbirth.
On a final note, occasionally one will encounter other
abnormalities which may at times interfere with identification
of the caudal margin of the internal anal sphincter. The latter
is, as mentioned in Chap. 6, important for reproducible slice
placement. Figure 48.26 is an inflamed, symptomatic haemor-
rhoid, while Fig. 48.27 shows what is likely an iatrogenic
defect of the internal anal sphincter after haemorrhoidectomy
repair, a not uncommon cause of post- haemorrhoidectomy
H. P. Dietz
anal incontinence. However, it has to be mentioned that such
abnormalities of the internal anal sphincter can at times be
observed in women without a history of surgical intervention.
48.3.1.6 Synthetic Implants
Synthetic implants have become popular for the surgical
treatment of stress urinary incontinence and since the
mid-­2000s also for POP. Over the last 5 years. There has
been a backlash due to novel complications such as
chronic pain and erosion, with substantial adverse public-
ity on social media and in the lay press. This is increas-
ingly leading to referrals for imaging of slings and meshes,
a task for which few imaging services are equipped or
trained.
While biological materials such as Surgisis or Permacol
tend to degrade over time and may not remain visible on any
imaging modality, this is not the case for implants made of
polypropylene and similar synthetic materials. Synthetic
sling and mesh implants are virtually invisible on MR, CT
and conventional X-ray but highly echogenic on sonographic
imaging. Ultrasound can confirm the presence of suburethral
slings (Figs. 48.28–48.34) and distinguish different types of
implants (see Fig.  48.29 for a transobturator sling) [58].
48  Transperineal Ultrasound: Practical Applications 601

Fig. 48.23  Poor reconstructive result after end-to-end repair of a 3c tear after forceps delivery

Fig. 48.24  Status after unsuccessful overlap repair of a 3c tear, showing substantial distortion and a marked perineal scar (arrows). The patient
was faecally incontinent
602 H. P. Dietz

Fig. 48.25  Small rectovaginal fistula 3 months after insufficiently repaired 3c tear. The fistula is a small filiform echogenic line, indicated by
arrows in two central slices. The two arrows in the top left-hand image indicate the longitudinal extent of the internal anal sphincter defect

Fig. 48.26  Inflamed haemorrhoid on tomographic imaging, indicated by arrows. Haemorrhoids can obscure the distal aspect of the internal anal
sphincter and sometimes even the external anal sphincter, interfering with the assessment
48  Transperineal Ultrasound: Practical Applications 603

Fig. 48.27  Status after haemorrhoidectomy in a 60-year-old patient with mild anal incontinence. The internal anal sphincter is invisible between
4 and 7 o’clock in most slices and thickened over the remaining circumference, possible iatrogenic trauma

a b

Fig. 48.28  Appearance of a typical suburethral sling (arrow) in the midsagittal plane at rest (a) and on maximal Valsalva (b). The line in (b)
demonstrates measurement of the sling- pubis gap. B bladder, R rectum, S symphysis pubis
604 H. P. Dietz

a b

Fig. 48.29  Suburethral slings are generally hyperechoic and easily wall to the other is clearly shown, demonstrating that the mesh remains
identified posterior to the urethra. On this image a Monarc transobtura- well outside the donut-shaped urethral rhabdosphincter (From [113],
tor tape is shown in the midsagittal plane (a) and in an axial rendered with permission)
volume (b). In the axial plane, the course of mesh from one pelvic side-

a b

Fig. 48.30  TFS (tissue fixation system) slings as seen in the midsagit- lapse. In (a) there is an implant under the trigone, and in (b) another is
tal plane in two different patients. The TFS has been used not just for found in the perineum. The latter is the most prone to erode and cause
urinary incontinence as a suburethral sling, which appears highly echo- chronic pain
genic and nondeformable (as seen in both a and b), but also for pro-

Standard ­polypropylene slings have a rather typical sono-
graphic appearance that changes under load as the implant is
deformed by interaction with surrounding tissues. More
densely woven tapes such as the IVS may be smaller and
harder to visualize or wider and less deformable, such as the
TFS (Fig. 48.31).
Suburethral slings all seem to act by direct, dynamic com-
pression under load, which is apparent on imaging, with the
sling changing from a linear to a c-shape [59]. Complications
due to excessive tensioning such as voiding dysfunction or
de novo symptoms of urgency and/or urge incontinence
commonly have a sonographic correlate in a tightly rolled-up
48  Transperineal Ultrasound: Practical Applications 605

a b

Fig. 48.31  ‘Tethered’ suburethral sling (TVT) in the midsagittal plane metry is perforation of the urehral rhabdosphincter on the patient’s left.
(a), the coronal plane (b) and the axial plane (c). The tape (arrows) The longitudinal smooth muscle does not seem to be affected. Such
seems unremarkable in (a), but in (b) it is apparent that it does not run placement is due to surgical error and may be asymptomatic. Its natural
symmetrically. In (c) it becomes obvious that the cause of this asym- history is unclear

a b

c d

Fig. 48.32  A TVT that has perforated the urethra as imaged in the midsagittal plane (a), the coronal plane (b), the axial plane (c) and a rendered
volume in the axial plane (d). Part of the tape on the patient’s right hand side has been removed
606
a b
c d
Fig. 48.33  Patient after TVT division due to de novo urgency, urge
incontinence and chronic mild obstruction. (a) shows the midsagittal
plane (A anal canal, B bladder, R rectal ampulla, S symphysis pubis,
U urethra). The arrow indicates the most likely location for a TVT, but
the tape is invisible in the midsagittal plane. (b) and (c) shows coronal
band that leaves only a small gap between the implant and
symphysis pubis, especially on Valsalva. This ‘sling-pubis
gap’ (Fig.  48.28) seems to be the most consistently useful
measure of ‘sling tightness’, with a gap of 8–14 mm on max-
imal Valsalva being rated as ‘normal’ [60]. An implant that is
seen as too close to the urethra, rigid and compressive, with
a low sling-pubis gap of less than 8 mm, will prompt the sur-
geon either to attempt dilatation/stretching of the sling if
identified within the first week or 10 days, or to undertake
sling division at a later stage.
In some instances slings are shown to be ‘tethered’, i.e.
placed deep to the fascia of the urethral rhabdosphincter and
therefore through the muscle rather than outside it, as shown
in Fig. 48.31. Occasionally, imaging will suggest perforation
and/or stenosis (Fig. 48.32). Sling division, a minor proce-
dure that may be performed under local anaesthetic, tends to
result in a 5–10 mm gap between mesh arms documenting
successful division as shown in Fig.  48.33. Rarely, faulty
sling placement will result in perforation and even transec-
tion of the urethra, and ultimately the implant may be found
in the space of Retzius (Fig. 48.34). Injectables are not used
H. P. Dietz
and axial views, with the two free tape ends indicated by arrows. The
gap between the two tape ends is also evident in the axial plane ren-
dered volume (d), with a gap between the cut ends of about 5–7 mm at
rest (Adapted from [114], with permission)
widely, but some materials such as Macroplastique (TM) are
echogenic and easily identified para-urethrally or under the
bladder neck (Fig. 48.35). However, appearances on imaging
are not predictive of treatment success.
Mesh implants used in prolapse surgery are another o­ bvious
indication for translabial ultrasound, and 3D/4D imaging with
sectional plane and rendering capabilities is particularly useful
in identifying polypropylene mesh implants (Figs.  48.36–
48.42) [61–63]. In the anterior compartment, mesh is com-
monly situated posterior to the bladder neck, caudal to the
trigone and the posterior bladder wall, visible as an echogenic
linear or curvilinear structure. Mesh can be identified in the
three orthogonal planes (Fig. 48.36) and also in rendered vol-
umes (Fig. 48.37).
A Valsalva manoeuvre often helps visualization and
shows mesh rotating around the fulcrum of the symphysis
pubis. More caudally placed transobturator meshes can act
like an oversized trigonal sling, rotating dorsocaudally.
Persistent prolapse of the central or posterior compartment
and distance from the transducer can impair visualization by
translabial imaging. While mesh shrinkage, contraction or
48  Transperineal Ultrasound: Practical Applications 607

Fig. 48.34  The final outcome of urethral tape erosion may not necessar-
ily be surgical removal. Occasionally the tape may erode through the
entire urethra to eventually be found in the space of Retzius, as in this
patient who had symptoms of the overactive bladder, voiding dysfunc-
tion and recurrent UTIs for years without being assessed or treated. (a)
This transobturator tape (arrow), 7 years after implantation, is now situ-
ated in the space of Retzius. (b–c) An orthogonal representation of imag-
ing shown here is particularly useful to define the spatial extent of
unusual para-urethral findings

a b

c d

Fig. 48.35  Macroplastique silicone macroparticles used in inconti- (a–c) and in a rendered volume (d). The implant is visible as a donut
nence surgery are very echogenic and found surrounding the urethra shape in c and d
both anteriorly and posteriorly, as shown both in the orthogonal views
608 H. P. Dietz

a b c

Fig. 48.36  Identification of anterior compartment mesh on Valsalva der, L levator ani, R rectum, S symphysis pubis (Modified from [59],
(a, midsagittal plane; b, coronal plane; and c, axial plane). Arrows show with permission)
mesh length in the midsagittal (a) and the coronal plane (b–c). B blad-

a b c

Fig. 48.37  Ultrasound images showing anterior mesh failure: (a) at the bladder neck, leading to dislodgement of the mesh from the bladder
rest; (b) on submaximal Valsalva manoeuvre; (c) on maximum Valsalva. base. B bladder; BN bladder neck, L levator ani muscle, R rectum, S
Cystocele recurrence ventral and caudal to a well-supported mesh sug- symphysis pubis, U urethra (From [60], with permission)
gests that the caudal aspect of the implant was insufficiently secured to

a b

Fig. 48.38  Translabial imaging of a transobturator anterior compartment mesh. The mesh (arrows) is seen posterior to proximal urethra and blad-
der neck in the midsagittal plane (a) and in a rendered volume in an oblique axial plane (b) (From [115], with permission)
48  Transperineal Ultrasound: Practical Applications 609

a b c

Fig. 48.39  Ultrasound images showing apical mesh failure: (a) at rest; nial mesh aspect suggests dislodgement of apical attachment. B blad-
(b) on submaximal Valsalva manoeuvre; (c) on maximum Valsalva. der, S symphysis pubis, U urethra (From [60], with permission)
Cystocele recurrence dorsal to the mesh with high mobility of the cra-

a b c

Fig. 48.40  Ultrasound images showing global mesh failure: (a) at rest; of the entire mesh on Valsalva, suggesting dislodgement of both lateral
(b) on submaximal Valsalva manoeuvre; (c) on maximum Valsalva. and apical attachments. B bladder, L levator ani muscle, R rectum, S
Cystocele recurrence behind the mesh is associated with high mobility symphysis pubis (From [60], with permission)

a b

Fig. 48.41  Midsagittal view (a) and axial plane rendered volume (b) despite severe levator ballooning evident in the axial plane (b) in this
in a patient after successful Perigee (P) and Apogee (A) implantation. patient with bilateral avulsion injury (Modified from [59], with
The midsagittal plane (a) demonstrates absence of prolapse on Valsalva, permission)

retraction is often considered as one of the causes of pelvic likely due to poor surgical technique and/or an excess of
pain after mesh repairs [64], this has been refuted by longitu- material, resulting in mesh folds during implantation or
dinal studies [62, 65]. The so-called mesh shrinkage is very immediately after closure [65].
610
a b
Fig. 48.42 (a) Suburethral sling (‘Monarc’) and posterior compart-
ment mesh repair (‘Apogee’) in a patient with clinical prolapse cure and
symptoms of obstructed defecation 6 months postoperatively. (b) A rec-
Prolapse recurrence after mesh use can be a particularly
vexing problem. In a recent study of recurrence after anterior
mesh repair [63], we identified three distinct anatomical situ-
ations: (1) anterior failure, cystocele ventral and caudal to a
mesh with intact anchoring; (2) apical failure, cystocele/
anterior enterocele/uterine prolapse dorsal and caudal to a
mesh with failure of apical anchoring and finally (3) global
failure, cystocele with high mesh mobility due to failure of
both apical and lateral anchoring mechanisms
(Figs. 48.38–48.40).
Most prolapse recurrence in this series was global or api-
cal (i.e. failure of apical and lateral anchoring). Only a small
minority showed anterior failures which suggest dislodg-
ment of the mesh from the bladder base, likely due to faulty
surgical technique [63]. This implies that most cases of cys-
tocele recurrence are ‘engineering’ problems rather than
issues of surgical technique. This is supported by the obser-
vation that dislodgment of mesh-anchoring structures is
associated with hiatal area on Valsalva [63]; the larger the
hiatus, the higher the loads placed on anchoring structures
such as transobturator arms and the higher the probability of
mechanical failure of load-bearing structures [66]. It should
not be difficult to come up with engineering solutions to the
problem of anchor dislodgment; unfortunately, research and
development in this field seems to have come to a halt due to
poor patient selection and unscrupulous marketing which
has provoked widespread medicolegal action. As a result,
many women have suffered complications such as chronic
pain and erosion without any conceivable benefit.
Unfortunately, ultrasound is largely useless in the evaluation
of these two main mesh complications.
Anterior compartment meshes, as long as they are
anchored effectively, result in superior anatomical outcomes,
especially in women with major levator tears [67, 68]. On the
H. P. Dietz
tal intussusception (I), which is due to an enterocele barred from devel-
oping into the vagina (A anal canal, L levator ani, R Rectum, S symphysis
pubis)
other hand, the evidence suggests that they are no more
effective and clearly more likely to lead to complications
than native tissue repair in the posterior compartment. They
may be encountered sonographically as hyperechogenic cur-
vilinear structures in the posterior vaginal wall (Figs. 48.41
and 48.42). Figure 48.42 shows an unusual complication in a
patient with post-­ hysterectomy vault prolapse who was
‘cured’ by a posterior compartment mesh. Postoperatively
she developed de novo obstructed defecation which on imag-
ing turned out to be an intussusception. Her enterocoele, pre-
vented from passing through and everting the vagina, now
inverts the rectal ampulla, trying to pass through the alternate
passage of the anal canal.
48.3.2 The Levator Ani
Axial plane imaging 3D/4D ultrasound has allowed the intro-
duction of axial plane imaging into clinical practice. This is
particularly useful for the assessment of the pelvic floor in the
narrower sense: the levator ani muscle and hiatus. Translabial
ultrasound has confirmed 60-year old, forgotten clinical data
[69, 70] and recent MRI studies [71] showing that major struc-
tural abnormalities of the levator ani muscle are common in
women who have given birth vaginally [3]. Most recent studies
use the methodology described in this chapter for the assess-
ment of such trauma and show a prevalence of 10–15% after
normal vaginal delivery, 10–20% after vacuum and 40–60%
after forceps delivery, with the highest prevalence after rota-
tional forceps; for an overview of prevalence, see [72].
Reproducible assessment of the levator ani muscle on
translabial 3D/4D ultrasound requires identification of the
plane of minimal dimensions, i.e. the minimal distance
between the interpubic disc ventrally and the anorectal angle
48  Transperineal Ultrasound: Practical Applications
dorsally (Fig. 48.43). This provides the reference plane for
standardized assessment both of the levator hiatus, the larg-
est hernia portal in the human body, and of the insertions of
the puborectalis muscle on the inferior pubic ramus, the
commonest location of major maternal birth trauma.
A defect of this muscle insertion is defined as ‘avulsion’,
due to the caudal aspects of the levator ani muscle, the
‘puborectalis’ or ‘pubococcygeus/pubovisceralis’ muscle,
being separated from the bone on which it inserts in a direct
muscle-bone ‘enthesis’. The only known mechanism for
such trauma is excessive distension of the muscle during
vaginal delivery at the time of crowning of the foetal head.
This trauma is most commonly occult as the vaginal skin and
muscularis layer tend to fail in a different location, together
with the perineal body. This frequently leaves the site of
avulsion covered by intact vagina, preventing discovery of an
avulsion, even if a vaginal haematoma may at times signal
major hidden trauma. It is not surprising therefore that it has
a b
Fig. 48.43  Measuring hiatal dimensions as shown in an oblique single
axial plane (a, b) and in a rendered volume (c, d). The determination of
hiatal dimensions using a single oblique axial plane is shown in (a) and
(b). The midsagittal plane on the left (a) demonstrates a line indicating
the minimal sagittal diameter of the hiatus, i.e. the location of the
oblique axial plane shown in (b). The region of interest (ROI) box in (c)
a b
Fig. 48.44  Typical right-sided levator avulsion injury was diagnosed
in the delivery suite after a normal vaginal delivery at term, (a) on 3D
ultrasound (b) and on magnetic resonance imaging (c) 3 months post-
611
taken clinical obstetrics so long to realize how common
major maternal trauma truly is, and how important for the
future life of the affected mother: avulsion is the primary
modifiable etiological factor in the pathogenesis of female
pelvic organ prolapse [72].
Figure 48.44 illustrates a comparison of clinical examina-
tion, axial plane rendered volume and MR imaging in a
patient with unilateral right-sided levator avulsion after a
normal vaginal delivery at term. The levator can in fact be
imaged with a 2D ultrasound—either with the help of a side-­
firing endocavitary probe or with an abdominal curved array
placed in a parasagittal orientation (Fig.  48.45) [73].
However, it is more convenient and much more reproducible
to use standard 3D/4D abdominal/obstetric probes placed on
the perineum in the midsagittal plane (Fig. 6.1). Using set-
tings similar to those for imaging a baby’s face, a rendered
volume, with the rendering direction set from distally to
proximally, results in images that rival MRI (Fig. 48.46).
c d
(approx. 1.8 cm deep) is located between the symphysis pubis and the
levator ani posterior to the anorectal angle. Image (d) represents a semi-­
transparent view of all pixels in the ROI box on the left. The dotted line
in (b) and (d) represents hiatal area measurements (23.05 cm2 in (b),
21.77 cm2 in (d)) (From [115], with permission)
c
partum. This patient was asymptomatic apart from deep dyspareunia
(From [115], with permission)
612 H. P. Dietz

a b

caudal
dorsal
Symphysis
pubis

Puborectalis muscle

Pelvic
sidewall

Fig. 48.45  Parasagittal view of the insertion of the puborectalis mus- transducer placement; (b) schematic line drawing of the principal struc-
cle on the pelvic sidewall. The image in (c) shows a normal insertion of tures seen in (c) (From [74], with permission)
the muscle, with the hyperechogenic muscle fibres clearly visible. (a)

Fig. 48.46  Right-sided avulsion in a patient with third-degree cysto- muscle contraction, showing a right-sided complete avulsion (asterisk).
cele and first-degree uterine prolapse. The midsagittal plane (a) shows A anal canal, B bladder, L levator ani, S symphysis pubis, U uterus. The
descent of bladder and uterus on Valsalva. (b) Tomographic representa- patient’s right side is represented on the left side of the slices
tion of the puborectalis muscle in the patient obtained on pelvic floor

Standardized evaluation of the levator ani is made possi- rently near impossible with other diagnostic modalities.
ble (and very simple) by the acquisition of volume data, i.e. Avulsion can be diagnosed in several different ways includ-
fan-shaped blocks of volume pixels or ‘voxels’, which is cur- ing palpation [74], but multislice or tomographic imaging
48  Transperineal Ultrasound: Practical Applications
(TUI) is probably the most reproducible and valid, [75–78],
and it correlates well with MR for the diagnosis of levator
trauma [79].
Figure 48.46 shows a typical right-sided complete avul-
sion of the puborectalis on tomographic imaging in a patient
with cystocele and stage 1 uterine descent, while Fig. 48.47
demonstrates a bilateral defect on TUI, complete on the right
and partial on the left. Incomplete defects do not seem to be
associated with prolapse or prolapse recurrence [80], which
means that the distinction between incomplete and complete
trauma, i.e. the definition of a ‘full avulsion’, is crucial.
Given the generally accepted 2.5 mm interslice interval for
pelvic floor tomography, the minimal criterion for a full
avulsion requires the three central slices in Figs. 48.46 and
48.47 to be abnormal [76]. This implies that slice location is
of the essence, and it is fortunate that the appearance of the
symphysis pubis allows standardization of slice location to
within 1  mm (Fig.  48.47). Care has to be taken, however,
with identification of the plane of minimal dimensions, as
Fig. 48.47  Tomographic imaging of the puborectalis, showing a com-
plete right-sided and partial left-sided avulsion. The required appear-
ance of the symphysis pubis (open on the left-central slice, closing on
613
omission of this step in the generation of a set of TUI slices
may result in false-positive findings in caudal slices. This
particularly affects women with a strong levator contraction
in whom warping of the levator plate from ventrocaudal to
dorsocranial may be quite marked.
If the appearance of muscle insertions on TUI is equivo-
cal due to partial trauma, scar tissue, limited image quality
or artefact, the ‘levator-urethra gap’ (LUG) (Fig.  48.48)
can be very useful in establishing a diagnosis, even if any
biometric measurement is of course subject to interethnic
and interindividual variation. It is therefore not surprising
that different cut-offs for a ‘normal’ LUG have been estab-
lished for Caucasians (2.5  cm) [81] and East Asians
(2.36 cm) [79]. The LUG has an equivalent on MRI [82]
and can be used as the only criterion for the diagnosis of
avulsion [83]. Usually, imaging for levator assessment is
performed on pelvic floor muscle contraction as this
enhances tissue discrimination, but TUI at rest seems to be
equally valid [84, 85].
the central slice and closed (invisible) on the right-central slice) is
shown by the arrows
614
Fig. 48.48  Illustration of the measurement of the levator-urethra gap (LUG) in the three central slices of a tomographic representation of the
puborectalis muscle. All measurements on the left (the patient’s right) are clearly abnormal, indicating a complete right-sided avulsion
Major delivery-related levator injury plays a substantial
role in the aetiology of female pelvic organ prolapse. Very
likely there are other factors, such as altered biomechanics of
intact muscle, fascial trauma and neuropathy. However, it is
clear that avulsion enlarges the levator hiatus [86], reduces
contractile strength [87] and is associated with prolapse,
especially in the anterior and central compartments [72, 88].
Levator defects seem to be the single strongest risk factor for
prolapse recurrence after reconstructive surgery [89–91],
which is not surprising since enlargement of the levator hia-
tus through whatever mechanism will necessarily result in
increased strain on any load-bearing structure [66].
Axial plane imaging of the levator ani muscle has not
just led to a rediscovery of avulsion as a central factor in the
pathogenesis of pelvic floor disorders; it has also made us
realize that prolapse is truly a hernia: a hernia of pelvic
organs through the largest potential hernia portal in the
human body, the levator hiatus. This triangular structure is
the most complex ‘defect’ in the abdominal wall as it is
crucial for the function of three vital organ systems: the
reproductive tract (intercourse and childbirth), the lower
urinary tract (elimination of liquid waste) and the lower
gastrointestinal tract (elimination of solid waste). Not sur-
prisingly, the pelvic floor in women is a compromise
between competing priorities. From an evolutionary point
of view, reproduction is of course the top priority, and it is
not surprising that pelvic floor disorders are common and
sometimes very difficult to treat.
The current functional anatomy of the female pelvic floor
is the result of rapid evolutionary change, with major differ-
ences in bony and soft tissue anatomy between our nearest
relatives, the simian primates and Homo sapiens. Over the
last 15 years, it has become evident that there are major inter-
individual and interethnic variations in dimensions and bio-
mechanical properties of the levator hiatus [92–94]. Such
international comparisons have become possible due to the
standardization of the assessment of hiatal dimensions by
axial plane pelvic floor ultrasound, first described in 2005
H. P. Dietz
[95] and since extensively validated against MRI [96] and
clinical examination [97, 98]. Repeatability is clearly excel-
lent [78, 99, 100].
In childbirth, the levator hiatus has to undergo a very sub-
stantial degree of distension [102, 103], which may result in
macroscopic trauma (avulsion) (see above) or irreversible
over-distension of the puborectalis muscle, i.e. ‘micro-
trauma’ [72]. Hiatal enlargement to 25  cm2 on Valsalva or
higher is defined as ‘ballooning’ on the basis of receiver
operator characteristics statistics [105] and normative data in
young nulliparous women [95].
Hiatal area can be assessed both in axial plane slices at the
plane of minimal hiatal dimensions or in rendered volumes
(see Fig. 48.43 for a comparison of the two methods). Since
the hiatal plane is non-Euclidean (warped rather than flat),
hiatal area measurements obtained in rendered volumes may
be more valid and more reproducible as well as easier to
obtain [105]. The degree of distension is strongly associated
with prolapse and symptoms of prolapse [106], and both
avulsion and ‘ballooning’ seem to be independent risk fac-
tors of female POP and POP recurrence after reconstructive
surgery [107, 108]. Most recently, it has become clear that
hiatal distensibility is the pathophysiological correlate of
‘vaginal laxity’ [109], a common and often misunderstood
complaint that can result in substantial bother, mainly
through its impact on sexual function [110].
48.4 Conclusions
Pelvic floor ultrasound imaging is a highly useful diagnostic
tool for physicians and researchers dealing with pelvic floor
disorders, especially since the introduction of 3D/4D ultra-
sound which allows simple, cheap and highly reproducible
assessment of the axial plane, and multislice or tomographic
imaging. The increasing ubiquity of such systems, new soft-
ware options, and the increasing availability of training will
likely lead to a more general acceptance of imaging as an
48  Transperineal Ultrasound: Practical Applications
integral part of the investigation of women with pelvic floor
disorders.
The issue of levator trauma, one of the most significant
developments in pelvic floor medicine, is taking pelvic floor
ultrasound into the mainstream of urogynaecology and will
enhance communication between the different clinical spe-
cialties dealing with such patients, such as urologists, gynae-
cologists, colorectal surgeons, physiotherapists and imaging
specialists. The method has great potential to improve not
just diagnostic but also therapeutic skills, and this is becom-
ing increasingly obvious.
Tomographic imaging of the anal sphincter and levator
ani will enable obstetricians to assess maternal birth trauma
with unprecedented ease and accuracy and at a minimal cost.
This will likely result in the establishment of maternal trauma
as a key performance indicator of obstetric services, a devel-
opment that is long overdue and likely to substantially
change obstetric practice.
Take-Home Messages
• Translabial ultrasound is the imaging method of
choice in the evaluation of pelvic floor disorders
such as urinary incontinence, defecation disorders,
anal incontinence and pelvic organ prolapse.
• 3D/4D imaging using volume transducers allows the
assessment of distinct abnormalities such as implants
or urethral diverticula in the orthogonal planes.
• Tomographic or multislice imaging has revolution-
ized the assessment of maternal birth trauma in the
form of levator avulsion and anal sphincter tears.
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84. Dietz HP, Pattillo Garnham A, Guzmán Rojas R.  Diagnosis
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85. van Delft K, Thakar R, Sultan AH, Kluivers KB. Does the
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88. Dietz HP, Steensma AB. The prevalence of major abnormalities of
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90. Weemhoff M, Vergeldt TF, Notten K, Serroyen J, Kampschoer
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 Three-Dimensional and Dynamic
Endovaginal Ultrasonography for Pelvic
Organ Prolapse and Levator Ani
Damage
Jonia Alshiek, Ghazaleh Rostaminia, Lieschen H. Quiroz,
and S. Abbas Shobeiri
Learning Objectives
• To describe three-dimensional (3D) endovaginal
sonographic anatomy of the pelvic floor structures.
• To understand the 3D endovaginal ultrasound
(EVUS) technique with transducer position and
image orientation and optimization.
• To provide overview of angles and measurements in
3D endovaginal pelvic floor ultrasound.
49.1 Introduction
49.1.1 Imaging Modalities for Endovaginal
Imaging
The pelvic floor is a complex three-dimensional structure,
with a variety of functional and anatomical areas. It consists
of a musculotendinous sheet that spans the pelvic outlet and
consists of paired levator ani muscle (LAM). It is broadly
accepted that the LAM consists of subdivisions that have
been characterized according to the origin and insertion
points, consisting of the pubococcygeal/iliococcygeal,
puborectal, and puboanal/puboperineal portions. Although
magnetic resonance imaging (MRI) descriptions of the pubo-
J. Alshiek
Department of Obstetrics and Gynecology, INOVA Health,
Falls Church, VA, USA
G. Rostaminia · L. H. Quiroz
The University of Oklahoma Health Sciences Center,
Oklahoma City, OK, USA
S. A. Shobeiri (*)
University of Virgina INOVA Campus, Department of Obstetrics
and Gynecology, INOVA Women’s Hospital,
Falls Church, VA, USA
e-mail: Abbas.shobeiri@inova.org
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_49
49
visceral included the puboperinealis, pubovaginalis, and
puboanalis (Fig. 49.1), more recent 3D EVUS literature uses
the term pubovisceralis to group iliococcygeus and pubococ-
cygeus together [1, 2]. Even though we use the term pubovis-
ceralis in this book, the term has caused much confusion,
and, where imaging allows, the terms pubococcygeus and
iliococcygeus should be used. The term pubovisceralis was
originally used because MRI could not delineate LAM sub-
divisions. Lateral to the pubovisceral muscle group is the
puborectal division, which forms a sling around and behind
the rectum, just cephalad to the external anal sphincter.
Lastly, the iliococcygeus division forms a flat, horizontal
shelf, spanning both pelvic side walls (Fig.  49.1) [3]. The
complex relationship of the LAM subdivisions could be
demonstrated to the learner by using one’s hands as a teach-
ing model (Fig. 49.2). The validity of 3D EVUS to visualize
LAM subdivisions has been established by meticulous ana-
tomic studies [2]. These subdivisions were localized in
cadaveric dissections (Figs. 49.3 and 49.4), then correlated
with images seen in nulliparous women, based on origin and
insertion points, and were shown to have excellent interob-
server reliability.
49.1.2 3D EVUS Technique for Levator Ani
Imaging
All the endovaginal and endoanal images in this chapter are
obtained from a Flex Focus scanner (BK Medical, Analogic,
Peabody, MA, USA) (Fig.  49.5). EVUS has been found a
valid method for visualization of the pelvic floor [4]. We rec-
ommend that the operator have a clear understanding of the
technique, as well as familiarity with the controls of the
machine. Most importantly, improper settings of the equip-
ment can lead to artifact.
Two 360° probes can be used interchangeably for endo-
vaginal levator ani imaging. The 2052 transducer (Fig. 49.6),
619
620
A B C D E F G H I J
PV
PR
IC
PP
STP
PA
1a 1b 2a 2b 2c 2d 3a 3b 3c 3d
Fig. 49.1  The relative position of levator ani subdivisions during ultra-
sound imaging. Levels 1–3 are identified below the figure. The A–J
markings on top of the figure correspond to the ultrasound images
shown in Fig.  49.5.5. Iliococcygeus (IC), puboanalis (PA), puboperi-
nealis (PP), superficial transverse perinei (STP) (Illustration: John
Yanson; From Shobeiri et al. [2], with permission)
which the probe originally introduced for colorectal imag-
ing, has a built-in 3D automatic motorized system (proximal-­
distal actuation mechanism is enclosed within the shield of
the probe). This equipment allows for the acquisition of 300
images in 60 s for a distance of 60 mm. The 8838 probe is a
60  mm 360° rotational transducer and obtains an image
every 0.55° for a total of 720 images (Fig. 49.7). The images
are acquired automatically with the touch of the 3D button
on the equipment console. The data from the closely spaced
2D images are combined as a 3D volume displayed as a data
volume that can then be stored and analyzed separately.
No special patient preparation is required and no vaginal
or rectal contrast is necessary. The patient is asked to keep
a comfortable amount of urine in the bladder. The patient is
placed on the dorsal lithotomy position, and the probe is
inserted in a neutral position, with care not to press on the
upper or lower vaginal areas so as not to distort anatomy.
J. Alshiek et al.
Fig. 49.2 The relative position of levator ani subdivisions using the
hand model. Although one’s hand works as a unit, each finger has a
distinct function. Just as with the hand, levator ani muscle (LAM) sub-
divisions have distinct functions. Using this analogy, losing one’s hand
is akin to LAM avulsion where muscles are torn from the pubic bone
attachment; losing one’s finger(s) is akin to LAM deficiency and dys-
function in individual LAM subdivisions. The thumbs form the anorec-
tum (AR), iliococcygeus (IC), perineal body (PB), pubic symphysis
(PS), puboanalis (PA), puboperinealis (PP), vagina (V). Anterior (A),
left (L), posterior (P), right (R). (© Shobeiri)
The probe should create a horizontal line with the body’s
axis. When placing the ultrasound gel in the probe cover,
we recommend for air bubbles to be gently squeezed out of
the probe cover, so as to minimize the potential for
artifact.
Once 3D endovaginal imaging is selected on the console,
the rotating crystal will begin to rotate, signaling that the
probe is ready for insertion. Based on our anatomic studies,
we recommend placing the probe 6 cm inside the vagina, just
2 cm above the level of the urethrovesical junction. If using
the 2052 probe, the two buttons that move the crystal cepha-
lad and caudad should be facing the 12 o’clock position.
Once the acquisition is started, it is important that the opera-
tor minimize movement by stabilizing the probe during the
full length of the scan. This will help optimize image quality
in obtaining the 3D volume (Fig. 49.8). We have character-
ized three levels for assessment of the axial plane [2]
(Fig.  49.1). Notice that these levels are different from
49  Three-Dimensional and Dynamic Endovaginal Ultrasonography for Pelvic Organ Prolapse and Levator Ani Damage
Fig. 49.3  Subgrouping of the pubococcygeus/iliococcygeus (PC),
puborectalis (PR), and the puboanalis/puboperinealis (PA) muscle
groups. The lines of actions of these muscle groups and their relative
contributions to the levator plate are shown. Anococcygeal ligaments
(ACL) and arcus tendineus fascia pelvis (ATFP) are shown. The blue
line is the puboperinealis; red, puboanalis; green, puborectalis; purple,
pubococcygeus/iliococcygeus Pubic symphysis (PS). (© Shobeiri)
Fig. 49.4  Gross cadaveric dissection. A needle is seen inserted into the
puboperinealis. Arcus tendineus fascia pelvis (ATFP), iliococcygeus
(IC), perineum (P), pubic bone insertion (PB), puboanalis (PA), pubo-
perinealis (PP), superficial transverse perinei (STP) (From Shobeiri
et al. [2], with permission)
DeLancey’s three levels of pelvic floor support [5] and are
used purely as reference points for looking at the levator ani
subdivisions in the axial plane.
• Level 1: Contains all the muscles that insert into the peri-
neal body, namely, the superficial transverse perinei
621
Fig. 49.5  BK Flex Focus ultrasound machine with a 2052 probe (BK
Medical, Analogic, Peabody, MA, USA)
(STP), puboperinealis, and puboanalis. The STP serves as
the reference point.
• Level 2: Contains the attachment of the pubovaginalis,
puboperinealis, puboanalis, puborectalis, and iliococcy-
geus to the pubic bone.
• Level 3: Contains the subdivisions cephalad to the infe-
rior pubic ramus, namely, the pubococcygeus and iliococ-
cygeus, which wing out toward the ischial spine.
Functionally, and based on the levator ani volume mea-
surements, we divide the muscles into (1) puboperinealis +
puboanalis [PA], (2) puborectalis [PR], and (3) pubococ-
cygeus  +  iliococcygeus [PC] (Fig.  49.3). By 3D EVUS
reconstruction of nulliparous subjects, PA, PR, and PC
groups had the volume of 4.4  cm3 (range 2.1–6.7  cm3),
4.2  cm3 (range 1.9–6.5  cm3), and 4.5 (range 2.2–6.8  cm3),
respectively. Although they have a wide range in volumes,
the proportions remain constant within the individual [6].
When analyzing a 3D volume caudad to cephalad, the first
structure to visualize as a landmark is the STP muscle
(Fig.  49.9). Visualization of this structure will consistently
point to the most caudad structure seen by the probe in the
vaginal canal. In normal nulliparous individuals, the external
anal sphincter may be visualized just below the STP. If using
the 2052 probe, there are two buttons located on the dorsal por-
tion of the probe handle used to move the rotating crystal cau-
dal or cephalad. By pressing the cephalad button, the rotating
622 J. Alshiek et al.

Fig. 49.7  BK 8838 transducer (BK Medical, Analogic, Peabody, MA,

USA)

Fig. 49.6  BK 2052 transducer (BK Medical, Analogic, Peabody, MA,

USA)

crystal can be slowly moved cephalad, and the p­ erineal body

and puboperinealis muscle come into view (Fig. 49.10). The
puboperinealis is hard to find consistently for the untrained
eyes, because it has perhaps less than 30 muscle fibers and lies
very close to the vaginal epithelium. At the same level but more
laterally are the fibers of the puboanalis that travel at a 45° to
surround the anal canal and insert into longitudinal fibers of the
anus at the level of the external anal sphincter (Fig.  49.11).
Continuing to move the crystal cephalad will show the puborec-
talis forming a sling around the rectum, and it can be followed Fig. 49.8  An endovaginal 3D volume at the level of puborectalis mus-
to its insertion into the inferior margin of the pubic symphysis cle hiatus in axial plane (© Shobeiri)
and the perineal membrane. Moving further cephalad will
show the medial relationship of the iliococcygeus muscle in its subdivisions in these scans were examined at levels 1, 2, and
medial relationship to the puborectalis (Fig. 49.12). 3 (Fig.  49.1). The visibility was scored by two blinded
The reliability of visualization of levator ani subdivisions observers. Interrater reliability was calculated by taking the
has been reported in nulliparous patients. The levator ani number of agreements and dividing by the number of obser-
49  Three-Dimensional and Dynamic Endovaginal Ultrasonography for Pelvic Organ Prolapse and Levator Ani Damage 623

Fig. 49.9  The most caudad muscle seen by 3D endovaginal ultrasound Fig. 49.11  The puboanalis (PA) lies just lateral to the puboperinealis
imaging is the superficial transverse perinei muscle, which is high- (PP), and they are part of the same functional groups. Anus (A), pubic
lighted. Anus (A), external anal sphincter (EAS), pubic symphysis (PS), symphysis (PS), transducer (T) (© Shobeiri)
transducer (T) (© Shobeiri)

a b

Fig. 49.10 (a) The scant fibers of the puboperinealis muscles (PP) are highlighted. (b) The perineal body (PB) is highlighted in the same axial
view as (a). Anus (A), perineal body (PB), puboperinealis (PP), pubic symphysis (PS), transducer (T) (© Shobeiri)

vations in the total number of subjects. There was 98%, 96%,
and 92% agreement for level 1, 2, and 3 muscles, respec-
tively. Cohen’s kappa index/standard error were calculated
for individual muscles as follows: STP and puborectalis
were seen by both raters 100%, puboperinealis 65%, pubo-
vaginalis, and puboanalis 65% (95% confidence interval
0.1–1), and iliococcygeus 90% (95% confidence interval
0.6–1).
In addition to visualization of the muscle subdivisions,
the interobserver and the interdisciplinary repeatability of
(1) levator hiatus length; (2) levator hiatus width; (3) levator
hiatus area; (4) LAM attachment to the pubic rami, on both
sides; (5) anorectal angle (ARA); and (6) urethral thickness
measurements using 3D EVUS have been established [7]. A
team of six investigators in three different specialties (urogy-
necology (UGN), radiology (RAD), colorectal surgery
624 J. Alshiek et al.

(CRS)) was formed. Each discipline included two investiga-
tors: UGN #1 and UGN #2; RAD #1 and RAD #2; and CRS
#1 and CRS #2. Prior to study initiation, a dedicated training
session was completed, and preliminary trial measurements
were performed. For the training session, an expert 3D reader
demonstrated to each of the readers the technique to be used
for measurements, including bony and soft tissue landmarks.
Readers discussed and refined the measurement technique
for each parameter until all readers were in agreement
regarding measurement methodology. In order to minimize
the effect of imaging variations on the final measurements, a
standardized protocol for review of the study data sets was
strictly defined and jointly approved by all investigators.
Each ultrasound volume was displayed in a symmetrical
orientation in the coronal, sagittal, and transverse planes and
assessed in standardized sequences. The overall interobserver
repeatability for levator hiatus dimensions was good to excel-
lent (ICC, 0.655–0.889), for urethral thickness was good (ICC,
0.624), and for ARA was moderate (ICC, 0472) (Table 49.1).
The interdisciplinary repeatability for levator hiatus indices
was good to excellent (ICC, 0.639–0.915), for urethral thick-
ness was moderate to good (ICC, 0.565–0.671), and for ARA
was fair to moderate (ICC, 0.204–0.434) (Table 49.2) [7].

49.2 Clinical Applications

Pelvic floor disorders are common, costly, and distressing

Fig. 49.12  The puborectalis (PR) is shown at its cephalad insertion
point to the pubic symphysis (PS). Note that PR has a wide insertion
area that includes the PS, and the perineal membrane, which is more
caudad. The iliococcygeus muscle (IC) fibers are seen medial to the
puborectalis fibers. Anus (A), transducer (T) (© Shobeiri)
conditions for women, resulting in greater than 300,000
operations per year, and leading to considerable suffering
from conditions not readily cured by surgery [8]. Fifty-five
percent of women with pelvic organ prolapse (POP) have

Table 49.1  Overall means and standard deviations (SD) of various measurements of individual readers
Urethral thickness
Observer LH length (mm) LH width (mm) LH area (cm2) (mm) ARA (degrees)
UGN #1 50.42 (SD: 4.18) 35.03 (SD: 3.50) 10.48 (SD: 1.51) 12.82 (SD: 1.6) 133.1 (SD: 12.3)
UGN #2 48.62 (SD: 4.87) 34.21 (SD: 3.30) 10.60 (SD: 1.31) 13.06 (SD: 1.41) 144.2 (SD: 7.03)
RAD #1 48.71 (SD: 4.84) 33.76 (SD: 3.50) 10.72 (SD: 1.70) 12.86 (SD: 1.73) 143.04 (SD: 12.5)
RAD #2 47.55 (SD: 5.62) 33.54 (SD: 3.32) 11.76 (SD: 1.35) 12.61 (SD: 1.32) 141.1 (SD: 7.99)
CRS #1 47.95 (SD: 4.20) 34.52 (SD: 3.38) 10.82 (SD: 1.60) 12.23 (SD: 1.77) 143.8 (SD: 9.97)
CRS #2 47.20 (SD: 4.05) 34.06 (SD: 2.96) 10.14 (SD: 1.60) 12.30 (SD: 1.44) 136.1 (SD: 5.94)
From Santoro et al. [6], with permission
ARA anorectal angle, CRS colorectal surgeon, LH levator hiatus, RAD radiologist, UGN urogynecologist

Table 49.2  Interobserver, intra- and interdisciplinary repeatability of three-dimensional endovaginal ultrasound parameters
LH length LH width LH area Urethral thickness ARA
Repeatability ICC 95% CI ICC 95% CI ICC 95% CI ICC 95% CI ICC 95% CI
Overall 0.655 0.509–0.794 0.889 0.822–0.940 0.810 0.707–0.894 0.624 0.472–0.772 0.331  0.179–0.528
Intradisciplinary
 UGN #1 vs. UGN #2 0.643 0.359–0.819 0.889 0.773–0.948 0.857 0.713–0.932 0.660 0.385–0.829 0.035 −0.339–0.402
 RAD #1 vs. RAD #2 0.717 0.473–0.860 0.981 0.958–0.991 0.893 0.781–0.950 0.601 0.298–0.795 0.569  0.252–0.777
 CRS #1 vs. CRS #2 0.883 0.761–0.945 0.910 0.815–0.958 0.887 0.770–0.947 0.735 0.501–0.869 0.216 −0.167–0.544
Interdisciplinary
 RADs vs. CRSs 0.677 0.514–0.815 0.915 0.855–0.956 0.831 0.724–0.909 0.651 0.482–0.798 0.434  0.241–0.639
 RADs vs. UGNs 0.639 0.467–0.790 0.897 0.826–0.946 0.851 0.755–0.921 0.565 0.380–0.739 0.327  0.139–0.549
 UGNs vs. CRSs 0.694 0.536–0.826 0.874 0.790–0.934 0.783 0.656–0.882 0.671 0.506–0.811 0.204  0.032–0.431
From Santoro et al. [6], with permission
ARA anorectal angle, CI confidence interval, CRS colorectal surgeon, ICC interclass correlation coefficient, LH levator hiatus, RAD radiologist,
UGN urogynecologist
49  Three-Dimensional and Dynamic Endovaginal Ultrasonography for Pelvic Organ Prolapse and Levator Ani Damage 625

visible major LAM damage compared to 15% of women ratios for LASR indicated positive and statistically signifi-
with normal support, making it the strongest known factor to cant associations with all obstetric outcomes examined. The
be associated with both vaginal birth and POP [9]. The abil- probability of the LASR correctly classifying those with the
ity to diagnose injury to the LAM relies on advancements in adverse obstetric outcome, as estimated by the area under the
imaging. Levator ani avulsion as imaged by transperineal curve, ranged from 0.64 to 0.80 with the strongest discrimi-
ultrasound appears to double the risk of any significant ante- natory ability observed for severe LAM trauma. We con-
rior and central compartment prolapse [10]. cluded that fetal head circumference/mother MLHC ratio
(HISR) is associated with longer length of second stage of
labor, assisted delivery, and increased severity of perineal
49.2.1 Prevalence of Pelvic Floor Injury trauma. Similar associations were observed for LASR, but in
Following Vaginal Delivery addition, LASR had good discriminatory ability to identify
severe LAM trauma (Table 49.7.) [17].
During parturition, the levator ani muscle (LAM) stretches
beyond its limits in some women [11] in order to allow pas-
sage of a term infant [12]. Researchers have calculated maxi- 49.2.2 Levator Ani Injury and Hematomas
mum stretch ratios of 2.28–3.26 of the levator muscle.
However, striated muscle in nonpregnant animals allows a There are various definitions of levator ani injury, according
maximum stretch ratio of only 1.5 [13]. Interestingly, as all to mode of assessment and imaging modality. Most authors
women sustain overstretching of the pelvic floor, only have used avulsion of the muscles as the end point of the
some  will have levator trauma. Alperin et  al. studied study. However, more recent publications using 3D EVUS
­pregnancy-­induced adaptations in the pelvic floor muscles of have found that up to 50% of women may have hematoma
rat models [14]. They demonstrated that the changes in pel- formation after their first delivery (Fig. 49.13). Assessment
vic floor muscles occur by adding sarcomeres to increase
muscle fiber length. The largest change in muscle fiber length
occurred in the muscle known to have the shortest fibers,
namely, the coccygeus muscle of the levator ani. Furthermore,
they found a substantial increase in extracellular matrix. This
increase in extracellular matrix is thought to provide addi-
tional support to the coccygeus muscle [14].
Studies have shown that LAM injury occurs in 13–36% of
women who deliver vaginally [15]. There are various defini-
tions of levator ani injury, according to mode of assessment and
imaging modality. Furthermore, timing of ultrasound assess-
ment following delivery can impact on the incidence of LAM
injury. Most authors have used avulsion of the muscles as the
end point of the study. However, (3D) EVUS has found that up
to 35% of women may have hematoma formation shortly after
their first vaginal delivery [16]. Assessment of the levator mus-
cles is essential for a complete understanding of pelvic floor
anatomy abnormalities, as well as of pelvic floor dysfunction.
There have been many studies that have investigated pre-
dictive modeling of vaginal birth-induced LAM injury. In
our study of the predictive role of obstetric variables for
obstetric outcomes and birth-related levator ani muscle
(LAM) trauma, we evaluated minimal levator hiatus circum-
ference (MLHC) and the ratio of fetal head circumference to
MLHC = head-induced stretch ratio (HISR) as an indicator
of the discrepancy between passage and passing canal. To
derive the true impact of baby’s mass on the levator ani mus-
culature, we devised the levator ani stretch ratio (LASR),
which was calculated by multiplying the HISR and the Fig. 49.13  Schematic representation of the 3D endovaginal ultrasound
image in the axial plane of the minimal hiatal dimensions. The landmarks
baby’s weight. Mean HISR and LASR values were
are visible: pubic bone (PB), urethra (U), vagina (V), anal canal (A), leva-
­statistically different across all binary outcome categories, tor ani muscle (L). The asterisk represents a right levator ani muscle hema-
with one exception for HISR and levator ani injury. The odds toma in the immediate postpartum (© Shobeiri)
626
of the levator muscles is essential for a complete understand-
ing of pelvic floor anatomy abnormalities, as well as of pel-
vic floor dysfunction.
It has been accepted that obstetric trauma is the main etio-
logical factor in the development of LAM avulsion. As
stated, trauma can occur by stretching of the inner part of the
LAM (namely, the pubococcygeus part of the muscle), and
by disconnection of its insertion from the inferior pubic
ramus and the pelvic side wall [11]. A recent review found a
13–36% incidence of LAM avulsion following the first vagi-
nal delivery [18]. Overall, the highest incidence (39.5%) was
found in a prospective study where women were seen in the
early postpartum period, using transperineal ultrasound. The
authors attributed this higher incidence to the difficulty in
differentiating fluid collections from LAM avulsion [19]. In
our opinion, they used transperineal ultrasound, which is less
discriminatory for the different parts of the LAM. Another
more recent study evaluated the LAM shortly after childbirth
using EVUS in a prospective study [16]. A total of 114
women underwent EVUS early postpartum. In 27 women
(23.7%), the investigators found well-delineated, hypoechoic
areas consistent with hematomas (Fig. 49.14). Importantly,
Fig. 49.14  Schematic representation of the 3D endovaginal ultrasound
image in the axial plane of the minimal hiatal dimensions. The land-
marks are visible: pubic bone (PB), urethra (U), vagina (V), anal canal
(A), levator ani muscle (L). Part 1: the asterisk represents a bilateral
hematoma in the muscles. Please note that the attachments to the pubic
J. Alshiek et al.
there was 100% agreement between the investigators for the
presence of a hematoma. Hematomas away from the LAM
attachment zone to the pubic bone resolved. Hematomas that
were found at the area of attachment of the pubococcygeus
part of the LAM to the pubic bone manifested as pubococ-
cygeus avulsions 3  months postpartum. Hematomas were
significantly associated with episiotomy, instrumental deliv-
ery, and increased hiatal measurements. Palpation of LAM
avulsion, according to a previously described protocol [20],
was unreliable early postpartum, as only seven avulsions
were diagnosed using the finger as an instrument.
In an additional, smaller, group of women, the investiga-
tors did not find hematomas but avulsion of the pubococ-
cygeus part of the LAM in the early postpartum period. The
overall incidence of LAM avulsion was 12.0% 3  months
postpartum. The authors therefore concluded that hemato-
mas in the pubococcygeus part of LAM, where it is sup-
posed to be attached to the pubic bone, always result in
avulsion diagnosed 3  months postpartum. On the other
hand, one third of avulsions confirmed at 3 months postpar-
tum are not preceded by a hematoma at the site of LAM
attachment to the pubic bone but could be seen as an avul-
bone remain intact within a few hours following vaginal delivery. Part
2: the asterisk represents a bilateral postpartum defect where the levator
ani muscle hematomas used to be, in the same patient, 3 months follow-
ing delivery (From van Delft [16])
49  Three-Dimensional and Dynamic Endovaginal Ultrasonography for Pelvic Organ Prolapse and Levator Ani Damage
sion in the early postpartum period [16]. The authors specu-
lated that a hematoma is formed when muscle is torn away
from the tendinous attachment. However, no hematoma is
formed when the tendon or pubovisceral enthesis is avulsed
from the pubic bone, due to the avascular nature of the
trauma [21]. The resolution of hematomas at or away from
the attachment zone of LAM to the pubic bone directs to the
body’s ability to heal itself [22].
49.2.3 Levator Ani Avulsion
Levator ani avulsion injury was originally defined as “a dis-
continuity between the inferior pubic rami and the puborecta-
lis muscle” by perineal pelvic floor ultrasound. A complete
defect was diagnosed if the reference slide and slices 2.5 mm
and 5 mm cranial to it showed a sonographic defect [10]. The
authors also described a scoring system where defects were
scored according to the number of slices in which a disconti-
nuity of the muscle with the pelvic side wall was documented,
with a minimum score of 0 and a maximum score of 16 in a
patient with complete bilateral avulsion [23]. Levator avul-
sion diagnosed by transperineal ultrasound appears to double
the risk of significant anterior and central compartment pro-
lapse, with less effect on posterior compartment prolapse
[10]. Using MRI, DeLancey et  al. described levator ani
defects and scored left and right muscle defects separately. A
score of 0 was assigned if no damage was visible, 1 if less
than half of the muscle was missing, 2 if more than half, and
3 if the complete muscle bulk was lost. The total score was
the sum of both sides, ranging from 0 to 6 and categorized as
follows: 0, normal or no defect; 1–3, minor defect; and 4–6,
major defect [9]. Miller et al. described a muscle tear if fibers
were absent in at least one 4 mm section or two or more adja-
cent 2 mm sections in both the axial and coronal planes, rated
for both sides separately. They also distinguished between
subtle (equivocal muscle fiber loss), low-­grade (muscle fiber
loss of <50%), and high-grade tears (muscle fiber loss >50%)
[24]. Obstetric levator avulsion is an important risk factor for
prolapse. In a study of vaginally parous women with or with-
out levator avulsion, 5–15 years after delivery, using perineal
three-dimensional pelvic floor ultrasound, levator avulsion
was identified in 15% (66/453) patients. A history of forceps-
assisted delivery was strongly associated with levator avul-
sion (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 gen-
ital 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. Forceps-assisted birth was an important marker for
levator avulsion but may not be an independent risk factor for
627
the development of pelvic muscle weakness or changes in
hiatus size in the absence of levator avulsion [25]. In the same
cohort of patients estimating the cumulative incidence of pro-
lapse and other pelvic floor disorders (PFDs), comparing
vaginally parous women with and without levator avulsion,
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% confi-
dence 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 inconti-
nence were marginally (but not significantly) increased
among women with levator avulsion in this cohort. The
authors concluded that the relationship between levator avul-
sion and other PFDs may not be significant [26].
49.2.4 LAD: Levator Ani Deficiency Score
as a Measure of Levator Ani Atrophy
Unlike the terms “defect” and “avulsion,” which may imply
an all-or-none phenomenon, the term “LAD” implies a mea-
surable gradient. While documenting the presence or absence
of injury is important, LAM damage after childbirth, leading
to symptomatic pelvic floor disorders or a decrement in mus-
cle strength, may depend on the location and severity of the
injury. Identifying the specific location and severity of
defects in LAM subdivisions may help to correlate specific
defects to corresponding clinical findings, providing further
insight into the form and function of this complex muscle
group. Recent imaging has pointed to the pubococcygeus
insertion of the levator ani as the most often avulsed portion
of the LAM group (Fig. 49.5) [27]. Besides avulsion that in
average occurs in 15% of women, another 28.5% suffer from
irreversible overdistention [28].
49.2.5 Scoring System
A LAD scoring system to grade levator injury has been
developed according to the morphology and clarity of each
subdivision’s origin-insertion points, scored unilaterally.
This is analogous to the scoring system used in MRI [29].
Subgroups were evaluated and were scored (0, no defect; 1,
minimal defect with ≤50% muscle loss; 2, major defect with
>50% muscle loss; 3, total absence of the muscle) on each
side based on thickness and detachment from the pubic bone
(Table 49.3). Each muscle pair score ranged from 0, indicat-
ing no defects, to maximum score of 6, indicating total mus-
cle absence. For the entire LAM group, a cumulative LAD
score that ranged between 0 and 18 was possible. Scores
were categorized as 0–6, mild (Fig. 49.15); 7–12, moderate
(Fig. 49.16); and >13, severe deficiency (Fig. 49.17) [30]. All
the correlation coefficients at the individual sites as well as
628 J. Alshiek et al.

Table 49.3  Endovaginal ultrasound validated scoring system for levator ani muscle deficiency (LAD)
0 (no muscle 1 (mild 2 (moderate 3 (complete Subtotal Total
Score damage) abnormality) abnormality) muscle loss) 0–3 0–18
(L) Puboanalis (PA + PP)
(R) Puboanalis (PA + PP)
(L) Puborectalis
(R) Puborectalis
(L) Pubovisceralis (IC + PC)
(R) Pubovisceralis (IC + PC)
IC iliococcygeus, L left, PA puboanalis, PC pubococcygeus, PP puboperinealis, R right

Fig. 49.15  3D ultrasound volume of a normal nulliparous woman with

levator ani deficiency score of 0. Anus (A), puboanalis (PA), puborecta-
lis (PR), pubic symphysis (PS), pubococcygeus (PV), urethra (U),
vagina (V) (From Rostaminia et al. [30], with permission)
Fig. 49.17  The axial view of pelvic floor muscles with severe levator
ani muscle deficiency. Asterisk denotes a missing muscle, and numbers
are muscle scores. Anus (A), puboanalis (PA), puborectalis (PR), pubic
symphysis (PS), pubovisceralis (PV), vagina (V) (From Rostaminia
et al. [30] with permission)

Table 49.4  Distribution of stages of prolapse and associated total

levator ani deficiency (LAD) scores
n (%) LAD score (median, range) p Valuea
Stage 0 50 (22.7) 6 (0, 18) <0.001
Stage 1 57 (25.9) 8 (0, 18)
Stage 2 60 (27.3) 10 (0, 18)
Stage 3 43 (19.6) 14 (6, 18)
Stage 4 10 (4.6) 13 (9, 18)
From Rostaminia et al. [30], with permission
a
Based on Kruskal-Wallis test results

the overall scores were positive at above 0.63 and significant

Fig. 49.16  The axial view of pelvic floor muscles with moderate leva-
tor ani muscle deficiency. Asterisks denote a missing muscle and num-
bers are muscle scores. Anus (A), puboanalis (PA), puborectalis (PR),
vagina (V) (From Rostaminia et al. [30], with permission)
at <0.0001 level [31].
In a study to evaluate if there is a LAD threshold above
which prolapse occurs, 220 patients were analyzed.
Table 49.4 [12] shows the distribution of stages of prolapse
and associated LAD scores. Kruskal-Wallis test demon-
strated that the distribution of scores significantly differed by
stage of prolapse (p < 0.0001). The distribution of LAD sta-
49  Three-Dimensional and Dynamic Endovaginal Ultrasonography for Pelvic Organ Prolapse and Levator Ani Damage 629

tus (mild, moderate, severe) was also significantly different
between stages of prolapse (Table 49.5). A moderate positive
correlation was demonstrated between LAD score and stage
of prolapse (rs  =  0.44, p  <  0.0001). When trying to find a
threshold of LAD above which vaginal prolapse developed,
no subjects with stage 3 prolapse had a score lower than 6,
and no subjects with stage 4 prolapse had a LAD score lower
than 9 (Fig. 49.18). While all patients with stage 3 and 4 pro-
lapse had moderate to severe LAD, in the group of patients
with no prolapse, there were 15.2% with moderate and 9.2%
with severe LAM deficiency. The frequency of severe LAD
increased progressively with increasing stage of POP-Q
(Fig. 49.19). Final adjusted logistic regression demonstrated
a significant relationship between LAD score and the pres-
ence of clinically significant POP (Table  49.6). Likelihood
ratio, c-statistics, and Hosmer-Lemeshow goodness of fit
tests each indicated excellent model fit (Table  49.6,
those with severe LAD have 6.44 times the odds of signifi-
cant POP than those with minimal deficiency. Thus, worsen-
ing LAD scores as identified by 3D EVUS is a predictor of
clinically significant POP [30]. From a biomechanical per-
spective, these data are important, since pelvic floor support
provided by these muscles will be weak, and the load will
shift from the deficient muscles to the supportive connective
tissues and cause their failure [13]. However, two women
with identical levator ani defects may present with different
POP presentations. Finite element modeling has demon-
strated that, in addition to LAM deficiency, development of
prolapse, such as a cystocele, also requires an increase in
abdominal pressure and apical and paravaginal support
defect [32].
Mild Moderate Severe

Patients with levator ani deficiency (%)

Fig. 49.20). After controlling for age, parity, and menopausal 100
status, patients with a moderate LAD have 3.2 times the odds 90
of significant POP than those with only minimal deficiency; 80
70
60
50
Table 49.5  Severity of levator ani deficiency (LAD) by compartment 40
and stage of prolapse 30
20
Minimal LAD Moderate LAD Severe LAD 10
n (%) n (%) n (%) p Value 0
Stage 0 32 (42.1) 12 (15.2) 6 (9.2) <0.001a 0 1 2 3 4
Stage 1 22 (29.0) 24 (30.4) 11 (16.9) Stage of prolapse
Stage 2 16 (21.1) 27 (34.2) 17 (26.2)
Fig. 49.19  Bar chart for stage of prolapse and levator ani (LA) score
Stage 3 6 (7.9) 11 (13.9) 26 (40.0)
frequency. Y axis denotes the percentile of patients with mild, moderate,
Stage 4 0 (0.0) 5 (6.3) 5 (7.7) or severe LA deficiency. X axis denotes the stage of prolapse as deter-
From Rostaminia et al. [30], with permission mined by POPQ staging system (From Rostaminia et  al. [30], with
Based on chi-square test
a
permission)

Fig. 49.18  Scatter plot of stage of 4

prolapse and cumulative LA score
(From Rostaminia et al. [30], with
permission)

3
Stage of Prolapse

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Cumulative LA Score
630 J. Alshiek et al.

49.2.6 Changes of Levator Ani with Aging pelvic floor structures and function in the absence of child-
birth trauma [34]. The role of age as a factor impacting pos-
Injuries to the LAM after a vaginal delivery are associated sible age-related abnormalities in nulliparous women is
with difficult vaginal birth and with older age [32, 33]. Age understudied (Table 49.7.).
is commonly cited as a risk factor for developing prolapse; It is not known whether atrophic changes related to age
however, few studies have examined the effect of aging on will affect the visualization of the LAMs, or mimic defects.
This is important because the thickness of normal muscles
Table 49.6 Severity of LA deficiency by clinically significant varies among nulliparous women [35]. We performed a study
prolapse to evaluate the visibility of LAMs in 80 community-dwelling
Minimal Moderate Severe nulliparous women. Unilateral and bilateral levator ani
defect defect defect ­subdivisions were scored according to the LAD scoring sys-
n (%) n (%) n (%) p Valuea tem described above (Fig. 49.21). Two observers read all the
Stage 0–1 54 (71.1) 36 (45.6) 17 (26.2) <0.0001 ultrasound cubes. The resulting exact agreement for bilateral
Stage 2–4 22 (29.0) 43 (54.4) 48 (73.9) scoring of each levator ani subdivision ranged from 82 to
From Rostaminia et al. [30], with permission 84% [36]. There was no correlation between increasing age
Based on chi-square test
a
and total LAM scores (r = 0.20, p = 0.072). We found high
levels of agreement among observers in assessing 3D EVUS
Model (defect, age, parity, scans of LAM subdivisions of nulliparous women of differ-
menopausal status): 0.8388 ent ages, suggesting that age alone does not significantly
Levator ani defect: 0.7165 impact reliable visualization of the LAM on 3D EVUS
Age by decade: 0.7804 (Fig. 49.22).
Defect, age, parity: 0.8371

49.2.6.1 L  evator Plate Descent Angle

1.00 and Minimal Levator Hiatus
It is known that the normal shape of LAMs become dis-
torted with different degrees of prolapse. Despite the asso-
0.75
ciation between prolapse and levator damage, there are
women with prolapse who do not have levator defects and
women with normal support who do have levator defects
[37]. The minimal levator hiatus (MLH) dimensions, leva-
Sensitivity

0.50 tor plate angle (LPA), iliococcygeal angle, and ARA have
been used for assessing the impact of levator damage on
static and dynamic MRI imaging features [38, 39]. The
puborectalis muscle is recognized as one of the compo-
0.25
nents of the levator ani that forms the vaginal high pressure
zone [40].
The puborectalis muscle is commonly thought to undergo
0.00 injury during vaginal childbirth, in the form of avulsion from
its insertion on the pubic ramus [33, 41, 42]. There had been
0.00 0.25 0.50 0.75 1.00 no argument on what constitutes an avulsion, mainly because
1-Specificity it was thought that the puborectalis is the muscle injured.
Avulsion of muscles from the pubic bone is known to have a
Fig. 49.20  Receiver operating characteristic (ROC) curve for com-
marked effect on levator dimensions [43]. The MLH, which
parison (From Rostaminia et al. [30], with permission)

Table 49.7.  AUC and 95% CIs for measures assessed as predictors of delivery outcomes and severe pelvic floor trauma
HISR AUC LASR AUC Head circumference, MLHC AUC Birth weight
Delivery outcome (95% CI) (95% CI) AUC (95% CI) (95% CI) AUC (95% CI)
Second stage of labor 0.70 (0.61–0.79) 0.68 (0.60–0.77) 0.60 (0.50–0.71) 0.65 (0.56–0.75) 0.57 (0.48–0.67)
>90 min
Assisted delivery 0.68 (0.60–0.76) 0.66 (0.57–0.74) 0.62 (0.53–0.70) 0.63 (0.55–0.72) 0.57 (0.49–0.66)
Third-/fourth-­degree 0.75 (0.64–0.86) 0.75 (0.64–0.86) 0.61 (0.48–0.75) 0.70 (0.58–0.82) 0.65 (0.51–0.78)
laceration
Episiotomy 0.69 (0.61–0.77) 0.67 (0.59–0.75) 0.61 (0.53–0.70) 0.63 (0.55–0.72) 0.58 (0.49–0.66)
Extreme LAD 0.67 (0.48–0.87) 0.80 (0.66–0.94) 0.62 (0.34–0.90) 0.66 (0.40–0.92) 0.74 (0.51–0.99)
HISR head induced stretch ratio, LASR levator ani stretch ratio, MLHC minimal levator hiatus circumference
49  Three-Dimensional and Dynamic Endovaginal Ultrasonography for Pelvic Organ Prolapse and Levator Ani Damage 631

Fig. 49.21  The levator ani

deficiency scoring GRADE 0 GRADE 1 GRADE 2 GRADE 3

LDA 0 1 2 3
No muscle loss

Muscle loss
<50% thickness
Muscle loss
>50% thickness

Total muscle loss

The score for left PA + Right PA + Left PR + Right PR + Left PV + Right PV = Total score 0-18

Fig. 49.22  Bland-Altman plot Difference Plot

showing mean difference of 20
measurements between readers Identity
(From Quiroz et al. [36], with
permission) 15 Bias (0,4)

95% Limits of agreement

Difference (R(2) - 0 - R(1) - 0)

10
(-7,5 to 8,3)

-5

-10

-15
-5 0 5 10 15 20 25
Mean of All

is the smallest fibromuscular dimension of the pelvic floor Due to variations in terminology, the borders of the MLH
outlet, is thought to be made of levator fibers. had not been consistently defined in the literature. The bor-
ders of the MLH have been described in detail using 3D
632
Fig. 49.23  Anorectal angle in midsagittal view by transvaginal 360°
ultrasound. Anterior (A), anal axis (AA), bladder (B), caudad (C), leva-
tor plate (LP), perineal body (PB), pubic symphysis (PS), rectal axis
(RA), urethra (U), vagina (V) (From Shobeiri et al. [44]. © Shobeiri)
Fig. 49.24  Shortest line between pubic symphysis and levator plate in
right midsagittal view by 3D endovaginal ultrasound; anterior (A),
bladder (B), cephalad (C), levator ani muscle (LAM), levator plate
(LP), posterior (P), pubic symphysis (PS), rectum (R), transducer (T),
urethra (U) (© Shobeiri)
EVUS [44]. 3D ultrasounds in this study were first performed
in fresh frozen cadavers, and structures were then confirmed
in cadaveric dissections. Excellent interobserver and inter-
J. Alshiek et al.
Fig. 49.25  The axial plane is rotated posteriorly and was advanced
cephalad parallel to the shortest line between pubic symphysis (PS) and
levator plate. (© Shobeiri)
disciplinary reproducibility of 3D EVUS in measuring leva-
tor hiatus dimensions has been previously reported [7].
We measured the MLH area, puborectalis area, anorectal
angle (ARA), and levator plate descent angle (LPDA). We
used the midsagittal view to measure the ARA, defined as the
angle between the rectal and anal canal axis (Fig.  49.23)
[44]. The ARA can be measured in the midsagittal plane as
the angle formed by the longitudinal posterior border of the
anal canal and the posterior rectal wall. The posterior
walls  may be obscured at times due to presence of gas in
the rectum. We located the shortest distance between pubic
symphysis and the levator plate, which formed the anterior-
posterior (AP) diameter of the MLH. To obtain MLH we first
draw a line between the pubic symphysis and the most ante-
rior point on the levator plate (Fig. 49.24). The MLH is not
in the axial plane. This is the strength of the BK software, as
it can easily tilt the plane to become parallel to the MLH
(Fig. 49.25), and once the 3D volume is expanded, the full
MLH comes into view (Fig. 49.26). To obtain correct mea-
surements, the observers should recognize the pubic sym-
physis and the anal canal for an appropriate AP orientation of
the image. In this plane, the levator ani was visualized as a
multilayer hyperechoic sling coursing lateral to the vagina
and posteriorly to the anal canal and attaching to the inferior
pubic rami. The plane of minimal hiatal dimensions can be
identified as the minimal distance between the inferior edge
of the pubic symphysis and the anterior border of the levator
ani at the ARA.  In order to ensure that the minimal hiatal
49  Three-Dimensional and Dynamic Endovaginal Ultrasonography for Pelvic Organ Prolapse and Levator Ani Damage 633

Fig. 49.26  The midsagittal plane was expanded to make the whole
volume visible. Levator ani muscle (LAM), pubic symphysis (PS), rec-
tum (R), transducer (T), urethra (U) (© Shobeiri)

dimensions are found, the axial and sagittal planes should be

carefully observed. The area of the levator hiatus can be cal-
Fig. 49.27  Levator plate descent angle in midsagittal view by trans-
culated as the area within the levator ani inner perimeter vaginal 360° ultrasound. Anterior (A), anterior-posterior (AP) line of
enclosed by the inferior pubic rami and the inferior edge of minimal levator hiatus (blue line), bladder (B), caudad (C), levator plate
the pubic symphysis. The length (AP diameter) of the levator (LP), levator plate descent angle (LPDA), pubic levator ultrasound ref-
hiatus should be measured from the inferior border of the erence assessment line (PLURAL) (green line), pubic symphysis (PS),
urethra (U) (From Shobeiri et al. [44]; © Shobeiri)
pubic symphysis to the 6 o’clock inner margin of the levator
ani. The width (latero-lateral, or left-right diameter) of the
levator hiatus should be taken on the widest part, perpendic-
ular to levator hiatus AP diameter [7].
The AP line of the MLH corresponds to the H line in MR
imaging [45]. We created the pubic levator ultrasound refer-
ence assessment line (PLURAL) plane, which is a line drawn
through the AP axis of the mid-pubic symphysis and extended
posteriorly. The data volume was then rotated such that the
PLURAL plane was vertical. The relative position of the
MLH to the PLURAL plane was measured using an angle
that we termed the levator plate descent angle, or LPDA
(Fig. 49.27). The MLH was measured along the puboanalis
muscle medially, pubic bone anteriorly, and the levator plate
posteriorly (Fig. 49.28). In order to measure the area created
by the puborectalis muscle (puborectalis muscle hiatus), the
puborectalis muscle borders were determined in the semi-­
axial view in a plane that had the puborectalis laterally, pubic
symphysis anteriorly, and the levator plate posteriorly
(Fig.  49.29). When the puborectalis muscle hiatus was
approached from the sagittal plane, its position relative to the Fig. 49.28  Minimal levator hiatus area in axial plane by transvaginal
MLH was clarified (Fig. 49.30). 360° ultrasound. AP line is in blue. The puborectalis-pubococcygeus
In order to determine normality, we used 80 nulliparous border is delineated with small arrows. Anus (A), anterior-posterior
(AP) line of minimal levator hiatus (blue line), left-right (LR) axis of
women and measured MLH area, puborectalis hiatus area, minimal levator hiatus, pubococcygeus (PC), puborectalis (PR), pubic
ARA, and the LPDA.  Having normal ranges of measure- symphysis (PS), urethra (U), vagina (V) (From Shobeiri et al. [44]; ©
ments helps investigators to define abnormality and perform Shobeiri)
634
Fig. 49.29  Puborectalis hiatus in the same patient of Fig. 49.28. Axial
view by transvaginal 360° ultrasound. Anterior-posterior (AP) line of
minimal levator hiatus, latero-lateral (LR) line, puborectalis (PR),
pubic symphysis (PS) (From Shobeiri et al. [44]; © Shobeiri)
Fig. 49.30  Ultrasound showing plane of minimal levator hiatus and
puborectalis hiatus (PRH) in right sagittal view. Anterior-posterior (AP)
line of minimal levator hiatus (blue line), bladder (B), levator plate
(LP), levator plate descent angle (LPDA), plane of minimal levator hia-
tus (P-MLH) (blue line), plane of puborectalis hiatus (P-PRH) (purple
line), puborectalis (PR), pubic symphysis (PS), rectum (R), vagina (V)
(From Shobeiri et al. [44]; © Shobeiri)
further research on how to restore normalcy. In summary, the
pubococcygeus forms the inner lateral border and anterior
attachment of the MLH to the pubic bone (Figs. 49.31 and
49.32). The puboanalis fibers are immediately lateral to
J. Alshiek et al.
Fig. 49.31  Cadaver dissection of the right hemipelvis with the pelvic floor
muscles visible. The planes of minimal levator hiatus and puborectalis hia-
tus are outlined. Anus (A), anterior-posterior line (AP) of minimal levator
hiatus (blue line), arcus tendineus fascia pelvis (ATFP), coccyx (CX), ilio-
coccygeus, (IC), ischial spine (IS), levator plate (LP), levator plate descent
angle (LPDA), obturator vessels (OB), pubic levator ultrasound reference
assessment line (PLURAL) (green line), plane of minimal levator hiatus
(P-MLH) (blue line), plane of puborectalis hiatus (P-PRH) (purple line),
perineal body (PB), pubococcygeus (PC), puborectalis (PR), pubic sym-
physis (PS), vagina (V) (From Shobeiri et al. [44]; © Shobeiri)
pubococcygeus attachments at the level of the pubic bone.
There are variable contributions of the puborectalis fibers
lateral to the puboanalis attachment. The posterior border of
the MLH is formed by the levator plate. Eighty community-­
dwelling nulliparous women underwent 3D EVUS
(Fig.  49.33). The median age was 47 (range 22–70). The
mean of MLH and puborectalis hiatus areas were 13.4 cm2
(±1.89 SD) and 14.8  cm2 (±2.16 SD). The mean anorectal
and LPDAs were 156 (±10.04 SD) and 15.9 (±8.28 SD)
degrees [44].
Our cadaveric dissections demonstrated the anterior bor-
der of the MLH is comprised of pubococcygeus and puboa-
nalis fibers. Kim and colleagues named this area the
“pubovisceralis entheses” [21]. Lateral to these fibers are a
variable number of puborectalis fibers. Therefore, levator ani
injury at childbirth at this location would most certainly
involve the pubococcygeus, as shown by 3D modeling by
Lien et al. [11], and cephalad edge of the puborectalis attach-
ment if the injury extends beyond the puboanalis fibers. In
our opinion total unilateral or bilateral disruption of all the
49  Three-Dimensional and Dynamic Endovaginal Ultrasonography for Pelvic Organ Prolapse and Levator Ani Damage
a b
Fig. 49.32 (a) The right midsagittal view of the levator plate descent
angle in a healthy patient without levator ani deficiency. The levator
plate position relative to the perineum is shown. The green line signifies
the anorectal angle (ARA). The levator plate (LP) descent angle relative
to the reference line (PLURAL) is −16 ° (above the reference line). (b)
muscles involved in the anterior attachment of the MLH
would constitute what has been called levator avulsion in the
literature. A levator avulsion, which is a total detachment of
the levator entheses at the level of the pubic bone, would
result in widening of the levators and the ARA.  To our
knowledge, the contribution of the puboanalis muscle to this
area has not been documented previously. The injury to the
puboanalis fibers alone can potentially result in perineal and
anal protrusion. The current repair methods for perineal and
anal protrusion do not involve the investigation or repair of
the puboanalis muscle. The inner border of the MLH is
mostly pubococcygeus, and the posterior border is the leva-
tor plate that forms the ARA.
The LPA as studied by the MRI investigators measured
the AP movement of the levator plate relative to the hori-
zontal reference line. Berglas and Rubin used levator
myography to demonstrate that with straining, women with
prolapse have greater inclination of the levator plate [46].
Goodrich et al. quantified the difference in the LPA of ten
normal volunteers and five prolapse patients before and
635
PLURAL
PS B
LPDA
ML
H-A
EAS
EAS LP
Schematic drawing of a right midsagittal view of the levator plate and
levator plate descent angle in a healthy woman. A anal canal, B bladder,
EAS external anal sphincter, MLH-A minimal levator hiatus area, PS
pubic symphysis, V vagina. (From Rostaminia [50] with permission)
after surgery [47]. Interestingly, they found that women
who had surgical repair of prolapse had a 10° more cepha-
lad-oriented LPA as well as a larger levator hiatus during
straining even without recurrence of prolapse. Ozasa and
colleagues compared the levator plate of 14 women with
prolapse and 19 women without prolapse [48]. They found
that a best fit line through the levator plate always crossed
the pubic bone in women with normal support but never
crossed the pubic bone in those with prolapse. Hsu and col-
leagues showed that in women with normal support, the
levator plate has a mean angle of 44.3° relative to a hori-
zontal reference line during Valsalva, and women with pro-
lapse have a 9.1° more vertically oriented LPA, which was
statistically different [49]. In our study, we measured the
LPDA, which is the position of the levator plate along the
caudad-cephalad plane relative to the PLURAL plane as
measured by EVUS not MRI.  This angle quantifies the
levator plate position in reference to pubic bone and peri-
neal body at rest. LPDA is potentially useful as a separate
marker of levator function [44].
636
References
Fig. 49.33  The right sagittal view of a 3D endovaginal showing the
minimal levator hiatus muscles and their contribution to the levator
plate. Anus (A), iliococcygeus (IC), pubococcygeus (PC), puborectalis
(PR), pubic symphysis (PS), transducer (T), urethra (U) (© Shobeiri)
49.3 Future Research
As the pelvic floor ultrasound has gained widespread popu-
larity, the practitioner has to decide which modality (trans-
perineal, translabial, or endovaginal/endoanal) is appropriate
for a given condition. Comparative studies about these ques-
tions are forthcoming. Additionally, with the increasing
availability of ultrasound units and improved core compe-
tency of the practitioners in evaluating pelvic floor disorders
using ultrasound, more large-scale and long-term population
studies will guide clinical decision-making.
Take-Home Messages
Advances in technology have allowed a better appre-
ciation of the functional anatomy of the pelvic floor.
3D imaging of the pelvic floor has provided an enrich-
ment of knowledge about the complex dimensions of
the pelvic floor and allowed clinicians to have an
in vivo view of pelvic floor structures and to observe
dynamic changes at the point of care.
J. Alshiek et al.
Clinical management should continue to rely on
historical and clinical evaluation, but we must recog-
nize that an adjunct imaging study may provide further
insight into complex pelvic floor disorders. The true
potential of point of care pelvic floor ultrasound is
unfolding.
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 Magnetic Resonance Imaging, Levator
Ani Damage, and Pelvic Organ Prolapse
John O. L. DeLancey
Learning Objectives
• Describe the functional anatomy of the levator ani
muscle including its three subdivisions
• Review data documenting the mechanism, type,
and location of the injury
• Elucidate the biomechanics of interactions between
muscle injury and pelvic organ support specifically
describing the interaction between muscular and
connective tissue supports
• Define the functional consequences of these inju-
ries and the relationship between these injuries and
pelvic organ prolapse
50.1 Introduction
If the floor of a box fails, then all its contents will fall down.
Over 100 years ago, Halban and Tandler suggested that pel-
vic floor failure due to levator damage is the cause of pelvic
organ prolapse [1]. As logical as this basic mechanical fact
is, this issue was hotly disputed by many authors, especially
Fothergill [2], who felt that support was provided exclusively
by the cardinal and uterosacral ligaments and fascial attach-
ments. Proof that levator ani muscle injury was associated
with pelvic organ prolapse, however, was made possible
when magnetic resonance imaging (MRI) allowed these
muscles to be seen in living women [3, 4]. This allowed direct
comparison of the levator ani muscle between women with
and without pelvic organ prolapse. One such study revealed
that 55% (83/151) of women with prolapse had major injury,
J. O. L. DeLancey (*)
Norman F. Miller Professor of Gynecology, Female Pelvic
Medicine and Reconstructive Surgery, Department of Obstetrics
and Gynecology, University of Michigan Medical School,
Ann Arbor, MI, USA
e-mail: delancey@umich.edu
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_50
50
compared to only 16% (22/135) of women with normal sup-
port showing major injuries—an odds ratio of 7.3 (Fig. 50.1)
[5]. Ultrasound evaluation of the levator at about the same
time revealed similar findings [6]—satisfying the scientific
requirement that an experiment’s findings be independently
reproduced. Since then, research using MR imaging has led
to progress in understanding the relationship between leva-
tor muscle injury and the mechanism of prolapse. MRI and
ultrasound have both played an important role in understand-
ing the mechanisms of muscle injury during vaginal birth.
This chapter will focus on the role of MRI; ultrasound will
be covered in other chapters in this book.
50.2 F
 unctional Anatomy: Levator Ani
Muscle and Connective Tissue Work
Together to Provide Pelvic Organ
Support
Understanding the role that the levator ani muscle plays in
preventing pelvic organ prolapse requires a consideration of
how this muscle fits into the overall picture of pelvic organ
support. Although whether muscle or connective tissue is the
most important in supporting the pelvic organs has been a
long-standing point of contention, modern biomechanical
analysis has shown that asking this question is like trying to
decide which scissors blade is most important. The muscles
and connective tissues work together to provide support in
much the same way that the ventricles and valves are both
needed for the heart to propel blood forward.
Normal pelvic organ support is provided by the interac-
tion between the levator ani muscles that close the pelvic
floor and the connective tissues that attach the uterus and
vagina to the pelvic sidewalls. The levator ani muscles hold
the pelvic floor closed and provide lifting and closing forces
to prevent descent (Fig. 50.2) [7]; in this situation, the pres-
sures in the anterior and posterior compartments are equal
and balanced, canceling each other out. When the levator
muscles are weakened or damaged, the levator hiatus can
639
640 J. O. L. DeLancey

a b

Fig. 50.1 (a) Anterior predominant prolapse. Note tipped perineal visceral muscle (arrowheads) attaching to the pubic bone but complete
body that appears as if a structure normal holding the left side up had loss of that muscle on the left (L). This would explain failure of the
failed. (b) MRI of that subject showing an intact right-sided (R) pubo- hiatus to be closed. U uterus, V vagina ©DeLancey 2018

a b c

CL
Ligament
Tension
USL

Balanced Unbalanced
Pressures Pressures
Pulls on
Uterus

Pressure
©DeLancey

Hiatus Closed Hiatus Open Differential

Normal Levator Injury Exposed Vagina

Fig. 50.2  Diagrammatic representation of interactions between levator anced. Levator damage (b) results in a hiatal opening, and the vagina
ani muscle, anterior vaginal wall prolapse, and cardinal/uterosacral becomes exposed to a differential between abdominal and atmospheric
ligament suspension. With normal levator function (a), the vaginal pressures. This pressure differential (c) creates a traction force on the
walls are in apposition, and anterior and posterior pressures are bal- cardinal ligament (CL) and uterosacral ligament (USL). ©DeLancey

be pushed open and cause the pelvic organs to descend so
that one or both vaginal walls protrude through the opening.
In this situation, the vagina comes to lie between abdominal
and atmospheric pressure; the resulting pressure differential
acts on the vaginal wall in much the same way that pres-
sures generated in the mouth force bubble gum to expand.
In the pelvis, this pressure differential creates a downward
force that places abnormal loads on the connective tis-
sues that attach the uterus and vagina to the pelvic walls.
Conversely, if the connective tissues cannot adequately hold
50  Magnetic Resonance Imaging, Levator Ani Damage, and Pelvic Organ Prolapse 641

the organs in alignment above the closed hiatus, the same
pressure imbalance can occur. Therefore, both connective
tissue and muscle must work together to provide normal
support. Understanding levator ani muscle anatomy and its
subdivisions is essential to understanding how they provide
support and how injuries to specific portions of the muscle
affect function.
50.2.1 Levator Ani Muscle Anatomy
Terminologia Anatomica [8]—the international gold
standard for anatomy terms—has long-recognized that
the ­levator ani muscle consists of three subdivisions
(Table  50.1): the pubococcygeal (also called the pubovis-
ceral [9]), the puborectal, and the iliococcygeal (Fig. 50.3).
In this chapter, the term pubovisceral muscle will be used
instead of pubococcygeal, because it describes the inser-
tions better than the latter term, which was coined over a
century ago on evolutionary rather than anatomical grounds.
These subdivisions of the levator ani muscle can each be
seen in MR images (Fig. 50.4) [10]. There are also three
portions of the pubovisceral muscle: the pubovaginal, the
puboperineal, and the puboanal. These terms represent the
pubovisceral muscle’s three points of insertion: the vagina,
the perineal body, and the anal sphincter complex. (Note the
similarity of the terms puborectal and puboanal. These are
different muscles; the puborectal forms a sling behind the
rectum that helps create the anorectal angle, while the pubo-
anal inserts into the anal sphincter complex and elevates

Table 50.1  Overview of the nomenclature and functional anatomy of the levator ani
Terminologia Anatomica Origin Insertion Function
Pubococcygeal (pubovisceral)
 –  Pubovaginal Pubis Vaginal wall at the level of the mid-urethra Elevates vagina in region of mid-urethra
 –  Puboperineal Pubis Perineal body Tonic activity pulls perineal body ventrally toward
pubis
 –  Puboanal Pubis Intersphincteric groove between internal Inserts into the intersphincteric groove to elevate the
and external anal sphincter to end in the anus and its attached anoderm
anal skin
Puborectal Pubis Sling behind rectum Forms sling behind the rectum forming the anorectal
angle and closing the pelvic floor
Iliococcygeal Levator Two sides fuse in the iliococcygeal raphe The two sides form a supportive diaphragm that spans
Arch the pelvic canal

a b
PVa

PPM
ATLA
PAM ATLA
PRM

ICM

EA
PVaM S
PPM
PAM
©DeLancey

ICM Coccyx SAC

Fig. 50.3 (a) shows a schematic view of the levator ani muscles from
below after the vulvar structures and perineal membrane have been
removed showing the arcus tendineus levator ani (ATLA); external anal
sphincter (EAS). The three portions of the pubovisceral muscle are
shown: pubovaginal (PVaM), puboperineal muscle (PPM), and pubo-
anal muscle (PAM), as well as the iliococcygeal muscle (ICM) and
puborectal muscle (PRM). Note that the urethra and vagina have been
transected just above the hymenal ring. (b) shows the levator ani muscle
seen from above looking over the sacral promontory (SAC) showing the
pubovaginal, puboperineal, and puboanal muscles, as well as arcus ten-
dineus levator ani and iliococcygeal muscle. The urethra, vagina, and
rectum have been transected just above the pelvic floor, and the internal
obturator muscles have been removed to clarify levator muscle origins.
©DeLancey. (Modified after Kearney[11])
642
a b
Fig. 50.4 (a) is a 3D model of levator ani subdivisions, including the
pubic bone and pelvic viscera. This model was created by using the
magnetic resonance images. The pubovaginal, puboperineal, and pubo-
anal muscles are all combined into a single structure—the pubovisceral
the anus.) The three portions of the pubovisceral muscle
are not three muscles, however, but rather one muscle with
three points of insertion. Although the muscles of the leva-
tor ani are relatively simple and are described consistently
by authors who have personally studied the muscle, a pro-
fusion of conflicting terms that have historically applied to
this region makes it somewhat complicated for readers to
interpret the literature by Kearney et al. [11].
The pubovisceral and puborectal muscles arise ventrally
from the inner surface of the pubic bones (Fig. 50.5). The
puborectal muscle lies lateral to the pubovisceral muscle and
forms a sling behind the rectum at the anorectal junction.
While the puborectal muscle creates an angulation in the rec-
tum, the pubovisceral muscle elevates the vagina, perineal
body, and anus. The iliococcygeal muscle is thin and sheet-
like, spanning the pelvic canal from the tendinous arch of
the pelvic fascia to the midline iliococcygeal raphe, where
it interdigitates with the muscle of the other side and con-
nects with the superior surface of the sacrum and coccyx. It
forms a relatively flat horizontal portion that spans the dis-
tance between the more medial pubic portions and the lateral
pelvic wall. The area behind the rectum has been called the
levator plate [1].
J. O. L. DeLancey
muscle. Inferior, left three-quarter view. (b) is the same model without
the pubic bone. B bladder, EAS external anal sphincter, IC iliococcy-
geus muscle, PB pubic bone, PR puborectal muscle, PVi pubovisceral
muscle, U uterus, Ur urethra, V vagina ©DeLancey 2006
50.2.2 Levator Ani Muscle Lines of Action
MRI has allowed the lines of action of the different aspects
of the levator ani muscle to be measured. This is impor-
tant, because the action of the pelvic floor muscles is deter-
mined by the direction of these muscle fibers, the shape of
the muscle, and the points of attachment. Therefore, injury
to one component may have mechanical effects that are
different than those caused by damage to another compo-
nent. As shown in Fig. 50.6, the pubovisceral muscle fibers
course 41° above the horizontal in the standing posture, in a
direction close to the iliococcygeal muscles (33°) [12]. By
contrast, the puborectal muscles actually act below the hori-
zontal (−19°).
The significant difference (60°) in mean fiber angle
between the pubovisceral and the puborectal muscles shows
that they have two different mechanical actions. These can be
understood within the context of the standing position (Fig.
50.6b). The diagonal vectors of the muscles can be resolved
into two physiological vectors. The first—a vertically ori-
ented “lifting” vector—acts against gravity by lifting the
perineal structures and can be attributed to the pubovisceral
muscle. Descent of the perineal structures is found in women
50  Magnetic Resonance Imaging, Levator Ani Damage, and Pelvic Organ Prolapse 643

a b

Fig. 50.5 (a): Left mediolateral view of the anterior pelvic sidewall,
with pelvic organs removed, showing the characteristic features of the
origin of the pubovisceral muscle. The dotted rectangle shows the ana-
tomic area of study (Reproduced from Halban and Tandler, Fig. 50.2,
p. 34 [1]). (b): a similar view of the right anterior pelvic sidewall of a
50-year-old nulliparous fresh cadaver showing the pubovisceral attach-
ments to the pubic bone. The fascial arch lies across the pubovisceral
muscle, and the levator arch forms the lateral margin of the pubovisceral
muscle as it attaches onto the pelvic sidewall. ICM iliococcygeal muscle,
LA levator ani, PVM pubovisceral muscle. ©DeLancey

with prolapse and is associated with injury to the pubovis-

a 33 ceral portion of the levator, which can occur either with or
°
without resulting prolapse [13, 14]. The second vector is ori-
ma

+S IC
M D M
x

ea ented horizontally toward the pubic bone. Both the puborec-

n
41 tal and pubovisceral muscles have a horizontal component,
−S °
D which helps to develop a “closing” force, by acting in a hori-
min
PRM zontal direction so as to close the levator hiatus. This horizon-
tal action creates a vaginal high-pressure zone [15, 16].
PV
M −19°
S

50.2.3 What Type of Injury Occurs to Lead

EA

3°
−4 horizontal to These Visible Abnormalities?
b
PVM PRM MRI studies have been done to help understand injury mech-
anisms after birth. This involves obtaining scans early (7
0.95N weeks) and late (6 months) after vaginal deliveries. At each
of these time points, both standard anatomical scans (proton
0.33N

−19°
0.67N

1N

density) to document structural changes and fluid-sensitive

1N
41°
0.75N
Fig. 50.6 (a): The thick arrow displays the mean direction to the hori-
zontal line in a two-dimensional graphic. The dashed line is the horizon-
tal line from which the angles are measured. Angles above the horizontal
line have a “+” sign and those below the horizontal line a “−” sign. On
MRI, the pubovisceral muscle (PVM) was found medial to the puborec-
tal muscle (PRM); for graphical reasons their lines of actions are
depicted in the same plane. (b): Horizontal and vertical components of
the PVM and PRM in the standing position. The thick arrows show the
average direction of the lines of action of the PVM and PRM muscles
relative to the horizontal with a theoretical 1 N force. Thin lines indicate
the portion of each force related to a closing and lifting function. (Note:
vectors are shown larger than the background anatomy to avoid an over-
lap in the display.) EAS external anal sphincter, ICM ileococcygeous
muscle ©DeLancey. Betschart [12]
sequences that reveal muscle edema are used (Fig. 50.7)
[17, 18]. The muscle defects are immediately evident after
birth and do not resolve. This is consistent with a muscle
tear, but not with denervation, which would cause atrophy
to develop over a longer period of time. The fluid sequences
reveal injury to intact muscle by showing the areas of edema.
If compression—as is sometimes suggested—was the injury
mechanism, then both the levator and internal obturator mus-
cles would be affected, since they are both inside the pelvic
bones and compression of one could not occur without com-
pression of the other. Therefore, since only the levator shows
edema, compression is not the cause, and one can conclude
that the muscle being stretched enough to tear is the mecha-
nism of injury.
644
a b
c d
Fig. 50.7  Mid-urethral axial MR images, early and late, in the region
where the pubococcygeal muscle is normally seen lateral to the vagina
(Vag). (a) is a proton density scan where the solid arrowheads mark the
pubococcygeal muscle and the open arrowheads show the obturator inter-
nus. Signal intensity is lower in the pubococcygeal (arrowhead) than the
50.2.4 Location and Types of Levator Injury
While we have seen that levator ani muscle injury is highly
associated with prolapse, it is not the entire levator that is
damaged. The portion of the muscle that is damaged was
established by studying women who had a unilateral leva-
tor muscle defect, where a normal side could be compared
with one that is intact [19]. This comparison revealed that
it is the pubovisceral portion of the muscle that is miss-
ing in injured women (Fig. 50.8). While these injuries vary
somewhat in appearance (Fig. 50.9), the location is consis-
J. O. L. DeLancey
adjacent internal obturator (open arrowhead). (b) is a fluid-­sensitive scan,
where this difference is more apparent. In (c), a normal pubococcygeal
muscle (black arrow) is seen between the vagina and internal obturator
(IO) (black arrow), while it is absent on the left (L). This pattern persists
in the late scan (d). PS pubic symphysis ©DeLancey
tent. Although it has become customary in the ultrasound
literature to refer to this as the puborectal muscle, in MRI,
where the puborectal muscle as defined in Terminologia
Anatomica can be distinguished from the pubovisceral
muscle, it is actually the pubovisceral and not the puborec-
tal muscle that is injured [20].
However, not all pubovisceral muscle injuries are alike.
MRI has revealed that there are two distinct types of pubo-
visceral injury (Fig. 50.10): (a) loss of part of the pubovis-
ceral muscle fibers with the overall attachment of the muscle
remaining intact (“Type I” injury) and (b) detachment of the
50  Magnetic Resonance Imaging, Levator Ani Damage, and Pelvic Organ Prolapse 645

a b

c d

Fig. 50.8  Upper panels: Axial MR scans of an exemplary 42-year-old
female with a right-sided complete unilateral levator defect are shown.
The intact levator ani muscle is traced (dashed line, labeled LA). The
missing muscle is denoted (asterisk). Each panel is labeled with a num-
ber indicating the level of scan in centimeters relative to the arcuate
pubic ligament; positive numbers indicate slices cephalad to the liga-
ment. Lower panels (a–d): 3D model generated from the axial MR
scans shown in the upper panels. (a, b) Oblique right and left infero-
lateral views, similar to the dorsal lithotomy position, are shown. In
these panels, the pubic bone is semitransparent, and the obturator inter-
nus muscle is not shown. (c, d) Oblique right and left views peering
over the pubic bone and down to the pelvic floor are shown. The ure-
thra, vagina, and rectum have been truncated so as not to obscure the
views of the levator muscles. EAS external anal sphincter, LA levator
ani, MM mirror image of the missing muscle, OI obturator internus, P
pubis, PB perineal body, R rectum, U urethra, V vagina. ©DeLancey
646 J. O. L. DeLancey

a b

c d

Fig. 50.9  Axial MR scans of four different women with complete uni- missing muscle is denoted (asterisk). In (a–c), the defect is shown on
lateral levator defects are shown. Note the variations in morphology. the right side and in (d), on the left side. ©DeLancey. EAS external anal
The intact levator ani muscle is traced (dashed line) and labeled LA. The sphincter, LA levator ani, P pubis, R rectum, U urethra, V vagina

muscle from its origin and of the levator arch from the pubic of the muscle in this injury zone [22]. When the muscle
rami (“Type II” injury). This detachment occurs because of detaches from the pubic bone, the anatomy of the entire pel-
the extreme stretching of the pubovisceral muscle that occurs vic sidewall is altered—causing a distortion in the normal
during birth [21] and the relatively thin, aponeurotic origin architecture of the vagina and surrounding tissues [23].
50  Magnetic Resonance Imaging, Levator Ani Damage, and Pelvic Organ Prolapse
a b
Fig. 50.10  Illustrations of the right inner pelvic sidewall showing the
fascial arch (F Arch) and levator arch (L Arch) originating from the
pubic bone (a). The pubovisceral muscle (PVM), pubic symphysis
(PS), urethra (U) and bladder can also be seen. In (b), atrophy in a por-
tion of the PVM is shown; a Type I injury. In (c), the levator arch and
PVM have become detached from the pubic bone exposing the obtura-
Fig. 50.11  Demonstration of the steps used in building 3D model. (a)
is an axial image showing fascial arch (FA) and levator arch (LA). 3D
models made from MRI showing arches with (b) and without (c) adja-
cent structures. A reference line from the pubic bone to the ischial spine
P-IS acts as the X axis in local pelvic sidewall coordinate system visible
in (c) on defect side. Note that blue marks indicate the fascial arch (FA)
50.2.5 Injury Distorts the Pelvic Sidewall
Supports
Loss of the pubovisceral muscle’s connection to the pel-
vis causes the pelvic sidewall structures (fascial and levator
arches) to fall downward (Fig. 50.11) [24]. It is therefore
important to consider the different mechanical consequences
of Type I injury, where there is a loss of a portion of the muscle
tissue but the levator arch remains intact, and Type II injury,
where the levator arch and pubovisceral muscle become
detached from their origin. Both the fascial and levator arches
647
c
tor internus muscle (OIM) in a Type II injury. Since there is only a sin-
gle point of pubic origin at the L Arch for the lateral margin of the
PVM, detachment of that point will result in complete offloading of that
region of the PVM. (Figure modified from Fig.  50.2a of DeLancey
2002) ©DeLancey
and red marks, the levator arch (LA). The normal side (right side of the
image) can be compared with the abnormal side (left). Note the lower
location of both arches showing how these arches have moved caudally
with to loss of the muscle origin. LAM levator ani, OI obturator inter-
nus, PS pubic symphysis, R rectum, U urethra, V vagina. From Larson
et al. 2012 [24]. ©DeLancey
lie in this region. Since the fascial arch lies on the medial por-
tion of the pubovisceral muscle (Fig. 50.5), detachment of the
levator ani from its origin causes the pelvic wall architecture
to change. When the levator’s pubic attachment is lost, both
the fascial and levator arches fall downward. The most pro-
nounced downward displacement occurs in the ventral region
near the pubic bone—close to where the muscle originates.
This distortion has two effects: (1) it impairs the muscle’s abil-
ity to close the urogenital hiatus due to loss of attachment to
the pubic bone, and (2) it redirects the vectors of the fascial
connections to the tendinous arch of the pelvic fascia.
648 J. O. L. DeLancey

Fig. 50.12  Examples of grades of defects in the pubovisceral portion side is indicated on the figure, and the black arrows indicate the location
of the levator ani muscle in axial MR images at the level of the mid-­ of the missing muscle. (a) = a grade 1 defect; (b) = a grade 2 defect; and
urethra. These were selected to illustrate degrees of defects in individu- (c) = a grade 3 defect. ©DeLancey
als with a normal contralateral pubovisceral muscle. The score for each

250
50.2.6 The Amount of Injured Muscle Matters Normal Support
Prolapse
200
As one might expect with muscle injury, the amount of mus-
Number of subjects

cle that is injured matters. MRI has established the degree

of muscle loss that is associated with prolapse (Fig. 50.12) 150
[5]. Our grading system identifies the degree of muscle loss
present on each side. Zero indicates normal muscle and three 100
indicates complete loss of the pubovisceral muscle (the com-
plete loss is typically a Type II defect). Between these two 50
extremes, there are different degrees of partial loss. A score
of 1 signifies loss of less than half the muscle, and 2 signifies 0
more. When the grades for the two sides are added together, 0 1 2 3 4 5 6
a score of 0–6 results. The body can easily compensate for LAD Score
the loss of a few muscle fibers, which would not be expected
100
to cause problems. However, with loss of more than half of
the muscle, especially if the muscle origin is detached, one
can expect that the muscle’s ability to resist downward forces
is impaired. When levator injury exceeds half of the muscle,
% of subjects

for a total score of 4 or greater (“major loss”), prolapse is

more common than when the injury affects less than half of 50
the muscle (Fig. 50.13) [25].

50.2.7 Levator Failure and Surgical Outcome

0
The gold standard operation for prolapse performed by 0 1 2 3 4 5 6
experienced urogynecologists has an anatomical failure LAD Score
rate of 25% at 7 years. Improvement in operative outcome
will depend on understanding why operations fail. Levator Fig. 50.13  Top panel shows number of cases (black bars) and controls
impairment and an enlarged hiatus are associated with opera- (white bars) at each levator ani defect score. Bottom panel shows the
proportion of cases (black bars) and controls (white bars) for each leva-
tive failure; this is logical, since none of the current operative tor ani defect score. Dashed line indicates overall proportion of indi-
strategies successfully correct these defects. There is also viduals with prolapse at least 1 cm beyond the hymen (56.5 %). LAD
clinical evidence for this association. levator ani defect
50  Magnetic Resonance Imaging, Levator Ani Damage, and Pelvic Organ Prolapse 649

Vakili and colleagues found that 44% of women with a 50.2.9 Levator Ani Injury and Fascial Failure
genital hiatus of 5 cm or greater had recurrent prolapse, com-
pared with 28% of those with a smaller hiatus (p = 0.034). The central tenant of our disease model maintains that the
In addition, increasing levator contraction strength was fascial tissues attaching the organs to the pelvic sidewall
associated with a decreased reoperation rate for pelvic floor and the levator ani muscles work together to maintain pelvic
disorders [26]. In women who had MRI for research pur- organ support. So, what evidence is there that this is true?
poses before an operation, a statistical model evaluating fac- Recent studies using stress 3D MRI comparing women with
tors that were predictive of recurrence revealed that levator and without anterior vaginal wall prolapse have allowed both
defects and increased hiatus size were key factors in estimat- the status of the connective tissue supports and the levator
ing the risk of anatomical cystocele recurrence—in addition ani muscle to be assessed at maximal Valsalva [35, 36]. In
to assisted vaginal delivery, which is known to cause levator this way, the relative contributions of these two factors of
damage [27]. Increased operative failure has also been iden- prolapse development can be assessed.
tified in women who have a deepening of the levator “bowl.” This analysis shows a strong relationship between three
Women with operative failures were more likely to have a factors that form a “collinear triad” consisting of (1) api-
large levator bowl compared to those with successful surgery cal descent, (2) paravaginal descent of the lateral vaginal
(84.6% vs. 39.6%; p = 0.005) [28]. wall, and (3) hiatal enlargement. From the strong correlation
between the apical and paravaginal descent and their similar
mechanistic roles of attaching the uterus and vagina to the
50.2.8 Muscle Injury Reduces Force pelvic walls, it is clear that these two factors are essentially
measurements of the same phenomenon. Conversely, the
The disease model presented at the beginning of this chapter role of hiatus size occurs in a different domain. The relation-
maintains that the connective tissue supports of the uterus ship between fascial attachment failure and enlarged hiatus
and vagina are only needed when the urogenital hiatus is size attests to the important interactions between these two
open. The levator ani is one important aspect of this closure. factors that relate to the pressure differential created when
The tonic activity of the levator ani muscle creates a high-­ the levators do not hold the hiatus closed and the vagina
pressure zone [16]—such as those created by the urethral becomes the barrier between abdominal and atmospheric
and anal sphincter muscles in their respective organs. In nul- pressure. These interactions are at the heart of our mechanis-
liparous women, a high vaginal resting pressure is correlated tic understanding of pelvic organ prolapse from the theoreti-
with a small levator hiatus area at rest (r = −0.451, p < 0.001) cal model presented at the beginning of this chapter.
[29]. As one might expect, injury to the muscle reduces the
force that it can generate. In women with levator defects,
the muscle generates 40% less force than in women without 50.2.10 Exposed Vaginal Length,
defects. Muscle injury is also associated with a widening of Pressure Differentials,
the levator hiatus [30] and caudal displacement of the entire and Symptomatic Prolapse
pelvic floor [31, 32]. Mechanistically, this failure to close the
hiatus results in the pelvic organs moving downward, posi- It is important to understand the strong relationship that exists
tioning them between abdominal and atmospheric pressure between the levator ani muscle’s ability to close the pelvic
and placing excessive forces on the suspending ligaments, floor and fascial failure, which involves the forces that result
as will be discussed. While it has been established that leva- from exposure of the vaginal wall to abnormal pressure dif-
tor injury is associated with an enlarged hiatus, it is impor- ferentials when the levators fail to hold the hiatus closed. The
tant to recognize that it is only one factor associated with force that results from pressure being applied to the vaginal
hiatal enlargement—explaining only about 10% of the phe- wall is directly proportional to the amount of vaginal wall
nomenon [33]. It is not completely understood what factors that is exposed to atmospheric pressure. MRI has shown that
are responsible for the remainder. There is also a significant there is a strong relationship between exposed vaginal wall
deepening of the “pelvic bowl” formed by the levator ani. length and how far the bladder descends (R2  =  0.91) [37]
The degree to which this bowl deepens is greater than that (Fig. 50.14). Initial descent while the vaginal wall is still in
of the protrusion of the pelvic organs below this level [32]. contact with the posterior vaginal wall does not increase the
This means that the abdominal organs move downward into amount exposed to a pressure differential, but when the blad-
this deepening bowl—a phenomenon that is not addressed der descends 4 cm below its normal position (approximately
by surgical correction. It has also been traditional to discuss at the introitus), the length of exposed vaginal wall subjected
the levator plate angle [34], but this is likely just a reflection to the difference in pressure increases significantly, with a
of the loss of forward pull on the plate caused by loss of force 2 cm increase for every additional 1 cm drop in bladder loca-
associated with the enlarged levator hiatus. tion. Exposed vaginal wall length is also highly correlated
 650 J. O. L. DeLancey

a b c
8
8
8 7
Exposed Vaginal Length (cm)

Exposed Vaginal Length (cm)

7

Exposed Vaginal Length (cm)

6 6
6
5
5
4 4
4
3
3
2 2 2

1 1

0 0 0
0 2 4 6 8 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
Most dependent Bladder Location Below Normal (cm) Apex Location Below Normal (cm) Hiatus Size (cm)

Fig. 50.14  The relationships between the exposed vaginal length and A bilinear relationship between exposed vaginal wall length and apex
most dependent bladder location, apex location, and hiatus size are location was also seen (b). Correlation coefficient R2 = 0.78. The esti-
shown. A bilinear relationship was used to describe the relationship mated transition point is at the apical descent at 5.0 cm below the nor-
between the position of the most dependent bladder point below normal mal position with a 95 % confidence interval (3.4–6.5 cm). Hiatus size
and the length of exposed vagina (a). Correlation coefficient R2 = 0.91. had a strong linear relationship between hiatus diameter and exposed
The estimated transition point is when the bladder location is 4.4 cm vaginal wall length (c), with correlation coefficient R2 = 0.85, but it is
below the normal position with a 95 % confidence interval (3.9, 4.9 cm). not bilinear. ©DeLancey

with hiatus diameter (R2 = 0.85), which is indicative of why 50.3 C

 oncluding Message and Future
the status of the levator and its responsibility for closing the Directions
hiatus is so important in prolapse.
There are clinical implications of these observations. MRI has allowed objective documentation of levator ani
When bladder descent is less than 4  cm, very little of the muscle injury and has proven it to be one of the most impor-
vagina is exposed. In the descent that occurs up to this tant causal factors leading to pelvic organ prolapse later in
­inflection point, the anterior vaginal wall is still in contact life. It has defined the location, extent, and mechanism of
with the posterior vaginal wall, so only a small portion is injury. To date most work has focused on the effects on the
exposed to the pressure differential. With further downward urogenital and levator hiatuses in the levator ani muscle, but
movement of the bladder, the exposed vaginal wall length future work on downward descent of the entire pelvic floor is
starts to increase linearly. A similar significant but weaker likely to reveal that there is more to levator dysfunction than
bilinear relationship was found between exposed vaginal is currently known. Longitudinal studies that help to clarify
wall length and apical location, where the inflection point is how many women who have a levator injury subsequently
at about 5 cm below the normal apex location. Both of these develop prolapse are needed. In addition, studies that allow
observations suggest a threshold effect, wherein some degree the interactions between levator defects and connective tis-
of descent is not associated with much exposure of the vagi- sue failure must be done to clarify differences between cause
nal wall to a pressure differential. and effect of injury.
The symptoms of bulging and pressure experienced by
women with anterior vaginal wall prolapse occur when the
enlarged hiatus and fascial failure allow the anterior vagi- Take-Home Messages
nal wall to descend to the level of the hymenal remnants • Levator ani injury primarily involves the pubovis-
[38]. The hymen lies at the lower border of the levator ani ceral (pubococcygeal) portion of the muscle.
and so marks the level of the levator hiatus through which • Injury is highly associated with pelvic organ pro-
prolapse occurs—i.e., the level when the vagina becomes lapse with an odds ratio of 7.3.
exposed to the pressure differential. A descent of 4  cm • Muscle injury is associated with an enlarged hiatus
would bring the vaginal wall just below the hymen. This and reduced muscle force acting to close the hiatus.
finding also supports the clinical position that the hymen • Muscle tearing is the injury mechanism involved,
should be considered an appropriate level both for defining not compression or neuropathic muscle loss.
symptomatic prolapse and for assessing surgical cure [39]. • It is an interaction between levator ani muscle
It is also consistent with the observation that women’s dis- injury and connective tissue failure that results in
satisfaction with surgical results increases once the vaginal prolapse, and neither of these factors alone can
wall is below the hymen. explain the occurrence of prolapse.
50  Magnetic Resonance Imaging, Levator Ani Damage, and Pelvic Organ Prolapse 651

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resonance images. Obstet Gynecol. 2006;107(5):1064–9.
liparous pregnant women. Int Urogynecol J. 2014;25(10):1357–61.
11. Kearney R, Sawhney R, DeLancey JO.  Levator ani muscle

30. Shek KL, Dietz HP. The effect of childbirth on hiatal dimensions.
anatomy evaluated by origin-insertion pairs. Obstet Gynecol.
Obstet Gynecol. 2009;113(6):1272–8.
2004;104(1):168–73.
31. Rodrigues AA Jr, Bassaly R, McCullough M, Terwilliger HL, Hart
12. Betschart C, Kim J, Miller JM, Ashton-Miller JA, DeLancey

S, Downes K, Hoyte L.  Levator ani subtended volume: a novel
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parameter to evaluate levator ani muscle laxity in pelvic organ pro-
tor ani muscle subdivisions: in vivo MRI measurements in women.
lapse. Am J Obstet Gynecol. 2012;206(3):244 e241–9.
Int Urogynecol J. 2014;25(9):1263–8.
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Swenson CW, DeLancey JOL. Interactions among pelvic organ pro-
affect perineal position independently of prolapse status. Am J
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without prolapse. Am J Obstet Gynecol. 2017;217(5):614 e611–7.
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Nandikanti L, Sammarco AG, Kobernik EK, DeLancey
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 Dynamic Magnetic Resonance Imaging
of Pelvic Floor Pathologies
Cäcilia S. Reiner and Khoschy Schawkat
Learning Objectives
• To identify pelvic floor descent within the three-­
compartment model and to get familiar with the
proposed grading system
• To identify the different pathologic conditions of
the anorectal region according to the finding in MR
defecography
• To know MR imaging findings of pelvic floor dys-
function in patients with dyssynergic defecation
51.1 I ntroduction and Definitions of Pelvic
Floor Dysfunction
Pelvic floor dysfunction is a common problem affecting pref-
erably postmenopausal, multiparous women, resulting in
reduced quality of life and a frequent need for surgical treat-
ments [1, 2]. In addition to age, risk factors for pelvic floor
insufficiency are multiparity, menopause, and obesity [3].
Clinical symptoms of pelvic floor dysfunction vary widely
and are usually determined by the pelvic organ or compart-
ment most affected. However, clinical symptoms are often
nonspecific and range from constipation to incontinence. A
complex variety of pelvic floor distortions can present in one
patient that range from stretching, denervation atrophy, inser-
tion detachment, and a combination of pelvic floor relaxation
and organ prolapse [4]. Identification of all pelvic floor struc-
tures is mandatory for an effective therapy as dysfunction of
one compartment often does not present solitary and affects
the whole functional entity of the pelvic floor. Given the com-
plexity and the interdependence of the pelvic floor compart-
C. S. Reiner (*) · K. Schawkat
Institute of Diagnostic and Interventional Radiology, University
Hospital Zurich, Zurich, Switzerland
e-mail: caecilia.reiner@usz.ch; khoschy.schawkat@usz.ch
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_51
51
ments, an effective workup and therapy strategy require a
multidisciplinary team including urogynecologists, urologists,
gastroenterologists, proctologists, and radiologists.
Pelvic floor dysfunction or weakness encompasses a
spectrum of functional disorders that result from alteration
of soft tissue structures such as ligaments, fasciae, or mus-
cles supporting the pelvic organs. It leads to pelvic organ
prolapse in case of insufficiency of the suspensory structures
and associated functional disturbance of the pelvic organs
involved such as the bladder (e.g., urinary incontinence and/
or voiding dysfunction), the vagina and uterus (sexual dys-
functions), or the rectum (obstructed defecation syndrome or
fecal incontinence) [1]. A general weakness of the pelvic
floor leads to the so-called pelvic floor relaxation with pro-
lapse of multiple pelvic organs and combined symptoms. A
missing relaxation of the puborectalis muscle or discoordi-
nated pelvic floor movement can lead to functional outlet
obstruction described as dyssynergic defecation [5].
51.2 I ndications of Dynamic Pelvic
Floor MRI
To date the most common indications for dynamic pelvic
floor MRI or MR defecography (MRD) are rectal outlet
obstruction, rectocele, recurrent pelvic organ prolapse,
enterocele, and dyssynergic defecation [6]. Other less fre-
quent indications include: stress urinary incontinence, peri-
toneocele, fecal incontinence, pelvic pain/perineal pain, and
descending perineal syndrome [6]. Prior to MRI a full
patients’ history should be taken and regardless of the lead-
ing symptom all patients should undergo the same prepara-
tion and protocol [6]. Findings reported at dynamic MRI of
the pelvic floor are valuable for selecting patients who are
candidates for surgical treatment and for choosing the appro-
priate surgery. The results of dynamic MRI of the pelvic
floor can change the initial surgical plan in 41% of patients
with pelvic floor disorders [7] and in 67% of patients with
fecal incontinence [8].
653
654
51.3 Anterior Compartment
The anterior compartment contains the bladder and urethra.
Frequent dysfunctions of the anterior compartment are stress
urinary incontinence (SUI) [9, 10] and overactive bladder
which is likely induced by bladder outlet obstruction [9].
Bladder outlet obstruction is most commonly caused by sur-
gical repair of SUI or by urethral hypermobility, cystocele
with kinking of the bladder outlet, outlet compression of the
bladder by a prolapsing uterus, or rectocele [11].
SUI is caused by urethral hypermobility (80–90% of
patients) [12] or intrinsic sphincter dysfunction (10–20% of
patients) [4]. Urethral hypermobility is caused by a defect in
the urethral support system, e.g., due to vaginal delivery,
hysterectomy, or after surgical cystocele repair.
A cystocele develops due to tears in the endopelvic fascia
and is defined as abnormal descent of the bladder at rest or
under stress (at straining and during defecation) [13].
Cystocele is defined as a bladder base descent below the bor-
der of the pubic symphysis and represents organ prolapse of
the anterior pelvic compartment through its respective hia-
tus. In dynamic pelvic floor MRI or MR defecography
(MRD) a cystocele is diagnosed on dynamic sequences when
the inferior border of the bladder descends >1 cm below the
pubococcygeal line (PCL) [9] (Fig. 51.1). A severe cystocele
can mask symptoms of SUI as the urethra becomes kinked at
the bladder neck and through bulging of the anterior vaginal
wall patients can present with dyspareunia [4]. On MRD cys-
toceles are measured from the bladder base perpendicularly
to the PCL and are graded according to their size as small
(<3 cm below the PCL), moderate (3–6 cm below the PCL),
and large (>6 cm below the PCL) [14]. Using the HMO sys-
tem, cystoceles are graded based on the distance of the blad-
der base relative to the H line as follows: grade 0 (no
prolapse), bladder base above the H line; grade 1 (mild or
a b
Fig. 51.1  54-year old female patient with urinary incontinence and
slight outlet obstruction. Midsagittal T2-weighted trueFISP MR image
at rest (a) shows a normal position of the pelvic floor. At straining (b) a
pathologic descent of the bladder (2.2  cm) and anorectal junction
C. S. Reiner and K. Schawkat
small cystocele), bladder base 0–2  cm below the H line;
grade 2 (moderate), bladder base 2–4 cm below the H line;
and grade 3 (severe or large cystocele), bladder base 4 cm or
more below the H line [9] (Fig. 51.2).
Recommendations for Practice
• The measurements to assess pelvic floor descent are per-
formed in the images with greatest straining effort, which
are displayed side by side with the rest images.
• Avoid overdistension of the urinary bladder as it is associ-
ated with underestimation of pelvic organ prolapse and
may obscure findings in other compartments.
• Enteroceles are best detected at the end of the defecation
phase as a consequence of the increased intra-abdominal
pressure.
• Functional abnormalities such as loss of urine during
straining should also be reported (Fig.  51.1) as well as
incidental findings of the pelvic floor soft tissue
structures.
51.4 Middle Compartment
The middle compartment contains the uterus and vagina and
therefore is only present in female patients. Uterine and vaginal
vault prolapse caused by levator ani trauma (e.g., after vaginal
childbirth) or damage to the supporting connective tissue due
to aging or congenital collagen defects may cause nonspecific
complains. A variety of symptoms are described that range
from pelvic pain and pressure to urinary or fecal incontinence
as well as dyspareunia [13]. The most common cause of pelvic
floor dysfunction arising in the middle compartment is
explained with an avulsion of the pubovisceral muscle at its
inferior aspect after vaginal delivery [15]. Complete tear of the
c
(3.8  cm) is seen with a horizontal orientation of the urethra (white
arrow). During defecation (c) the urinary bladder is emptied uninten-
tionally and an intrarectal intussusception develops (white arrowheads).
PCL pubococcygeal line
51  Dynamic Magnetic Resonance Imaging of Pelvic Floor Pathologies
Fig. 51.2  64-year old female patient with a large cystocele. MR image
obtained during defecation shows a large cystocele (C, white line) with
the bladder base >4 cm below the H line according to the HMO-system.
The H (5.5 cm) and M line (2 cm) are normal. H H line, M M line, PCL
pubococcygeal line
suspensory ligaments (uterosacral ligaments) causes uterine
descent into the vaginal introitus and with severe uterine pro-
lapse complete vaginal eversion can occur [16]. Patients may
present with a vaginal mass in case of uterine prolapse and
progressive ureteral obstruction can occur.
Vaginal prolapse is defined as descent of the vaginal vault
below the PCL. In cases of uterine prolapse, on axial images,
the cervix is often at the level of the pubic symphysis and
there is loss of the normal H shape of the vagina, often with
posterior displacement of the fornix on the affected side. A
vaginal vault or uterine prolapse is diagnosed if the vaginal
vault or external cervical canal is located >1 cm below the
PCL at rest or straining. For grading vaginal vault or uterine
prolapse the same reference values are used as for grading of
cystoceles. Vaginal vault prolapse is often associated with
prolapse of other pelvic floor organs.
51.5 Posterior Compartment
51.5.1 Anorectal Descent
The landmark of the posterior compartment is the position of
the anorectal junction with respect to the PCL [17]. On MRD
anorectal descent is defined as an abnormal descent of the ano-
rectal junction more than 3 cm below the PCL. A descent below
the PCL between 3 and 6 cm is considered moderate and severe
when greater than 6 cm (Fig. 51.1). It is often combined with an
655
Fig. 51.3  76-year old female patient with an enterocele and anterior
rectocele. Midsagittal T2-weighted trueFISP MR image during defeca-
tion shows protrusion of a moderate enterocele (5  cm) (E) into the
extended perineum leading to compression of the distal rectum result-
ing in outlet obstruction. The large anterior rectocele shows retention of
contrast medium due to compression by the enterocele. The extension
of the anterior rectocele is measured as the maximum wall protrusion
beyond the expected margin of the normal anterior rectal wall (white
arrow). PCL pubococcygeal line, E enterocele
abnormal descent of the anterior and middle compartment [18].
The main cause for anorectal descent is excessive and repetitive
straining leading to weakening of the pelvic floor musculature.
Other conditions leading to weakening of the pelvic floor mus-
culature are trauma due to vaginal delivery with pudendal nerve
impairment as well as neuropathies of other etiologies.
51.5.2 Rectocele
A rectocele is a bulging of the anterior rectal wall and less
frequently the posterior or lateral wall. Anterior rectocele is
caused by weakening of the supporting rectovaginal fascia
above the anal canal [19] (Fig. 51.3). Posterior rectoceles are
rare and due to levator plate damage [20]. On clinical exami-
nation an anterior rectocele can be seen as an outpouching of
the posterior vaginal wall with sensitivity between 30 and
80% [2, 21]. Most rectoceles only become apparent during
defecation. Related symptoms include dyspareunia, sensa-
tion of incomplete evacuation, and constipation. For measur-
ing an anterior rectocele the expected location of the anterior
anorectal wall serves as posterior border of the rectocele in
anterior posterior dimension. On MRD rectoceles are mea-
sured during maximal straining and evacuation. Small
656
r­ ectoceles (<2 cm) are a very common finding in asymptom-
atic subjects, are more frequently found in women, and are
considered normal [14, 22]. A bulge of 2–4 cm is considered
moderate and >4  cm large; both are considered pathologic
findings. Besides objective information about the size of a
rectocele MRD displays the dynamics of its emptying and
possibly entrapment of the rectal gel [17]. The retention of
rectal gel may serve as a surrogate for retention of stool in
the rectocele, which may lead to a sensation of incomplete
evacuation. The clinical relevance of a rectocele is defined by
size, retention of contrast material (Fig. 51.3), need for evac-
uation assistance, and symptoms.
51.5.3 Intussusception and Rectal Prolapse
Rectal prolapse is defined as an infolding of the rectal wall.
An inner rectal pro-lapse (intussusception) is distinguished
from an external rectal prolapse, corresponding to the widely
used clinical term “rectal prolapse” [23].
51.5.3.1 Intussusception
Invagination or infolding of the rectal wall toward the anal
canal during defecation is called intussusception. It can
involve mucosal or mural components. Depending on the
extension of the invagination the intussusception may remain
in the rectum (intrarectal) (Figs. 51.1 and 51.4) or extent into
the anal canal (intraanal intussusception). Patients with
a b
Fig. 51.4  41-year old female patient with full-thickness intrarectal
intussusception. MR image (a) shows an anterior rectocele at the begin-
ning of defecation. MR image (b) during defecation shows the develop-
ment of a circumferential mural intussusception, which extends into the
C. S. Reiner and K. Schawkat
intraanal intussusception may experience incomplete defeca-
tion due to severe outlet obstruction. The intussusception can
be seen anterior, posterior, or circumferential. Small invagi-
nations of the rectal wall are considered normal during def-
ecation, observed in nearly 80% of healthy subjects.
However, an intussusception can be missed in pathologic
conditions as it is commonly only visible at the end of the
defecation phase. Therefore, the evacuation phase is manda-
tory to evaluate the full extent of pathologies [24]. The dif-
ferentiation between a mucosal intussusception and a
full-thickness intussusception is possible with dynamic pel-
vic MRI (Fig. 51.4), which is of clinical relevance, because
the two different forms entail different treatment strategies
[25, 26]. In up to 30% of patients with intussusception, asso-
ciated anterior or middle pelvic floor compartment descent
has been shown [21], underlining the importance of a com-
plete pelvic floor evaluation.
51.5.3.2 External Rectal Prolapse
If parts of the rectal wall protrude through the anal canal
outward, this condition is referred to as “rectal prolapse”
(Fig.  51.5). Women are more commonly affected than
men (6:1) with an incidence of 4:1000. Symptoms range
from constipation, sensation of incomplete evacuation,
fecal incontinence to rectal ulcerations with bleeding.
Although it is a clinical diagnosis patients are referred to
MRD to diagnose associated pathologies and for surgical
planning.
rectum (intraarectal, full-­ thickness intussusception) (arrowheads).
Associated anterior and posterior rectoceles are seen (large arrows). In
addition, a small cystocele evolves during defecation (small arrow)
51  Dynamic Magnetic Resonance Imaging of Pelvic Floor Pathologies
Fig. 51.5  63-year old female patient with external rectal prolapse. MR
image obtained during defecation shows an external rectal prolapse
(arrow) and an additional moderate anterior and small middle compart-
ment descent. PCL pubococcygeal line
51.5.4 Enterocele
An enterocele is a generic term for herniation of the perito-
neal sac, which contains omental fat (peritoneocele), small
bowel (enterocele), or large bowel (sigmoidocele) which
extents below the PCL into the rectovaginal or retrovisceral
space (Fig. 51.3). Women are more frequently affected espe-
cially if they have a history of vaginal or abdominal hysterec-
tomy as a hysterectomy causes a separation of the anterior
(pubo-cervical) and posterior (rectovaginal) wall fascia. As a
result of the widespread use of hysterectomy the incidence of
enteroceles has markedly increased. In patients with pelvic
floor disorders the prevalence ranges between 17 and 37%
and they are frequently associated with rectoceles [17]
(Fig.  51.3). As clinical examination misses 50% of entero-
celes and therefore is insufficient for its detection, imaging in
cases of suspicion is indispensable. MR imaging being supe-
rior to conventional cystocolpoproctography is the best suited
imaging modality for diagnosis of enteroceles [27] and often
allows the differentiation between peritoneocele, enterocele,
and sigmoidocele. Enteroceles are often concomitant findings
of other pelvic floor pathologies and are best detected at the
end of the defecation phase. Especially in patients planned for
surgical pelvic floor repair the additional diagnosis of an
enterocele influences the surgical approach. Large entero-
celes may follow the sacral curve and lead to compression of
the ano-rectum, resulting in outlet obstruction. The distance
from the most inferior point of the e­ nterocele to the PCL line
657
Fig. 51.6  78-year old female patient with descending perineum syn-
drom (pelvic floor relaxation). Midsagittal balanced steady state free
precession T2-weighted MR image obtained during maximal straining
shows a bulging of the whole pelvic floor with a large descent of the
anterior compartment (1: 6.5 cm), small descent of the middle compart-
ment (2: 2  cm) and a large descent of the posterior compartment (3:
7.5 cm). B bladder, P symphysis pubis, PCL pubococcygeal line, R rec-
tum, U uterus
is measured in a perpendicular fashion in order to measure the
size. Depending on the size enteroceles are graded as small
(<3 mm), moderate (3–6 mm), and large (>6 mm) [14].
51.6 Pelvic Floor Relaxation
Pelvic floor relaxation (also known as descending perineal
syndrome) is defined as a pathologic descent of the pelvic
floor at rest or at straining caudal to the PCL (Fig.  51.6).
Usually all three compartments of the pelvic floor are
involved. It is initially characterized by perineal pain and
constipation. Prolonged and excessive straining lead to
denervation and thereby in the chronic stage the patients
develop fecal incontinence [28]. Most commonly affected
are women, aged 50 or older, with multiple vaginal deliver-
ies, gynecological operations, and chronic constipation [29].
Although it can be already seen at rest, the maximus exten-
sion of the pelvic floor relaxation is seen at straining and
defecation. The descent is defined as the maximum distance
between the PCL and the lowest point of the anterior (blad-
der base), middle (vaginal vault), and posterior pelvic floor
compartment (ARJ). A distance <3  cm below the PCL is
graded as mild, 3–6 cm is moderate, and >6 cm is considered
a large descensus.
658
a b
Fig. 51.7  60-year old female patient (s.p. hysterectomy and surgical
repair of an enterocele) with clinical suspicion of dyssynergic defeca-
tion. On MR images obtained at rest (a) the anorectal angle measures
103°, whereas the anorectal angle during squeezing is 81° (b). During
51.7 Dyssynergic Defecation
At rest the puborectalis muscle constantly pulls the rectum
anteriorly to maintain the continence and relaxes during the
evacuation phase. In patients with dyssynergic defecation
during defecation no relaxation or a paradoxical contraction
of the puborectalis muscle and/or anal sphincter is observed
C. S. Reiner and K. Schawkat
evacuation a pathologic decrease of the anorectal angle (48°) is seen (c).
Paradoxical sphincter contraction is noted with impression of the dorsal
anorectal wall during evacuation (arrowhead in c). The patient was able
to evacuate only less than two thirds of the contrast agent
leading to functional outlet obstruction during defecation
(Fig.  51.7). It typically causes chronic constipation and
patients can present with a variety to symptoms including
sensation of blockage, need for manually assisted defeca-
tion, and frequent use of enemas [30] as well as delay
between opening of the anal canal and initiation of defeca-
tion [31]. Many other terms have been used in the literature
51  Dynamic Magnetic Resonance Imaging of Pelvic Floor Pathologies
to describe this phenomenon such as anismus, spastic pelvic
floor syndrome, and pelvic floor dyssynergia. The term “dys-
synergic defecation” was proposed by an expert group [5] to
correctly describe the failure of coordination of the abdomi-
nal and pelvic floor muscles involved in defecation [32].
How exactly dyssynergic defecation evolves is still unclear,
but associations seem to exist between dyssynergic defeca-
tion and pelvic surgery, previous sexual abuse, anxiety, and
psychologic stress [33]. As the diagnosis is extremely diffi-
cult, it is recommended to use a combination of diagnostic
tests, imaging, and clinical history to properly diagnose dys-
synergic defecation. Besides imaging, different physiologi-
cal tests exist to investigate this functional disorder (e.g.,
balloon expulsion test, electromyography, anorectal manom-
etry); however none can be used as a gold standard by itself
as false-positive and false-negative results are common.
Functional imaging with conventional defecography or
MRD is considered to be a useful adjunct in establishing the
diagnosis of dyssynergic defecation. In addition, MRD can
be performed to rule out structural rectal abnormalities.
Delayed initiation of evacuation and/or incomplete evacua-
tion was shown to be highly predictive in patients with dys-
synergic defecation as seen on conventional defecography
[31, 34]. MRD has been shown to be a valuable alternative to
evacuation proctography [14, 32, 35, 36]. Findings on MRD
include lack of normal pelvic descent, inability to evacuate,
paradoxical decrease of the anorectal angle during straining
and evacuation, and a posterior prominent impression of the
contracted puborectalis muscle on the anorectal junction
(Fig. 51.7) [32, 37]. Impaired evacuation, which was defined
by Halligan et al. [34] as an inability to evacuate two-thirds
of the contrast enema within 30 s, is especially highly sug-
gestive for the presence of dyssynergic defecation. In addi-
tion to morphologic and dynamic changes implying the
diagnosis of dyssynergic defecation, MRD can be used for
therapy monitoring as it can also assess changes in dynamics
of the pelvic floor after biofeedback therapy [38].
51.8 Conclusion
By providing morphologic and functional information on
pelvic floor structures and pathologies MRD and therefore
the radiologist is gaining a central role in the workup of
patients with pelvic floor disorders. Profound knowledge of
pelvic floor anatomy, patients’ history, clinical finding, as
well as the ability to correctly depict pathologic condition of
the pelvic floor on MRD are crucial to contribute to an accu-
rate management of these patients. The use of guidelines
helps to standardize MRD protocols and provide a system-
atic approach to report MRD findings for a better communi-
cation between the different specialists involved in the
management.
659
Future Directions
• To focus on imaging of pelvic floor support struc-
tures and their defects, more than on pelvic organ
prolapse, which is simply the effect of the structural
defects
• To develop measurement systems, which allow the
measurement of pelvic organ location in a three-
dimensional space instead of midsagittal two-
dimensional planes to improve diagnosis and
surgical planning
Take-Home Messages
• Knowing normal pelvic floor anatomy and being
able to recognize physiologic conditions of the pel-
vic floor is key for correct interpretation of MRD
finding and its pathologic conditions.
• The presence and degree of pelvic floor abnormali-
ties may be underestimated if the evacuation phase
is not performed. Therefore, the evacuation phase
should be an integral part of every MRD protocol.
• MRD offers the possibility of a comprehensive
evaluation of pelvic floor dysfunction most often
being a combination of pathologies of more than
one pelvic floor compartment.
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 Pelvic Floor Muscle Training
in Prevention and Treatment of Pelvic
Organ Prolapse
Kari Bø and Ingeborg H. Brækken
Learning Objectives
Readers of this chapter should learn about
• Mechanisms of how pelvic floor muscle training
can reduce symptoms and improve anatomic pelvic
organ prolapse
• The evidence for the effect of pelvic floor muscle
training on symptoms of POP and stage of POP
• How to conduct an effective pelvic floor muscle
training program for POP
52.1 Introduction
The prevalence of symptomatic pelvic organ prolapse (POP)
is reported to be 3–28% [1–5]. The feeling of vaginal bulge
into or out of the vagina is the most common and specific
symptom of POP with a prevalence ranging from 5 to 10%.
The prevalence increases if pelvic pressure and heaviness are
included as symptoms of POP [1, 6, 7], and these symptoms
may greatly impair quality of life with restriction of partici-
pation in, for example, physical activity. POP may occur in
the anterior, middle, and/or posterior compartment of the
pelvic floor and it is defined as descent of the anterior vaginal
wall (bladder, urethra), posterior vaginal wall (bowel), and/
or apex of the vagina (cervix, uterus). Absence of prolapse is
defined as stage 0 support; prolapse can be staged from stage
I to stage IV (total eversion) [8, 9].
K. Bø (*)
Department of Sports Medicine, Norwegian School of Sport
Sciences, Oslo, Norway
e-mail: kari.bo@nih.no
I. H. Brækken
Department of Global Public Health and Primary Care, University
of Bergen, Bergen, Norway
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_52
52
It is estimated that approximately 50% of all women lose
some of the supportive mechanisms of the pelvic floor due
to childbirth, leading to different degrees of pelvic organ
prolapse (POP) [10]. In the UK, POP accounts for 20% of
women on waiting lists for major gynecological surgery [11].
Based on databases including more than ten million women
in the USA, the lifetime risk of any primary surgery for SUI
or POP was 20.0% by the age of 80  years [12]. Prolapse
recurs in up to 58% of women after surgery [13], and about
one-third of operated women undergo at least one more
surgical procedure for prolapse [14]. Stress urinary incon-
tinence, dyspareunia, and mesh exposure are other risk fac-
tors associated with surgery [13]. The high prevalence and its
increase with age light the need for prevention measures that
could reduce the incidence and the impact of POP.
However, prolapse may be asymptomatic until the
descending organ is through the introitus, and therefore POP
may not be recognized until an advanced condition is present
[6, 7]. In some women, the prolapse advances rapidly, while
others remain stable for many years. Most clinicians have
considered that POP does not seem to regress [10]. However,
Handa et al. [15] found that spontaneous regression is com-
mon, especially for minor prolapse. This was also confirmed
by Miedel et al. [16].
Treatment of POP can be conservative (lifestyle interven-
tions and/or pelvic floor muscle training (PFMT)), mechani-
cal (use of a pessary), or surgical [13, 17]. While systematic
reviews and randomized controlled trials (RCTs) have shown
convincing effect of PFMT for stress and mixed urinary
incontinence [18, 19], the effect on POP is a relatively new
area of research. A survey of UK women’s health physical
therapists showed that several women attending physical
therapy practice presented with a mixture of pelvic floor dys-
functions such as stress urinary incontinence and prolapse
and that 92% of the physiotherapists assessed and treated
women with POP [20]. The most commonly used treatment
was PFMT with and without biofeedback. The aim of the
present chapter is to give an up-to-date systematic review of
RCTs on PFMT to prevent and treat POP.
661
662
52.2 Methods
The basis for this review is a search on the Cochrane data-
base, PubMed, and the abstract books from the International
Continence Society and International Urogynecology
Annual Meetings from 2016, for RCTs on PFMT to prevent
or treat POP.
52.3 Results
52.3.1 In the General Population
Till date, 11 RCTs have been found applying PFMT to treat
POP [21–32]. Typically most RCTs compared PFMT plus
lifestyle intervention, against lifestyle interventions alone.
Lifestyle intervention included use of pre-contraction of the
PFM before and during increase in intra-abdominal pressure,
“the Knack” and advice to avoid pushing down during def-
ecation [24, 25, 28], or general lifestyle advice [23, 28, 29].
None have compared the effect of these lifestyle interventions
with untreated controls and there is no report of adherence to
these protocols. Hence, the effect of lifestyle interventions on
POP is still unknown. Brækken et  al. [25] did not find any
effect of advice to use the Knack on muscle morphology.
The RCTs are all in favor of PFMT to be effective in treat-
ing POP, demonstrating statistically significant improvement
in symptoms [22–24, 26–29] and/or prolapse stage [21,
23, 24, 26, 27]. Frawley et al. (2012) and Due et al. (2016)
did not find a significant change in stage of POP [28, 32].
Methodological score on PEDro ranged from 4 to 8 with
most studies scoring 7–8.
52.3.1.1 Hypopressive Technique
The hypopressive technique was developed by Caufriez
(1997) and involves a combination of a breathing and postural
techniques and contraction of the abdominal muscles which
has shown to pull the prolapse upward/inward [33]. It remains
to be scientific proven whether the hypopressive exercises can
reduce intra-abdominal pressure in a way that prevents the
pelvic organs to be pushed down and thereby prevent aggra-
vation of POP. However, based on current evidence hypopres-
sive exercise will not increase the strength nor thickness of
the PFM muscles. Resende et al. [34] assessed 36 nulliparous
physical therapists with vaginal surface EMG during PFM
contraction, hypopressive technique, and a combination of
the two. They found that PFM contraction was more effective
than the hypopressive technique to increase sEMG activation
of the PFM and that there were no additional effects of add-
ing the hypopressive technique. Not surprisingly, the hypo-
pressive technique was significantly more effective than PFM
contraction in activation of the transverse abdominal muscle.
In an RCT, Stupp et  al. (2011) found that both PFMT and
K. Bø and I. H. Brækken
PFMT + the hypopressive technique were significantly more
effective than lifestyle advice in increasing muscle strength
(Oxford grading) and muscle activation (sEMG), but there
was no additional effect of adding the hypopressive technique
to PFMT [26]. Ultrasound assessment of the cross-sectional
area (CSA) of the levator ani muscle showed increased CSA
in the PFMT and the PFMT + hypopressive technique com-
pared to the lifestyle group, but there was no additional effect
of the hypopressive technique on CSA [35].
52.3.2 FMT to Prevent and Treat POP
in the Peripartum Period
We have only been able to find one RCT evaluating the effect
of PFMT to prevent and treat POP after childbirth [36]. In
a group of 175 first-time mothers stratified on major leva-
tor ani injury and randomized to either PFMT or control,
no effect was shown either on prevention or treatment of
POP. The intervention lasted 4 months and the participants
had been taught correct PFM contraction by an experienced
physical therapist. The training consisted of group training
once a week and daily home training with three sets of 8–12
close to maximum contractions. It was concluded that indi-
vidual and more intensive training may be necessary, espe-
cially if there are major injuries. Further studies are needed
to address whether PFMT can restore injured muscles and
treat POP in postpartum women.
52.3.3 Prevention
The most important goal would be to prevent POP from
occurring in the first place. However, primary prevention
studies are difficult, or almost impossible, to conduct. It
is not feasible or ethical to randomize women to PFMT or
control and follow them for 30–40 years, which would have
been the optimal design to answer this research question.
No RCTs or studies using other designs have been found in
evaluating the effect of PFMT on POP in primary prevention
(stop prolapse from developing). Only one prevention study
has been found [37]. Four hundred and seven women, not
seeking treatment, but still with POP symptoms, were fol-
lowed for 2 years with a program of two sessions of week
with Pilates training, including isolated PFM contractions.
The results showed that there were significantly less report of
POP symptoms in the PFMT group compared to the controls.
Given that it is unlikely to have high-quality studies in this
area, one could argue from theory and studies showing that
women with POP have weaker PFM than healthy controls
[37] and that PFMT has shown to lift the bladder neck and
the rectal ampulla, narrowing the levator hiatus, reduce PFM
length and increase PFM cross-sectional area [25] that it is
52  Pelvic Floor Muscle Training in Prevention and Treatment of Pelvic Organ Prolapse
plausible that PFMT can prevent POP in women. However,
to date there is no evidence for this proposal. Based on an
understanding of functional anatomy and exercise science,
we recommend that general exercise programs for women
should include PFMT.
52.3.4 PFMT in Combination with Surgery
PFMT has shown to be effective in reducing symptoms and
improve stage of POP. Women should be offered PFMT as a
first choice treatment for prolapse, before surgery [17]. Most
surgeons would also recommend to continue to do PFMT
after surgery to prevent relapse and to improve PFM func-
tion. To date there are only few RCTs assessing the effect
of PFMT in combination with surgery [38–42]. Only one of
these studies showed a positive additional effect [42].
However, this is a feasibility study with a small sample
size, and the results must be interpreted with caution. Recent
systematic reviews have concluded that there is insufficient
evidence to conclude whether PFMT has any additional
effect to surgical repair of POP [17, 42, 43]. One reason for
the lack of effect may be that the follow-up period has been
too short to show effect on relapse. And in addition, such
expected long-term effects involve that the women continue
to perform PFMT regularly for many years.
52.3.5 Long-Term Effect
To date, there is only one abstract reporting long-term effect
of PFMT for POP. Hagen et al. [44] reported a 2-year fol-
low-­up after PFMT. Unfortunately, only 40% of the original
447 participants responded. There was no longer any differ-
ence between the training and control group in Pelvic Organ
Prolapse Symptom Score, but fewer women in the PFMT
group opted for further treatment and 6% in the PFMT group
had surgery vs. 13% in the control group. Further and lon-
ger follow-up trials are needed in this area. However, long-
term studies imply strict adherence to the training program to
allow for meaningful interpretations of results.
52.4 Discussion
The conclusion from 11 RCTs and systematic reviews are
consistent that there is strong evidence that PFMT is effec-
tive in reducing POP symptoms and improves stage of POP.
The published studies only reported short-term effects.
To maintain the effect, similar to the recommendations for
general strength training, it is expected that PFMT must be
continued, although with a reduced frequency of training, to
avoid relapse [45].
663
There are two main hypotheses for mechanisms as to how
PFMT may be effective in prevention and treatment of stress
urinary incontinence [46, 47], and the same theories may
apply for a possible effect of PFMT to prevent and treat POP.
The two hypotheses are as follows: (1) women learn to
consciously contract before and during increases in abdomi-
nal pressure (also termed “bracing” or “performing the
Knack”) and continue to perform such contractions as a
behavior modification to prevent descent of the pelvic organs
and pelvic floor muscles; and (2) women are taught to per-
form regular strength training in order to build up “stiffness”
and structural support of the pelvic floor over time [45].
52.4.1 Conscious Contraction (Bracing or
“Performing the Knack”) to Prevent
and Treat POP
Research on basic and functional anatomy supports conscious
contraction of the PFM as an effective maneuver to stabilize the
pelvic floor [48, 49]. However, to date, there are neither studies
on how much strength or which neuromotor control strategies
are necessary to prevent descent during cough and other physi-
cal exertions nor how to prevent gradual descent due to activi-
ties of daily living. Brækken et al. (2010) found that advice to
do “the Knack” and not to strain on defecation improved stage
of POP in 4% [24], but no morphological changes of the PFM
were found after this training modality [25].
An interesting, but difficult, hypothesis to test is whether
women at risk for POP can prevent development of prolapse
by performing bracing or “the Knack” during a rise in intra-­
abdominal pressure. Since it is possible to learn to hold a
hand over the mouth before and during coughing, one would
expect that it is possible to learn to precontract the PFM
before and during simple and single tasks such as coughing,
lifting, and isolated exercises such as performing abdominal
exercises. However, multiple task activities and repetitive
movements such as running, playing tennis, aerobics, and
dance activities cannot be conducted with intentional co-­
contractions of the PFM.
52.4.2 Strength Training
The theoretical rationale for intensive strength training of the
PFM to treat POP is that strength training may build up the
structural support of the pelvis by:
• Elevating the levator plate to a permanently higher loca-
tion inside the pelvis
• Enhancing hypertrophy and increased stiffness of the
PFM and connective tissue, reducing muscle length of the
puborectalis, narrowing the levator hiatus
664
As described by DeLancey [50] in the “boat in dry dock”
theory, the connective tissue support of the pelvic organs
fails if the PFM relax or are damaged, and organ descent
occurs. This underpins the concept of elevation of the PFM
and closure of the levator hiatus as important elements in
conservative management of POP. All the RCTs in this area
have used strength training principles in the treatment proto-
cols. However, Brækken et al. [24] measured PFM strength
increase in both randomized arms. They found a significant
and huge increase in strength in the PFMT group only. They
also found statistically significant increases in muscle vol-
ume, shortening of the muscle length, narrowing of the leva-
tor hiatus, and lifting of the bladder neck and rectal ampulla
[25], factors that may be essential in prevention and rever-
sion of POP.
Readers may learn more about how to perform an effec-
tive PFMT program by watching www.Corewellness.
52.5 Conclusions
11. Thakar R, Stanton S.  Management of genital prolapse. BMJ.
To date there is strong evidence that PFMT can significantly
reduce symptoms and improve stage of POP. Further studies
are needed to address which women respond to training and
if POP can be prevented. A suggested primary prevention
strategy for the general female population would be to avoid
straining, to learn to contract the PFM during an increase
in intra-abdominal pressure, and to conduct regular strength
training of the PFM.
Take-Home Message
PFMT has 1A evidence to be effective in treating POP
and there are no known side effects or complications.
Women with POP stage I, II, and III should be offered
PFMT as first-line treatment.
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30. Wiegersma M, Panman CM, Kollen BJ, et al. Pelvic floor muscle
training versus watchful waiting or pessary treatment for pelvic
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36. Bø Bo K, Hilde G, Tennfjord MK, et  al. Randomized controlled
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 Use of Pessaries for Pelvic Organ
Prolapse
Dimos Sioutis and Rohna Kearney
Learning Objectives
• To understand the role of pessary care in the man-
agement of vaginal prolapse symptoms.
• To learn the assessment of a woman considering
pessary treatment, the variety of pessaries available,
possible complications and their management.
53.1 Introduction
Pessary management is the most commonly used conserva-
tive treatment of pelvic organ prolapse. Vaginal pessaries are
passive mechanical devices designed to provide support to the
pelvic organs to improve symptoms of pelvic organ prolapse.
The concept of inserting a device into the vagina to relieve
prolapse symptoms is not a recent idea. The Kahun Papyrus
from ancient Egypt, in approximately 2000 BC, reports that
standing over specific burning ingredients could move pro-
truding pelvic organs back to normal position [1]. Ancient
Greek physicians developed some of the earliest pessary-like
devices to reduce prolapse. Polybus suggested the insertion
of half a pomegranate into the vagina and Soranos used a
linen tampon soaked in vinegar or a piece of beef meat. The
word “pessary” derives from the Greek word “peso”, which
refers to the oval-shaped stone used in an Ancient Greek
game, similar to modern checkers. Such stone pessaries were
D. Sioutis
Third Department of Obstetrics and Gynaecology, Attikon
Hospital, National and Kapapodistrian University of Athens,
Athens, Greece
R. Kearney (*)
Warrell Unit, St Mary’s Hospital, Manchester University Hospitals
NHS Trust, Manchester Academic Health Science Centre,
Manchester, UK
School of Medical Sciences, Faculty of Biology, Medicine and
Health, University of Manchester, Manchester, UK
e-mail: rkearney@nhs.net
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_53
53
inserted intravaginally as tampons in animals for contracep-
tion. A 1000 years later there are descriptions of purpose-
made devices replacing natural objects. In the sixteenth
century oval-shaped pessary-like devices were designed ini-
tially by Ambroise Pare and later in different other shapes
from oval to spheroidal by C.  Bauhin (1588) and William
Fabry of Hilden (1592) [2, 3]. Today pessaries are usually
made of vinyl, polythene, latex or silicone and come in a
variety of shapes and sizes. They are commonly offered as a
non-surgical option to manage prolapse symptoms.
53.2 Types of Pessaries
There are two categories of pessaries in common use: sup-
port pessaries and space-filling pessaries.
53.2.1 Support Pessaries
Ring pessaries are the most frequently used pessary. They
are available in rigid polythene or flexible vinyl or silicone
(Figs. 53.1 and 53.2). A variety of size options are available
from 50 to 110  mm. Polythene and vinyl are designed for
single use whereas silicone pessaries can be used for up to
5 years provided there is no visible damage. The advantages
of ring pessaries are that they are easy to fit and the woman
can have sex with the pessary in place. They are also amena-
ble to self-management. Shaatz pessaries, rings with support,
Gehrung or Falk sieve pessaries may provide better support
when the uterus is prolapsing (Figs. 53.3 and 53.4).
53.2.2 Space-Filling Pessaries
Gellhorn and shelf pessaries are the most commonly used
space-occupying pessaries (Figs.  53.5 and 53.6). They are
inserted with the concave surface against the prolapsed
cervix or vaginal cuff and the stem posteriorly towards the
667
668
Fig. 53.1  PVC ring pessary
Fig. 53.2  Folding silicone ring pessary
introitus. Their size varies from 38 to 114  mm. They are
more difficult to insert and replace than the ring pessaries
and are not compatible with vaginal intercourse. Cube and
inflatable pessaries require the woman to be able to self-­
manage. Donut pessaries can be used for severe prolapse
with lax perineal support.
D. Sioutis and R. Kearney
Fig. 53.3  Silicone Schaatz pessary
Fig. 53.4  Silicone ring with support pessary
53.2.3 Incontinence Pessaries
There are a range of pessaries which may be of benefit for
women with incontinence as well as prolapse. They have a
knob on the anterior portion to compress the urethra or blad-
der neck and reduce leakage (Fig. 53.7).
53  Use of Pessaries for Pelvic Organ Prolapse
Fig. 53.5  Silicone Gellhorn pessary
Fig. 53.6  Shelf pessary
53.3 Pessary Selection
There is little evidence regarding pessary selection. In gen-
eral ring pessaries are usually tried first line, as they are the
easiest type to manage. Space-occupying pessaries, with
the exceptions of cube and inflatable pessaries, are usually
reserved for women who do not wish to be sexually active or
as an interim measure before surgical management.
53.3.1 Assessment and Insertion
A thorough history should be taken to establish prolapse
symptoms; effect on urinary, bowel and sexual function; and
preferences for further treatment. An examination is required
to rule out a pelvic mass and assess the type and degree of
prolapse and presence of vaginal atrophy or ulceration. There
are no published trials looking at the effect of vaginal oestro-
669
Fig. 53.7  Silicone incontinence ring pessary
gen on pessary use but several retrospective studies suggest
that treating vaginal atrophy prior to pessary insertion may
increase the likelihood of successful pessary treatment [4, 5].
There is very little evidence regarding appropriate pessary
selection and fitting. The Continence Society of Australia
has published guidelines for the use of pessaries in 2012 [6].
Previously pessaries were considered to be a better option
for older women or women who are unfit for surgery or wish
further childbearing. However many younger women with
prolapse symptoms wish to try a pessary, particularly if they
are able to self-manage.
There are several ways to assess for the size of pessary.
These include asking the woman to strain and measuring the
genital hiatus as a guide to pessary size, inserting the first and
middle fingers into the vagina and spreading the fingers at
the top of the vagina to estimate a measurement or inserting
a finger into the vagina to the posterior fornix and estimating
the distance to the pubic symphysis. The woman should be
advised that the first fitting may not be successful and a differ-
ent size or type of pessary may be required. Ring, Shaatz or
Falk pessaries are inserted by squeezing the pessary or forming
it into a figure of eight (Figs. 53.8 and 53.9). Lubricant should
be placed on the leading edge of the pessary to make inser-
tion more comfortable and the pessary should be inserted to
be above the pelvic floor muscles underneath the pubic bone.
Gellhorn and shelf pessaries can be harder to fit but the princi-
pal is the same. The pessary is placed in the vagina to reduce
the prolapse with the pessary stem coming down towards the
introitus. After insertion, the woman should be asked to cough
670
Figs. 53.8 and 53.9  Demonstrating method of preparing pessary for insertion
or strain as the pessary is checked for repositioning or expul-
sion. The woman should be advised to void before leaving
clinic and she should not feel any discomfort if the pessary is
fitted correctly. Further advice should be given regarding the
possibility of the pessary falling out particularly when opening
the bowels and she should also be advised of pessary compli-
cations including discharge and bleeding. The woman should
receive contact details in case she experiences problems with
her pessary prior to her next scheduled appointment.
Some studies have looked at predictors of success-
ful fitting and identified that failure to retain a pessary is
­associated with higher parity and previous hysterectomy [7].
Retrospective studies suggest the use of local HRT in meno-
pausal women is associated with a higher rate of pessary
retention and reduced vaginal discharge [4, 8]. A prospec-
tive observational trial of 100 women identified that a short
vaginal length (<6 cm) and a wide vaginal introitus (4 finger-
breadths) were risk factors for unsuccessful pessary fitting
[9]. In some women fitting two pessaries at the same time
may be required for optimal reduction of prolapse.
53.3.2 Follow-Up Pessary Care
There is very little evidence to guide further care. A UK-based
survey of 678 medical, nursing and physiotherapy profession-
als reported that pessary care is predominantly delivered by
medical staff; that ring, shelf and Gellhorn were the most com-
monly fitted pessaries; and that there was significant variance
in the organization and provision of follow-up care with only
17% offering the option of self-management [10]. Similarly a
D. Sioutis and R. Kearney
survey of members of the American Urogynecologic Society
(AUGS) reported a variation in pessary follow-up. Over half
of all physicians taught their patients to self-manage their
pessary [11]. A survey of IUGA members on practice regard-
ing shelf and Gellhorn pessaries reported that most members
follow up their patients every 6–12 months [12]. It would
appear that the most common follow-up period is 6 monthly
but this is not based on high-­quality evidence. A pilot study
has reported greater patient satisfaction with care with self-
management of ring pessaries compared with standard care
but this needs to be robustly investigated [13]. In this self-care
study some women used a pessary only when they felt it was
required, for example, exercising, and therefore reduced the
amount of time that a pessary was in place. Some women pre-
ferred to remove it before intercourse or defecating. Routine
practice in the UK is a 6 monthly follow-up clinic visit at
which the pessary is removed and a speculum examination is
performed to assess for evidence of granulation or ulceration.
The pessary is then replaced if the examination is normal.
53.4 Complications of Pessary Treatment
Complications of pessary use are the commonest reason for
women discontinuing pessary management. Complications
include displacement or failure to retain pessary, vaginal
discomfort, bleeding, ulceration or discharge and worsen-
ing urinary, bowel or sexual function. Severe complications
reported include vesicovaginal and rectovaginal fistula, pes-
sary incarceration requiring removal under anaesthetic and
vaginal or cervical cancer.
53  Use of Pessaries for Pelvic Organ Prolapse
A review of 61 articles reporting pessary complica-
tions between 1952 and 2014 classified the complications
according to the Clavien-Dindo classification of complica-
tion severity [14, 15]. This review included 25 case studies
and 36 case reports. The most frequently reported compli-
cations were pain and discomfort, vaginal discharge, ero-
sion, ­vesicovaginal fistula, bleeding and foul odour. As most
of the included studies were case reports it is not possible
to report the frequency of complications as the denomina-
tor is unknown. Vesicovaginal and rectovaginal fistulas are
the most serious complications and are usually related to
a neglected pessary. Several reports suggested that a pes-
sary was the cause of a vaginal or cervical cancer due to
chronic inflammation; however the exact risk is unclear.
Complications were found in all Clavien-Dindo levels with
deaths being recorded due to pyelonephritis with hydrone-
phrosis and erosion of pessary into upper rectum.
A prospective UK study comparing surgery and pes-
sary treatment of prolapse followed 133 women after pes-
sary insertion at 12  months and 12 women discontinued
pessary use by 6 months due to difficulty retaining the pes-
sary, discomfort and discharge. Vaginal oestrogen was only
prescribed if there was evidence of vaginal atrophy [16]. A
Spanish prospective study of 94 postmenopausal women
using a ring pessary with a median follow-up of 27 months
reported a continuation rate of 81%. Most discontinuations
occurred in the first week and reasons included discomfort,
extrusion during daily activities, bleeding and dislike by hus-
band. All women were prescribed oestrogen cream in this
study unless there was a contraindication. For women con-
tinuing with pessary use the most common complication was
extrusion during daily activities or defecation (18%), bleed-
ing or excoriation (10.5%) and pain or discharge (2.6%). In
contrast to the review of complications discussed above all
complications were classed as Clavien-Dindo 1 [17]. This
may reflect the fact that prospective studies are poor at iden-
tifying rarer complications such as fistulae.
Many women who are motivated to find a pessary solu-
tion to improve their prolapse symptoms are happy to try
more than one type or size of pessary, if it is explained to
them that it typically takes more than one fitting to achieve
a successful pessary solution. It is important that they are
made aware that if it is a correct fit they should feel no dis-
comfort and be unaware that the pessary is in place. They
should also be advised that a pessary may fall out and how
to push it back in if it comes down during defecation. If sig-
nificant vaginal atrophy is present at initial assessment, it
is the author’s approach to pretreat with vaginal oestrogen
for 2  weeks prior to inserting a pessary provided there are
no contraindications. Women should be advised that they
may develop a vaginal discharge and they should contact the
clinic if they experience excessive or foul smelling discharge,
bleeding or discomfort. There is no evidence that discharge
is less with a silicone pessary compared to a polythene or
671
vinyl pessary; however many practitioners prefer silicone
pessaries as they can be used for up to 5 years, feel softer
and are easier to self-manage. If a pessary results in vaginal
excoriation or ulceration it may be necessary to remove the
pessary for 2–4 weeks to allow the vagina to heal. If there
is a contraindication to using oestrogen cream an antibiotic
cream such as clindamycin may be helpful.
53.5 Evidence of Effectiveness
There are no randomized trials comparing pessary use to sur-
gery; however prospective studies have shown that pessaries
are an effective intervention to reduce prolapse, urinary and
bowel symptoms [7, 18]. There are several prospective stud-
ies following women with pessaries. A 5-year prospective
UK study of 246 women reported that 76% of women suc-
cessfully retained a pessary 4 weeks after insertion and that
86% of the 151 women followed up over 5 years continued
with pessary use. Most failures of pessary treatment occurred
within the first 4 weeks [16]. The same research group com-
pared the outcomes of 287 women undergoing prolapse
surgery or using pessaries with questionnaires at 1 year and
reported similar outcomes in vaginal, bowel, urinary and
quality of life scores [19]. Women who chose pessaries were
older (67 vs. 59 years), less likely to be sexually active, and
76% of the pessary group used a ring pessary. Of the 133
women who opted for pessary use first line, 12 women (9%)
discontinued pessary use within 6 months. Reasons for dis-
continuation included difficulty retaining pessary, discom-
fort and vaginal discharge. There was an improvement in
vaginal soreness, bowel evacuation and sexual symptoms in
the surgery group compared with the pessary group but these
symptoms were not bothersome as assessed by validated
questionnaires.
A prospective Dutch study reported that at 1  year 72%
of women using pessaries did not opt for surgery and that
women choosing surgery had less severe symptoms [20].
A US study looking at patient-reported goal attainment in
160 women undergoing surgery or using a pessary found
a higher proportion of women in the surgery arm reported
achieving symptom and function goals although both groups
experienced an improvement in symptoms and functioning.
Interestingly women who discontinued pessaries or crossed
over to the surgery arm had worse goal attainment whereas
those who continued pessary use had similar goal attainment
to the surgery arm [21].
The most recently published Cochrane review in 2013
found only one randomized controlled trial comparing ring
to Gellhorn pessaries [22, 23]. However several other tri-
als have been published since then comparing pessaries to
other treatment modalities. One trial compared pessary use
to pelvic floor muscle training in 162 women over the age of
55 years recruited in primary care practices and reported on
672
improvement in symptoms measured by the PFDI question-
naire [24]. This showed no significant difference between
women randomized to pessary or pelvic floor muscle train-
ing at 2 years; however the prolapse-specific symptom score
(POP-DI) improved more in the pessary group. The cost of
pessary use was less than PFMT but there were more com-
plications with pessary use. Pessary use combined with
PFMT has been compared with PFMT alone in a random-
ized controlled trial of 276 women, again using the PFDI-
20 questionnaire to record symptom improvement. In both
the intention to treat and per protocol analysis there was a
statistically significant improvement in the prolapse sub-
scale (POP-DI) in both groups with a greater improvement
in the pessary group [25]. One randomized trial compared
134 women using either a ring with support or a Gellhorn
pessary and reported no difference in symptom improvement
or quality of life measured by the PFDI and PFIQ question-
naires between these two types of pessary at 3 months [23].
53.6 Training of Pessary Practitioners
Currently there is no single recognized training programme
for fitting and managing pessaries. In practice pessaries
are fitted by a variety of healthcare professionals includ-
ing nurses, doctors and physiotherapists. The James Lind
Alliance Priority Setting Partnership for pessaries in pro-
lapse has identified the research priority of “what is the ideal
training to be a qualified pessary practitioner?” as a top 10
priority for research in the use of pessaries [26].
53.7 Future Directions
Although pessaries have been used for thousands of years, most
of the evidence regarding pessary care is from retrospective stud-
ies with only a few prospective studies. There are a few random-
ized controlled trials looking at pelvic floor muscle training as an
alternative or adjunct to pessary use. There are no randomized
trials and only one prospective study comparing surgery to pes-
sary care for management of prolapse. The James Lind Alliance
Priority Setting Partnership has identified that the top three pri-
orities for research related to pessary care are as follows: how
might a pessary affect sexual activity, do pessaries have an effect
on the sexual well-being of women and what is important for
a pessary self-management programme? In the UK recruitment
has completed and data collection continues for a randomized
trial comparing self-management of ring pessary to standard
care and the results are awaited. There is a paucity of data to
counsel women considering a pessary for prolapse regarding
longer-term outcomes and complications. Data on surgery sug-
gests that one in 4–5 women undergoing prolapse surgery will
have a second pelvic floor procedure but we still do not have data
D. Sioutis and R. Kearney
on the long-term outcome of pessary use including lifetime con-
version to surgery [27]. Research in this area is required for us to
provide women with the knowledge that they require to make an
informed decision regarding their treatment options.
Take-Home Messages
Current evidence supports offering women the option
of pessary management to control prolapse symp-
toms. Ring pessaries are the most successful option
for women who wish to remain sexually active. Space-­
occupying pessaries are suitable for women who are
not sexually active or as a temporary measure prior to
surgery. Women should be advised:
• More than one fitting may be required to achieve a
successful pessary solution.
• The pessary should be removed and reinserted at
least every 6 months.
• Of the risk of pessary complications including
expulsion, discomfort, discharge and bleeding.
• Advised that vaginal oestrogen may improve pes-
sary retention in postmenopausal women.
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25. Cheung RY, Lee JH, Lee LL, Chung TK, Chan SS. Vaginal pessary
in women with symptomatic pelvic organ prolapse: a randomized
controlled trial. Obstet Gynecol. 2016;128:73–80.
26. http://www.jla.nihr.ac.uk/priority-setting-partnerships/pessaries-
for-pelvic-organ-prolapse/top-10-priorities.htm.
27. Abdel-Fattah M, Familusi A, Fielding S, et al. Primary and repeat
surgical treatment for female pelvic organ prolapse and inconti-
nence in parous women in the UK: a register linkage study. BMJ
Open. 2011;1:e000206.
 Anterior and Posterior Colporrhaphy:
Native Tissue Versus Mesh
Bernard T. Haylen
Learning Objectives
• Vaginal defects—What needs to be fixed?
• Anterior colporrhaphies—Native tissue and
alternatives.
• Posterior colporrhaphies—Native tissue and
alternatives.
• Vaginal vault fixation—Important to achieve more
effective colporrhaphies.
• Relative efficacies of outcomes of native tissue and
mesh colporrhaphies.
54.1 Introduction
A chapter such as this, in the past, might have been written on
the basis of the relative safety and efficacy of native tissue
anterior and posterior repairs (colporrhaphies  – [kol’pō
vagina + raphē suture]) to those same repairs incorporating a
prosthesis, i.e. mesh. While this will be covered on a retro-
spective basis, a question prospectively is the potential avail-
ability or acceptability of mesh for use in pelvic organ
prolapse (POP) surgeries. Since January 2018, such products
will be severely restricted or unavailable in Australia and
New Zealand [1, 2], following similar initiatives in Scotland
[3], with many other jurisdictions likely to follow. Many com-
panies previously supplying mesh products have either ceased
offering this option or even ceased trading. Publicity in regard
to the complications of the vaginal use of mesh is widespread
and intense with legal proceedings including class actions
prolific. As a result, patient sentiment toward the use of mesh
for POP surgery is at least cautious and often negative.
B. T. Haylen (*)
University of New South Wales, Sydney, NSW, Australia
e-mail: bernard@haylen.co
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_54
54
The commercial use of mesh for POP repairs occurred
around 2004/2005. Complications were seen from early days
prompting US Federal Drug Administration (FDA) warnings
in 2008 [4] and 2011 [5] and the development of an interna-
tional classification of complications of prostheses and grafts
[6]. A similar classification was also deemed necessary for
native tissue colporrhaphies [7], which are certainly subject
to complications though considerably less risk of readmis-
sion in the 5 years following initial surgery than mesh col-
porrhaphies [3]. As noted in a 2012 editorial [8], one of the
positive reactions to the FDA warnings is to “improve the
results from native tissue surgery to such a degree that the
use of prostheses and grafts is far less indicated.”
The author has not used mesh for over 13 years, with
“­primum non nocere” (first do no harm) in mind, under-
standing however that (a) it has been the preference for most
other pelvic floor surgeons to have this option; (b) it was
legitimate that suitable trials on mesh occur to see if the effi-
cacy of mesh use outweighed any complication profile. The
future of POP surgeries may well lie in a greater understand-
ing of “basics” of the vaginal defects prompting the need for
colporrhaphies, including and especially the role of vaginal
vault defects. A starting point was clarifying the vaginal
vault supports including the uterosacral [9] and cardinal [10]
ligament anatomy.
54.2 V
 aginal Defects: What Needs
to Be Fixed?
It is assumed from the scope of the title that vaginal defects
only are involved, i.e., either a hysterectomy has been per-
formed or is not indicated as part of the POP repair. As per
the International Urogynecological Association (IUGA)/
International Continence Society (ICS) joint report on POP
terminology [11], involved are any, or more commonly all,
of the following three defects: (a) anterior vaginal wall (com-
partment) prolapse (Fig.  54.1a), (b) posterior vaginal wall
675
676
a b
Fig. 54.1 (a) Anterior vaginal wall prolapse [11]. (b) Posterior vaginal wall prolapse [11]. (c) Vaginal vault prolapse [11]
Fig. 54.2  Vaginal levels [11]
(compartment) prolapse (Fig.  54.1b), and (c) vaginal vault
prolapse (Fig. 54.1c).
In order to understand the surgical management of these
defects, it is important to know the level(s) [11, 12] of the
vaginal involved (Fig. 54.2):
Level I: uterine cervix (if present) and/or upper 2.5 cm of
vagina.
Level II: mid-vagina from distal end of level I to hymen.
Level III (vestibule) [12]: vaginal entrance (Latin: “ves-
tibulum” = “entrance”) from hymenal ring to urethral opening
anteriorly (anterior vestibule), labia minora laterally, and ante-
rior perineum posteriorly (posterior margin of vestibule). It is
relevant for completeness to note the definition of the poste-
rior vestibule [11, 12] (Fig.  54.3): hymenal ring to anterior
perineum (posterior margin of vestibule) posteriorly.
Vaginal vault prolapse is a level I defect [11, 13]. Anterior
vaginal (compartment) wall prolapse appears a largely level II
defect [11, 13] anteriorly though it has been shown [14] that
52% of anterior vaginal laxity relates to vaginal vault descent.
Posterior vaginal (compartment) wall prolapse is not primarily
a level II defect (i.e., rectovaginal “hernia”—as traditionally
B. T. Haylen
c
Fig. 54.3  Posterior vestibule [11, 12]
thought). It may involve levels I, II, and III. It has been recently
shown [15] that 55% of posterior vaginal wall laxity relates to
vaginal vault descent, i.e., a “concertina” rather than “hernia
effect” on level II. It was also shown [15] that posteriorly the
level I defect was the largest defect (mean 6.0  cm vault
descent) followed by the level III defect (mean 2.8 cm trans-
verse introital defect) with the level II defects being the small-
est at mean 1.2 and 1.0  cm, respectively. These results are
based on both intraoperative POP-Q [11, 16] and the newer
posterior repair quantification (PR-Q) [11, 15, 17]. Both of
these measurement techniques are included as an appendix.
54.3 V
 aginal Vault Fixation: Importance
to More Effective Colporrhaphies
The implications of the above analysis are that some form of
vaginal vault repair/fixation is likely to be important in
achieving higher success rates for all colporrhaphies, native
tissue, or mesh. Early mesh implants did not incorporate
54  Anterior and Posterior Colporrhaphy: Native Tissue Versus Mesh 677

vaginal vault fixation (and thus did not specifically address
vaginal vault defects) though later ones involved attachment
of the prosthesis unilaterally or bilaterally to the sacrospi-
nous ligament(s).
Published rates for vault fixation in native tissue repairs
have been as low as 15% [18] and as high as 84% [15].
Published numerical “cutoff” for the performance of a
native tissue sacrospinous vaginal vault fixation is limited to
a posterior vaginal vault descent (PVVD—the level I defect
measurement from PR-Q) over 5.0 cm [15, 17]. The ratio-
nale for this arbitrary figure/colopexy (SSC) was stated as
follows: for PVVD >5.0 cm, an SSC is more anatomically
and surgically desirable; for PVVD <5.0  cm, posterior
­vaginal vault support is less in question, while the approxi-
mation of vaginal vault and sacrospinous ligament (SSL)
becomes more difficult.
Vault support procedures to be described later will be
those achieved by a vaginal approach, as part of a compre-
hensive colporrhaphy. Those achieved by a laparoscopic or
other abdominal approach are acknowledged but not covered
in this chapter.
54.4 Anterior (Level II) Repair [11]
(a) Native tissue: the most common of these is as
follows:
• Midline fascial plication: Involving midline incision,
wide exposure of the pubovesical fascia, midline fas-
cial plication, excision of redundant vaginal skin, and
midline re-suturing. See Fig. 54.4.
There are also as follows:

a b

Fig. 54.4  Anterior (native tissue) colporrhaphy [11]. (a) Preoperative. (b) Vesicovaginal fascial repair. (c) Anterior vaginal mucosal repair
678
• Site-specific repair: Paravaginal—bilateral vaginal
reattachment of the lateral edge of damaged fascia to
the arcus tendineus fasciae pelvis (Alt: white line).
• Other site-specific repairs: Transverse, distal,
combined.
• Anterior enterocele repair: Very thinned out vaginal
mucosa directly behind which is peritoneum, occur-
ring generally after multiple previous colporrhaphies.
Some uterosacral ligament support can generally be
found (see MUSPACC below) after careful dissection
and ligation of enterocoele sac.
• Midline uterosacral plication anterior colporrhaphy
combo (MUSPACC) [18]:
The uterosacral ligament (intermediate segment)
can be found consistently post-hysterectomy on the
internal aspect of a prolapsed anterior vaginal vault
following midline mucosal incision, fascial dissec-
tion, and bladder retraction. It will not be evident till
a curved suture needle puts it under tension. A com-
pleted first suture will allow more obvious exposure
for a second and third suture (PDS). Uterosacral pli-
cation sutures after pubovesical fascial sutures are
tied, providing some anterior vaginal vault support,
particularly in a cystocele-predominant prolapse
where posterior vaginal vault is reasonably well sup-
ported (Fig. 54.5).
( b) Anterior vaginal wall repair with mesh or graft
reinforcement:
A structural addition or inclusion used to give additional
strength in function. It should be noted whether the graft
a b
Fig. 54.5  Midline uterosacral plication anterior colporraphy combo (MUSPACC). (a) Suture needle starts to lift and expose intermediate section
of uterosacral ligament. (b) USL—left side exposed (under tension). (c) First suture completed, suture needle starts second suture on left side
B. T. Haylen
is biologic, absorbable synthetic, or permanent syn-
thetic. This may be further subclassified into:
• Mesh or graft placement without additional vault/uter-
ine support with or without concurrent fascial plication
• Mesh or graft placement with additional vault/uterine
support either: Transobturator mesh kit: Normally
involves two needles which pass through the obtura-
tor membrane bilaterally to retrieve and secure mesh
arms through the area of the arcus tendinous fasciae
pelvis (ATFP) and thus stabilize a central mesh sup-
port to the anterior vaginal wall
Mesh kit with bilateral fixation to sacrospinous
ligament [SSL]: Anterior vaginal wall mesh or graft
with concurrent vault/uterine suspension employing
either bilateral iliococcygeal fixation or fixation to the
SSL
54.5 Posterior (Level II) Repair [11]
Below are the IUGA-ICS definitions [11] for traditional pos-
terior colporrhaphy. As indicated earlier and shown recently
the true “hernia-type” rectovaginal defect rectocele is far less
common than generally believed [15, 17], with level II
defects the least prominent of the three levels I–III.  With
vaginal vault support accounting for the mean 55% mid-­
vaginal laxity due to the “concertina” effect [15, 17], exten-
sive rectovaginal dissection might be both unnecessary and
counterproductive. There are plenty of exceptions where the
true rectocele exists justifying the following text.
c
54  Anterior and Posterior Colporrhaphy: Native Tissue Versus Mesh
(a) Posterior vaginal wall repair with native tissue:
The commonest of these is as follows:
• Midline fascial plication: involving midline incision
of full thickness of vaginal epithelium, wide expo-
sure of the pre-rectal fascia, midline fascial plica-
tion, excision of redundant vaginal skin (care to
avoid stenosis/dyspareunia), and midline re-sutur-
ing. See Fig. 54.6.
• Site-specific repair: lateral (uni- or bilateral), trans-
verse (upper and/or lower), combined.
• Closure and/or excision of enterocele vaginally with
or without concurrent posterior wall repair.
(b) Posterior vaginal wall repair with mesh or graft rein-
forcement [11]:
A structural addition or inclusion used to give additional
strength in function. It should be noted whether the graft
is biologic, absorbable synthetic, or permanent synthetic.
This may be further subclassified into:
Fig. 54.6  Traditional posterior vaginal repair [11]. (a) Preoperative. (b) Rectovaginal fascial repair. (c) Posterior vaginal mucosal repair
679
• Mesh or graft placement without additional vault/
uterine support with or without concurrent fascial
plication
• Mesh or graft placement with additional vault/uter-
ine support, either:
–– Mesh kit with bilateral mesh fixation to the SSL
–– Mesh suspension kit with ischio-anal needle pass
–– Posterior vaginal wall mesh/graft with concurrent
vault/uterine suspension employing either bilat-
eral iliococcygeal fixation or fixation to the SSL
–– Transperineal mesh/graft insertion
54.6 Posterior (Level III) Repair [11, 19]
The introital repair has traditionally been very subjective
and empiric but can be made objective and relatively sim-
ple. Key aims are to (a) excise relevant defects and repair,
680 B. T. Haylen

(b) improve posterior support for any anterior vaginal
repairs, and (c) avoid creating dyspareunia which is a
greater risk with a posterior repair compared to an anterior
repair.
There is a positive relation between the size of the introi-
tal defects genital hiatus [20] (anteroposterior measure) and
perineal gap [21] (transverse) and the amount of vaginal
vault descent and thus the overall vaginal prolapse. There are
anatomical advantages of commencing the repair at the pos-
terior introitus. A simple excision of the perineal gap and
repair [19] (Figs. 54.7, 54.8) results in: (a) 100% excision of
thinned out perineal skin (gap—Fig. 54.7), (b) 24% increase
in the total posterior vaginal length (TPVL—Fig. 54.2) over
that if the PR was commenced at the hymen, (c) mean 31%
decrease in GH (Fig. 54.7b), (d) mean 28% increase in peri-
neal length PL (Fig. 54.7c), and (e) mean 57% increase in
mid-perineal thickness (MPT—Fig. 54.7d).
The case for any deeper perineal muscle suturing has not
been made. It may serve to increase patient discomfort
including dyspareunia [23]. It has been recently shown that
vaginal vault (level I) fixation significantly improves the
vaginal introital (level III) repair [21], as judged by the
greater decreases in genital hiatus and perineal gap than if
there is no vaginal vault fixation.

a b

c d

Fig. 54.7 (a) Perineal gap (PG—cm): thinned out medial area (cm) (PL): distance from posterior margin of vestibule to anterior anal verge.
between Moynihan forceps placed bilaterally, where the labia minora (d) Mid-perineal thickness (MPT): thickness (cm) of the mid-perineum
meet the perineum. (b) Genital hiatus (GH—cm): from the external ure- in the midline (Fig. 54.8)
thral meatus to the posterior margin of the hymen. (c) Perineal length
54  Anterior and Posterior Colporrhaphy: Native Tissue Versus Mesh 681

a b c

Fig. 54.8  Perineal gap [22]. (a) Prior to excision. (b) After excision. (c) Reconstituted perineum

54.7 Posterior (Level I) Repair

This chapter has emphasized from the introduction through

all sections the importance of vaginal vault support as part of
improving the success of all colporrhaphies, be they native
tissue or mesh, though with the aim to minimize or eliminate
the latter options. The confluent distal segments of the utero-
sacral and cardinal ligaments are only an option for vaginal
vault support at vaginal hysterectomy which is not the brief
of this chapter. Post-hysterectomy, the remaining ligaments
for vaginal vault support are the: (a) sacrospinous ligament
(SSL) and the (b) intermediate segment of the uterosacral
ligament (USL) [9].
(a) Sacrospinous ligament fixation/colpopexy (SSC): The
SSL is the strongest ligament in the pelvis, readily acces-
sible via digital/sharp pararectal dissection in one (right)
or less frequently both vaginal fornices. Instrumentation
(narrow Deaver 1 o’clock, Miya speculum 7 o’clock,
Yankauer sucker) aids visualization of the ligament.
Suture insertion can be facilitated with a range of com-
mercial products. The author prefers the Capio (Boston
Scientific). Safest insertion area is at the junction of the
middle third and lateral two-thirds of the ligament.
Two sutures (nonabsorbable generally favored) are
generally required attached to the posterior vaginal vault.
There is very little evidence to guide the choice between
delayed absorbable and permanent sutures. This author
prefers a buried permanent suture for long-term surgical
security with the small risk of suture exposure. Suture
removal, diathermy of any granulation, and oversew of
any mucosal defect effectively solve this issue.
The SSC as outlined is generally safely performed
and effective in conjunction with other colporrhaphies.
Local trauma around the stitch insertion site is gener-
ally temporary; excessive bleeding has been mini-
Fig. 54.9  Sacrospinous colpopexy
mized using atraumatic instrumentation. Because of
the posterolateral deviation, recurrent cystocele can be
an issue (Fig. 54.9).
( b) Uterosacral ligament (USL) plication: The intermedi-
ate USL is strong but not as strong as the SSL. There are
two approaches independent of hysterectomy with the
McCall [24] procedure only possible at hysterectomy
(Fig. 54.10):
• Intraperitoneal options (e.g., Shull [25], Barber [26],
Karram [27], Silva [28]): Access difficulties can
occur while there is a risk of up to 10% of ureteric
injury.
• Extraperitoneal approach (e.g., Dwyer [29]).
The USL plication has a vector of support for the vaginal
vault posterosuperior and in the midline compared with that
of the SSC which is posterosuperior though with a lateral
vector (Fig.  54.11). Provided both supportive procedures
hold, there may be less chance of recurrent cystocele with
the USL plication. There is generally much greater dissec-
682
Fig. 54.10  Uterosacral ligament vaginal vault suspension
tion with the USL repairs with, at times, multiple compart-
ments opened. This may make it more difficult to “finesse”
the final anatomical result.
54.8 E
 fficacy of Outcomes of Native Tissue
and Mesh Colporrhaphies
(a) Anterior vaginal wall (compartment) repairs [31]:
The most recent (2016) Cochrane review [31] indi-
cates the following:
• Increased patient awareness of recurrent POP and
increased risk of surgery for recurrence compared to
polypropylene mesh.
• Decreased overall risk of repeat surgery (SUI, POP,
mesh exposure).
• Conclusion: Current evidence does not support use of
mesh over native tissue in primary POP surgery (ante-
rior) due to increased morbidity of mesh and “unproven
safety and efficacy.”
(b) Posterior vaginal wall (compartment) repairs [32]:
Evidence does not support the utilization of any mesh or
graft materials at the time of posterior vaginal repairs.
Withdrawal of some commercial transvaginal kits may
lessen the generalizability of the findings.
(c) Vaginal vault prolapse [33]: The limited evidence does
not the support the use of transvaginal mesh compared to
native tissue surgery for vaginal vault prolapse.
B. T. Haylen
Fig. 54.11  Vector of support of uterosacral ligament (USL) and sacro-
spinous ligament (SSL) suspensions [30]: USL support is oriented pos-
terosuperior in the midline whereas SSC support is posterosuperior and
slightly lateral
54.9 Conclusion
The future of POP surgeries appears to be largely native tis-
sue colporrhaphies with care to examine for and treat vaginal
vault defects. Mesh appears to lack the appropriate evidence
for safety and efficacy. This chapter has concentrated on
­giving a greater understanding of “basics” of the vaginal
defects prompting the need for colporrhaphies, including and
especially the role of vaginal vault defects. Greater quantifi-
cation of the defects, particularly posteriorly, will assist in
optimizing surgical management.
Take-Home Messages
• Know how to identify the different vaginal defects
to determine what needs to be fixed.
• Identifying and fixing vaginal vault defects should
receive special attention.
• Current evidence does not support the use of mesh
over native tissue in the main POP surgeries.
54  Anterior and Posterior Colporrhaphy: Native Tissue Versus Mesh 683

Appendix Posterior Vaginal Vault Descent (PVVD [11, 15, 17]:

Descent of the posterior vaginal vault toward the perineal
 elvic Organ Prolapse Quantification (POP-Q)
P gap obtained by subtracting the inferiorly displaced vaginal
[11, 16] vault and the anterior perineum (second figure) from the total
posterior vaginal length (TPVL—first figure—posterior vag-
inal vault to anterior perineum).

D
3 cm Ba
C

Aa

Bp

Ap
tvl

gh

pb

 osterior Repair Quantification (PR-Q) [11, 15, 17]

P
Perineal Gap (PG): Thinned out medial area (cm) between
Moynihan forceps placed bilaterally where the labia minora
meet the perineum.
684
Mid-vaginal Laxity (MVL) (Undisplaced) [11, 15, 17]:
Laxity of the vaginal mucosa (anterior traction) midpoint in
the vagina super-posteriorly and in the midline with the vagi-
nal vault held in an undisplaced position (similar to that after
vault fixation).
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P.  High uterosacral vaginal vault suspension with fascial recon-
struction for vaginal repair of enterocoele and vaginal vault pro-
lapse. Am J Obstet Gynecol. 2001;185:1339–43.
685
28. Silva WA, Pauls RN, Segal JL, Rooney CM, Kleeman SD, Karram
M.  Uterosacral ligament vaginal vault suspension: 5-year out-
comes. Obstet Gynecol. 2006;108:255–63.
29. Dwyer PL, Fatton B. Bilateral extraperitoneal uterosacral suspen-
sion: a new approach to correct post-hysterectomy vaginal vault
prolapse. Int Urogynecol J. 2008;19:283–92.
30. Haylen BT, Vu D, Birrell W, Vashevnik S, Tse K.  A preliminary
anatomical basis for dual (uterosacral and sacrospinous ligaments)
vaginal vault support at colporrhaphy. Int Urogynecol J. 2012;23:
879–82.
31. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N,
Brown J. Surgical management of pelvic organ prolapse in women.
Cochrane Database Syst Rev. 2013;(4):CD004014.
32. Mowat A, Maher D, Baessler K, Christmann-Schmid C, Haya N,
Maher C. Surgery for women with posterior compartment prolapse.
Cochrane Database Syst Rev. 2018;(3):CDC12975.
33. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N,
Brown J. Surgical management of pelvic organ prolapse in women.
2016. www.Cochrane.org/CD012376.
 Apical Prolapse Surgery
55
Christopher Maher

lapse and can broadly be separated into those performed

Learning Objectives vaginally or abdominally. Although precise estimates are
• Contraindications to uterine preservation surgery not available, most studies suggest that the vaginal
• Should salpingectomy and or salpingo-­ approach is most common with 80–90% of procedures
oophorectomy be considered at time of prolapse being performed through this route [8–11]. The individual
surgery woman’s surgical history and goals, as well as her indi-
• Surgical management of uterine prolapse vidual risks for surgical complications, prolapse recur-
• Surgical management of vault prolapse rence and de novo symptoms, affect surgical planning and
choice of procedure for apical POP.

While anterior vaginal prolapse is the most common site

of vaginal prolapse, loss of apical support is usually pres-
ent in women with prolapse that extends beyond the
hymen [1, 2]. There is growing recognition that adequate
support for the vaginal apex is an essential component of
a durable surgical repair for women with advanced pro-
lapse [3–5]. There is a strong correlation between anterior
vaginal prolapse and apical descent seen on anatomical
studies [6, 7]. Eiber et al. demonstrated that the reopera-
tion rates for recurrent prolapse 10 years after index sur-
gery were halved in women who underwent apical support
procedures at time of repairs as compared to those with
vaginal repair without apical support [5]. While recogni-
tion of apical defects is one of the biggest challenges in
the preoperative evaluation of pelvic support defects, sur-
gical correction of the apex has several good options with
relatively high success rates. Apical suspension proce-
dures for prolapse are performed at uterine preservation
surgery, at hysterectomy or for post-­hysterectomy pro-
Electronic Supplementary Material The online version of this chap-
ter (https://doi.org/10.1007/978-3-030-40862-6_55) contains supple-
mentary material, which is available to authorized users.
C. Maher (*)
Urogynaecologist Wesley and Royal Brisbane and Women’s
Hospital, University of QLD, Brisbane, Australia
e-mail: chrismaher@urogynaecology.com.au
55.1 Uterine Prolapse
The shared decision-making for the surgical management
of uterine prolapse involves discussion regarding uterine
preservation or hysterectomy. While the rate of hystero-
pexy performed remains low at 5% of prolapse surgery in
2012 the rate had increased from 1.8% a decade earlier
indicating increased interest in this option [12]. The deci-
sion-making regarding uterine preservation or hysterec-
tomy is increasingly complex. Some women wish to
preserve fertility, while others feel that the uterus contrib-
utes to their sense of identity. Many women consider hys-
terectomy to be a major surgery associated with significant
risks. However, surveys have shown that many of the rea-
sons for desiring uterine conservation have more to do with
ovarian conservation. These include beliefs that removal of
the uterus will worsen mood, relationships, quality of life
and sex drive and result in weight gain [13]. Patient demo-
graphics have been associated with hysteropexy prefer-
ences. For example, college-­educated women were almost
three times more likely to choose uterine conservation, and
women living in the southern USA were less likely to
request uterine preservation (OR 0.17) [14, 15]. Each
patient’s interest in uterine conservation should be assessed
during surgical planning. This can easily be accomplished
by enlisting the patient’s goals and preferences early on
during the informed consent process.

© Springer Nature Switzerland AG 2021 687

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_55
688
55.1.1 Uterine Preservation
In those wishing to retain fertility conservative management
with a pessary is recommended for women with uterovaginal
prolapse. If surgery is required, the data relating to the type
of hysteropexy and its impact on fertility, pregnancy and
recurrence of prolapse is limited.
Candidates for uterine conservation should be carefully
considered and strict selection criteria applied to decrease the
likelihood of subsequent hysterectomy, which may be more
technically challenging. Absolute and relative contraindica-
tions to uterine preservation are listed in Table 55.1. Women at
increased risk for endometrial, cervical or ovarian cancer and
those with a personal history of estrogen receptor-­positive
breast cancer, especially those taking tamoxifen, should have
their uterus, cervix and possibly ovaries removed at the time of
prolapse repair. Hysteropexy should also be avoided in cases
of uterine abnormalities listed in Table  55.1. Patients with
recent postmenopausal bleeding even with a negative workup
should probably undergo hysterectomy based on a 13% risk of
unanticipated endometrial cancer or hyperplasia [16].
During the consent process for postmenopausal women
considering uterine preservation or hysterectomy, women
should be informed of the lifetime risk of cervical (0.6%),
uterine (2.7%) and ovarian cancer (1.4%) [17, 18]. While
ovarian cancer is uncommon, the general late presentation of
disease is associated with poor outcomes. Routine bilateral
oophorectomy demonstrated a tenfold decrease in the small
risk of ovarian cancer without increased morbidity when
results were stratified by age [19, 20]. Furthermore in women
who have completed their family and considering prolapse
surgery options, they should be informed that bilateral sal-
pingectomy may decrease the risk of ovarian cancer (OR
0.51, 95% CI 0.35–0.75) [21].
Higher-risk women with hereditary conditions (BRCA
mutations, Lynch syndrome) and obesity should consider
hysterectomy with or without oophorectomy during prolapse
repair. Cervical elongation is included as a possible contrain-
dication to uterine preservation as a prospective two-part
Table 55.1  Relative contraindications to uterine-preserving surgery
Uterine abnormalities
Fibroids, adenomyosis, endometrial pathology sampling
Current or recent cervical dysplasia
Abnormal menstrual bleeding
Postmenopausal bleeding
Cervical elongation
Familial cancer BRAC1&2: ↑risk ovarian cancer and theoretical risk
fallopian tube and serous endometrial cancer
Hereditary non-polyposis colorectal cancer (Lynch syndrome): 60%
lifetime risk endometrial cancer
Tamoxifen therapy
Obesity: up to threefold increased risk endometrial cancer
Unable to comply with routine gynaecology surveillance
C. Maher
study showed an almost 11-fold increased risk of failure in
patients with cervical elongation undergoing sacrospinous
hysteropexy. Success rates were 96–100% after excluding
patients with severe prolapse and performing partial trache-
lectomy for cervical elongation [22].
The 2017 International Collaboration on Incontinence
(ICI) has developed an evidenced surgical pathway using the
Oxford grading system with guidance between the various
surgical options for the management of uterine prolapse
(Fig.  55.1) [23]. The pathway points to obliterative surgery
such as colpocleisis in those happy to sacrifice vaginal inter-
course and is usually performed with uterine preservation after
preoperative evaluation to minimise the risk of underlying
malignancy. In these patients colpocleisis with uterine preser-
vation is a safe, effective and low-morbidity option. A large
publication following 153 women for 12 months demonstrated
95% of women being “satisfied” or “very satisfied” with the
outcome. Continence surgery was performed in 40% and saw
significantly improved bladder function with low morbidity
[24]. Considering the surgery is usually performed in the
elderly with significant comorbidities the procedure is well
tolerated. Major complication unrelated to surgery (cardiac,
pulmonary or cerebrovascular) occurred in 2% and major
complications specific to surgery (pyelonephritis, transfusion)
in 4% [25]. The vast majority of women in the pathway will
elect reconstructive options for uterine prolapse which ini-
tially divide between hysterectomy and uterine preservation
with a wide variety of options available in each group.
55.1.2 Uterine Prolapse: Hysterectomy or
Uterine Preservation
Vaginal options reviewed include sacrospinous /Manchester
hysteropexy with or without mesh and vaginal hysterectomy
with uterosacral or sacrospinous colpopexy with or without
mesh. Apical transvaginal mesh procedures were not prefer-
enced based on grade A evidence from the 2016 Cochrane
review on the surgical management of prolapse that reviewed
six RCTs ( n = 548) comparing vaginal apical suspensions
with and without permanent mesh. Maher et al. reported no
benefit in the addition of the apical mesh in terms of recur-
rent prolapse, awareness of prolapse or reoperation for pro-
lapse was identified with increased morbidity associated
with an 18% rate of mesh exposure. Hysterectomy performed
via the abdominal or vaginal routes at the time of permanent
mesh introduction increases the risk of mesh exposure by
two to three times as opposed to vaginal repair without mesh
and is usually avoided for this reason [26].
Current abdominal options then include subtotal hyster-
ectomy and sacral colpopexy (SC), sacral hysteropexy with
uterine preservation and native tissue uterosacral
hysteropexy.
55  Apical Prolapse Surgery 689

Fig. 55.1  2017 International

Consultation on Incontinence
(ICI) pathway for surgical ICI 2017 Surgical Treatment POP
management of prolapse

Bladder
function
Factors to Consider
Possible Pathway Pop Bowel
Preferred Option Surgery function
Further Data Required
Risk of
recurrent
prolapse

Reconstructive Obliterative
surgery surgery

Apical Anterior Posterior

support support support

Graft Suture
Vault Uterine
repair repair

Hysterectomy
Hysteropexy
± BSO

Sub-total
Vaginal ASC + Vaginal SS Sacral
hysterectomy
hysterectomy hysterectomy hysteropexy hysteropexy
ASC

ASC: Abdominal sacral colpopexy

LSC + Sacrospinous Uterosacral LSC: Laparoscopic sacral colpopexy
repair colpopexy colpopexy SS: Sacrospinous
BSO: Bilateral Salpingo-Oopherectomy

Trying to sort thru all these options is challenging but
after establishing suitability for uterine preservation 31–60%
of women preference for considering hysterectomy or uter-
ine preservation is couched upon similar success rates being
obtained in each intervention [13–15].
A variety of hysteropexy techniques have been described
to treat uterovaginal prolapse. The abdominal
sacro-­
­ hysteropexy involves mesh being suspended to the
anterior and posterior vaginal walls with the anterior leaf tun-
nelling around the uterus in the broad ligament before being
fixed to the sacral promontory as seen in Fig. 55.2. The vagi-
nal sacrospinous hysteropexy involves the posterior lip of the
cervix being fixed the right sacrospinous ligament as demon-
strated in Fig.  55.3. Comparative studies show short-term
safety with decreased blood loss and shorter operating time
when vaginal sacrospinous hysteropexy was compared to
690 C. Maher

Fig. 55.2  At sacrohysteropexy Edge of peritoneum

mesh is secured to the anterior
and posterior vaginal wall with Arms of anterior mesh
the anterior mesh tunnelling
Sacral promontory
around the uterus thru the
broad ligament before being Window created in
attached to the sacral broad ligament
Main part of
promontory
anterior mesh
attached to cervix
and vaginal wall
Uterus Posterior mesh

Left ureter

Uterine artery
Bladder

gina
Va
Rectum

Fig. 55.3  Demonstrates the Level two support

with final fascial pilcation
vaginal sacrospinous bite including
hysteropexy where the Left internal iliac anterior lip of cervix
artery
posterior lip of the cervix is
attached to the right
sacrospinous ligament Left internal pudendal
artery

Levi ani nerve (LAN)

Uterus
Level one support with
posterior lip of cervix
attached to sacrospinous
Bladder ligament

Rectum Left sacrospinous

ligament

Pudendal nerve

Central pilcation of
pubocervical fascia

Closure of anterior and

posterior vaginal wall

Central pilcation of
rectovaginal fascia

vaginal hysterectomy; however efficacy results were mixed in comes. Gutman et  al. reviewed randomised and non-­
the two available RCTs [27, 28]. Dietz et al. [27, 28]demon- randomised trials comparing vaginal hysterectomy and
strated superior apical support in the hysterectomy group and hysteropexy and demonstrated no difference in anatomical
Detollenaere et  al. found no difference in anatomical out- outcomes [26]. The only multicentre RCT conducted by the
55  Apical Prolapse Surgery
Pelvic Floor Disorders Network compared SSHP with ante-
rior graft (n = 88) using uphold to vaginal hysterectomy with
USLS (n = 87) at 3 years [29]. The primary composite out-
come of treatment failure (any reoperation or retreatment for
prolapse, any anatomic prolapse beyond the hymen and any
bothersome prolapse symptoms) was observed in 21% of
hysteropexy compared to 27% of hysterectomy subjects.
Failures were mostly anatomic and rarely by symptoms alone
(0% vs. 1%) with a total of 6% vs. 12% retreatments at 3
years. While there was a trend toward greater improvement in
the hysteropexy group, no significant differences were
observed in the composite outcome failure risk after perform-
ing an adjusted hazard ratio of failure (0.62, 95% CI 0.38–
1.02). There were no differences in the overall satisfaction
(90% vs. 89%), surgical pain, pelvic pain and body image.
Mesh exposures occurred in 8% of hysteropexy (all related to
prolapse mesh, no sling exposures) and 5% of hysterectomy
(all from slings). More granulation tissue and suture expo-
sures were observed with hysterectomy (1% vs. 11% and 3%
vs. 21%, respectively) although none of the mesh exposures,
suture exposures or granulation tissue required reoperation.
Sexual function, dyspareunia and pain improved for both the
groups with low rates of de novo dyspareunia.
A single RCT compared mesh sacral hysteropexy (n = 41)
to vaginal hysterectomy with uterosacral colpopexy (n = 41)
demonstrated that 21% required further surgical intervention
for prolapse after the sacral hysteropexy as compared to
none in the vaginal hysterectomy group suggesting an advan-
tage with the vaginal hysterectomy and uterosacral suspen-
sion arm [30].
While there are no other RCTs comparing vaginal and or
abdominal interventions for uterine prolapse to inform the
decision pathway, the recent analysis of five non-randomised
comparisons between sacral hysteropexy (n  =  118) and
sacral colpopexy with hysterectomy (n = 165) demonstrated
a higher rate of reoperation or pessary use after the sacral
hysteropexy as compared to sacral colpopexy and hysterec-
tomy (15% versus 0%). Unfortunately, the hysterectomy arm
suffered from a 7% rate of mesh exposure as compared to
none after the sacral hysteropexy [23]. The subtotal hysterec-
tomy and sacral colpopexy serves to minimise the risk of
mesh exposure associated with hysterectomy but is fre-
quently associated with the need for uterine morcellation
which is controversial. A single retrospective review recently
demonstrated when using the robotic approach the rate of
recurrent stage 2 prolapse was significantly greater after sub-
total hysterectomy and SC as compared to total hysterec-
tomy and SC (42% vs. 20%) [31].
So in summary, the ICI 2017 pathway for the surgical
treatment of uterine prolapse makes the following recom-
mendations. Hysterectomy and hysteropexy are both suitable
options for uterine prolapse providing no contraindications
to uterine prolapse exist. Regarding uterine preservation
interventions, due to higher rates of recurrent prolapse after
sacral hysteropexy, the vaginal-based hysteropexies were
691
preferred. In those considering hysterectomy vaginal hyster-
ectomy with apical support was preferenced over abdominal
options. The summary points include:
• Significant relative contraindications exist to uterine pres-
ervation surgery (GoE B).
• Vaginal uterine preservation procedures have reduced
operating time and blood loss when compared to vaginal
hysterectomy; however the anatomical results are con-
flicting in available RCTs and further evaluation is
required to inform this outcome (GoE B).
• Vaginal apical mesh interventions have similar outcomes
when compared to native tissue vaginal repair but are
associated with high rates of mesh exposure and are nor
recommended (GoE A).
• Vaginal hysterectomy and apical suspension had a lower
reoperation rate for prolapse when compared to sacral
hysteropexy in a single RCT (GoE B).
• In non-randomised trials the sacral hysteropexy was asso-
ciated with higher reoperation or pessary use when com-
pared to total hysterectomy and sacral colpopexy;
however the hysterectomy group suffered a significant
rate of mesh exposure. In a single non-randomised trial
the subtotal hysterectomy and sacral colpopexy had a
higher rate of recurrent prolapse as compared to total hys-
terectomy and sacral colpopexy (GoE C).
• Further data is urgently required on efficacy of hystero-
pexy and hysterectomy and the various options for per-
forming the intervention
55.1.3 Vault Prolapse
The surgical options that have comparative data for the
reconstructive management of post-hysterectomy include
vaginal uterosacral and sacrospinous colpopexy, vaginal api-
cal mesh or abdominal sacral colpopexy. A Cochrane meta-­
analysis of six RCTs demonstrated no benefit and significant
mesh morbidity when transvaginal apical mesh was com-
pared to native tissue vaginal apical repairs including sacro-
spinous and uterosacral colpoexy [32]. The majority of the
transvaginal mesh kits evaluated have been removed from
the market. The 2016 Cochrane meta-analysis of six RCTs
compared abdominal sacral colpopexy (Fig. 55.4 and Video
55.1) to a variety of transvaginal procedures including trans-
vaginal mesh or uterosacral or sacrospinous colpopexy and
found that the sacral colpopexy had lower rates of awareness
of prolapse, prolapse on examination and reoperation for
prolapse and lower rates of stress urinary incontinence and
dyspareunia when compared to vaginal interventions [32].
On the basis of this data the 2017 ICI surgical management
of prolapse points to sacral colpopexy as the preferred option
for vaginal vault prolapse. In recognition that not all women
are suitable for sacral colpopexy (morbidly obese, those with
692 C. Maher

prior radiation or multiple prior laparotomies) the pathway
also points to sacrospinous and uterosacral colpopexy as
viable options for vault prolapse. Following the 2-year data
from the Optimal trial [33] that compared uterosacral and
sacrospinous colpopexy for apical prolapse and reported
Fig. 55.4  At sacral colpopexy mesh secures the anterior and posterior
vagina to the sacral promontory
equivalence between the procedures, the pathway prefer-
ences both interventions for vault or uterine prolapse equally.
At 2-year review 60% in both groups had obtained primary
definition of success (no surgery or pessary for prolapse, no
prolapse beyond the hymen on examination or symptoms of
prolapse). While the rate of serious complications was simi-
lar at 17% in both groups the complications experienced
with each colpopexy were distinctly different. The sacrospi-
nous colpopexy was associated with higher rates of neuro-
logical pain (12%) possibly relating to incorporation of
branches of the pudendal or sciatic nerves in the suspensory
sutures as seen in Fig. 55.5. Alternatively, at the uterosacral
colpopexy 4% experienced ureteric obstruction secondary to
incorporation or kinking of the ureter as it runs in close prox-
imity to the distal uterosacral ligament as demonstrated in
Fig. 55.5.
More recently the Pelvic Floor Disorders Network in the
USA retrospectively evaluated abdominal sacral colpopexy
as compared to a variety of native tissue vaginal repairs for
vault or uterovaginal prolapse in just over 1000 women at
1–2-year review [34]. The authors acknowledge that the two
groups were significantly different prior to evaluation with
those undergoing abdominal interventions being older, had
undergone more continence or prolapse interventions, have
greater prolapse on examination and more bother from the
prolapse than those undergoing vaginal interventions. Most
of these factors are clearly defined risk factors for recurrent
prolapse and poor outcomes. The failure of the study meth-
odology of the paper to match the two groups prior to evalu-

Fig. 55.5  Demonstrates the

course of the uterosacral
ligament on the right pelvic
side wall in close proximity to
the distal ureter and the Arcus tendineus
fascia pelvis
sacrospinous ligaments (white line)
proximity to the pudendal and
Urethra
posterior femoral cutaneous Ureter
nerve
Levator ani
Commom
iliac vessels
Obturator internus
Vagina muscle
Ureter
McCall
1 L4-5
placement Sciatic nerve
Ischial
Uterosacral spine
ligaments 2 S1
Rectum

S2
Levator ani 3
(cut edge) S3
S4
Traditional
placement
Modification
(high uterosacral)

SSL-C muscle complex Internal

pudendal vessels
Pudendal nerve
Posterior femoral cutaneous nerve
55  Apical Prolapse Surgery
ation erodes the validity of any conclusions that can be drawn
from this retrospective review.
55.2 Route of Sacral Colpopexy
Sacral colpopexy can be performed via an open laparotomy,
laparoscopic or robotic approach. Most RCTs observed that
laparoscopic sacral colpopexy is as effective as open abdom-
inal procedure, with a reduced rate of intraoperative bleed-
ing, hospitalisation and wound complications [35–37].
However, a single RCT showed that LSC provides symptom-
atic outcomes similar to the open procedure but not for ana-
tomical success of the anterior vaginal wall [38].
Despite the clinical advantages of a laparoscopic
approach, adoption of LSC has been relatively limited pos-
sibly related of the steep learning curve associated with
attaining laparoscopic suturing and knot tying skills that are
required to attach the mesh to the vagina and sacrum.
Claerhout et al. evaluated their learning curve in the first 206
cases performed by a single surgeon [39]. Operating times
declined rapidly during the first 30 procedures in this series
and reached steady state (175 min) after 90 cases. Using a
cumulative sum (CUSUM) approach to evaluate operative
time and failures (laparotomy, complication or anatomic fail-
ures) they found that adequate learning occurred after 60
cases. Complication rates remained unchanged throughout
this series. Other studies have shown a decrease in operating
time after 15–24 cases [40].
Given the concern regarding the learning curve of the
laparoscopic approach the robotic approach to sacral colpo-
pexy has been promoted. Two RCTs have compared the
laparoscopic and robotic approach and no difference in ana-
tomic outcomes or quality of life was identified [41–43].
However, both trials demonstrated the robotic approach was
longer, more painful and more expensive than the laparo-
scopic approach and explaining the 2017 ICI pathway on
prolapse pointing to laparoscopic approach as the preferred
option. A recent review among members of British
Urogynaecology Society demonstrated that the laparoscopic
approach was the preferred route of access for sacral colpo-
pexy [44].
55.3 Conclusion
For apical prolapse the obliterative colpocleisis is a suitable
option for uterine and vault prolapse. The evidence -based
2017 ICI pathway preferences laparoscopic sacral colpopexy
for vault prolapse and vaginal hysterectomy and vault sup-
port with sacrospinous or uterosacral colpopexy for uterine
prolapse.
693
Take-Home Messages
• While uterine preservation is a viable option in the
management of uterine prolapse important relative
contraindications exist.
• Elective salpingectomy should be discussed in peri-
menopausal women undergoing hysterectomy in
prolapse surgery.
• Elective salpingo-oophorectomy should be dis-
cussed in postmenopausal considering hysterec-
tomy in prolapse surgery.
• Data on the most effective uterine-preserving pro-
lapse surgery is not clearly available.
• For post-hysterectomy vault prolapse the sacral col-
popexy is the preferred option with the laparoscopic
approach preferenced. In those not suitable for
sacral colpopexy, vaginal based colpopexy (utero-
sacral and sacrospinous) is a suitable alternative.
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associated with oophorectomy compared with ovarian conservation
in the nurses’ health study. Obstet Gynecol. 2013;121(4):709–16.
21. Yoon SH, Kim SN, Shim SH, Kang SB, Lee SJ.  Bilateral sal-
pingectomy can reduce the risk of ovarian cancer in the general
­population: a meta-analysis. Eur J Cancer (Oxford, England: 1990).
2016;55:38–46.
22. Lin TY, Su TH, Wang YL, et al. Risk factors for failure of transvagi-
nal sacrospinous uterine suspension in the treatment of uterovaginal
prolapse. J Formosan Med Assoc. 2005;104(4):249–53.
23. Maher C, Baessler K, Barber M, Cheong C, Consten E, Cooper
K, Deffieux X, Dietz V, Gutman R, Ierserel J, Sung V, DeTayrac
R. Surgical management of pelvic organ prolapse. In: Abrahams P,
Cardozo L, Wagg A, Wein A, editors. International consultation on
incontinence. 6th ed. ICUD ICS 2017, p. 1855-992.
24. Gutman RE, Bradley CS, Ye W, Markland AD, Whitehead WE,
Fitzgerald MP. Effects of colpocleisis on bowel symptoms among
women with severe pelvic organ prolapse. Int Urogynecol J.
2009;21(4):461–6.
25. Fitzgerald MP, Richter HE, Bradley CS, et  al. Pelvic support,
pelvic symptoms, and patient satisfaction after colpocleisis. Int
Urogynecol J Pelvic Floor Dysfunct. 2008;19(12):1603–9.
26. Gutman R, Maher C.  Uterine-preserving prolapse surgery. Int
Urogynecol J. 2013;24(11):1803–13.
27. Dietz V, van der Vaart CH, van der Graaf Y, Heintz P,
Schraffordt Koops SE.  One-year follow-up after sacrospinous
hysteropexy and vaginal hysterectomy for uterine descent:
a randomized study. Int Urogynecol J Pelvic Floor Dysfunct.
2010;21(2):209–16.
28. Detollenaere RJ, den Boon J, Stekelenburg J, et  al. Sacrospinous
hysteropexy versus vaginal hysterectomy with suspension of
the uterosacral ligaments in women with uterine prolapse stage
2 or higher: multicentre randomised non-inferiority trial. BMJ.
2015;351:h3717.
29. Nager CW, Visco AG, Richter HE, et al; for the NICHD Pelvic
Floor Disorders Network. Effect of vaginal mesh hysteropexy vs
C. Maher
vaginal hysterectomy with uterosacral ligament suspension on
treatment failure in women with uterovaginal prolapse: a random-
ized clinical trial. JAMA. 2019;322:1054–65.
30. Rahmanou P, Price N, Jackson SR.  Laparoscopic hysteropexy
versus vaginal hysterectomy for the treatment of uterovaginal
prolapse: a prospective randomized pilot study. Int Urogynecol J.
2015;26(11):1687–94.
31.
Myers EM, Siff L, Osmundsen B, Geller E, Matthews
CA. Differences in recurrent prolapse at 1 year after total vs supra-
cervical hysterectomy and robotic sacrocolpopexy. Int Urogynecol
J. 2015;26(4):585–9.
32. Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya
N, Brown J.  Surgery for women with apical vaginal prolapse.
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OPTIMAL randomized trial. JAMA. 2014;311(10):1023–34.
34. Rogers RG, Nolen TL, Weidner AC, et al. Surgical outcomes after
apical repair for vault compared with uterovaginal prolapse. Obstet
Gynecol. 2018;131(3):475–83.
35. Freeman R, Pantazis K, Thomson A, et al. A randomised controlled
trial of abdominal versus laparoscopic sacrocolpopexy for the treat-
ment of post-hysterectomy vaginal vault prolapse: LAS study. Int
Urogynecol J. 2013;24:377–84.
36. Tyson MD, Wolter CE.  A comparison of 30-day surgical out-
comes for minimally invasive and open sacrocolpopexy. Neurourol
Urodyn. 2015;34(2):151–5.
37. Coolen A-LWM, van Oudheusden AMJ, Mol BWJ, van Eijndhoven
HWF, Roovers J-PWR, Bongers MY.  Laparoscopic sacrocolpo-
pexy compared with open abdominal sacrocolpopexy for vault
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2017;28(10):1469–79.
38. Costantini E, Mearini L, Lazzeri M, et  al. Laparoscopic versus
abdominal sacrocolpopexy: a randomized, controlled trial. J Urol.
2016;196(1):159–65.
39. Claerhout F, De Ridder D, Roovers JP, et al. Medium-term anatomic
and functional results of laparoscopic sacrocolpopexy beyond the
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40. Mowat A, Maher C, Pelecanos A. Can the learning curve of lapa-
roscopic sacrocolpopexy be reduced by a structured training pro-
gram? Female Pelvic Med Reconstr Surg. 2018;24(4):272–6.
41. Anger J, Mueller E, Tarnay C, et al. Robotic compared with lapa-
roscopic sacrocolpopexy: a randomized controlled trial. Obstet
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Paraiso MF, Jelovsek JE, Frick A, Chen CC, Barber
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43. Rondini CBH, Alvarez J, Urzua M, Villegas R, Escobar M, et al.
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 Laparoscopic Pelvic Floor Surgery
Jan Deprest, Ann-Sophie Page, Albert Wolthuis,
and Susanne Housmans
Learning Objectives
• To describe the indications and technique of laparo-
scopic colposuspension, sacrocolpopexy, and asso-
ciated rectopexy
• To describe the most common complications and
outcomes one may expect with laparoscopic colpo-
suspension and sacrocolpopexy or ventral
rectopexy
56.1 Introduction
Laparoscopy, has long been recognized to offer better expo-
sure and surgical detail, reduction in blood loss, and the need
for excessive abdominal packing and bowel manipulation.
Next to the generic advantages of minimal access surgery all
this leads to lesser morbidity. Laparoscopy has gradually
found its way in the field of urogynecology, with the intro-
duction of a laparoscopic modification of colposuspension
by Vancaillie and sacrocolpopexy by Nezhat [1, 2]. Also
other pelvic floor surgeries, such as paravaginal repairs [3],
lateral “Kapandji” suspension [4], high uterosacral ligament
suspension [5], or even sacrospinous fixation [6], and sal-
vage procedures such as the removal of mesh material [7],
may benefit or are amenable for a laparoscopic approach.
Herein, we will however focus on sacrocolpopexy and col-
posuspension, which are most commonly practiced. It has
taken quite some time before the laparoscopic modification
of these procedures were shown to be equally effective as
their open counterparts, but this is now reality. The generic
limitations of laparoscopy are its steep learning curve and
long operation times, the limited number of degrees of free-
dom and its two-dimensional vision [8]. Those limitations
J. Deprest (*) · A.-S. Page · A. Wolthuis · S. Housmans
Pelvic Floor Unit, University Hospitals Leuven, Leuven, Belgium
e-mail: jan.deprest@uzleuven.be
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_56
56
may in part or completely be overcome by a robotic approach.
Indeed, robotic-assisted surgery (RAS) has the advantage of
its 3D view, the elimination of surgeon tremor, permitting
more precise and intuitive movements while the use of
wristed instruments improves dexterity and more favorable
ergonomics. RAS would also shorten the learning curve, in
particular for surgeons not familiar with standard laparos-
copy. Anyway, RAS combines the above advantages with
those of conventional or “straight stick” laparoscopy. At
present no true benefit of RAS has been demonstrated in uro-
gynecology, and this approach will therefore not be specifi-
cally dealt with herein [8].
56.2 Laparoscopic Colposuspension
56.2.1 Management of Stress Urinary
Incontinence
Continence is achieved by a combination of anatomical and
physiological properties of the bladder and urethra, the
sphincteric complex as well as other pelvic floor muscles and
structures, including a normally functioning nervous system.
Disruption of any of these components may lead to inconti-
nence. Stress Urinary Incontinence (SUI) is the complaint of
involuntary loss of urine through the urethra, synchronous
with an increase in intra-abdominal pressure. This typically
occurs when sneezing, laughing, coughing, or during physi-
cal exercise. SUI occurs when the intra-abdominal pressure
exceeds the urethral closure pressure, for instance in the
presence of urethral hypermobility or relative sphincter defi-
ciency (or both). Urethral hypermobility occurs when there
is insufficient support of the pelvic floor muscles and/or con-
nective tissue around urethra, bladder neck and to the vagina.
In that case, on effort the urethra and bladder neck incom-
pletely close against the anterior vaginal wall. Leakage may
also occur when the urethral sphincter functions insuffi-
ciently, yet “intrinsic sphincter deficiency” is no longer con-
sidered as a separate entity [9]. Also the term “urodynamic
695
696 J. Deprest et al.

Invasiveness of incontinence surgery was later further

reduced with the advent of mid-urethral slings (MUS). A trocar
system is used to insert a polypropylene sling under the mid-
urethra, resulting in further reduction of blood loss, pain, com-
plications, faster recovery, and better cosmetic results [13].
Originally the tape was directed retropubically to exit the ante-
rior abdominal wall (Fig. 56.2). This route explains a high rate
of bladder injuries, which, when timely recognized, are easy to
manage and without long-term consequences. This complica-
tion can however be nearly completely avoided by using a tran-
sobturator approach (Fig. 56.2). Transobturator slings are less
likely to induce obstructive voiding, yet the risk for repeat
incontinence surgery seems to be higher [14]. Mini-slings are
done using less tape material, yet outcomes are not as good so
far [14]. Irrespective of the access method, the use of sling mate-
rial may cause graft-related complications, of which the most
frequent is vaginal exposure, better known as erosion. This
Fig. 56.1 Schematic drawing of a laparoscopic colposuspension.
Insert: vaginal mobilization by palpating fingers, facilitating needle
positioning and passage through the vaginal fascia. Drawing: Myrthe
Boymans. Copyright: UZ Leuven, Belgium

stress incontinence” is no longer used as this would infer that

invasive testing is done to demonstrate leakage in the absence
detrusor activity during filling cystometry [10].
Treatment for SUI may be conservative, pharmacological,
or surgical in nature. Surgical procedures aim to keep the ure-
thra in the intra-abdominal high pressure zone and/or support
the urethra. The standard procedure for years was the retropu-
bic suspension of peri-urethral tissues (colposuspension)
(Fig. 56.1); alternatively auto- or heterologous material were
put as a sling under the urethra (pubovaginal slings). Although
effective, these procedures carry an inherent m
­ orbidity as they
are done via a large incision and require extensive dissection,
and in some case additional morbidity at the donor site.

56.2.2 The Rise and Fall of Laparoscopic

Colposuspension

A laparoscopic modification of the typical Burch colposus-

pension was first described by the Belgian Vancaillie [1, 11].
This way colposuspension became less invasive and because
of short-term patient benefits it became very popular, yet ini-
tially at the expense of higher cost and longer operation times.
In a systematic review of ten trials comparing laparoscopic
with open colposuspension, the subjective cure rates were
equivalent. However, short-and medium-term objective out-
comes were somewhat poorer for the laparoscopic procedures.
There was a trend toward fewer perioperative complications,
less postoperative pain and shorter hospital stay for laparo-
scopic compared with open colposuspension, however, lapa- Fig. 56.2  Types of mid-urethral slings. Top: retropubic sling; middle:
mini-sling; bottom: transobturator sling. Drawing: Myrthe Boymans.
roscopic colposuspension remained more expensive [12]. Copyright: UZ Leuven, Belgium
56  Laparoscopic Pelvic Floor Surgery
occurs in about 2% of tape insertions [14]. The tape is also often
blamed for causing pain during intercourse or even spontane-
ously. The efficacy and safety profile, the standardization of
technique and strong marketing have made this procedure
extremely popular. Contemporary data comparing laparoscopic
colposuspension and MUS indicate equal subjective cure rates
yet higher objective cure rates for MUS [12]. Moreover, placing
a MUS is less invasive, has a shorter learning curve and the
procedure is standardized and reproducible [12]. It is therefore
fair to say that MUS has become the gold standard for the surgi-
cal management of SUI, leaving laparoscopic colposuspension,
at least in our unit, a procedure being offered only to patients
who either prefer the avoidance of graft material, or that undergo
simultaneously other procedures by laparoscopy [15].
The use of colposuspension may increase in the future, as
the use of synthetic durable materials in prolapse surgery is
questioned or even banned, because of the risk for graft-related
complications, which may be difficult to treat. The lay public
and certain authorities now question also the use of MUS,
including the National Health System Improvement in a letter
to trust directors [16]. Indeed, in the U.K. “the government has
announced a pause on the use of ... tape to treat SUI ... follow-
ing a recommendation of the chair of an independent review
committee, who heard women and families [16].” This pause
takes the form of a high vigilance restriction, and it was meant
to lead to the postponement of any new cases, if it was clini-
cally safe to do so, as communicated by NHS Improvement.
Conversely, the FDA affirmed that the concerns about vaginal
mesh do not apply to the use of mesh for SUI [17].
56.2.3 Technique of Laparoscopic
Colposuspension
We prescribe on a soft diet to reduce intra-operative bowel
distension, three days prior to the surgery. We use a single
shot cefazolin 2 g administered intravenously 1 h prior to the
first incision. After general anesthesia, the patient is posi-
tioned in a modified lithotomy position. After disinfection
and sterile draping, a Foley catheter is introduced to empty
the bladder to enable identification of the bladder neck. One
can use a three-way catheter to fill the bladder with dyed
sterile water at any time during the operation. This allows
easy recognition of an accidental bladder perforation. Four
trocars are used: one subumbilical primary port, two lateral
5 mm ports and one trocar of 7 mm or more halfway between
the symphysis and the umbilicus, allowing needle passage.
56.2.3.1 Preperitoneal or Transperitoneal
Approach
It is uncertain whether an extra-peritoneal approach has advan-
tages over a transperitoneal approach [18]. The preperitoneal
approach is mainly performed when colposuspension is the
697
only procedure to be performed. The transperitoneal approach
can be performed primarily, when concomitant intraperitoneal
procedures are done, or secondary, after failure of the preperi-
toneal approach. First, the anterior peritoneum is incised about
3 cm above the symphysis. Then the urachus is coagulated and
an incision from the left to the right obliterated umbilical artery
is made. The dissection in the space of Retzius is first oriented
toward the symphysis, hence keeping the midline. Lateral dis-
section does not help the surgery and may cause laceration of
more lateral venous structures. A thin fascial layer must be
pierced to reach the posterior aspect of the rectus muscles to
avoid entering the dome of the bladder. In cases of previous
abdominal surgery, the top of the bladder may be attached to
the abdominal wall and peritoneal scar. In that case, filling the
bladder may help to identify the upper margin of the bladder
and locate the best place for peritoneal incision.
56.2.3.2 Operative Technique
The symphysis pubis is used as a landmark. From there, the
dissection extends laterally to the ileopectineal ligaments and
downward along the midline into the retropubic area until the
Cooper’s ligaments can be identified. The bladder neck and the
vaginal vault are the next landmarks. Dissection of the Retzius
space is done by blunt dissection. When dissecting the vagina,
all fatty tissue is removed to allow perfect visualization and the
grasping of an appropriate bite of perivaginal tissue.
The use of sutures now is considered more effective than
clips or mesh and staples to approximate the vagina to the
ileopectineal ligaments. Two sutures are also more effective
than one [12] (Fig. 56.1). The sutures are placed after dissec-
tion and meticulous hemostasis. To facilitate proper placement
of the sutures, the anterior vaginal wall is lifted with the aid of
two fingers in the vagina. The needle is inserted with the needle
holder 2  cm beyond the suture end of the needle. We use
braided non-resorbable Ethibond 0 sutures (Ethicon,
Johnson&Johnson, Zaventem, Belgium), which are 90 cm or
more in length to allow extracorporeal suturing. Vancaillie pro-
posed the use of Weston clinch knots [19]. The knots allow
tightening the knot at any degree of elevation of the vagina, also
without approximation to the ileopectineal ligament. We use at
least two single-bite sutures placed approximately 2.0 cm lat-
eral to each side of the urethra and 2.0 cm distal to the bladder
neck, as described in the Tanagho modification [20].
After checking hemostasis and bladder integrity, the perito-
neum is closed with a running suture. For that purpose we use
a monofilamentary suture with large needle, such as Monocryl
(Ethicon) 0 suture, because this one slides easily when tying
the knot. The large needle also facilitates quick closure of the
peritoneum in a single run. We remove the catheter as early as
possible following which the voided and residual volumes are
checked. When preoperative residual bladder volume was nor-
mal, we target for a residual volume <125 mL. If too large, the
catheter is reinserted temporarily, but intermittent self-cather-
698
ization is preferred. We empirically forbid heavy lifting or
sports for 6 weeks postoperatively.
56.2.3.3 Outcomes
Hemorrhage rarely occurs, and should be addressed appro-
priately. It rarely leads to discontinuation of the laparoscopic
procedure. Lower urinary tract injury is the most common
complication of colposuspension, in particular bladder
lesions. The majority of these lesions can be easily repaired
endoscopically but may cause prolonged catheterization.
Even ureteral obstruction has been described but it is rare
(<1%). Urinary tract infection is a common complication
after this surgery. Other infectious complications such as
wound infections or retropubic abscesses, although rare, are
a source of serious morbidity. Urinary retention, de novo uri-
nary urgency and voiding dysfunctions may occur. The later
development of enterocele due to the anterior displacement
of the anterior vaginal wall is less documented for laparo-
scopic procedures, but there is no reason to believe these
would be less likely as earlier observed for open surgery.
Initially several case series and historical comparisons
demonstrated outcomes comparable to those observed fol-
lowing open colposuspension. To our knowledge Kitchener
(2006) and Carey were the first to demonstrate equal objec-
tive and subjective cure rates for open and laparoscopic col-
posuspension [21, 22]. Since, this has been confirmed at the
meta-analytic level [12]. Laparoscopic colposuspension is
more expensive than its open counterpart and more expen-
sive than MUS.
56.2.4 Conclusion
Today there is level I evidence that the clinical outcomes from
laparoscopic colposuspension are comparable to those from
its open counterpart. Today the procedure is much less prac-
ticed because of the popularity and outcomes of MUS.  In
view of the increasing concerns about the use of synthetic
durable materials laparoscopic colposuspension may witness
a revival. The challenge will then be to train a new generation
of urogynecologists who master this endoscopic operation.
56.3 Laparoscopic Sacrocolpopexy
56.3.1 Management of Level I Defects
Whereas most patients with symptomatic Pelvic Organ
Prolapse (POP) can be adequately managed by the vaginal
route, correction of apical descent or multi-compartment
prolapse including a so-called level I defect are better treated
J. Deprest et al.
by the abdominal approach [4]. In sacrocolpopexy (SC) the
vaginal vault and/or cervix is fixed by means of a graft to the
anterior longitudinal ligament over the sacrum. This opera-
tion conserves vaginal length, hence should not compromise
its function. Sacrocolpopexy by laparotomy (referred to as
abdominal sacrocolpopexy (ASCP)) yields an over 90% suc-
cess rate, which is better than by sacrospinous fixation. This
is however at the expense of longer operation times, higher
morbidity, and increased hospital cost [4]. These shortcom-
ings are avoided by performing sacrocolpopexy by minimal
access, either by laparoscopy (LSCP) or by its RAS-
equivalent (RASC).
Single incision vaginal mesh prolapse repair initially
seemed to be a reasonable alternative to SCP, as it was sup-
posed to combine the durability and comprehensiveness of a
mesh repair, and the advantages of the vaginal route. In a
randomized clinical trial (RCT), LSCP was associated with a
shorter hospital stay, earlier return to daily activity, better
2-year anatomical outcomes, less graft-related complications
and, as a consequence less reinterventions as well as lower
hospital costs, despite longer operation times [5, 6]. These
findings, together with the global move away from vaginal
prolapse mesh, have made that type of vaginal procedures
extremely unpopular, except in a country like France, where
transvaginal mesh procedures were designed. However, also
in that country, a recent randomized clinical trial again dem-
onstrated superiority of LSCP [23].
56.3.2 Laparoscopic Versus Open
Sacrocolpopexy
Though the feasibility of LSCP was already demonstrated
as in 1994, the procedure became only later embraced
widely than colposuspension, probably because vault
prolapse occurs more rarely and LSCP needs extensive
dissection and advanced suturing skills, limiting this as
a procedure within reach of the general gynecologist or
urologist [2, 24].
Only by 2012 level I evidence became available support-
ing the hypothesis that a LSCP yields as good anatomic
(point C) and subjective (in that study the patient global
impression of improvement score) outcomes as the same
operation by laparotomy. Moreover, LSC was associated
with less blood loss, less pain, and a shorter hospital stay.
Conversely, operation time, return to normal activities, or
functional effects were similar for both modalities [25–28].
At this moment, new trials rightfully compare the two mini-
mally invasive alternatives, i.e., vaginal sacrospinous fixa-
tion and LSCP, and this might change the landscape in the
future [29].
56  Laparoscopic Pelvic Floor Surgery 699

56.3.3 Technique of Laparoscopic parietal peritoneum is incised and retroperitoneal fat is dis-
Sacrocolpopexy sected to allow exposure of the anterior vertebral ligament.
An area as large as required for fixing the mesh needs to be
There is at present no standardized technique. The dissected on the promontory just right from the midline.
International Urogynaecological Association Special Interest Pitfalls are the median sacral vessels, or when moving to
Group is currently drafting a review of techniques and the much laterally the ureter, or to the left the main vessels.
level of evidence for certain details. This report is at present Occasionally bipolar forceps is used for that purpose.
not available yet. Herein we describe our technique for
patients with symptomatic vault prolapse or uterine descent.
Patients have to present with minimally stage II prolapse of
the apex or upper posterior wall of the vagina according to
the Pelvic Organ Prolapse-Quantification system (POP-Q)
[30]. In case of associated rectal prolapse, a rectopexy may
be performed (Fig.  56.3). In our unit, patient preparation
involves bowel preparation for good exposure. We give
cefazolin (2  g) and metronidazole (1500  mg) prophylaxis.
After induction of general anesthesia, the patient is posi-
tioned in a modified lithotomy position with access to the
vagina and rectum. After disinfection and sterile draping a
3-way Foley catheter is inserted to empty the bladder. The
additional channels allow for bladder filling with dyed saline,
to exclude bladder lesions or identifying the bladder margins
during dissection and suturing. At least four trocars are nec-
essary: one primary umbilical 10  mm cannula, two lateral
5  mm trocars and one wider (10–12 mm) trocar halfway Fig. 56.4  Laparoscopic view from the umbilical port on the promon-
between the symphysis and the umbilicus. tory. The presacral venous structures are bluish and compressed by the
After careful identification of L5-S1, the inferior limit of pneumoperitoneum. The inferior border is the dashed red line. The iliac
arteries and bifurcation are indicated by the white dashed line. The
the left common iliac vein and the right ureter, the dissection promontory is indicated by the white interrupted line. Insert: view after
of the promontory is started (Fig. 56.4). First the prevertebral dissection. Copyright: UZ Leuven, Belgium

Fig. 56.3  Schematic drawing of a laparoscopic sacrocolpopexy (left) and sacrocolpopexy associated with a ventral rectopexy (right). The syn-
thetic mesh covers different aspects of the vagina and rectum. Drawing: Myrthe Boymans. Copyright: UZ Leuven, Belgium
700
Fig. 56.5  View after dissection of the prolapse vault, which is mobilized by a vaginal instrument; left anterior; right posterior and about two-thirds
along the posterior aspect of the vagina. Copyright: UZ Leuven, Belgium
The peritoneal incision at the promontory is then extended
along the rectosigmoid to continue over the deepest part of
the cul-­de-­sac, opening the recto- and vesicovaginal space
(Fig. 56.5). Some prefer to create a tunnel under the perito-
neum, avoiding later suturing. The lateral incision as well as
the dissection downward toward the perineal body can be
extended as far as required. This will be so when there is a
large rectocele or when a concomitant rectopexy is required
for rectal prolapse.
At this point in time we change gloves to prevent contami-
nation of the mesh. Usually, two separate meshes are sutured
to the posterior resp. anterior aspect of the vagina, using a
knot pusher, needle holder, and assistant needle holder. As
much as possible we try to avoid perforating the vagina while
suturing. Because this might not always be avoided, we
moved away from braided to monofilamentary resorbable
sutures (Fig. 56.6). Whether sutures need to be non-resorb-
able is questionable [31]. There is no agreement on how lat-
eral and deep one would dissect, neither the number or type of
sutures; there are already some reports on fixation with glue
[32]. One may need to palpate the rectum and vagina to define
their borders. Once this is finished, the vault is positioned by
the rectal pusher (placed in the vagina) at the level of the
ischial spines and then fixed in a tension-free position. We use
either staples or sutures to fix the mesh to the promontory;
there is no true evidence for preferring one above the other in
terms of complications. It is at this time that one needs to be
alerted and avoid hemorrhage from the presacral vessels. We
then close the peritoneum with both a running suture and the
staples left over from the sacral fixation. This will avoid adhe-
sions to the mesh; however, some authors leave the perito-
neum open [33]. At the end of the procedure we pack the
vagina for 24 h. Postoperatively, low molecular weight hepa-
J. Deprest et al.
rin injections are administered as long as the patient is admit-
ted, as well as a stool softener are continued for 6 postoperative
weeks to prevent heavy pushing. Also sexual inactivity is rec-
ommended until the 3 months postop visit. All these measures
were empirically determined.
We try at all price not to open the vagina to avoid graft-­
related complications [34, 35]. For that reason, if hysterec-
tomy is indicated, we would perform a laparoscopic
cervicopexy following subtotal hysterectomy. We use non-­
resorbable mesh material, following our frustrating experience
with acellular collagen matrices—though other series had
equal outcomes after 1 year [36–38]. In Europe, the SCENIHR
has recommended the use of polypropylene or polyester,
though without providing evidence whether for instance
hybrid materials (polypropylene with polyglecaprone) or
polivinylidene fluoride would be less performant or cause
more complications [39].
56.3.4 Outcomes
There are numerous reports on the successful outcome of
LSCP, most of them retrospective in nature, monocentric or
from a single surgeon, often rather small, potentially including
the learning curve [40]. A somewhat dated review on 11 retro-
spective studies (n = 1197 patients at a mean follow-up of 24.6
months) reported overall objective anatomical and subjective
success rates of 92% and 94.4%, respectively [41]. Today
larger single center series have confirmed the efficacy of LSCP
and acceptable short-term complication rates [42–44]. We
implemented LSCP in our unit in the late 1990s, and earlier
reported on the medium-term outcomes [36, 45]. At a mean
follow-up of 12.5 months, we observed an anatomical cure
56  Laparoscopic Pelvic Floor Surgery
Fig. 56.6  Suturing of the mesh to the posterior aspect of the vagina
(left, top) and anterior (right, top). Tension-free suspension of the mesh
by stapling it to the promontory (left, bottom). The remainder of the
rate approaching 95% and a functional cure rate of 92% [45].
Since, we reported on a much larger consecutive series
(n = 571) at a median age of 66.3 years (range: 27–91) [42]
(Table 56.1). 73.4% had a vault suspension, 24.2% a cervico-
pexy with concomitant ­laparoscopic-­assisted subtotal hyster-
ectomy (LASH) and 2.8% a hysteropexy. Twenty-six were
redo-sacropexies (4.6%), and concomitant rectopexy, inconti-
nence surgery or vaginal prolapse surgery was performed in
5.3%, 3.7%, and 3.0% respectively.
Conversions were categorized into either a strategic con-
version, i.e., instances where the surgeon as a precaution
decided to open up the abdomen or to proceed vaginally, or
re-active, i.e., as a result of an intraoperative complication
which the surgeon felt was better managed through open
abdomen [46, 47]. The overall conversion rate was 3.0% in 17
patients, including 13 strategic conversions early on in the
701
staples is used to close the peritoneum, which is finished by a purse
string (right, bottom). Copyright UZ Leuven, Belgium
experience, mainly for adhesions (Fig. 56.7). There were four
reactive conversions (0.7%) for anesthetic reasons or surgical
complications. In retrospect, there was an early (<60 cases)
peak of strategic conversions, yet thereafter conversions were
rare and equally distributed along the experience (Fig. 56.1).
There were 20 patients (3.6%) with intraoperative complica-
tion, their nature displayed in Table 56.2. The majority were
lesions to the bladder (n  =  10), vagina (n  =  6) or epigastric
arteries (n  =  2), which were managed laparoscopically. The
postoperative complications were categorized according to the
Clavien-Dindo classification system [48]. Eighty-four women
(15.2%) had in total 95 postoperative Dindo grade II or higher
complications within 3 months (Table 56.3). Dindo II compli-
cations are those events that cause a deviation from the normal
postoperative course, and that prompt the use of drugs other
than analgesics, antipyretics, anti-emetics, diuretics, electro-
702 J. Deprest et al.

Table 56.1  Patient characteristics of our cohort and operative vari- Table 56.2  Rate and nature of complications in 554 consecutive
ables, for all patients and broken down by age category (under and patients who had their sacrocolpopexy completely by laparoscopy, also
above 70 years). broken down by age group
Baseline Median P
characteristics or % ≤70 years >70 years P Intra-operative n (%) ≤70 years >70 years value
Number of patients Total: 571 367 204 Number of patients 554 356 198
(100%) (64.3%) (35.7%) (64.3%) (36.7%)
Age (years) 66 (IQR 15) 61 (IQR 11) 75 (IQR 6) 0.000 Visceral injuries 16 (2.9%) 10 (2.8%) 6 (3.0%) 0.882
BMI (kg/m2) 25 (IQR 5) 25 (IQR 5) 25.5 (IQR 4) 0.917  Bladder 7 (1.3%) 5 (1.4%) 2 (1.0%) –
Menopausal 90.7% 87.2% 100% 0.000  Ureter 3 (0.5%) 3 (0.8%) 0 (0.0%) –
Diabetes mellitus (all 10.8% 9.5% 13.4% 0.344  Vaginal 6 (1.1%) 2 (0.6%) 4 (2.0%) –
types) Vascular injury 2 (0.4%) 0 (0.0%) 2 (1.0%) 0.127
Current smoker 12.2% 15.7% 3.9% 0.001  Epigastric artery 2 (0.4%) 0 (0.3%) 2 (1.0%) –
Prior hysterectomy 73.4% 70.3% 78.9% 0.025 bleeding
Prior POP surgery 72.1% 68.9% 77.8% 0.022 Anesthetic problems 1 (0.2%) 1 (0.3%) 0 (0.0%) 1.000
Prior LSCP 4.6% 5.7% 2.5% 0.072  Hypercapnia 1 (0.2%) 1 (0.3%) 0 (0.0%) –
Nature of procedures (index operation) Other 1 (0.2%) 1 (0.3%) 0 (0.0%) 1.000
Sacrocolpopexy 73.4% 70.3% 78.9% 0.025  Needle detachment 1 (0.2%) 1 (0.3%) 0 (0.0%) –
Concomitant 24.2% 27.0% 19.1% 0.036 Total number 20 (3.6%) 12 (3.3%) 8 (4.0%) 0.686
LASH + cervicopexy
–: not calculated because of low number per individual cell. P values
Hysteropexy 2.8% 3.0% 2.5% 0.705
are based on χ2 testing (Fisher exact)
Concomitant 5.3% 5.5% 4.9% 0.783
rectopexy
Concomitant 3.7% 3.6% 3.9% 0.814
incontinence surgery
Concomitant vaginal 3.0% 3.3% 2.5% 0.584
surgery
BMI Body Mass Index, LASH Laparoscopic Subtotal Hysterectomy,
LSCP Laparoscopic SacroColpoPexy. Absolute values not displayed;
missing values range prior surgery: 0%—certitude on menopausal sta-
tus 26.4%

10
Reactive conversions Strategic conversions Intra-operative complications
9
8
Absolute number of cases

7
6
5
4
3
2
1
0
60 120 180 240 300 360 420 480 540 571
Number of patients in blocks of 60

22% 43% 33% 28% 43% 48% 42% 37% 30% 26%
percentage of patients aged >70

Fig. 56.7  Effect of experience on (blue) the number of reactive con- 57]; Y axis: absolute number of cases. The number below each block
versions, (red) strategic conversions and (green) the number of intraop- refers to the percentage of patients above 70 years. (From Vossaert
erative complications. X axis: number of patients in blocks of 60 [40, et al., 2018, with permission of authors [42])
56  Laparoscopic Pelvic Floor Surgery 703

Table 56.3  Nature and number of 95 early postoperative complications in 83 patients, broken down according to the Dindo classification, and
categorized by age groups
Early postoperative complications n ≤70 years >70 years P value
Number of patients 554 356 198
Number of patients with complications (% of the population) 84 (15.2%) 57 (16.0%) 27 (13.6%) 0.455
Number of complications 95 61 34
Dindo II—any deviation from the normal postoperative course requiring pharmacological 77 53 (14.9%) 24 (12.1%) 0.372
treatment with drugs other than such allowed for grade I complications
Antibiotics for asymptomatic or symptomatic urinary tract infection 33 24 9
Antibiotics for postoperative fever and/or CRP rise 11 9 2
Treatment of vaginal infection 4 3 1
Antibiotics for umbilical/trocar wound infection 4 4 0
Antibiotics for Chronic Obstructive Pulmonary Disease exacerbation/pneumonia 2 2 0
Antibiotic prophylaxis after vomiting during extubation 1 1 0
Blood transfusion 11 6 5
Administration of (additional) drugs (amlodipine, perindopril, digoxin, bisoprolol, 7 1 6
haloperidol)
Low Molecular Weight Heparin for treatment of Deep Venous Thrombosis/Pulmonary 4 3 1
Embolism
Dindo III a—Complication requiring surgical, endoscopic or radiologic intervention not 4 1 (0.3%) 3 (1.5) 0.100
under general anesthesia
Infection with mesh extrusion, vaginally removed in the office 1 0 1
Urinary retention, catheterization 3 1 2
Dindo III b—Complication requiring surgical, endoscopic or radiologic intervention under 13 7 (2.0) 6 (3.0) 0.429
general anesthesia
Reoperation for prolapse 1 0 1
Reoperation for suspected hemorrhage 4 2 2
Reoperation for ureter reimplantation 1 1 0
Reoperation for mesh removal 2 1 1
Reoperation for exposure sling 1 1 0
Reoperation: cholecystectomy 2 2 0
Reoperation for bowel obstruction 2 0 2
Dindo IV—Life-threatening complication 1 0 (0.0%) 1 (0.5%) 0.357
ICU admission for cardiac decompensation and pulmonary edema 1 0 1
When several complications occurred, the patient was counted in the highest category applicable. CRP C-reactive protein. Statistics were done on
individual patient basis for each Dindo category

lytes, and physiotherapy. Among these, urinary tract infection
was the most common (5.9%), the majority identified on urine
culture and asymptomatic. Other common Dindo II complica-
tions were the need for blood transfusion (1.9%) and the
administration of antibiotics (1.9%). Dindo III and higher
were categorized as major. Interventions without the need for
general anesthesia (Dindo IIIa) were for patients with urinary
retention and in one patient in office mesh removal.
Reintervention under general anesthesia (Dindo IIIb) and
ICU admission (Dindo IV) are clinically very relevant com-
plications. These were rare (2.3%). There were four early
second look laparoscopies for suspected hemorrhage, though
despite a hemoperitoneum, no source could be identified.
There were three directly prolapse surgery-related addi-
tional surgeries. One patient with chronic coughing required
an immediate redo, one had a spondylodiscitis (IUGA
6CT2S4), from which she recovered after 9 weeks of antibi-
otic therapy, and in one patient we removed the mesh early
on because of severe pelvic infection. She recovered and did
not develop recurrence. In retrospect, this patient had multi-
ple co-morbidities among which essential thrombocytosis,
for which she was on the antitumoral agent hydroxy-
carbamide. Two patients had a reintervention for bowel
obstruction. Four patients experienced complications away
from the operation field. One had a reintervention for a
symptomatic sling exposure. Two patients suffered from
cholecystitis for which they were operated. One patient who
underwent simultaneous LASH was postoperatively diag-
nosed with a ureteric obstruction at the level of the uterine
artery and underwent reimplantation. We had 2.7% mesh-­
related complications, most of them easy to manage, except
for the above patient with discitis.
704
56.3.5 Outcomes in the Elderly
In 2016, 19.2% of the EU-28-population was over 65 years
(5.4% >80 years), but by 2030 that segment will be 23.9%
(7.2% >80 years) [49]. With increased activity and a health-
ier population, POP surgery, hence also the demand for SCP
in the elderly will increase accordingly. In one study [50],
the annual risk for POP surgery was 4.3/1000 women aged
71–73 years and in another one it was 5.0/1000 women aged
65–69 years [51]. With age the prevalence of chronic ill-
nesses and comorbidities increases, including poor cardio-
pulmonary reserve, not to forget, the prevalence of prior
surgery [52]. Though complex operations seem risky in the
elderly, minimally invasive surgery may be particularly ben-
eficial in those patients [53]. The literature on the effect of
age is controversial [54–56]. Most studies show similar
complication rates in younger and elder patients, yet occa-
sionally higher complication rates are reported [54]. In that
study, age ≥65 years remained a significant predictor of
complications after correction for BMI, estimated blood
loss and operating time (adjusted OR 2.28, 95% CI 1.21–
4.29, p = 0.01). In the above study on 571 consecutive LSCP,
septuagenarians were not more likely to have intraoperative
(4.0% vs. 3.3% <70 years, p = 0.686) or early postoperative
complications (13.6% vs. 16.0% <70 years, p = 0.455) than
younger patients. Mesh complications were also equally
uncommon [42].
56.3.6 Learning Curve
We studied the feasibility and the learning process of LSC by
documenting our entire experience, from the first laparo-
scopic case onward [40, 57]. We demonstrated that LSC can
be implemented without increasing the complication rate.
Using different statistical techniques we eventually defined
the endpoint for the learning curve as the moment that the
trainee was able to complete the procedure by laparoscopy,
without complications and with good anatomical outcome in
at least 90% of patients. With this as an endpoint the surgeon
required 60 cases. Operation time can also be used as a sole
endpoint. Operation time declined rapidly over the first 30
procedures, declining slower thereafter, to reach a steady
state after 90 cases. This rather long learning curve tickled us
to get better insight into the limiting factors or challenging
steps of the procedure. To investigate this we studied the
learning curve of a fellow who was familiar with advanced
laparoscopic surgery but not LSCP. Instead of only focusing
on total operation time and complication rate we split the
operation empirically into five steps: (1) dissection of the
promontory, (2) dissection of the right parasigmoidal, para-­
rectal gutter, and the vaginal vault, (3) fixation of the implant
to the vault, which involves the placement of several sutures;
J. Deprest et al.
(4) fixation of the implant to the promontory, (5) reperitone-
alization. We analyzed for each step the operation time, per-
formance, and complication rate. Taking operation time as
outcome measure, we found an apparent learning curve for
all steps of the procedure, except for the dissection of and
fixation to the promontory. The most challenging step was
the dissection of the vault. It took the trainee 31 procedures
to achieve an operation time that was comparable to that of
an experienced surgeon. After a skills lab for suturing, the
trainee could suture the implant as fast to the vault as the
teacher.
56.3.7 Conclusion
Laparoscopic sacrocolpopexy yields equally good objective
and subjective cure rates as by open surgery, but is associated
with less blood loss, less pain, and a shorter hospital stay.
The operation can be done by conventional “straight stick”
laparoscopy as well as robotic assisted, though no benefits
have been demonstrated for the latter. The learning curve for
LSCP may be between 30 and 60 cases, depending on what
outcome measures are considered. At this moment, new tri-
als are comparing LSCP to that of vaginal sacrospinous fixa-
tion and LSCP; the findings of these change the landscape in
the future [29].
56.4 Associated Ventral Rectopexy
56.4.1 Concurrence with Posterior Pelvic Floor
Dysfunctions (PFD)
Just as the risk factors for PFD cluster, very often differ-
ent dysfunctions co-occur. This is particularly so for POP
and fecal incontinence [58]. This necessitates a multidisci-
plinary approach, which in our center started off with the
urologists but over the last years our collaboration with the
colorectal surgeons and proctologists has intensified. In
particular, patients with obstructed defecation syndrome
(ODS) as well as fecal incontinence (FI), which may both
be present in patients without POP, yet not uncommon in
our population, are assessed and operated together. Indeed,
POP patients often also have anatomically rectal intussus-
ception or perineal descent. In patients with symptomatic
ODS and/or FI and anatomical intussusception, next to
level I defects, we combine surgical repair of the middle
compartment with a rectopexy, which also repairs a pos-
terior compartment prolapse. In this population we use
imaging techniques, such as colpocystodefecography and/
or transperineal ultrasound, which both can demonstrate
intussusception/transanal prolapse and anatomical poste-
rior vaginal prolapse [59].
56  Laparoscopic Pelvic Floor Surgery 705

56.4.2 Associating Anterior Rectopexy sion. The procedure requires advanced dissection and sutur-
in Combined Middle and Posterior ing skills, which not many surgeons master today. Appropriate
Compartment Problems training programs will need to be designed to allow pelvic
floor surgeons to acquire the required skills and give colpo-
The choice for associating an anterior laparoscopic mesh-­ suspension back a place in their operative portfolio.
rectopexy as the preferred surgical procedure for associated Efforts are being done to document the impact of varia-
rectal prolapse by our colorectal colleagues in our unit has tion in techniques for laparoscopic sacrocolpopexy, such as
two reasons: (1) laparoscopic ventral rectopexy with mesh the nature and number of sutures, the extent of dissection, the
has been pioneered by our colorectal colleagues and out- nature of the implant, the impact of uterine conservation, etc.
comes are good [60, 61] and (2) it can be easily combined Though open sacrocolpopexy has been shown to be supe-
with a colpopexy. The procedure requires similar skills, dis- rior to vaginal sacrospinous fixation, new trials are being
section in the same anatomical spaces and for the technique conducted comparing minimally invasive sacrocolpopexy or
used (mesh anterior rectopexy) in our unit the same instru- laparoscopic hysteropexy and vaginal sacrospinous fixation
ments and devices are used. The symptomatology, diagnostic [29, 65].
assessment, and surgical management of ODS and perineal
descent is described in detail elsewhere in this book (Van
Geluwe & D’Hoore, Chap. 68). Occasionally we also treat Take-Home Messages
patients with an associated sigmoidocele together, for which Laparoscopic colposuspension is equally effective as
a partial bowel resection is done. open colposuspension, but is currently much less prac-
ticed because of the widespread embracement of
MUS. Slings are equally effective yet cheaper and are
56.4.3 Technique and Outcomes easier to learn.
of an Associated Anterior Rectopexy Laparoscopic and open sacrocolpopexy yield
equally good objective and subjective cure rates. The
In case of an associated rectopexy, the dissection of the recto- laparoscopic approach is associated with less blood
vaginal space along the rectal muscularis goes as far as the loss, less pain and a shorter hospital stay. The proce-
anal sphincter using monopolar dessication. Denervation or dure can be easily associated with a ventral rectopexy
damage to the inferior hypogastric nerve is to be avoided. The in selected cases.
peritoneal incision is started at the bottom of the pouch of The learning curve of laparoscopic sacrocolpopexy
Douglas and continued upward along the left side of the rec- is long and prior training on a simulator and on sutur-
tum. Redundant prerectal fat and when required part of the ing may shorten it. The benefit of robotic sacrocolpo-
pouch of Douglas may need to be resected, so that the mesh pexy has not been demonstrated; it may however
can cover directly the anterior aspect of the rectum. Sutures shorten the learning curve for physicians not familiar
will be placed on the front and alongside the rectum so that the with laparoscopy.
mesh eventually prevents the rectum from sliding downward
and bulging anteriorly, without true tension. The posterior,
middle, and anterior aspect that is covered by mesh is excluded
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Impact of laparoscopic sacrocolpopexy learning curve on opera-
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44. Vandendriessche D, Sussfeld J, Giraudet G, Lucot JP, Behal H,
Cosson M. Complications and reoperations after laparoscopic
56  Laparoscopic Pelvic Floor Surgery
sacrocolpopexy with a mean follow-up of 4 years. Int Urogynecol
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14: 112.
 The Robotic Approach to Urogenital
Prolapse
Claire M. McCarthy, Orfhlaith E. O’Sullivan,
and Barry A. O’Reilly
Learning Objectives
• Understand the history and evolution of robotic sur-
gery and its application to urogynaecology.
• Explore approaches and techniques to the robotic
repair of apical prolapse.
• Discuss the advantages and disadvantages of robotic
surgery as it is applied to urogynaecology.
• Develop an awareness of the use of robotic surgery
in both urogynaecology and other surgical
specialties.
57.1 Introduction
The evolution of surgery has increased rapidly over recent
decades. As a field, urogynaecology has evolved and
embraced these advances, with an increasing number of
practitioners adopting robot-assisted surgical techniques.
Performing more complex urogynaecological procedures
using robot-assisted platforms can have a major advantage
over open or laparoscopic surgery and has had an impact on
the management of complex urogynaecological conditions,
as well as offering an alternative to abdominal and conven-
tional minimal access surgery.
Despite a significant cost at outset and the need for con-
tinued development of expertise in this area, robot-assisted
C. M. McCarthy (*) · O. E. O’Sullivan
Department of Obstetrics and Gynaecology,
Cork University Maternity Hospital, Cork, Ireland
B. A. O’Reilly
Department of Obstetrics and Gynaecology,
University College Dublin, Dublin, Ireland
Department of Urogynaecology,
Cork University Maternity Hospital, Cork, Ireland
ASSERT Centre, University College Cork, Cork, Ireland
e-mail: barry.oreilly@ucc.ies
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_57
57
surgery provides many advantages in the treatment of api-
cal prolapse. While abdominal sacrocolpopexy is the current
gold standard for the management of apical prolapse, there is
the potential in years to come that the robotic approach may
supersede both the abdominal and laparoscopic approach.
57.2 Robot-Assisted Surgery: The Context
While the art of medicine and surgery have been evolving
over centuries, other concepts such as robot-assisted surgery
are more novel and have had exponentially greater effects
over shorter periods of time. The word “robot” has its origin
from the Czech word robota (meaning forced labour) and
was coined by Capek in his theatrical production R.U.R.
(Rossum’s Universal Robots) in 1920 [1]. Following on from
this, the concept of a remote manipulator to perform bodily
functions was developed in the 1940s to handle and move
hazardous materials while minimizing harm to humans.
This included those developed by the likes of Raymond
Goertz, which handled radioactive material while working
for the Atomic Energy Commission at Argonne National
Laboratory [2]. The concept of robotics was further devel-
oped into areas such as microelectronics and computing over
the subsequent four decades, such as those utilized by the
National Aeronautics and Space Administration (NASA) [3]
prior to being considered as a useful adjunct in the field of
medicine and surgery where it has now revolutionized the
concept of minimal access surgery.
Prior to this at the start of the twentieth century, instru-
ments were utilized to obtain access to the peritoneal cavity
by surgeons such as George Kelling [4]. The term “laparotho-
rakoskopie” was first proferred by Hans Christian Jacobaeus
in 1910, describing 17 such procedures in 1910 [5]; both sur-
geons were subject to much criticism [6]. As the twentieth
century progressed superior laparoscopes were developed,
and the first laparoscopic fallopian tube electrocoagulation
was performed in 1936 [7]. Criticism continued of laparo-
scopic techniques up until the 1980s, when Kurt Semm, a
709
710
revolutionary gynaecologist, performed the first laparoscopic
appendicectomy [8]. However, the laparoscopic revolution
began in earnest by the 1990s with the first laparoscopic hys-
terectomy performed in 1990 by Nezhat and Reich [9].
57.2.1 History of Robot-Assisted Surgery
As minimal access surgery continued to become widely uti-
lized, it demonstrated superiority in areas such as reduced
perioperative morbidity and shorter length of hospital stay,
in addition to being both more economical and reducing
the exposure to adverse events. The development of robotic
surgery was in part due to work by the Defense Advanced
Research Projects Agency (DARPA), which funded research
into the possibility to performing minimally invasive surgery
in a remote surgery programme, with surgeons controlling
the console and procedure remote from the battlefield [10].
The role of robotic surgery has never been to replace the sur-
geon, but rather enhance his/her performance with highly
advanced tools [11].
In 1999, Intuitive Surgical® developed and introduced
the first da Vinci® System to the market and in 2000 it was
cleared by the FDA (Food and Drug Authority) [12] for
minimally invasive surgery including urological procedures.
Subsequently it was approved for gynaecological surgery in
2005. In Europe, the da Vinci robot has full regulatory clear-
ance and has the CE (Conformité Européenne) mark since
1999 [13].
The success of the da Vinci system has been seen world-
wide, with availability in 66 countries and 44,000 surgeons
trained in the use of the da Vinci system [14]. Over five mil-
lion surgeries have been performed since their introduction
under 20  years ago, which shows an unparalleled level of
evidence in comparison to other non-robotic surgical system
providers with over 15,000 peer-reviewed publications uti-
lizing a single surgical system.
As the twenty-first century progresses, other companies
are beginning to venture into the field of robot-assisted sur-
gery. CMR Surgical Limited® is currently developing a sur-
gical robotic system called Versius® which will in theory be
portable and transportable, with a footprint of 38 cm × 38 cm
[15]. Medtronic® also plans to introduce a competitor to
the market with Hugo®, as does TransEnterix®, Synaptive
Medical® and Titan Medical Inc.™. These continuous inno-
vations demonstrate that robotic surgery will continue to
evolve and adapt to maximize patient outcomes, as well as
making the market more competitive and thus robot-assisted
procedures more cost-efficient. With further focus on the
C. M. McCarthy et al.
development of robot-assisted surgical systems, there are
opportunities to capitalize on the ergonomic and economic
advantages of robot-assisted surgery, as well as increase
access across all levels of healthcare. Thus, robot-assisted
surgery has the potential in the future to replace conventional
laparoscopy throughout many fields of surgery [16].
57.2.2 Components of Robotic Surgery System
The first da Vinci® System introduced in 1999 [12] was
upgraded in 2003 from a three-armed to four-armed robot,
providing the fourth (retractor) arm. The system consists of
three main components:
1. The console from where the surgeon controls the opera-
tion (Fig. 57.1)
2. The patient side cart with four interactive robotic arms to
which the operating instruments are attached (Fig. 57.2)
3. The vision system (Fig. 57.2)
The EndoWrist® instruments used during surgery com-
bine seven degrees of freedom, with 90° of articulation to
provide a range of motion superior to the human hand [14].
It also combines intuitive motion and fingertip control with
motion scaling and tremor reduction technology to provide
instruments with greater capabilities and improved surgical
dexterity. The latest model in common usage, the da Vinci®
Xi Surgical System (2014) [14], allows for more efficient
anatomical access with crystal clear three-dimensional and
high-definition visualization. Further modifications such
as provision of a dual console facilitate training of the next
generation of surgeons. Other adaptations include the capa-
bility to identify key landmarks utilizing integrated fluores-
cence technology and single incision versatility minimizing
port placement for common procedures such as the benign
hysterectomy. The principle of robot-assisted surgery is that
the surgeon operates unscrubbed while seated at the con-
sole, from which they are able to view the operating field
in three dimensions through a stereoscopic viewer. This has
been further streamlined into the da Vinci SP [15], utiliz-
ing single port and arm access to the operative field, which
as well as being at the cutting edge of conventional laparo-
scopic surgery has rapidly been extrapolated to the arena of
robot-­assisted surgery.
Recommendation for Practice
Surgeons should familiarize themselves with surgical equip-
ment including troubleshooting minor technical issues.
57  The Robotic Approach to Urogenital Prolapse 711

Figs. 57.1 and 57.2 The

main components of the da
Vinci Xi Surgical System.
©2019 Intuitive Surgical, Inc.
712
57.2.3 Use of Robotic Surgery in Other Sub-­
specialties of Gynaecology and Surgical
Specialties
Since its introduction into clinical practice, robot-assisted
surgery has expanded exponentially to include many surgical
specialties such as gynaecology, general surgery, colorectal,
head and neck, cardiothoracic and urological surgery. The
greatest volume of evidence for the use of robot-assisted sur-
gery is in the area of urology, with cardiothoracic surgery
the most recent speciality to benefit from robot-assisted
techniques.
The robotic telepresence technology is flourishing, and
opportunities have expanded to incorporate its use into
specialties and procedures which have been previously
unattainable.
57.2.4 Laparoscopic Versus Robot-Assisted
Surgery
Laparoscopic surgery has been an integral part of clini-
cal practice much longer than robot-assisted surgery, and
its evolution was unprecedented during the late twenti-
eth century. However, this innovation, development and
advancement has been capped, with its capabilities reach-
ing a veritable glass ceiling. Surgeons are now primarily
trained in minimally invasive surgery with the advantages
of minimally invasive surgery largely extrapolated to robot-
assisted surgery. These include reduced blood loss, fewer
complications, faster recovery, reduced length of hospital
stay and improved cosmesis. However, conventional lap-
aroscopic surgery has a number of drawbacks which are
minimized by robot-assisted surgery, which have been
described in the fields of urogynaecology [17], general and
oncological gynaecology surgery [18] and in other surgical
specialties [19, 20].
Laparoscopically, surgeons operate exclusively with
a two-dimensional image, which can limit depth percep-
tion and also increase surgeon fatigue. Surgeons utilize
straight, rigid instruments with decreased precision, which
is associated with reduced dexterity and control, culminat-
ing in poorer surgeon ergonomics and increased practitioner
fatigue. In addition, operating in a small surgical field with
conventional laparoscopy can exacerbate tremor, which is
reduced with robot-assisted surgery. It has been theorized
that the high-volume laparoscopic surgeon has the potential
of causing irreparable strain injury leading to earlier retire-
ment [21–23], as well as being associated with a more stress-
ful operative approach [24]. This could potentially impact on
the number of skilled surgeons treating us and our patients.
Robot-assisted surgery has been shown to have a lower rate
C. M. McCarthy et al.
Table 57.1  Comparison of laparoscopic versus robot-assisted surgery
Conventional laparoscopic
surgery Robot-assisted surgery
Two-dimensional image Three-dimensional image
Straight, rigid instruments Enhanced dexterity
Surgeon fatigue Improved ergonomics and thus
reduced fatigue
Camera motion/tremor Camera controlled by primary
surgeon leading to improved
visualization and reduced tremor
Primary surgeon limited to two Primary surgeon can control up to
active instruments four instruments
Challenges of those at Overcomes complexities of obese
extremes of weight patients
Increased incidence of Improved safety features to
physical and psychological minimize physical injury
sequelae for surgeons
of physical symptoms or discomfort, supporting a more
favourable ergonomic environment in robotic surgery than
in laparoscopy [25]. Conventional laparoscopic surgery also
requires skilled assistants to carry out a range of activities,
such as manoeuvring the camera, obtaining the best pos-
sible image as well as anticipating future movements of the
primary surgeon. In addition, assistants may need to utilize
accessory instruments through additional ports, as the pri-
mary surgeon is limited to utilizing two instruments at any
one time in conventional laparoscopy. Table  57.1 summa-
rizes these limitations of laparoscopic surgery and demon-
strates how robot-assisted surgery surpasses the limitations
of traditional minimal access surgery.
With the advances of laparoscopic surgery incorporated
with the advances of robotic surgery, we have been able to
overcome the limitations in the advancement of conventional
laparoscopic surgery, allowing more complex procedures to
be carried out to the same high standard as has been seen
over the past century.
Recommendation for Practice
Surgeons intending on performing robot-assisted surgery
should have attained competency in at least one alternative
approach in order to manage surgical complications.
57.3 Robotic Approach to Apical Prolapse
Following the use of robot-assisted surgery in benign gynae-
cology, its use expanded to procedures that are the remit of
subspecialists in the field, such as in gynaecological oncol-
ogy and urogynaecology. Common procedures performed in
the urogynaecological setting include robot-assisted sacro-
colpopexy (RASC), robot-assisted hysteropexy (RASH) as
well as mesh removal procedures and secondary repair pro-
cedures, such as vaginal fistula repair.
57  The Robotic Approach to Urogenital Prolapse
57.3.1 Robot-Assisted Sacrocolpopexy (RASC)
The first case of RASC was reported in 2004 [26], and since
then, a number of authors have published case series of its
performance, suggesting alternative surgical techniques
and nuances to maximize clinical results. Despite this, there
remains a limited number of randomized controlled trials com-
paring laparoscopic-assisted sacrocolpopexy (LASC) with
RASC with the main endpoints of operation time, pain, func-
tional activity symptoms, cost, anatomical support and quality
of life [27, 28]. Overall, Paraiso demonstrated no significant
functional differences between laparoscopic and robot-assisted
procedures; however, the latter was associated with increased
pain scores and increased operative time. Increased pain fol-
lowing RASC however does not corroborate with other studies,
which typically show similar or reduced pain scores [29]. This
is potentially due to port insertion technique, and in view of the
fulcrum effect of robotic instrumentation, it is imperative that
ports are inserted at a 90-degree angle to the skin surface.
The rationale and surgical principles of RASC are simi-
lar to the laparoscopic approach, and when we examine
the inaugural operative RASC approach [26], we can see
adaptations from standard laparoscopy to maximize utiliza-
tion of the da Vinci robotic system. One camera port, two
robotic ports and two standard laparoscopic ports are placed.
Standard laparoscopic dissection is used for initial anterior
and posterior vaginal mobilization and exposure of the sacral
promontory. The da Vinci robot is then docked and used to
suture a silicone Y-shaped graft from the vagina to the sacral
promontory. Culdoplasty, with plication of the uterosacral
ligaments, is then performed, followed finally by retroperito-
nealization of the graft.
As with all procedures, it is the natural evolution that as
more surgeons perform and undertake a procedure modifica-
tions occur [30]. We describe one commonly used technique
here.
The patient is placed in moderate to steep Trendelenburg,
with legs placed in the low lithotomy position. Once posi-
tioning is satisfactory, the ports are placed in a W shape
(Fig.  57.3) with the camera port (12  mm) cephalad to the
umbilicus (blue); the right instrument arm port (8 mm, yel-
low) is placed 10 cm right of the umbilicus and ~30° inferior
to camera port. The left instrument arm port (8 mm, green)
is placed 10  cm left of the umbilicus and ~30° inferior to
camera port, the third instrument arm port (8  mm, red) is
placed on the left side ~3 cm from the iliac crest and >10 cm
from the left instrument port at the level of the camera port
and, finally, the assistant port (8  mm, white) is placed far
right ~8  cm from the right instrument port, just below the
level of the camera port. The measurements for port place-
ment should be made after insufflation. The robot is then
docked, the camera arm attached to the camera port and
713
Fig. 57.3  Diagram for port insertion sites: a routine approach. ©2019
Intuitive Surgical, Inc.
the instrument arms subsequently attached and instruments
introduced under direct vision. The assistant port is the left
superio-­lateral port to facilitate introduction of sutures and
potentially mesh grafts. Dissection is then performed by the
surgeon sitting at the console via the robot; to aid this vagi-
nal and rectal manipulators are introduced. The anterior and
posterior vaginal walls are mobilized and following this the
sacral promontory is exposed, and a track created to allow
the peritoneum to be closed over the mesh. The Y-shaped
polypropylene mesh is then attached from the anterior and
posterior walls of the vagina to the anterior longitudinal liga-
ment using permanent sutures, e.g. GORE-TEX®. Finally,
the peritoneum is then closed over the graft.
Other surgical variations are in the number and calibre
of ports utilized, type of vaginal manipulator, deviations in
suture material, mesh graft and additional techniques [31–
36]. Some of these techniques are highlighted in “Further
Reading” at the end of this chapter.
There are limited numbers of randomized controlled trials
comparing robot-assisted, laparoscopic and open techniques,
and those that do exist have different endpoints, outcome
measures and follow-up times. Some of the most pertinent
and notable papers are described in Table 57.2. However, we
may never obtain high-quality evidence for robot-assisted
procedures such as this, due to firstly the heterogeneity in
published studies [37], as well as the belief that there are dif-
ficulties performing randomized controlled trials with new
technologies, held by epidemiologists such as Professor Sir
Rory Collins [38].
714 C. M. McCarthy et al.

Table 57.2  Publications comparing robotic (RASC) versus laparoscopic (LASC) and/or abdominal (ASC) sacro-colpopexy
Patient
Paper RASC vs Operative time Length of stay Blood loss Cost Pain POP-­Q score satisfaction
Paraiso [27] LASC Increased Increased Increased No difference
Anger [28] LASC No difference Increased No difference
White [29] ASC and No difference No difference No difference Increased No difference
LASC
Geller [32] ASC Decreased Decreased Improved
Hoyte [39] ASC Increased Decreased Increased
Lee [40] LASC Increased Increased Improved Increased
Pan [41] LASC Increased Increased Increased
Li [42] ASC Decreased Decreased Increased

To highlight some of the findings with respect to endpoints
and outcome measures, there is little difference between
lengths of hospital stay between laparoscopic and RASC,
yet the abdominal procedure is associated with a longer hos-
pitalization [29]. The robotic approach is associated with
decreased blood loss while having little difference in func-
tional outcomes and recurrence rates. Complication rates are
more difficult to stratify due to heterogeneity between stud-
ies, but overall are similar.
There are also advantages of RASC over laparoscopic
and open approaches, which are not as amenable to clinical
study, such as ease of suture placement in the case of the
former, and increased risk of wound complications and pro-
longed length of stay owing to the latter.
Anecdotally, when comparing robot-assisted surgery to
laparoscopic surgery, surgeons find dissection over the sacral
promontory less problematic owing to an increased range of
movement of the instruments [43], which can also contribute
to more efficient and facile suture placement and knot tying,
eliminating challenges of intra-corporeal dexterity. It also
allows the potential avoidance of surgical fixation products and
their associated risks [44]. The learning curve initially has also
been shown to be less steep, with as little as ten cases required
to achieve surgical proficiency and competency [34, 45, 46].
Given the sparsity of research with focussed, concise
and consistent outcome measures reported, the PARSEC
(Prospective Assessment of Robotic Sacrocolpopexy: a
European Multicentric Cohort) study is currently complet-
ing recruitment of women who have undergone RASC in
high-­volume European institutions and is due for completion
in 2022 [47]. Interim results have demonstrated successful
anatomical outcomes at one year, with low intraoperative
complication rates, with console times as low as 53 min [48].
Additional work due to be published from the group demon-
strates the largest prospective cohort study on robot-assisted
surgery having safe and durable results (van Zante et al. on
behalf of PARSEC).
Recommendation for Practice
Surgeons should be familiar with multiple approaches to
surgical procedures to allow intraoperative adaptation as
required
Case Box 57.1. Complex RASC
A 57-year-old woman was referred by her primary
case physician with a 3-year history of vault pro-
lapse. She had three previous vaginal deliveries and
a surgical history comprising of vaginal hysterectomy
performed 10 years previous for prolapse. This proce-
dure was complicated by a pelvic haematoma, requir-
ing ultrasound-guided drainage in the post-operative
period. Owing to a road traffic collision in recent
years, she had limited abduction secondary to lower
limb and pelvic injury.
These factors were considered when making an
operative decision, with her limited mobility com-
promising vaginal access, her wish to maintain sexual
function as well as the potential for further apical pro-
lapse given her young age. Following a full discussion,
this lady was admitted for a robot-assisted sacrocolpo-
pexy. Intraoperatively, it was evident that an excessive
amount of scarring was present between the vagina and
bladder, which impacted considerably on dissection.
The anterior and posterior vaginal walls were mobi-
lized and following this the sacral promontory was
exposed, and a track created to allow the peritoneum
to be closed over the mesh. The Y-shaped mesh was
then attached from the anterior and posterior walls of
the vagina to the anterior longitudinal ligament using
permanent sutures, e.g. GORE-TEX®. Finally, the
peritoneum is then closed over the graft. The patient
was followed up and to date there is no evidence of
recurrence.
57  The Robotic Approach to Urogenital Prolapse
57.3.2 Robot-Assisted Sacrohysteropexy
(RASH)
While hysteropexy dates back to the 1800s, robot-assisted
sacrohysteropexy (RASH) is a much more recent adjunct
to the robot surgeon’s armamentarium. It is a uterine- and
thus fertility-preserving procedure less often performed than
RASC and aims to restore uterine anatomy utilizing a variety
of techniques. Studies have shown similar success rates for
the open, laparoscopic and RASH approaches, varying from
87 to 98% [49–51]. Lee et al. concluded that the surgery was
associated with minimal blood loss and had excellent subjec-
tive and objective success rates making it a safe and feasible
surgical option in the management of pelvic organ prolapse
where uterine preservation is required [52]. A further Dutch
trial demonstrated that once the learning curve was sur-
mounted, there were similar operative times compared to
other approaches, with high rates of patient satisfaction and
improvements in health-related quality of life measures [53].
As RASH offers a uterine-preserving procedure, success-
ful pregnancies have been reported following laparoscopic
hysteropexy; however the long-term effects of pregnancy on
the surgery are not yet fully appreciated [54]; this has yet to
be studied in the case of robot-assisted procedures. Women
and their surgeons may also opt for uterine-preserving sur-
geries for non-reproductive reasons, such as bodily auton-
omy, femininity and sexual function [55].
Fertility-preserving robot-assisted apical surgery con-
sists primarily of uterosacral plication and mesh RASH. The
mesh-free techniques of suture hysteropexy and colpopexy
utilize native tissue to support the uterus to the uterosacral
ligaments, often using suture material. Following the proce-
dure, a surgical vaginal support device is placed in the vagina
for up to 4 weeks following surgery. Yong et al. have described
the use of a U-shaped mesh placed circumferentially around
the cervix and attached to the sacral promontory, with post-
procedure vaginal splinting for 5 weeks in 30 women [56].
However, in their outcome measures, the robotic approach
was not separated from the laparoscopic approach and thus it
is difficult to compare these two modalities.
Case Box 57.2. RASH
A 35-year-old woman was referred by her primary care
physician with symptomatic prolapse to a urogynae-
cology clinic. She was recently married and was plan-
ning to conceive over the coming years. Her body mass
index was elevated at 35 kg/m2, with a previous history
of an open appendicectomy and laparoscopic left ovar-
ian cystectomy. Examination revealed uterine descent
to the level of the genital hiatus. A detailed discus-
sion took place, and in an effort to maintain fertility, a
RASH was chosen as the therapeutic mode of choice.
715
Following positioning in moderate Trendelenburg,
the abdominal cavity was insufflated with CO2 to
20  mmHg of water using a Veress needle and the
supraumbilical port placed. On inserting the camera,
extensive adhesions were delineated on the right side
of the abdominal cavity secondary to her appendicec-
tomy. These limited visibility and required dissection
to allow the procedure to continue; this was per-
formed using laparoscopic instruments following the
placement of the ports (Fig. 57.1). The robot was then
docked and the arms attached. The procedure was
completed using the robot-assisted approach. The
technique comprised of identifying the sacrum and
opening the overlying peritoneum. By maintaining
the intra-abdominal pressure at 20  mmHg of water
the CO2 tracks between the planes facilitating the for-
mation of a peritoneal tunnel and dissection to the
level of the anterior longitudinal ligament (Fig. 57.4).
During the procedure the third robot arm is used
as a bowel retractor. Manipulation of the uterus is
achieved using uterine manipulators which aid with
the acute anteversion required for suture placement or
alternatively by placing a suture to secure the uterus
to the anterior abdominal wall. Two windows are
made through the avascular area of the broad liga-
ment through which the arms of the mesh are passed.
They can then be sutured anteriorly and posteriorly
at the uterocervical junction using a GORE-TEX®
suture. The long arm of the mesh is then attached
to the sacrum ensuring it is tension-­free. The mesh
must then be covered totally with peritoneum to avoid
complications such as herniation of small bowel, ero-
sion through the bowel or bladder and the formation
of dense adhesions.
Fig. 57.4 Dissection to expose the anterior longitudinal liga-
ment©2019 Intuitive Surgical, Inc.
716 C. M. McCarthy et al.

57.3.3 Other Procedures Amenable the right patient at the right time by the right surgeon. In
to Urogynaecological Robot-Assisted the case of pelvic surgery, a steep Trendelenburg position
Procedures is often adopted, in combination with CO2 pneumoperi-
toneum. This can increase upper airway resistance, caus-
As has been demonstrated in other chapters, continence uri- ing airway oedema and reduced lung compliance [69].
nary diversion is an appropriate surgical alternative in some Thus, the robot-assisted approach may not be suitable for
patients who are unable to perform clean intermittent self-­ patients with respiratory disease/compromise or morbid
catheterization (CISC). More commonly performed utilizing obesity. Other anaesthetic considerations that need to be
an open approach, there are reported case series which dem- evaluated and managed are reduced access to the patient
onstrate potential in the robot-assisted approach as being a owing to robot placement, which can delay patient man-
safe and feasible alternative that can be considered in appro- agement [70].
priate patients [57].
Similarly, fistula repair is an area that the robot-assisted
approach can offer significant advantages as both a primary 57.4.2 Education and Learning
repair method and a useful adjunct to vaginal surgery [58].
The increased dexterity, precision and control facilitate more As with the adoption of any new technique, there is a period
time-efficient and effective repairs to be achieved. Robot-­ of education and learning to reach satisfactory surgical
assisted procedures have been shown to have reduced blood ability and proficiency. With its exponential increase, there
loss, shorter length of stay and lower recurrence rates [59, have been successful robotic surgery fellowships, educa-
60], as well as facilitating complex dissection and recon- tional courses and curricula established to allow acquisition
struction that may be difficult to achieve utilizing open, lapa- of basic robotic skills, followed by more complex skills.
roscopic or open approaches. Structured curricula can allow the safe and stepwise accu-
In recent years, RASC has been combined with rectopexy mulation of these skills over a relatively short learning curve
to treat multi-compartment pelvic floor prolapse, with this [71]. Training programmes typically consist of patient side
first described by van Iersel et al. in 2016 [61], showing this training and console training and can involve the multidisci-
to be an effective technique with 12-month follow-up data. plinary team. Online modules have been provided by the da
Since their introduction, mid-urethral slings have been Vinci surgery community in basic concepts, and advanced
widely documented to be associated with vaginal extrusion console skills can be pursued in virtual reality simulators
[62] and urethral [63] and intra-vesical exposure [64], despite (which are evaluated for face, content and construct valid-
being curative for a significant number of women who previ- ity), dry labs or wet labs [72, 73].
ously suffered from stress urinary incontinence [65]. Over Education, training and support for all members of the
the past number of years, robot-assisted techniques have multidisciplinary team are essential when introducing new
also been utilized in mesh removal surgery, such as that technology to the operating environment. Teamwork is an
following mid-urethral sling surgery. Given robot-assisted essential component to success in all operative procedures,
systems’ greater dexterity, range of movement and access, it and focus should be placed on the provision of ongoing pro-
can be successfully performed in tandem with other surgical fessional development for all members of the operative team
approaches [66, 67]. These typically have included a vagi- in all phases of the patients’ operative journey (i.e. preopera-
nal approach combined with abdominal approaches [68], but tive assessment, intraoperative and post-operative care).
the use of robot-assisted procedures has reduced the need for Proctorship has also become an essential part of robot-­
an open approach, providing equivocal outcomes in tandem assisted surgery training, providing efficient and rapid pro-
with reducing length of stay. Overall, this has the potential to gression of learning curve amongst surgeons [74].
be more time efficient, reducing patient risk. When we examine the learning curve with respect to api-
cal prolapse surgery, it has shown to be as short as 10–20
procedures [75], but more recently has been shown to be up
57.4 Considerations with Robotic Surgery 60 cases [76]. However, given that there is significant hetero-
geneity in what is reported as the learning curve, and who is
57.4.1 Preoperative Evaluation and Risk considered, it is difficult to secure a definite figure for spe-
Assessment cific procedures at this juncture without bias.
As newer models consist of additional consoles, this
As with other operative procedures, patient selection is allows training to be pursued in a formal clinical setting, an
imperative to ensure that the right procedure is chosen for essential adjunct to the operators.
57  The Robotic Approach to Urogenital Prolapse
Recommendation for Practice
Self-audit including during the learning curve should be per-
formed to examine outcomes.
57.4.3 Cosmesis
Cosmesis is an important consideration for patients, and
undoubtedly, successful robot-assisted surgery has improved
cosmesis versus open surgery. Even when compared with
multi-port laparoscopic surgery, robot-assisted surgery is
associated with improved cosmesis satisfaction and body
image perception [77].
57.4.4 Safety
Patient safety is of paramount importance in all areas of
medicine and particularly comes under scrutiny in the case of
novel advances and changes in management practices. While
there has been worldwide review of the use of vaginally
placed mesh products [78] following FDA reclassification
of surgical meshes to repair pelvic organ prolapse transvagi-
nally from moderate-risk devices to high-risk devices, there
is not the same level of concern with regard to abdominally
placed mesh [79].
Souders et al. evaluated the FDA Manufacturer and User
Facility Device Experience database was evaluated and dem-
onstrated 334 adverse events over a 10-year period, which
have decreased in the latter 4-year period [80]. Malfunctions
comprised the majority (88.62%, n  =  296) of reported
adverse events which infrequently caused serious injury
or had an impact on surgical approach. A non-systematic
review also documented an increase in non-surgical site-
related adverse events with robot-assisted surgery, poten-
tially related to steep Trendelenburg and operating time of
more than 240 min [81]. As both the performance of robotic
surgery increases as well as technological advances, there
will be a natural reduction in adverse events.
While conversion rates are low in robot-assisted proce-
dures, all staff should be aware of emergency undocking
protocols to effectively, efficiently and safely convert the
procedure to an alternative technique if required [82].
Since the introduction of robotic surgery, focus has been
placed on the advantages and disadvantages of robotic sur-
gery with an emphasis on the clinical outcomes, the patient
perspective and a health economics point of view. However,
since these issues have been largely classified, a greater
focus is now being placed on the surgeon and their experi-
ence, both economically and from a healthcare perspective.
717
Both surgeon physical injury and stress have been
reported to be decreased by robotic surgery and have been
shown in both doctors and their non-medical counterparts
[83]. While initial reports of robot-assisted surgeons suffer-
ing from back pain [84], the console is now adjustable to sur-
geon-specific requirements, thus counteracting this potential
issue. An increased robot-assisted surgical workload has
not been demonstrated to increase physical discomfort and
symptoms [85]. This reduction in surgeon injury is signifi-
cant from a surgical point of view but also from an economic
point of view as surgical injury has a significant personal and
institutional cost.
57.4.5 Economical Cost
As with all new technologies, the economic burden needs to
be considered, and this is significant from outset with robot-­
assisted surgery. The initial cost acquisition of the robot sys-
tem is significant and can include outlays in excess of the
equipment, such as surgeon training and the establishment of
proficiency and a consequent decrease in the number of oper-
ating cases owing to increased operating time. In addition,
there are costs with purchase and maintenance as well as the
utilization of non-reusable instruments. Hospitalization costs
are generally reduced compared to other forms of surgery;
however, overall the estimated per-patient costs of robotic
surgery are higher than their comparators [86]. This can be
counteracted by increasing annual caseloads, but more work
needs to be done on reducing the overall economic burden of
robot-assisted surgery.
However, overall this is a complex combination of numer-
ous variables when you combine economical cost with other
variables such as shorter length of stay and surgeon fatigue
and injury [87].
57.5 S
 ummary of Pros and Cons of Robotic
Surgery
When robot-assisted surgery is brought into the mix, it is
seen to provide superior economics, user comfort and per-
formance [88] (Table 57.3).
Table 57.3  Summary of pros and cons of robotic surgery
Pros Cons
Improved ergonomics Economic cost
Improved dexterity Learning curve
Future advances Lack of high-quality randomized evidence
718
57.6 Future Directions
Since the turn of the century, robot-assisted surgery has
climbed barriers that were limiting the expansion of open
and conventional minimal access techniques. With the
­potential introduction of a number of robotic platforms over
the coming years, the scope for expansion is exponential.
This includes the introduction of further integrated energy
instruments and improved tissue interaction concepts. In
addition, image-guided technology, such as fluorescence,
can be adapted and improved and integrated with radio-
logical systems to improve surgical planning and outcomes.
Further advances that are not beyond the spectrum of pos-
sibility include in vivo microscopy allowing real-time func-
tional and molecular imaging and diagnosis to allow prompt
diagnosis and more accurate treatment of medical conditions.
Within the spectrum of urogynaecological conditions and
as our population ages becoming more medically complex,
robotic urogynaecological surgery will expand to treat con-
ditions which up until now are refractory to surgical manage-
ment. This can include procedures such as mesh removal and
retreatment with alternative approaches.
Robotic surgery and its advances are not without draw-
backs, with the Royal College of Surgeons in the United
Kingdom noting that innovative surgical techniques need
guidelines for their introduction and performance into clini-
cal practice. This can only be achieved by the demonstration
of proficiency and safety in the procedural skills for each
operation performed. Ideally, all surgeons would be compe-
tent at the open, laparoscopic and robot-assisted approaches,
in order to manage complications and unforeseen surgical
challenges; this would consist of a single training trajectory
incorporating all approaches.
This merits the introduction of advanced surgical train-
ing or fellowship programmes in accredited centres in sub-­
specialty relevant areas. These have expanded to include
urogynaecological-specific training programmes throughout
internationally renowned centres. In addition, continuous
professional development such as robotic cadaveric courses is
available and supported by national and international societ-
ies in the maintenance, refinement and advancement of skills.
Recommendation for Practice
Membership of a community of robot-assisted surgeons
allows continued learning, skill development and a sharing
of expertise in the advancement of robot-assisted surgery
57.7 Conclusion
Since its introduction into widespread gynaecological surgi-
cal practice, robot-assisted surgery has revolutionized urogy-
naecology and the treatment of urogenital prolapse. With
C. M. McCarthy et al.
options such as robot-assisted sacrocolpopexy becoming a
common approach to treat apical prolapse, and continued
adaptations of uterine-preserving procedures, the future of
robot-assisted procedures in urogynaecology is secure. In
addition, with mesh complications becoming more prevalent
on the back of the aforementioned review, the use of robot-­
assisted surgery will diversify to include mesh removal proce-
dures, as well as the potential to repair vesico-vaginal fistula.
The introduction of portable robot-assisted surgery platforms
can facilitate robot-assisted fistula repair, a condition more
prevalent in low- and middle-income countries meaning that
robot-assisted surgery will be accessible worldwide. While
research remains ongoing in this area, they have been shown
to have equivocal and even superior results to alternative pro-
cedures. As time advances, with the introduction of newer
models, more trained surgeons having completed robot-
assisted surgery training programmes, efficiency and the cost-
benefit ratio will improve, demonstrating that robotic surgery
will supersede alternative forms of surgery and become the
gold standard of care for women with urogenital prolapse.
Take-Home Messages
• Robotic surgery systems first gained FDA approval
for gynaecological surgery in 2005 and since then
their role in gynaecology has expanded greatly,
encompassing benign, oncological and urogynae-
cological. Additional robot-assisted surgical pro-
viders will increase the availability of this
technology, making it more ubiquitous and thus
easier to adopt into widespread clinical practice.
• Advantages for the surgeon of robot-assisted surgery
include improved ergonomics, improved dexterity
and access/visualization of confined spaces such as
the space of Retzius. For the patient, advantages can
include shorter length of stay, reduced blood loss and
subsequent transfusion and excellent anatomical
cure rates with high levels of patient satisfaction.
• Disadvantages of robot-assisted surgery include an
increased cost outlay initially, along with introduc-
ing a learning curve and thus potential confounder
in initial surgeries. There is a potential longer initial
operating time, partly due to docking the device and
surmounting the robot-assisted learning curve.
• Robot-assisted surgery can be easily utilized to
manage apical prolapse in urogynaecology, includ-
ing robot-assisted sacrocolpopexy and robot-
assisted sacrohysteropexy. Both approaches have
been introduced in the twenty-first century, and thus
further research will further enhance and encourage
its use, with the potential of superseding more tradi-
tional approaches to apical prolapse surgery.
57  The Robotic Approach to Urogenital Prolapse 719

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Further Reading
h t t p s : / / w w w. m d e d g e . c o m / o b g y n / a r t i c l e / 6 4 4 6 8 / s u r g e r y /
correcting-pelvic-organ-prolapse-robotic-sacrocolpopexy/page/0/1.
Brien JC, Fabrizio MD, Lukban JC. Robotic sacrocolpopexy and sacro-
cervicopexy for the correction of pelvic organ prolapse. In: Baik
SH, editor. Robot surgery. London: Intech Open; 2010. ISBN:
978-953-7619-77-0.
Coomarasamy A, Shafi M, Davila GW, Chan KK, editors. Gynecologic
and obstetric surgery: challenges and management options.
New York: Wiley; 2016.
Gilleran. Robotic-assisted laparoscopic mesh sacrocolpopexy. Ther
Adv Urol. 2010;2(5–6):195–208.
 Concurrent Prolapse and Incontinence
Surgery 58
Annette Kuhn

Learning Objectives
• Aim of this chapter is to learn about the advantages
and disadvantages of concurrent prolapse and
incontinence surgery, to be able to inform patients
who suffer from prolapse and overt and masked
incontinence about surgical possibilities weighing
benefits and risks of concomitant surgery for pro-
lapse and for incontinence.

58.1 Introduction

Urinary stress incontinence (SUI) may develop after pel-
vic organ prolapse (POP) repair in approximately 25% of
patients (Fig. 58.1).
In women with stage II POP roughly 55% have concurrent
SUI, which decreases with increasing POP stages to 33% in
patients with stage IV POP due to progressive kinking of the
urethra that protects the patient from leakage.
Reducing the prolapse may restore normal voiding func-
tion or not depending on detrusor contractility and nerval
function.
Three groups of potentially incontinent patients may be
distinguished:
1. Patients with concomitant POP and SUI, who suffer from
SUI before their POP is treated; this type is defined as
overt incontinence.
2. If the prolapse is surgically reduced and the vagina is put
into the physiological position, patients who were conti-
nent before may experience de novo incontinence. This
type of SUI is defined as occult, masked or latent SUI.
A. Kuhn (*)
Department of Urogynaecology, University of Bern, Frauenklinik,
Inselspital, Bern, Switzerland
e-mail: annette.kuhn@insel.ch
Fig. 58.1  Uterine prolapse with cystocele and ulcerations
3. Patients who suffer from POP only without overt or
masked incontinence.
Despite POP surgery leading occasionally to de novo
incontinence, preoperative SUI might be treated by prolapse
repair only without additional continence procedures.
Although the majority of publications concentrate on de
novo SUI after prolapse repair, an analogue situation may
occur after prolapse repair of the posterior compartment
resulting in de novo faecal incontinence. There is a paucity
of data analysing this issue, and general recommendations
cannot be given.
The following chapter will discuss what diagnostic tests
detecting occult urinary incontinence may be of help and
whether women with overt or occult incontinence should
undergo concomitant continence surgery at the time of
prolapse repair and what potential side effects are to
experience.
Additionally, the type of surgery for the treatment of SUI
will be discussed.

© Springer Nature Switzerland AG 2021 723

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_58
724
58.2 Diagnostic Tests to Unmask
Occult SUI
The Cochrane review on surgical interventions of POP
found that new SUI symptoms were described by 187 of
1280 women [1]. Preoperative tests to determine the risk of
postoperative SUI aim to mimic the postoperative anatomi-
cal situation and reducing the prolapse manually, insertion
of speculum, sponge holder or pessary. The importance of
these findings is ambiguous: these tests do not necessarily
predict postoperative incontinence and do not mimic pro-
lapse surgery. The tests themselves may obstruct the urethra
or put undue tension on the urethra, thus preventing urinary
leakage. No gold standard to determine occult SUI has been
developed, and none of these tests has acceptable positive
predictive values to determine who may and who may not
benefit from additional continence surgery.
However, negative predictive values of pessary and spec-
ulum tests were 92.5% and 91.1%, respectively, meaning
that women with negative stress test during the insertion of a
speculum or pessary are at low risk to suffer from SUI post-
operatively [2].
In clinical practice the use of a pessary prior to surgery
is advisable (Fig.  58.2); if the patient reports de novo SUI
during the use of the pessary, the patient should be informed
about the possibility of postoperative SUI.
Frigerio [3] determined a higher preoperative ICIQ-SF
score, a detrusor pressure at maximum flow rate less than
30  cmH2O and urodynamically diagnosed SUI as inde-
pendent risk factor for postoperative SUI.  No additional
urodynamic values as independent risk factors could be
determined.
Fig. 58.2  Arabin pessary reposition test; a cube pessary (Arabin®) is
inserted into the vagina
A. Kuhn
Generally, the validity of urodynamics prior to surgical
prolapse repair remains unclear. An acontractile detrusor
may or may not remain acontractile after prolapse repair;
residual urine may or may not disappear after restoring nor-
mal anatomy.
In summary, no gold standard to examine bladder func-
tion or to unmask occult SUI in patients with POP exists.
Prolapse reduction methods in combination with stress tests
may hint at lower risks for de novo SUI but are not entirely
reliable.
Table 58.1 summarizes the results of prolapse surgery
alone versus combination surgery from a meta-analysis [4].
The majority of study demonstrates benefits from combi-
nation surgery.
58.3 P
 atients with Concomitant POP
and SUI (Overt Incontinence)
Preoperative SUI might be treated by prolapse repair alone
without an additional continence procedure alone [5].
Therefore many clinicians prefer repairing the prolapse as
initial step and later on address SUI in case of necessity.
Some patients find it unacceptable to undergo surgery twice.
Few studies have investigated prolapse surgery in women
with coexisting SUI symptoms prior to surgery. One study
[6] investigated sacrocolpopexy with or without additional
Burch colposuspension in women with overt, masked and
mixed incontinence and found no benefit in the group of
patients with Burch colposuspension; two other studies
investigated vaginal prolapse repair with additional midure-
thral slings in women with coexisting SUI [7, 8] and showed
contradictory results. Pooled data [9] of these studies dem-
onstrated that in women with prolapse and coexisting SUI
one should combine vaginal prolapse repair with MUS in
2.5 women to prevent one woman needing subsequent MUS
after prolapse surgery only (number needed to treat 2.5). Not
surprisingly, the latter studies showed that concurrent con-
tinence procedures significantly increased the success rates
for SUI (RR 2.73 95% CI 1.66, 4.49; 9).
One third of patients with POP and overt SUI will be cured
of their SUI after prolapse repair only [8]. Unfortunately, we
have no tool to distinguish between the patients who will
benefit from an additional continence procedure and those
who will not.
A feasible strategy is to discuss the possibilities with the
patient during the preoperative visit and to let her choose.
Individual risk factors, ideas and personal timetables and
expectations may influence the patient’s choice of having
a prolapse repair with or without concomitant incontinence
surgery.
58  Concurrent Prolapse and Incontinence Surgery 725

Table 58.1  Box plot analyses of prolapse surgery alone vs. prolapse surgery and incontinence surgery [4] SUI stress urinary incontinence

Combination surgery Prolapse surgery Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
2.1 objective SUI in women with co-existing SUI preoperatively
Borstad (1y) 4 87 67 94 49.9% 0.06 [0.02, 0.17]
Costantini (with UI 5y) 7 23 6 22 50.1% 1.12 [0.44, 2.80]
Subtotal (95% CI) 110 116 100.0% 0.27 [0.01, 5.63]
Total events 11 73
Heterogeneity: Tau2 = 4.58; Chi2 = 20.77, df = 1 (P < 0.00001); I2 = 95%
Test for overall effect: Z = 0.85 (P = 0.40)

2.2 objective SUI in women asymptomatic for SUI preoperatively

Costantini (continent 8y) 7 34 2 32 16.6% 3.29 [0.74, 14.70]
Schierlitz (6m) 3 37 21 43 19.4% 0.17 [0.05, 0.51]
Wei (OPUS trial 1y) 5 143 31 151 21.0% 0.17 [0.07, 0.43]
Brubaker (CARE trial 2y) 11 116 9 134 21.5% 1.41 [0.61, 3.29]
Liapis (2y) 6 43 18 39 21.7% 0.30 [0.13, 0.68]
Subtotal (95% CI) 373 399 100.0% 0.49 [0.17, 1.41]
Total events 32 81
Heterogeneity: Tau2 = 1.15; Chi2 = 22.19, df = 4 (p = 0.0002); I2 = 82%
Test for overall effect: Z = 1.32 (P = 0.19)

2.3 subjective SUI in women asymptomatic for SUI preoperatively

Liapis (2y) 7 43 17 39 28.2% 0.37 [0.17, 0.80]
Brubaker (CARE trial 2y) 38 147 63 155 71.8% 0.64 [0.46, 0.89]
Subtotal (95% CI) 190 194 100.0% 0.55 [0.34, 0.88]
Total events 45 80
Heterogeneity: Tau2 = 0.05; Chi2 = 1.57, df = 1 (p = 0.21); I2 = 36%
Test for overall effect: Z = 2.51 (P = 0.01)

2.4 objective SUI in women with occult SUI preoperatively

Liapis (2y) 6 43 18 39 36.7% 0.30 [0.13, 0.68]
Brubaker (CARE trial 2y) 12 38 23 40 63.3% 0.55 [0.32, 0.94]
Subtotal (95% CI) 81 79 100.0% 0.44 [0.25, 0.78]
Total events 18 41
Heterogeneity: Tau2 = 0.06; Chi2 = 1.48, df = 1 (p = 0.22); I2 = 32%
Test for overall effect: Z = 2.80 (P = 0.05)

0.01 0.1 1 10 100

Favours combination Favours prolapse only

58.4 P
 atients with POP and Masked 58.5 P
 atients Who Suffer from POP Only
(Occult) Incontinence Without Overt or Masked Incontinence

Patients with prolapse and with the absence of SUI com-
plaints may be tested for occult SUI.
Several randomized trials examined postoperative SUI in
women who were clinically continent prior to prolapse sur-
gery [9–13].
The meta-analysis of these trials found that a concomitant
suburethral sling significantly improved postoperative SUI
success rates (RR 3.04, 95% CI 2.12–4.37; 14).
Therefore, a simultaneous sling insertion should be dis-
cussed in patients with clinical hints of occult SUI.
Women with POP only without symptoms of overt or masked
incontinence will be discussed in this paragraph; will they
benefit from additional continence procedures?
The overall cumulative risk for de novo SUI after native
tissue anterior repair is 8% (44/559; 14). After anterior
armed mesh repair the overall cumulative de novo SUI rate
is significantly higher at 14% [14].
The CARE trial randomly allocated preoperatively
continent women to undergo sacrocolpopexy either with
or without colposuspension (157 vs. 165, respectively).
726 A. Kuhn

Colposuspension significantly reduced the risk of de novo
SUI (26% vs. 41%, respectively; [15]). However, objec-
tive testing demonstrated rather similar results (9% vs. 7%,
respectively). This study was terminated prematurely due to
the high rate of postoperative SUI in the non-Burch group.
In another study, in which patients were included with
preoperatively negative stress test with the prolapse reduced,
44% developed de novo SUI [16].
The essential issue is that we do not have an excellent
preoperative clinical test to predict who exactly is at risk
for the development of postoperative SUI; therefore every
woman who undergoes an operation for vaginal prolapse
is at risk for the development of de novo stress urinary
incontinence.
The International Consultation on Incontinence [14]
(Page 1929) recommends the following flow chart:

Women with POP and SUI

Assessment:

Validated questionnaire

POP-Q

No SUI Symptomatic SUI

Stress test with POP reduced Recommend / offer

continence procedure

Negative occult SUI test Positive occult SUI test

Abdominal surgery Vaginal surgery Recommend / offer Consider staged procedure

continence procedure consider MUS at abdominal surgery

Counsel regarding Burch if Counsel regarding low risk

patient sets priority on of de novo SUI
postoperative continence

MUS midurethral sling, POP pelvic organ prolapse, POP-Q Pelvic Organ Prolapse Quantification, SUI stress urinary incontinence

58.6 S
 ide Effects of Additional
Incontinence Surgery in Patients Who
Undergo Prolapse Operations
Table 58.2 summarizes side effects of additional continence
procedures; data are obtained from a meta-analysis [4].
Overall, side effects compromising prolonged catheter-
ization, longer operating time and urinary tract infections
(UTI) occurred more frequent in patients who underwent
simultaneous continence procedures.
approach versus a single operation including prolapse repair
and a simultaneous incontinence procedure. The latter
approach may result in more adverse events that may include
prolonged catheterization, increased operating time and uri-
nary tract infections. The two-step approach may possibly be
more difficult for patients who have comorbidities and who,
e.g., require bridging of anticoagulation, have an increased
anaesthetic risk or are under immunosuppressants.
58.8 Future Directions

58.7 Recommendations for Practice
In order to get best informed consent from the patient before
surgery, we need to inform patients who suffer from pro-
lapse and incontinence about the possibility of a two-step
Future research should aim at diagnostic tests to identify the
women who are at risk for the development of postopera-
tive incontinence. A reliable test would help to predict who
requires an additional incontinence procedure so that unnec-
essary additional operations could be avoided.
58  Concurrent Prolapse and Incontinence Surgery 727

Table 58.2  Side effects of additional continence surgery (SAE) in comparison to prolapse only procedures [4] SUI Stress urinary incontinence

Combination surgery Prolapse surgery Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
4.1 Urgency incontinence in women asymptomatic for SUI preperatively
Brubaker (CARE trial 2y) 10 147 19 155 83.5% 0.55 [0.27, 1.15]
Liapis (2y) 3 43 3 39 14.2% 0.91 [0.19, 4.23]
Costantini (continent 8y) 1 34 0 32 2.3% 2.83 [0.12, 67.01]
Subtotal (95% CI) 224 226 100.0% 0.66 [0.35, 1.24]
Total events 14 22
Heterogeneity: Chi2 = 1.19, df = 2 (P = 0.55); I2 = 0%
Test for overall effect: Z = 1.29 (P = 0.20)

4.2 Prolonged catherization (1 week or longer) after vaginal prolapse repair with or without midurethral sling
Borstad (1y) 5 87 2 94 49.7% 2.70 [0.54, 13.56]
Wei (OPUS trial 1y) 9 163 1 169 25.4% 9.33 [1.20, 72.83]
Schierlitz (6m) 3 25 1 27 24.9% 3.24 [0.36, 29.15]
Subtotal (95% CI) 275 290 100.0% 4.52 [1.54, 13.28]
Total events 17 4
Heterogeneity: Chi2 = 0.96; df = 2 (P = 0.62); I2 = 0%
Test for overall effect: Z = 2.74 (P = 0.006)

4.3 SAE after vaginal prolapse repair with or without midurethral sling
Wei (OPUS trial 1y) 28 165 20 172 77.2% 1.46 [0.86, 2.49]
Borstad (1y) 11 87 6 94 22.8% 1.98 [0.77, 5.13]
Subtotal (95% CI) 252 266 100.0% 1.58 [0.99, 2.51]
Total events 39 26
Heterogeneity: Chi2 = 0.30, df = 1 (P = 0.58); I2 = 0%
Test for overall effect: Z = 1.93 (P = 0.05)

4.4 SAE after sacrocolpopexy with ot without Burch colposuspension

Brubaker (CARE trial 2y) 56 153 64 158 91.1% 0.90 [0.68, 1.20]
Costantini (continent 8y) 7 34 6 32 8.9% 1.10 [0.41, 2.92]
Costantini (with UI 5y) 0 24 0 23 Not estimable
Subtotal (95% CI) 211 213 100.0% 0.92 [0.70, 1.21]
Total events 63 70
Heterogeneity: Chi2 = 0.14; df = 1 (P = 0.71); I2 = 0%
Test for overall effect: Z = 0.59 (P = 0.55)

0.01 0.1 1 10 100

Favours combination Favours prolapse only

Up to then patients need to be informed about the risk
of de novo postoperative incontinence after vaginal prolapse
surgery and informed choice is advisable to make the choice
for a one-step or a two-step intervention keeping in mind
that an additional incontinence procedure may produce addi-
tional adverse events.
Take-Home Message
If additional continence procedures are performed
during vaginal prolapse surgery, less postoperative
stress urinary incontinence is expected; however, more
adverse events will occur.
7. Van Der Ploeg JM, Oude Rengerink K, Van Der Steen A, Van
References
8. Borstad E, Abdelnoor M, Staff AC, Kulseng-Hansen S.  Surgical
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L, Tobiasson G.  Can de novo stress incontinence after ante-
rior wall repair be predicted? Acta Obstet Gynecol Scand.
2011;90(5):488–93.
3. Frigerio M, Manodoro S, Palmieri S, Spelzini F, Milani R. Risk fac-
tors for stress urinary incontinence after native-tissue vaginal repair
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4. Van der Ploeg JM, Van der Steen A, Oude Rengerink K, Van der
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5. Colombo M, Vitobello D, Proietti F, Milani R. Randomized com-
parison of Burch colposuspension vs anterior colporrhaphy in
women with stress urinary incontinence and anterior vaginal wall
prolapse. BJOG. 2000;107(4):544–51.
6. Constatinini E, Lazzeri M, Bini V, Del Zingaro M, Zucchi A, Porena
M. Burch colposuspension does not provide any additional benefit
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Leeuwen JH, Stekelenburg J, Bongers MY. Transvaginal prolapse
repair with or without the addition of a midurethral sling in women
with genital prolapse and stress urinary incontinence a randomized
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10. Meschia M, Pifarotti P, Buonaguidi A, Gattei U, Somigliana A. A
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X.  Outcome following vaginal prolapse repair and midure-
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AW. A prospective randomized controlled study comparing vaginal
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prolapse repair with and without tension free vaginal tape (TVT) in
women with severe pelvic organ prolapse and occult stress inconti-
nence. Neurourol Urodyn. 2007;26(5):743–4.
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 Management of Pelvic Organ Prolapse:
A Unitary or Multidisciplinary 59
Approach?

David Ossin and G. Willy Davila

59.2 E
 pidemiological Basis for Coexistence
Learning Objectives of Pelvic Floor Disorders
• What are the coexisting elements of the female pel-
vic disorders? Similar contributing risk factors, particularly injury to
• How were pelvic floor disorders managed in the pudendal nerve and levator ani muscles, likely influence
past and how has management evolved? developing coexisting pelvic floor conditions [3]. In
• What are the different multidisciplinary approaches Gonzalez-Argente et al., patients surgically treated for fecal
currently practiced? incontinence had a high prevalence of coexisting pelvic floor
conditions: 53% with urinary incontinence and 18% with
pelvic organ prolapse. In patients surgically treated for rectal
prolapse, the prevalence of coexisting urinary incontinence
59.1 Introduction was 18% and 34% for pelvic organ prolapse [4]. In the same
study, only 45% of subjects reported their coexisting symp-
The traditional view has been that of a vertical organization toms to their colorectal surgeons.
of organ systems (e.g., kidneys-ureters-bladder, colon-­ In a retrospective review of 55 women diagnosed with
rectum-­anus) within the pelvis. Under this premise, pelvic rectal prolapse, 52 were found to have defects in pelvic floor
floor dysfunction symptoms such as bladder dysfunction, support and/or stress urinary incontinence [5]. This review
pelvic organ prolapse, and colorectal dysfunction are each also reported that surgical treatment for pelvic organ pro-
managed by a separate specialty: urology, gynecology, and lapse occurred at a median age of 16 years younger than first
colorectal surgery. Figure 59.1 shows the distribution of care surgical treatment for rectal prolapse with the mean number
for pelvic floor disorders. of 1.5 procedures for genital prolapse before the diagnosis
The notion of the pelvic floor as a single functional entity and treatment of rectal prolapse.
with horizontal rather than vertical organization is becom- Among women with symptoms of urinary incontinence
ing a more recognized valid concept [1]. Evaluation of dys- and pelvic organ prolapse (beyond the hymenal ring), the
function of the pelvic floor in one compartment frequently prevalence of coexisting fecal incontinence was 24% and
leads to discovering to some degree dysfunction of neigh- 21% [6]. Between 31% and 41% of patients presenting with
boring compartments of the pelvic floor. This is likely due to pelvic organ prolapse or urinary incontinence report coexist-
a commonality of risk factors for condition such as pelvic ing constipation based on Rome II criteria [7]. Anorectal pain
organ prolapse including vaginal birth and associated neuro- disorders coexist in 16–25% of patients with pelvic organ
muscular damage also linked to other disorders of the pelvic prolapse or urinary incontinence. In addition, the presentation
floor [1, 2]. of proctalgia fugax (functional recurrent anorectal pain) is
elevated in patients with pelvic organ prolapse compared to
urinary incontinence [7]. Various observations can be made
D. Ossin · G. W. Davila (*) based on the above literature. Due to direct pelvic floor trauma
Department of Gynecology, Section in Female Pelvic Medicine being the most frequent etiology of fecal incontinence and
Reconstructive Surgery, Cleveland Clinic Florida,
urogynecologic conditions, simultaneous coexistence of
Weston, FL, USA
symptoms is not surprising. However, rectal prolapse tends to
Dorothy Mangurian Comprehensive Women’s Center, Holy Cross
present at an older age, suggesting a requirement for a greater
Medical Group, Fort Lauderdale, FL, USA
e-mail: OSSIND@ccf.org; GWILLY.DAVILA@holy-cross.com degree or more longstanding, pelvic floor trauma.

© Springer Nature Switzerland AG 2021 729

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_59
730 D. Ossin and G. W. Davila

Fig. 59.1  Distribution of

Distribution of Care for
care for pelvic floor disorders
Pelvic Floor Disorders

Medical Condition Urogynecology/Urology Colorectal Surgery

Urinary Incontinence ++++ O

Fecal Incontinence +++ ++++

Rectal Prolapse + ++++

Pelvic Pain +++ +++

Vaginal prolapse

Cystocele/Vaginal Vault ++++ O

Rectocele ++++ +

Fistula
Vesicovaginal ++++ O

Rectovaginal ++++ +++

Colo -vaginal O ++++

Legend: Likelihood to manage O to ++++

59.3 Why the Multidisciplinary Approach
A survey of International Urogynecological Association
(IUGA) members found overall agreement in management
of dysfunction in the anterior and middle compartments
between urologists and urogynecologists, but colorectal sur-
geons seem to differ in the proposed management of the pos-
terior compartment. For example, colorectal surgeons
regularly conduct functional/dynamic analysis of posterior
compartment dysfunction prior to initiating therapy [8].
Urogynecologists tend to look at the posterior compartment
with a primarily anatomic focus.
To comprehensively treat pelvic floor dysfunction, clini-
cians must be specialized not only in the management of pel-
vic organ prolapse but also disorders effecting the urinary
system, the colorectal system, the pelvic neuromuscular sys-
tem, and the patient’s sexual function. Since no one clinician
is an expert in all these areas, a team approach is required to
achieve optimal outcomes.
Many organizations, such as the National Institute for
Health and Care Excellence (NICE) in the UK, suggest
patients may benefit from the expertise of a team approach in
the treatment of pelvic floor prolapse and associated pelvic
floor dysfunction [9]. NICE recommends a multidisciplinary
team which would include a urogynecologist, a urologist
specializing in female urology, a specialist nurse, a pelvic
floor therapist, a colorectal surgeon, a specialist in elderly
care, and an occupational therapist [9]. This concept is not
new and has been successfully utilized at tertiary referral
centers such as Cleveland Clinic Florida for many years [1].
59.4 T
 he Use of Quality of Life
Questionnaires
There are several validated quality of life (QoL) question-
naires which assess a broad range of pelvic floor disorders.
They can be particularly useful to help identify and assess
severity of various pelvic floor symptoms. We only mention
a few in this chapter.
The Pelvic Floor Distress Inventory short form 20
(PFDI-­20) and Pelvic Floor Impact Questionnaire (PFIQ-7)
are composed of three scales which evaluate urinary dys-
function, pelvic organ prolapse, and colorectal dysfunction
[10]. The Pelvic Organ Prolapse/Urinary Incontinence
Sexual Questionnaire (PISQ-12) is a validated self-admin-
istered questionnaire to assess sexual function in the setting
of pelvic organ prolapse and/or urinary incontinence [11].
The Pelvic Floor Bother Questionnaire (BPFQ) goes on to
assess the degree of bother of different conditions in a
patient [12].
Other useful questionnaires include e-PAQ, a computer-
ized clinical tool based on the paper-based Birmingham
Bowel and Urinary Symptoms Questionnaire (BBUS-Q), the
Sheffield Prolapse Symptoms Questionnaire (SPS-Q), and
Female Sexual Function Index (FSFI), which have been
59  Management of Pelvic Organ Prolapse: A Unitary or Multidisciplinary Approach? 731

found in preliminary studies to be superior in efficiency and floor dysfunction and should be included in a multidisci-
acceptability [13]. plinary center.
These questionnaires can help link associated conditions
and in turn help direct consultation with multiple specialties.
Severity of symptoms and efficacy of surgical and medical 59.6 Models for Multidisciplinary
treatment of pelvic floor conditions can be evaluated with Approach
quality of life questionnaires before and after interventions.
One approach to multidisciplinary care of patients is a sched-
uled multidisciplinary conference where patient cases with a
59.5 Improved Treatment Rates with Pelvic set criteria are reviewed by a group of specialists [20].
Floor Rehabilitative Therapy Multidisciplinary evaluation and care can then be prioritized
and coordinated. Concomitant rather than sequential surger-
Pelvic floor muscle rehabilitative therapy has been shown to ies can be planned and the intraoperative order of procedures
reduce the prevalence of bladder, bowel, and sexual symp- determined. The feasibility of multidisciplinary conferences
toms [14, 15]. This form of therapy is a nonsurgical treat- is challenged by required conference time, cost, and surgical
ment modality for pelvic organ prolapse, urinary, and fecal wait time. One of the disadvantages of multidisciplinary con-
incontinence. Most recently in the POPPY trial, women in ferences includes the lack of personal contact with the patient
the intervention group of one-to-one pelvic floor muscle being discussed. We prefer to hold the conference once a
therapy reported greater improvement in prolapse symptoms selected patient has completed the examinations ordered by
at both 6 months and 12 months compared to the control all treating clinicians.
group [14]. After 12 months, significantly fewer women in Another approach to logistically organize a multidisci-
the intervention group received further treatment for pelvic plinary program includes a pelvic floor specialty clinic for
organ prolapse. But this is based on the trial’s relatively short women with combined urogynecological/colorectal symp-
follow-up period and cannot exclude the possibility of delay- toms [3]. In the specialty clinic, the team is led by a colorec-
ing, rather than avoiding surgical treatment. A randomized tal surgeon and a urogynecologist. After workup, a
controlled trial reported that 19% of pelvic floor muscle ther- management plan is designed for each patient. If conserva-
apy group, versus only 8% of the control group, improved by tive management is desired, a specialized mid-level provider
1 POP stage [15]. such as a colorectal nurse specialist will monitor the patient’s
A meta-analysis by Li et al., assessing pelvic floor muscle care independently. If combined surgery is indicated, the
therapy as an adjunct to surgical management of pelvic organ patient is scheduled on a predetermined session when both
prolapse, showed the analysis to be inconclusive [16]. Four surgeons are available. When patients are found to have iso-
studies were included in the meta-analysis, but validity lim- lated issues, follow-up appointments are scheduled in the
ited due to the varied methods used to measure outcomes. corresponding urogynecologic or colorectal clinic. There is a
Two of the studies showed that women undergoing surgical theoretical benefit in cost reduction with a combined clinic
treatment for pelvic organ prolapse could improve physical and surgical model that results in reduced outpatient visits,
outcomes and quality of life with pelvic floor muscle ther- operative time, and hospital stay. Advantages of the com-
apy, but the other two studies reported no improvement of bined specialty clinic approach reported through patient sat-
prolapse symptoms with pelvic floor muscle therapy in con- isfaction surveys include joint physical examination, the
junction with prolapse surgery. development of a combined management plan, and a reduced
As stated above, pelvic floor muscle therapy has been number of office visits, which are associated with patient
considered as an effective treatment for multiple pelvic floor logistical difficulties such as transportation, childcare, and
disorders. A review by Scott on pelvic floor muscle therapy time off from work. Of all the advantages mentioned, the
for the treatment of fecal incontinence reported that the greatest number of patients, 70%, listed reduced office visits
majority of studies had success rates of 50–80% [17]. A as the most advantageous. Advantages of combined surgery
Cochrane review by Dumoulin et al. found women with any include resolution of multiple problems at the same time,
type of urinary incontinence in the pelvic floor muscle ther- having to undergo anesthesia only once, a single recovery
apy group were more likely to report cure versus the control period, reduced time off from work, and reduced burden on
group and were also more satisfied with treatment [18]. A family members. Patient satisfaction with overall care
review by Bo proposes pelvic floor muscle therapy as a first-­ reported by patients who attend a combined specialty clinic
line treatment for stress urinary incontinence and pelvic was reported as 46% excellent, 27% good, 12% satisfactory,
organ prolapse, but proper training and close follow-up are and 6 % unsatisfactory.
required for effectiveness [19]. Therefore, pelvic floor mus- A limitation of combined specialty clinic is the require-
cle therapy can be an effective addition to treatment of pelvic ment for a screening and triage system to help with patient
732
placement into the clinic when needed. All specialists have
to be engaged in the process and be willing to refer their
patients to the clinic.
A special mention should be made of the roles of neurolo-
gists and physical therapists as part of the multidisciplinary
team. Not all patients benefit from neurologic assessment, so
specific neurology appointments can be scheduled. Since
most patients will require pre- or postoperative physical ther-
apy, access should be planned, and the diagnosed dysfunc-
tions communicated clearly to the physical therapist. It is
usually not valuable for the physical therapist to be present at
a multidisciplinary clinic or conference.
59.7 Combined Surgical Cases
Several studies have shown that combined pelvic organ pro-
lapse and colorectal surgery procedures improve patient sat-
isfaction [3, 21, 22]. Halverson et al. reported on a prospective
study comparing outcomes and cost in patients undergoing
anal sphincteroplasty alone versus combined with proce-
dures for pelvic organ prolapse and/or urinary incontinence.
There was no significant difference in overall subjective
improvement or physical and/or sexual limitations postop-
eratively, but there was a noted cost benefit [21]. Similar
results have been reported from other tertiary referral centers
where a comprehensive multidisciplinary surgical team is
convened.
59.8 Barriers to Multidisciplinary
Management of Pelvic Floor Prolapse
Wall and DeLancey introduced the concept that political
compartmentalization of care by medical specialties repre-
sents a barrier to shifting to a multidisciplinary approach for
pelvic floor disorders [23]. The pelvis has been divided into
sections to fit the scope of the clinician specialization, which
has led to neglect of the critical interrelationships among pel-
vic organ systems. This has also created a financial incentive
to individual care, which specialists may fight to maintain.
59.9 Future of Multidisciplinary Approach
The future of the multidisciplinary approach to pelvic floor
disorders includes an initiative for collaborative research.
The Pelvic Floor Disorder Network (PFDN) was established
by the NICHD (National Institute of Child Health and
Human Development) in 2001 to develop a research collab-
orative to improve patient care. In 2003, at the urging of the
PFDN questions about pelvic floor disorders were added to
the 2005–2006 National Health and Nutrition Examination
D. Ossin and G. W. Davila
Survey (NHANES) [24]. This was the first study to assess
pelvic floor disorders of women in the USA nationwide and
found that 23% of women had one or more pelvic floor dis-
orders based on patient symptoms.
Nonsurgical specialists such as neurologists, physical
therapists, epidemiologists, and geriatricians have been
found to be very valuable in the care of patients with pelvic
floor disorders and are increasingly included in their care.
59.10 Conclusion
Since the organs of the female pelvic floor have common
muscular and soft tissue support, vascularity, and innerva-
tion, dysfunction in one organ system is very frequently
associated with symptomatic problems in adjacent organs.
As such, a multidisciplinary approach is rational and is asso-
ciated with improved outcomes.
Take-Home Messages
• There are several multidisciplinary management
options developed over the years, which can be
adapted to best meet one’s practice.
• Optimal outcome may not be achieved unless all of
a patient’s symptomatic pelvic floor dysfunctions
are addressed at the same time.
References
1. Davila G, Ghoniem G. Pelvic floor dysfunction: the importance of
a multidisciplinary approach. Clin Colon Rectal Surg. 2003;16:3–4.
2. Swash M, Snooks S, Herny M.  Unifying concept of pelvic floor
disorders and incontinence. J R Soc Med. 1985;78:906–11.
3. Kapoor D, Sultan A, Thakar R, Abulafi M, Swift R, Ness
W. Management of complex pelvic floor disorders in a multidisci-
plinary pelvic floor clinic. Colorectal Dis. 2006;10:118–23.
4. Gonzalez-Argente F, Jain A, Nogueras J, Davila G, Weiss E, Wexner
S. Prevalence and severity of urinary incontinece and pelvic genital
prolapse in females with anal incontinence or rectal prolapse. Dis
Colon Rectum. 2001;44:920–6.
5. Peters W, Smith M, Drescher C.  Rectal prolapse in women with
other defects of pelvic floor support. Am J Obstet Gynecol.
2001;184:1488–95.
6. Meschia M, Buonaguidi A, Pifarotti P, Somigliana E, Spennacchio
M, Amicarelli F.  Prevalence of anal incontinence in women with
symptoms of urinary incontinence and genital prolapse. Obstet
Gynecol. 2002;100:719–23.
7. Jelovsek J, Barber M, Paraiso M, Walters M.  Functional bowel
and anorectal disorders in patients with pelvic organ prolapse and
incontinence. Am J Obstet Gynecol. 2005;193:2105–11.
8. Davila G, Ghoniem G, Kapoor D, Contreras-Ortiz O. Pelvic floor
dysfunction management practice patterns: a survey of members of
Teh International Urogynecological Association. Int Urogynecol J.
2002;13:319–25.
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9. National Institute for Health and Care Excellence. Urinary incon-
tinence in women: the management of urinary incontinence in
women. Cg171;2013.
10. Barber M, Chen Z, Lukacz E, Markland A, Wai C, Brubaker L,
Nygaard I, Weidner A, Janz N, Spino C. Further validation of the
short form versions of the pelvic floor distress inventory (PFDI)
and pelvic floor impact questionnaire (PFIQ). Neurourol Urodyn.
2011;30:541–6.
11. Rogers R, Coates K, Kammerer-Doak D, Khalsa S, Qualls C.  A
short form of the pelvic prolapse/urinary incontinence sexual ques-
tionnaire. Int Urogynecol J. 2002;14:164–8.
12. Peterson T, Karp D, Aquilar V, Davila G.  Validation of a global
pelvic floor symptom bother questionnaire. Int Urogynecol J.
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13. Radley S, Jones G, Tanquy E, Stevens V, Nelson C, Mathers
N.  Computer interviewing in urogynaecology: concept, devel-
opment and psychometric testing of an electronic pelvic floor
assessment questionnaire in primary and secondary care. BJOG.
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floor muscle tranining in women with pelvic organ prolapse
(POPPY): a multicentre randomised controlled trial. Lancet.
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Obstet Gynecol. 2010;203:170.e1–7.
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 Part VII
Constipation and Obstructed Defecation
 Epidemiology and Etiology
of Constipation and Obstructed
Defecation: An Overview
Mahmoud Abu Gazala and Steven D. Wexner
Learning Objectives
• Definition of constipation
• Epidemiology of constipation
• Etiology of constipation
60.1 Introduction
Constipation is the most common digestive complaint, with
approximately 63 million people suffering from constipation
in the United States alone, resulting in significant healthcare,
social, and economic implications [1]. Constipation signifi-
cantly impairs quality of life and is associated with the mul-
tiple colorectal conditions, such as development of diverticular
disease, hemorrhoids, anal fissure, pelvic floor dysfunction,
and others. It has been estimated that more than 1$ billion is
annually spent on laxatives and that the aggregate national
cost of constipation-related emergency department visits has
increased to more than 1.5$ billion in 2011 [2].
60.2 Definition
Constipation definition can vary drastically when subjec-
tively addressed, as peoples’ conception of the term varies
and may address disturbances in the stool consistency or
caliber, difficult defecation, or infrequent defecation. In
addition, there is significant variation based on ethnicity and
geography. In a survey of healthy young adults, 60% of those
who reported themselves to be constipated had daily bowel
movements [3]. Historically, a frequency of less than three
bowel movements weekly was considered by healthcare pro-
M. Abu Gazala · S. D. Wexner (*)
Department of Colorectal Surgery, Digestive Disease Center,
Cleveland Clinic Florida, Weston, FL, USA
e-mail: wexners@ccf.org
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_60
60
Table 60.1  Diagnostic criteria for functional constipation (Rome IV)a
1. Must include two or more of the following:
 – Straining during more than one fourth (25%) of defecations.
 – Lumpy or hard stools (Bristol stool form scale (BSFS) 1–2)
more than one fourth (25%) of defecations.
 – Sensation of incomplete evacuation more than one fourth (25%)
of defecations.
 – Sensation of anorectal obstruction/blockage more than one
fourth (25%) of defecations.
 – Manual maneuvers to facilitate more than one fourth (25%) of
defecations (e.g., digital evacuation, support of pelvic floor)
 – Fewer than three spontaneous bowel movements per week.
2. Loose stools are rarely present without the use of laxatives.
3. Insufficient criteria for irritable bowel syndrome.
Criteria fulfilled for the last 3 months with symptom onset at least 6
a
months before diagnosis
fessionals to determine constipation. However, a more robust
definition of constipation was introduced in 1988 as the
Rome criteria, which has been modified three times to yield
the newly updated Rome IV criteria (Table 60.1). Functional
constipation is defined as the presence of two or more of the
following during the previous 3 months: (a) defecatory
straining (≥25% bowel movements); (b) hard or lumpy
stools (≥25% bowel movements); (c) a feeling of incomplete
evacuation (≥25% bowel movements); (d) defecatory
obstruction (≥25% bowel movements); (e) manual maneu-
vers to facilitate defecation (≥25% bowel movements); and
(f) fewer than three spontaneous complete bowel movements
per week. Symptoms must be present for at least 6 months
before the diagnosis, diarrhea must not be present except
after using a laxative, and irritable bowel syndrome (IBS)
criteria must not be met. Other useful scoring systems to bet-
ter evaluate constipation include the Cleveland Clinic Florida
Constipation Score [4] (Table  60.2). This score assesses
eight variables which consist of the frequency of bowel
movements, difficulty (painful evacuation effort), complete-
ness (feeling incomplete evacuation), pain (abdominal pain),
time (minutes in lavatory per attempt), assistance, number of
unsuccessful attempts for evacuation (per 24  h), and the
737
738 M. Abu Gazala and S. D. Wexner

Table 60.2  Cleveland Clinic Florida Constipation Score

Points
Questions 0 1 2 3 4 Total
Frequency of bowel movements 1–2 times per 2 times per Once per Less than Less than
1–2 days week week once per week once per
month
Difficulty: painful evacuation effort Never Rarely Sometimes Usually Always
Completeness: feeling incomplete evacuation Never Rarely Sometimes Usually Always
Pain: abdominal pain Never Rarely Sometimes Usually Always
Time: minutes in lavatory per attempt Less than 5 5–10 10–20 20–30 More than 30
Assistance: type of assistance Without Stimulative Digital
assistance laxatives assistance or
enema
Failure: unsuccessful attempts for evacuation Never 1–3 3–6 6–9 More than 9
per 24 h
History: duration of constipation (yr) 0 1–5 5–10 10–20 More than 20
Total score: _____________ (Max = 30, constipation >15)

duration of constipation (years). A total score of 15 or more 60.4.1 Secondary Constipation

is suggestive of constipation, while a score of 30 indicates
severe constipation.
60.3 Epidemiology
Various studies have stated a vastly different prevalence of
constipation, ranging from 2% to 30% depending on the
diagnostic criteria used and the population studied. In 2004,
Higgins et al estimated that approximately 63 million people
in North America met the Rome II criteria for constipation
[1]. A more recent meta-analysis of more than 40 publica-
tions corresponding to a study population of more than a
quarter million subjects reported a pooled prevalence of con-
stipation to be 14% [5]. In general, prevalence rates are
higher in studies based on self-reporting of constipation,
compared to studies using the more stringent Rome criteria.
Females are more at risk for constipation. A Spanish study
that evaluated 600 healthy young women found that almost
29% met the Rome II criteria for constipation [6]. Other risk
factors for constipation include race (nonwhites), age over
60 years, and lower socioeconomic status [5, 7].
Extraintestinal causes of constipation are numerous. The
most common causes are probably lifestyle related, such
as inadequate intake of fluids and fiber and reduced phys-
ical activity. The western diet is characterized by pro-
cessed grains, which is low in fiber content. Dietary fiber
has a plethora of beneficial effects including risk reduc-
tion for heart disease, better glycemic control, and appe-
tite control and is of great importance to normal bowel
function and health. Dietary fiber fights constipation in
several mechanisms of action, which include the
following:
1. Increased stool bulk, allowing adequate colonic disten-
sion and more effective peristalsis and propulsion of
stool.
2. Short-chain fatty acids, which are products of fiber fer-
mentation, increase the intraluminal osmotic pressure and
aid stool propulsion.
3. Fiber absorbs water which improves stool consistency.
4. Affect the bowel microbiome, which by itself promotes
bowel function.

Recommended dietary fiber intake is 30–40 g/day, with a

60.4 Etiology and Pathophysiology
Normal bowel function and the defecatory process are very
complex and include fecal dehydration and absorption of elec-
trolytes, fecal propagation and storage, and eventually coordi-
nated evacuation. This involves complex sensory and motor
functions of the colon, rectum, and the pelvic floor muscula-
ture. Any disturbance in this process might cause constipation.
Constipation is often multifactorial; however, etiologies
can be categorized into primary or secondary in nature.
hydration goal of >2 L of liquids daily.
Other causes of secondary constipation include endo-
crine and metabolic disorders (diabetes mellitus, hypothy-
roidism, hypercalcemia, and other electrolyte imbalances),
neurologic disorders (spinal cord injury, Parkinson’s dis-
ease, multiple sclerosis), psychological issues (depression,
anxiety, anorexia nervosa), connective-tissue disease
(scleroderma, amyloidosis), and pharmacological (opiates,
anticholinergics, antidepressants, iron supplementation,
and many others).
60  Epidemiology and Etiology of Constipation and Obstructed Defecation: An Overview
60.4.2 Primary Constipation
Primary or intestinal causes of constipation can be broadly
divided into three large groups, of either primary or coexis-
tent pathology:
60.4.2.1 Normal Transit Constipation
and Irritable Bowel Syndrome (IBS)
This condition represents up to 70% of cases, and these
patients demonstrate normal bowel transit time and lack of
pelvic floor dysfunction. Patients have difficulty in evacuating
their bowels and frequently demonstrate significant accompa-
nied distress. Patients with c­onstipation-­ predominant IBS
have accompanied abdominal pain and discomfort, while typi-
cally the physical examination is normal. This diagnosis is
typically made by exclusion.
60.4.2.2 Slow Transit Constipation
Slow transit constipation (STC), sometimes referred to as
“colonic inertia,” is a dysfunction in the colonic motility in
which there is a severe functional delay in bowel motility,
infrequent bowel movements (<1/week), laxative depen-
dence, and radiologic evidence of increased colonic transit
time (typically the markers are scattered throughout the
colon). Patients typically complain of nausea and bloating
that does not necessarily improve with defecation. There is a
reduced urge to defecate and, typically, patients do not com-
plain of rectal fullness. STC is more common in women and
accounts for 15–30% of patients with constipation [8]. In
STC, the pelvic floor function is typically normal, and there is
evidence of neurodegeneration of myenteric plexus ganglia
and reduced number of the intestinal pacemaker cells of
Cajal, as well as abnormal levels of enteric neurotransmitters
such as pancreatic polypeptide, peptide YY, neuropeptide Y,
serotonin, vasoactive intestinal peptide, substance P, and cho-
lecystokinin. These patients demonstrate reduced cholinergic
response and accelerated adrenergic response, with abnormal
gastrocolic reflex and blunted response to administered cho-
linergic agents and stimulants such as bisacodyl [9, 10].
60.4.2.3 Outlet Obstruction
Outlet obstruction is characterized by persistent sensation of
rectal fullness and painful prolonged or excessive straining,
accompanied by a sensation of incomplete evacuation and
clustering, often, digital manipulation. Typically, symptoms
are refractory to laxative use. Colonic transit studies typi-
cally show normal transit through most of the colon with
markers retained in the rectosigmoid.
Constipation due to outlet obstruction represents approxi-
mately 7–15% of all causes of constipation [11]. The etiol-
ogy for constipation due to outlet obstruction can be broadly
divided into mechanical and functional causes (Table 60.3).
Mechanical causes physically interfere with and prevent
739
Table 60.3  Constipation due to pelvic outlet obstruction
Mechanical causes Functional causes
Rectal prolapse Anismus (dyssynergic defecation)
Rectocele Megarectum
Enterocele Hirschsprung’s disease
Anal stenosis Descending perineum syndrome
Anal/rectal strictures or Neuropathy (spinal cord injury, multiple
masses sclerosis)
stool passage. The normal defecatory process is very com-
plex, and it consists of coordinated movement of the abdomi-
nal and colonic and rectal wall musculature, with reflexory
relaxation of the puborectalis and the anal sphincter muscles,
allowing for straightening of the anorectal angle, as well as
shortening and opening of the anal canal and perineal
descent. Functional causes of outlet obstruction include vari-
ous neurologic or behavioral disorders, leading to pelvic
floor dysfunction, discoordination of the defecatory process,
and impaired rectal sensation. In dyssynergic defecation, for
example, this results in inadequate relaxation or even para-
doxical contraction of the pelvic floor muscles during defe-
cation, which hinders evacuation [11, 12].
Recommendations for Practice
Physicians should use the Rome IV criteria for the diagnosis
of constipation and the Cleveland Clinic Florida Constipation
Score to help differentiate the etiology of the constipation. A
standardized and organized evaluation for the etiology of
constipation should also be implemented.
60.5 Future Directions
More studies should be undertaken to allow a better under-
standing of the different mechanisms of constipation. This
hopefully will allow a better treatment strategy.
Take-Home Messages
• Constipation is the most common GI complaint.
• Constipation has considerable healthcare, social,
and economic implications.
• Diagnosis of constipation should be based on the
Rome IV criteria and the Cleveland Clinic Florida
Constipation Score.
• Constipation has a plethora of primary and second-
ary etiologies.
• Primary constipation can be divided into normal
transit, slow transit, and outlet obstruction.
• A standardized and organized approach is mandatory
for efficient evaluation of patients with constipation.
740 M. Abu Gazala and S. D. Wexner

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America: a systematic review. Am J Gastroenterol. 2004;99(4):
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8. Bassotti G, Roberto GD, Sediari L, Morelli A. Toward a definition
2. Sommers T, Corban C, Sengupta N, Jones M, Cheng V, Bollom
of colonic inertia. World J Gastroenterol. 2004;10(17):2465–7.
A, Nurko S, Kelley J, Lembo A.  Emergency department burden
9. Andromanakos NP, Pinis SI, Kostakis AI.  Chronic severe con-
of constipation in the United States from 2006 to 2011. Am J
stipation: current pathophysiological aspects, new diagnostic
Gastroenterol. 2015;110(4):572–9.
approaches, and therapeutic options. Eur J Gastroenterol Hepatol.
3. Sandler RS, Drossman DA. Bowel habits in young adults not seek-
2015;27(3):204–14.
ing health care. Dig Dis Sci. 1987;32(8):841–5.
10. Frattini JC, Nogueras JJ.  Slow transit constipation: a review
4. Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD. A consti-
of a colonic functional disorder. Clin Colon Rectal Surg.
pation scoring system to simplify evaluation and management of
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11. D’Hoore A, Penninckx F.  Obstructed defecation. Colorectal Dis.
5. Suares NC, Ford AC.  Prevalence of, and risk factors for, chronic
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idiopathic constipation in the community: systematic review and
12. Steele SR, Mellgren A.  Constipation and obstructed defecation.
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6. Ribas Y, Saldaña E, Martí-Ragué J, Clavé P. Prevalence and patho-
 Patient-Reported Outcome Assessment
in Constipation and Obstructed 61
Defecation

Toshiki Mimura

with FC should not meet irritable bowel disorders (IBS) cri-

Learning Objectives teria, although abdominal pain and/or bloating may be pres-
• To know the currently available validated PROMs ent but are not predominant symptoms” [3]. Although this
for constipation and obstructed defecation. definition is often used as that of “constipation,” it is NOT a
• To know how to choose appropriate PROMs for definition of “constipation” but that of “functional constipa-
clinical practice and research in patients with con- tion,” excluding the other type of constipation causing a pre-
stipation or obstructed defecation. dominant symptom of abdominal pain, which is defined as
IBS-constipation type in Rome IV.
Whatever its definition is, constipation certainly causes a
constellation of annoying symptoms and impairs quality of
61.1 Introduction life (QOL). To choose an optimal therapy and evaluate the
efficacy of treatment, individual symptoms and their impact
Constipation is defined as “unsatisfactory defecation, which on QOL must be assessed as accurately and objectively as
is characterized by infrequent stools, difficult stool passage, possible. In order to evaluate the symptoms of constipation
or both” by American College of Gastroenterology Chronic and their impact on QOL, reliable and valid instruments
Constipation Task Force [1]. Difficult stool passage includes must be used, particularly in research settings.
straining, a sense of difficulty passing stool, incomplete A Patient-Reported Outcome Assessment (PRO) is
evacuation, hard/lumpy stools, prolonged time to stool, or defined as “any report of the status of a patient’s health con-
need for manual maneuvers to pass stool. Frequency of dition that comes directly from the patient, without interpre-
bowel movements, however, depends on the oral intake vol- tation of the patient’s response by a clinician or anyone else”
ume, and consequently, the merely infrequent bowel motions [4]. PROs measure different aspects of symptom severity and
do not necessarily mean “constipation.” Similarly, complaint its impact on QOL, such as symptom frequency and degree,
of incomplete evacuation causing straining and a sense of health-related quality of life (HRQoL), and satisfaction for
evacuation difficulty does not necessarily mean “constipa- treatment.
tion” or “obstructed defecation” because some patients with For the evaluation of constipation, many Patient-Reported
obsessive disorders complain of the same symptoms without Outcome Assessment Measures (PROMs) have been devel-
any objective evidence of evacuation disorders. Therefore, oped and validated including Constipation Assessment Scale
“constipation” is defined as “a condition, in which a certain (CAS) [5], Constipation Scoring System (CSS) [6], Patient
amount of stool that ought to be defecated cannot be evacu- Assessment of Constipation-Symptoms (PAC-SYM) ques-
ated sufficiently and comfortably” by the Japanese Evidence-­ tionnaire [7], Knowles–Eccersley–Scott Symptom (KESS)
based Clinical Practice Guideline for Chronic Constipation questionnaire [8], Chinese Constipation Questionnaire
published in 2017 [2]. (CCQ) [9], Constipation Severity Instrument (CSI) [10],
Rome IV also defines “functional constipation” (FC) as Obstructed Defecation Syndrome (ODS) score [11], and
“a functional bowel disorder in which symptoms of difficult, Bowel Function Index (BFI) [12], as well as Patient
infrequent, or incomplete defecation predominate. Patients Assessment of Constipation Quality of Life (PAC-QOL)
questionnaire [13] and Constipation-Related Quality of Life
T. Mimura (*) (CRQOL) questionnaire [14].
Division of Gastroenterological, General and Transplant Surgery, The CSS and PAC-SYM are frequently used at present to
Department of Surgery, Jichi Medical University, Tochigi, Japan
evaluate symptomatic severity of constipation mainly by
e-mail: mimurat@jichi.ac.jp

© Springer Nature Switzerland AG 2021 741

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_61
742 T. Mimura

colorectal surgeons and gastroenterologists, respectively.
The ODS score is specifically used to evaluate the symptom-
atic severity of evacuation disorders. BFI is utilized to evalu-
ate the symptomatic severity of opioid-induced constipation
(OIC). The PAC-QOL and CRQOL are used to assess the
constipation-specific QOL.
In this chapter, the currently available PROMs for consti-
pation are described, and it is proposed how to choose appro-
priate PROMs for constipation in clinical practice and
research. For the information of principal methods regarding
the development and validation of PROMs including their
reliability, validity, and responsiveness, please refer to the
chapter “PROMs in Fecal Incontinence.”
61.1.1 Constipation Symptom Severity Scales
At least 10 scales have been reported for rating the severity
of constipation [15, 16]. Among them, Constipation Scoring
System (CSS) [6] and Patient Assessment of Constipation
Symptom (PAC-SYM) questionnaire [7] are most widely
used in clinical studies at present. Eight scales that have been
validated and are currently available with their characteris-
tics as well as the presence or absence of confirmation
regarding reliability, validity, and responsiveness are sum-
marized in Table 61.1.
Constipation Assessment Scale (CAS) (Table  61.2) is an
eight-item self-report measure that was designed for nurses to
assess the presence and severity of constipation during the past
1 week [5]. Each symptom is rated with a 3-point scale from 0
to 2, and the total CAS score ranges between 0 and 16. A score
of >1 indicates constipation, but no cutoff score was provided.
The eight items were developed through the literature
review. The formal item generation and reduction were not
performed, and the content validity was not examined. The
CAS was validated in 32 cancer patients receiving vinca
alkaloids or morphine and in 32 healthy controls. Although
its reliability of internal consistency (Cronbach’s
alpha = 0.70) and test–retest reliability (Pearson correlation
coefficient = 0.98) as well as the discriminant validity were
confirmed, its convergent validity and responsiveness were
not formally examined.
One of the characteristics unique to CAS is the item of
“oozing liquid stool,” which is not included in any other

Table 61.1  Constipation symptom severity scales

Item
generation
Published No of Score and Internal Test–retest Content Convergent Discriminant
Scale year items range reduction consistency reliability validity validity validity Responsiveness
Constipation 1989 8 0–16 No Yes Yes NR NR Yes NR
Assessment Scale
(CAS) [5]
Constipation 1996 8 0–30 Yes 12 to NR NR NR Yes Yes NR
Scoring System >8 items
(CSS) [6]
Patient Assess- 1999 12 0–48 Yes 44 to Yes Yes Yes Yes Yes Yes
ment of >12 items
Constipation–
Symptom
(PAC-SYM) [7]
Knowles–Eccers- 2000 11 0–39 No NR NR NR Yes Yes NR
ley–Scott
Symptom (KESS)
questionnaire [8]
Chinese 2005 6 NR Yes 30 to Yes Yes Yes Yes Yes Yes
Constipation >6 items
Questionnaire
(CCQ) [9]
Constipation 2007 16 0–73 Yes 80 to Yes Yes Yes Yes Yes NR
Severity >16 items
Instrument (CSI)
[10]
Obstructed 2007 8 0–31 No Yes Yes NR NR Yes NR
Defecation
Syndrome (ODS)
[11]
Bowel Function 2009 3 0–100 No Yes Yes NR Yes Yes Yes
Index (BFI) [12]
NR not reported
61  Patient-Reported Outcome Assessment in Constipation and Obstructed Defecation 743

PROM for constipation. It implies passive overflow fecal Although it is sometimes referred as Cleveland Clinic
incontinence due to rectal fecal impaction. In the original Constipation Score or Wexner Constipation Score, it should
study, this item was separately analyzed and finally kept with be called CSS to avoid the confusion with Cleveland Clinic
the statement of “The item of ‘oozing liquid stool’ was cho- Florida Fecal Incontinence Score (CCFIS) that is also called
sen by only 16% of the sample. Because of this result, the Wexner score [19].
alpha coefficient was recomputed with the item deleted. The The original 12 items were generated through patient
result was a lower alpha (0.67). Further analysis of individ- interview and were reduced to the final eight items based on
ual responses revealed that subjects with the highest scores some statistical analysis although its details were not
were the ones who chose the item. Therefore, it was left in described in the original CSS paper [6]. The CSS was evalu-
the scale” [5]. ated in 68 patients with colonic inertia and 164 patients with
The CAS was subsequently modified and validated for pelvic outlet obstruction as well as in 50 nonconstipated
use in women during pregnancy, being revised to a 5-point patients. Their diagnosis was confirmed with colonic transit
rating scale (score range: 0–32) instead of an original 3-point study, anorectal physiology testing, defecography, and anal
scale [17]. At present, the CAS is rarely used, although its electromyography. Its discriminant validity was confirmed
Italian version was validated in 2012 [18]. by differentiating between constipated and nonconstipated
Constipation Scoring System (CSS) (Table  61.3) is an patients, and the physiological tests were used to establish
eight-item self-report scale designed to diagnose constipa- convergent validity. However, the internal consistency, test–
tion and evaluate its symptomatic severity. Each item is rated retest reliability, and responsiveness were not reported in the
with 5-point Likert scale from 0 to 4 except for the item of CSS paper [6].
“type of assistance,” which is rated with 3-point scale from 0 It is reported that a score of more than 15 is the definition
to 2, and the total CSS score ranges between 0 and 30 [6]. of “constipation” in the CSS study because 97% of the entire
group of constipated patients had a score greater than 15.
However, this must be interpreted with caution. This study
Table 61.2  Constipation Assessment Scale (CAS) [5]
included 68 patients with “colonic inertia,” which was
Item 0 1 2
defined as “the presence of at least 80 percent of transit
Abdominal distention or No Some Severe
bloating problem problem problem
markers scattered diffusely throughout the colon on the fifth
Change in the amount of gas No Some Severe day after ingestion,” citing the study by Hinton et al. [20]. In
passed rectally problem problem problem the study by Hinton et al. [20], however, nonconstipated sub-
Less frequent bowel No Some Severe jects “passed 80% of the markers within five days.” In other
movements problem problem problem words, constipation was defined as “the presence of more
Oozing liquid stool No Some Severe
problem problem problem
than 20 percent of transit markers on the fifth day after inges-
Rectal fullness or pressure No Some Severe tion” according to the Hinton’s study. Therefore, the 68
problem problem problem patients in the CSS study had severe slow transit constipa-
Rectal pain with bowel No Some Severe tion, namely “colonic inertia,” and a CSS score of more than
movement problem problem problem 15 is NOT the definition of “constipation” but could imply
Small volume of stool No Some Severe
“severe constipation.”
problem problem problem
Urge but inability to pass No Some Severe One of the characteristics unique to CSS is the item of
stool problem problem problem “History: duration of constipation,” which is not included in
Score range: 0–16 any other PROM for constipation except for PAC-SYM. Long

Table 61.3  Constipation Scoring System (CSS) [6]

Item 0 1 2 3 4
Frequency of bowel movements 1–2 times per 2 times per Once per week Less than once Less than once
1–2 days week per week per month
Difficulty: painful evacuation effort Never Rarely Sometimes Usually Always
Completeness: feeling incomplete evacuation Never Rarely Sometimes Usually Always
Pain: abdominal pain Never Rarely Sometimes Usually Always
Time: minutes in lavatory per attempt Less than 5 5–10 10–20 20–30 More than 30
Assistance: type of assistance Without Stimulant Digital assistance – –
assistance laxatives or enema
Failure: unsuccessful attempts for evacuation per 24 h Never 1–3 3–6 6–9 More than 9
History: duration of constipation (year) 0 1–5 5–10 10–20 More than 20
Score range: 0–30
The cutoff score for the diagnosis of “severe constipation” is more than 15
744 T. Mimura

history of constipation does not necessarily mean severe con- consisting of 12 items in three domains that include “abdom-
stipation, because some patients with no symptoms of consti- inal symptoms” (four items), “rectal symptoms” (three
pation due to appropriate medical therapy can have a long items), and “stool symptoms” (five items) [7]. Each symp-
history of constipation. Another problem of including “the tom is rated with a 5-point Likert scale from 0 (=absence of
duration of constipation” is that the CSS score does not symptoms) to 4 (=very severe) with each domain and the
become zero even if the constipation is completely cured with total score being calculated as an average score raging
some appropriate therapy. For the assessment of treatment, between 0 and 4. A formal questionnaire table exactly pre-
therefore, modified CSS (mCSS) can be proposed, in which senting the 12 items of PAC-SYM is not available in the
one item of “the duration of constipation” is deleted from the original paper [7], but it can be obtained in another literature
original CSS with the mCSS score ranging between 0 and 26. by Neri et al. [21].
In spite of these problems and insufficient evidence of The original 44 items were generated through literature
reliability and validity, CSS has been popular and is still review and patient interview, and they were reduced to the
widely used at present in clinical studies, particularly among final 12 items based on the evaluation of information redun-
colorectal surgeons, probably because it is easy to adminis- dancy, floor and ceiling effects, and internal consistency.
ter, and its questions seem appropriate to evaluate symptoms Because a high correlation was observed between the fre-
of constipation. quency items and the severity items, and given the clinical
Patient Assessment of Constipation Symptom (PAC-­ meaningfulness of severity ratings for symptoms, the fre-
SYM) questionnaire (Table  61.4) is a self-report measure quency items were deleted. Moreover, the exploratory factor
analysis and multitrait analysis identified original five
Table 61.4 Patient Assessment of Constipation–Symptom (PAC-­ domains, including “abdominal symptoms,” “rectal symp-
SYM) [7] toms,” “stool symptoms,” “systemic symptoms,” and
Item 0 1 2 3 4 “urgency symptoms.” Because the two domains of “systemic
Abdominal symptom symptoms” and “urgency symptoms” were considered clini-
Discomfort in your Absent Mild Moderate Severe Very cally separate from the constipation symptom domain, they
abdomen severe
were deleted, resulting in the final three domains with 12
Pain in your abdomen Absent Mild Moderate Severe Very
severe items.
Bloating in your Absent Mild Moderate Severe Very The PAC-SYM was evaluated in 216 patients with chronic
abdomen severe idiopathic constipation. It is one of the most formally and
Stomach cramps Absent Mild Moderate Severe Very meticulously developed and validated PROMs, in which all
severe of the internal consistency (Cronbach’s alpha = 0.89), test–
Rectal symptoms
retest reliability (intraclass correlation coefficient  =  0.75),
Painful bowel move- Absent Mild Moderate Severe Very
ments severe content validity, convergent validity, discriminant validity,
Rectal burning during or Absent Mild Moderate Severe Very and responsiveness were confirmed. Its convergent validity
after a bowel movement severe was demonstrated with the comparison between PAC-SYM
Rectal bleeding or Absent Mild Moderate Severe Very scores and the investigator and subject global rating of con-
tearing during or after severe
bowel movement
stipation severity on a 7-point scale (absent to very severe).
Stool symptoms Its discriminant validity was confirmed by comparing
Incomplete bowel Absent Mild Moderate Severe Very responders with nonresponders to treatment (mean total
movement like you did severe scores, 0.63 for responders vs. 1.44 for nonresponders,
not finish P = 0.0001).
Bowel movement that Absent Mild Moderate Severe Very
The reliability, validity, and responsiveness of PAC-SYM
were too hard severe
Bowel movement that Absent Mild Moderate Severe Very were also confirmed for opioid-induced constipation in 680
were too small severe patients with chronic lower back pain [22]. Furthermore, the
Straining or squeezing Absent Mild Moderate Severe Very minimal important difference of “−0.6” for clinical practice
to try to pass bowel severe and “−0.75” for clinical trials was proposed for the threshold
movements
of reduction in total PAC-SYM score to be used in defining a
Feeling like you had to Absent Mild Moderate Severe Very
pass a bowel movement, severe meaningful clinical response [23].
but you could not Modified PAC-SYM (M:PAC-SYM) was proposed,
For total score, the scores of nonmissing items were summed and claiming that only a minority of patients reported any rectal
divided by the total number of nonmissing items (total score range: tearing (38%) [21]. Deletion of such item (rectal bleeding or
0–4) tearing during or after bowel movement) led to a 11-item
For subscales, the scores of nonmissing items within the subscale were
summed and divided by the total number of nonmissing items for that version, and the remaining two items in the original “rectal”
subscale (subscale score range: 0–4) domain in PAC-SYM were merged into “stool” domain in
61  Patient-Reported Outcome Assessment in Constipation and Obstructed Defecation 745

Table 61.5  Knowles–Eccersley–Scott Symptom (KESS) questionnaire [8]

Item 0 1 2 3 4
1.   Duration of constipation 0–18 months 18 months to 5 5–10 years 10–20 years >20 (or all life)
years
2.  Laxative use None Prn (on demand) or Regular, long Regular, long –
for short duration duration duration, ineffec-
tive
3.  Frequency of bowel move- 1–2 times/1–2 days 2 or less times per Less than once per Less than once per –
ments (using current therapy) week week 2 weeks
4.  Unsuccessful evacuatory Never/rarely Occasionally Usually Always = manual –
attempts evacuation
5.   Feeling incomplete evacuation Never Rarely Occasionally Usually Always
6.   Abdominal pain Never Rarely Occasionally Usually Always
7.  Bloating Never Perceived by Visible to others Severe causing Severe with
patient only satiety or nausea vomiting
8.  Enema/digitation None Enema/supposito- Enema/supposito- Manual evacuation Manual evacuation
ries occasionally ries regular occasionally always
9.  Time taken (minutes in <5 5–10 10–30 > 30 –
lavatory/attempt)
10. Difficulty evacuating (causing Never Rarely Occasionally Usually Always
a painful evacuation effort)
11. Stool consistency (without Soft/loose/normal Occasionally hard Always hard Always hard, –
laxatives) usually pellet-like
Score range: 0–39
Rarely ≤25% of time, occasionally =25–50%, usually ≥50% of the time
The cutoff score for the diagnosis of constipation is 10

M:PAC-SYM because they were moderately correlated with
“stool” domain. Consequently, the M:PAC-SYM consists of
only two domains including “abdominal” (four items) and
“stool” (seven items). The authors concluded that “the rectal
domain may not represent a relevant cluster of symptoms for
patients with chronic constipation” and that M-PAC-SYM
“might better represent symptom severity of most patients
seeking care in gastroenterology referral centers” [21].
Another and more major problem of PAC-SYM is the
lack of item regarding bowel movement frequency and its
reason. In the process of the item reduction, overlap between
the PAC-SYM and Patient Assessment of Constipation
Quality of Life (PAC-QOL) questionnaire [13] was exam-
ined. The instruments were finalized on the basis of consid-
eration of the joint results, and two items from the original
PAC-SYM including “decreased appetite” and “less frequent
bowel movements than desired” were identified as more
appropriate to measure the quality of life and were included
in the final version of the PAC-QOL. Therefore, it is recom-
mended to utilize “full PAC,” which means the usage of both
PAC-SYM and PAC-QOL at the same time, for the evalua-
tion of constipation [7, 24]. It is also recommended that
“when used without the PAC-QOL, a frequency item should
be asked in addition to the PAC-SYM,” which effectively
means that the PAC-SYM alone is not enough to evaluate the
symptomatic severity of constipation.
PAC-SYM has been popular and is widely used at present
in clinical studies, particularly among gastroenterologists. It
is probably because it possesses good reliability, validity,
and responsiveness with the minimal important difference
established. PAC-SYM is also appropriate to use with PAC-­
QOL as the “full PAC,” while it is not suitable to use on its
own to evaluate the symptomatic severity due to its develop-
ment process.
Knowles–Eccersley–Scott Symptom (KESS) question-
naire (Table  61.5) is an 11-item interviewer-led question-
naire to assist in diagnosing constipation and in
discriminating among pathophysiologic subgroups of slow
transit constipation and rectal evacuatory disorders [8].
Each symptom is rated with a 4- or 5-point Likert scale
either from 0 to 3 or from 0 to 4, and the total KESS score
ranges between 0 and 39.
The 11 items were developed by incorporating items from
CSS [6] and Rome II criteria. The formal item generation
and reduction were not performed, and the content validity
was not examined. KESS was evaluated in 71 patients with
intractable constipation and 20 healthy controls. Although its
convergent validity against CSS and discriminant validity
with healthy controls were confirmed, its reliability and
responsiveness were not formally examined. The KESS was
able to predict which patients had pure slow transit constipa-
tion or rectal evacuatory disorder for 55% (95% CI: 43–67%).
The cutoff score for constipation was >10 with both a sensi-
tivity and specificity of 100%.
KESS was further validated in 105 patients with consti-
pation, and the overall prediction of the correct pathophysi-
ologic subgroup was reported to be 47% [25]. In clinical
studies, the KESS has been less frequently utilized than
746
Table 61.6  Chinese Constipation Questionnaire (CCQ) [9]
Item 0 1 2 3 4 (four items). Each symptom is rated with a 5-point Likert
1. Severity of false Absent Mild Moderate Severe Very
alarm: feeling like severe
you have to pass a
stool, but you cannot
2. Frequency of <3 Not provided
defecations/week
3. Severity of incom- Absent Mild Moderate Severe Very
plete evacuation severe
4. Severity of lumpy or Absent Mild Moderate Severe Very
hard stool severe
5. Number of laxatives Not provided
used
6. Severity of abdominal Absent Mild Moderate Severe Very
bloating severe
Score range: not reported, possibly 0–24
The cutoff score for the diagnosis of constipation is 5
CSS probably because it is similar to CSS with more items
than CSS.
Chinese Constipation Questionnaire (CCQ) (Table 61.6)
is a six-item self-report measure designed to diagnose con-
stipation and evaluate its symptomatic severity in Chinese
participants [9]. Although each item is rated with a 5-point
Likert scale from 0 (absent symptom) to 4 (very severe
symptom), it was not provided how to rate the items of
“bowel frequency” and “number of laxatives used” in the
original paper [9]. The total CCQ score is not reported and
could range between 0 and 24.
The original 30 items were generated through literature
review and patient interview, which were reduced to the final
six items based on a principal component analysis. The CCQ
was evaluated in 111 patients with constipation and 110
healthy controls. Its reliability of internal consistency
(Cronbach’s alpha  =  0.79) and test–retest reliability (intra-
class correlation coefficient = 0.77) was demonstrated, while
content validity, convergent validity against SF-36, discrimi-
nant validity, and responsiveness were all confirmed. A cut-
off score of >5 was determined to discriminate between
constipated patients and controls with both a sensitivity and
specificity of 91%.
The CCQ has rarely been utilized since its development
although it is one of the most formally and rigorously vali-
dated PROMs. There are possible two reasons for this. First,
the CCQ was validated only in Chinese and requires another
validation study of its English version to be reliably used in
English. Second, a formal questionnaire table exactly pre-
senting the six items of CCQ was not provided in the original
paper.
Constipation Severity Instrument (CSI) (Table 61.7) is a
16-item self-report measure designed to assess constipation
severity and identify subtypes of constipation, including
obstructed defecation and slow transit constipation [10]. The
CSI consists of three subscales that include “obstructed def-
T. Mimura
ecation” (six items), “colonic inertia” (six items) and “pain”
scale either from 0 to 4 or from 1 to 5, and the total CSI score
ranges between 0 and 73.
The original 80 items were generated through literature
review and patient interview, which were reduced to the final
16 items by exploratory and confirmatory analysis. The CSI
was evaluated in 191 constipated patients and 103 healthy
volunteers. Its reliability of internal consistency (Cronbach’s
alpha = 0.9) and test–retest reliability (intraclass correlation
coefficient = 0.91) was demonstrated. Content validity, con-
vergent validity against PAC-SYM, and discriminant validity
were confirmed, while responsiveness was not examined.
The CSI has rarely been utilized since its development
although it was formally developed and meticulously vali-
dated. It is probably because the CSI has too many items and
its rating is rather complicated although its authors claimed,
“The CSI is a short, easy to use, reliable, and valid instru-
ment to assess constipation severity and identify subtypes of
constipation.”
Obstructed Defecation Syndrome (ODS) score
(Table  61.8) is an eight-item interviewer-led questionnaire
specifically designed to assess obstructed defecation syn-
drome (ODS), in which the stool in the rectum cannot be
evacuated sufficiently or comfortably due to various patho-
physiologies, including pelvic floor incoordination, recto-
cele, and rectal intussusception [11]. Each symptom is rated
with a 5-point Likert scale from 0 to 4 except for the item of
“stool consistency,” which is rated with a 4-point scale from
0 to 3, and the total ODS score ranges between 0 and 31.
The eight items were developed by incorporating items
from CSS [6] and KESS [8] with taking into account the
definition of constipation by Rome II criteria. The formal
item generation and reduction were not performed, and the
content validity was not examined. The ODS score was eval-
uated in 76 patients with ODS and 30 healthy controls. Its
test–retest reliability was confirmed by the Bland–Altman
plot, and relatively weak internal consistency (Cronbach’s
alpha = 0.51) was demonstrated. Discriminant validity with
healthy controls was confirmed, while convergent validity
and responsiveness were not examined.
The ODS score is suitable and frequently used in evaluat-
ing the ODS symptomatic severity and the effect of treat-
ments for ODS.
There is another scale, called Longo’s ODS score, that is
designed to evaluate ODS. It is specifically used to evaluate
the efficacy of a surgical procedure, called Stapled Transanal
Rectal Resection (STARR), for the treatment of rectocele
and/or rectal intussusception [26]. This score, however, has
never been formally validated to examine its reliability and
validity.
Bowel Function Index (BFI) (Table 61.9) is a three-item
clinician-administered and patient-reported questionnaire,
61  Patient-Reported Outcome Assessment in Constipation and Obstructed Defecation 747

Table 61.7  Constipation Severity Instrument (CSI) [10]

Item 0 1 2 3 4 5
Obstructed Defecation Subscale
CSI 1. Incomplete bowel movements
(a) How often do you experience incomplete Never Occasionally Sometimes Usually Always –
bowel movements? experience experience experience this experience experience
this this this this
(Skip to #2)
(b)  How severe is this symptom for you? – Not at all Mild Somewhat Severe Extremely
severe severe severe
(Most of my (I bear (I push on my
BM comes down hard) belly, grunt and
out) bear down very
hard)
(c)  How much does this bother you? – Not at all A little Somewhat Very Extremely
bothersome bothersome bothersome bothersome bothersome
CSI 2. Straining/difficulty in having a bowel movement
(a)  How often do you experience this? Never Occasionally Sometimes Usually Always –
experience experience experience this experience experience
this this this this
(Skip to #5)
(b)  How severe is this for you? – Not at all Mild Somewhat Severe Extremely
severe severe severe
(I push a (I bear (I push on my
little) down hard ) belly, grunt and
bear down very
hard )
(c)  How much does this bother you? – Not at all A little Somewhat Very Extremely
bothersome bothersome bothersome bothersome bothersome
Colonic Inertia Subscale
CSI 3. Think about when you are having difficulty with your bowel habits: During a typical month, how many times do you usually have a
bowel movement? (please check only one)
N/A—I never Daily A few times Once per Once every 2 Once a month
have per week week weeks
difficulty
with my
bowel habits
CSI 4. Infrequent bowel movement (less than 1 bowel movement every 3 days)
(a) How often do you experience infrequent Never Occasionally Sometimes Usually Always –
bowel movement? experience experience experience this experience experience
this this this this
(Skip to #5 )
(b)  How severe is this symptom for you? – Not at all Mild Somewhat Severe Extremely
severe severe severe
(I go almost (I go 1–2 (I can go up to
everyday) times per 4 weeks
week) without going)
(c)  How much does this symptom bother you? – Not at all A little Somewhat Very Extremely
bothersome bothersome bothersome bothersome bothersome
CSI 5. Lack of urge to have a bowel movement (BM)
(a)  When you lack the urge to have a BM, how severe is this for you?
Never Not at all Mild Somewhat Severe Extremely
experience severe severe severe
this (I have a (I only (I don’t have
pretty good have a any sensation in
sense when I vague the pelvic area)
have to go) sense that I
might have
to go)
(b)  When you lack the urge to have a BM, how much does this bother you?
Never Not at all A little Somewhat Very Extremely
experience bothersome bothersome bothersome bothersome bothersome
this

(continued)
748 T. Mimura

Table 61.7 (continued)
Item 0 1 2 3 4 5
Pain Subscale: Rectal/anal pain due to your bowel problems
CSI 6. During the last month, on average how severe was the pain in your rectum/anus?
I haven’t Mild Somewhat Severe Extremely ―
experienced severe severe
this
CSI 7. Rate the level of your rectal/anal pain at the present moment
No pain Mild Somewhat Severe Extremely ―
severe severe
CSI 8. How much suffering do you experience because of rectal/anal pain?
None Mild Somewhat Severe Extremely ―
suffering severe suffering severe
suffering
CSI 9. During the last month, due to your bowel habits, how often have you had bleeding during/after a bowel movement?
Never Rarely Occasionally Usually Always ―
Score range: 0–73

Table 61.8  Obstructed Defecation Syndrome (ODS) score [11] Table 61.9  Bowel Function Index (BFI) [12]
Item 0 1 2 3 4 Item 0 – 100
Mean time <5 min 6–10 min 11– 21–30 min >30 min 1. Ease of defection during the last 7 Easy/no – Severe
spent at the 20 min days according to patient assessment difficulty Difficulty
toilet 2. Feeling of incomplete bowel Not at all – Very strong
N attempts to 1 2 3–4 5–6 >6 evacuation during the last 7 days
defecate per according to patient assessment
day 3. Personal judgment of patient Not at all – Very strong
Anal/vaginal Never >1/month, Once a Two to Every regarding constipation during the
digitation <1/week week three per defecation last 7 days
week BFI (numerical analogue scale: 0–100) is calculated as the mean score
Use of Never >1/month, Once a Two to Every day of the three items
laxatives <1/week week three per Score range: 0–100
week The cutoff score for the diagnosis of constipation is 30
Use of Never >1/month, Once a Two to Every day For item 1, ask the subject: “During the last 7 days, how would you rate
enemas <1/week week three per your ease of defecation on a scale from 0 to 100, where 0 = easy or no
week difficulty and 100 = severe difficulty?”
Incomplete/ Never >1/month, Once a Two to Every For item 2, ask the subject: “During the last 7 days, how would you rate
fragmented <1/week week three per defecation your feeling of incomplete bowel evacuation on a scale from 0 to 100,
defecation week where 0 = no feeling of incomplete evacuation and 100 = a very strong
Straining at Never <25% of <50% <75% of Every feeling of incomplete evacuation?”
defecation the time of the the time defecation For item 3, ask the subject: “During the last 7 days, how would you rate
time your constipation you felt on a scale from 0 to 100, where 0 = not at all
Stool Soft Hard Hard Fecaloma – and 100 = very strong?”
consistency and formation
few ered in the Rome III criteria. The third item relates to the
Score range: 0–31 personal judgment of patient regarding constipation
severity.
which has been developed and validated to evaluate opioid-­ The three items were developed through the literature
induced constipation (OIC) in cancer and noncancer chronic review including Rome III criteria. The formal item genera-
pain patients [12, 27–29]. Each item is rated from 0 to 100 tion and reduction were not performed, and the content
using a numeric analogue scale over the last 7 days, and the validity was not examined. The BFI was evaluated using the
total BFI score is calculated as the mean of the three-item data from clinical studies of prolonged-release oxycodone/
scores (range 0–100). The two items include ease of defeca- naloxone in three multicenter, randomized controlled double-­
tion and feeling of incomplete bowel evacuation that are cov- blind parallel group trials involving 202, 460, and 323
61  Patient-Reported Outcome Assessment in Constipation and Obstructed Defecation 749

Table 61.10  Constipation-specific quality-of-life questionnaires

Item Psychometric
generation Internal validation in
Published No of Score Period for and consis- Test retest Content Convergent Discriminant Respon- other
year items range Subscale evaluation reduction tency reliability validity validity validity siveness languages
Patient 2005 28 0–4 Worries and Past 2 Yes Yes Yes Yes Yes Yes Yes Yes
Assessment concerns (11 weeks 35 to 28 French, Dutch,
of Quality items), items Japanese,
of Life physical Turkish,
(PAC- discomfort Persian
QOL) (4 items),
question- psychologi-
naire [13] cal
discomfort
(8 items),
satisfaction
(5 items)
Constipa- 2009 18 18–90 Distress (6 Past 12 Yes Yes Yes Yes Yes Yes NR No
tion- items), months 59 to 18
Related social items
Quality of impairment
Life (5 items),
(CRQOL) eating habits
question- (3 items),
naire [14] bathroom
attitudes (4
items)
NR not reported

patients, respectively [12]. The reliability of internal consis-
tency (Cronbach’s alpha >0.7) and reproducibility was con-
firmed [12]. Correlations between BFI item and total scores
to stool frequency were statistically significant, demonstrat-
ing convergent validity [12], and another study also demon-
strated convergent validity against PAC-SYM [27]. Each BFI
item in the scale decreased with increased doses of naloxone,
indicating the responsiveness [12]. The clinical validity and
responsiveness of this scale were further validated in a mul-
ticenter prospective observational study of 7836 patients suf-
fering from chronic pain and being treated with oxycodone
PR/naloxone PR [30]. Tests using standard error of measure-
ment and standard deviation showed that a decrease in BFI
score of ≥12 points represents a clinically meaningful
change in constipation [12]. The cutoff score >30 was pro-
posed to differentiate between OIC and nonconstipated
patients [28, 31].
BFI has been utilized to evaluate the severity of OIC
and efficacy of medical treatment for OIC. It is, however,
not frequently used among gastroenterologists and
colorectal surgeons to evaluate symptomatic severity of
general constipation, probably because the number of
three items in BFI seems too small and might not be
enough to evaluate a constellation of symptoms in consti-
pation particularly to evaluate the efficacy of surgical
interventions. If the three items of BFI are enough to eval-
uate constipation symptomatic severity, just one item of
visual analogue scale might be also enough, and if that is
the case, the development and validation of PROMs might
not be required anymore.
61.1.2 Constipation-Specific Quality-of-Life
Questionnaire
Constipation causes annoying symptoms and impairs QOL,
which can be evaluated by generic or symptom-specific
instruments. Increasing evidence suggests that chronic con-
ditions should be assessed not only by the severity of symp-
toms but also by their impact on QOL.  The
constipation-specific QOL PROMs provide a refined assess-
ment of the impact of constipation on QOL, and there are
currently only two such validated tools including Patient
Assessment of Constipation Quality of Life (PAC-QOL)
questionnaire [13] and Constipation-Related Quality of Life
(CRQOL) [14]. These two questionnaires are summarized
in Table 61.10.
Patient Assessment of Constipation Quality of Life (PAC-­
QOL) questionnaire is a self-administered questionnaire con-
sisting of 28 items in 4 subscales that include “worries and
concerns” (11 items), “physical discomfort” (4 items), “psy-
chological discomfort” (8 items), and “satisfaction” (5 items)
[13]. Each item is rated with a 5-point Likert scale from 0 to
4, and the total score is calculated as an average score of the
28 items (total score 0–4), with lower scores indicating better
health-related quality of life. If there are missing items, the
scores of nonmissing items were summed and divided by the
total number of nonmissing items. The subscales are also cal-
culated as an average score of each subscale items (score
range 0–4), and if there are missing items, the scores of non-
missing items within the subscale were summed and divided
by the total number of nonmissing items for that subscale.
750
PAC-QOL is one of the most formally and meticulously
developed and validated PROMs to evaluate constipation-­
specific QOL in patients with chronic constipation. For the
development of PAC-QOL, original 35 items were generated
through literature review, clinical and outcomes research
experts, and patient interview. They were evaluated in 260
patients in the United States or the United Kingdom and
were reduced to the final 28 items based on an exploratory
principal component analysis. During this item generation
and reduction process, three items were removed due to the
redundancy with the PAC-SYM [7], while two items were
added from the PAC-SYM based on the relevance of their
content.
For the validation study, the 28-item PAC-QOL was eval-
uated in 223 patients in the United States and was classified
into 4 subscales based on a principal component analysis and
a multitrait analysis. The PAC-QOL demonstrated excellent
reliability of internal consistency (Cronbach’s alpha = 0.93)
and test–retest reliability (intraclass correlation coeffi-
cient = 0.82). Its convergent validity was confirmed against
“abdominal pain” and “patient and investigator global rat-
ings of constipation severity,” while its discriminant validity
was demonstrated with its difference depending on the sever-
ity of “abdominal pain” and “patient and investigator global
ratings of constipation severity.” The responsiveness of the
PAC-QOL was also demonstrated with its effect sizes being
moderate to large in patients reporting improvements in con-
stipation over a 6-week period.
In the original study, the PAC-QOL was translated into
French, Dutch, Canadian English, Canadian French, and
Australian English [13]. The English French and Dutch ver-
sions of the PAC-QOL were evaluated in the United Kingdom
(n = 74), France (n = 30), the Netherlands (n = 33), Belgium
(n = 20), Canada (n = 55), and Australia (n = 33). The three
versions continued to demonstrate internal consistency,
reproducibility, convergent validity, discriminant validity,
and responsiveness.
In the original study, 0.5-point change was proposed to be
a valid threshold for defining a clinically meaningful differ-
ence [13], while 1.0-point improvement used as target
response level for the main treatment effect analyses was
validated as a relevant definition of response for treatment
group comparison in an analysis of the pooled data from the
three prucalopride trials for chronic constipation [32].
The PAC-QOL is the best constipation-specific PROM
available at present and deserves to be called the gold stan-
dard for the evaluation of the QOL in patients with constipa-
tion, because it has been most frequently used in many
high-quality studies and has been translated into and vali-
dated in many languages [13, 33–35]. The utilization of the
PAC-QOL makes it easy to compare international studies on
constipation and enables us to conduct international multi-
center studies in several languages.
T. Mimura
Constipation-Related Quality of Life (CRQOL) is a self-­
administered questionnaire consisting of 18 items in 4 sub-
scales that include “distress” (six items), “social impairment”
(five items), “eating habits” (three items), and “bathroom
attitudes” (four items) [14]. Each item is rated with a 5-point
Likert scale from 1 to 5, and the total score is calculated as a
sum of the 18 items ranging between 18 and 90, with lower
scores indicating better quality of life. The subscale scores
are also calculated as a sum of each subscale items with their
score ranging from 6 to 30 in distress, from 5 to 25 in social
impairment, from 3 to 15 in eating habits, and from 4 to 20 in
bathroom attitudes.
For the development of CRQOL, original 59 items were
generated through literature review, patient interview, and
healthcare providers, including internists, gastroenterolo-
gist, nurses, and colorectal surgeons. They were evaluated
in 240 patients with constipation and 103 healthy volun-
teers, and they were reduced to the final 18 items based on
an exploratory factor analysis and a confirmatory factor
analysis.
In the validation study, the 18-item CRQOL demonstrated
excellent reliability of internal consistency (Cronbach’s
alpha = 0.93) and test–retest reliability (intraclass correlation
coefficient  =  0.92). Its convergent validity was also con-
firmed with its significant correlation with the Medical
Outcomes Study Short Form-36 Mental and Physical
Component Summary Score (SF-36) as well as with Irritable
Bowel Syndrome Quality of Life Scale (IBS-QOL). The
CRQOL well differentiated between patients with constipa-
tion and healthy controls, demonstrating the discriminant
validity. However, its responsiveness was not evaluated in
the original study. Each of the CRQOL subscales and the
CRQOL total score was well correlated with the Constipation
Severity Index (CSI) subscales and the CSI total score [10],
which was developed and validated in conjunction with the
CRQOL.
61.1.3 Recommendation for Practice
in Choosing Appropriate PROMs
for Constipation
It is commonly assumed that the QOL in patients with con-
stipation is well correlated with its symptomatic severity
[36]. This might be true in most patients, but it is not always
true because the impact on QOL caused by constipation
symptoms varies depending on individuals, particularly in
psychological and social aspects. In clinical research set-
tings, therefore, it is essential to evaluate both symptomatic
severity of constipation and constipation-specific QOL. On
the other hand, in clinical practice, only the constipation
symptom severity scale would be enough to minimize the
burden of both patients and healthcare providers.
61  Patient-Reported Outcome Assessment in Constipation and Obstructed Defecation
To choose appropriate PROMs for constipation, charac-
teristics of each PROM should be considered. To evaluate
symptomatic severity of constipation, the CSS [6] and PAC-­
SYM [7] have been widely used by colorectal surgeons and
gastroenterologist, respectively. Although PAC-SYM was
more formally and rigorously developed and validated than
CSS, it is supposed to be used in conjunction with PAC-QOL
[13]. Therefore, the PAC-SYM might not be suitable to be
used on its own in clinical practice, particularly when the
evaluation of bowel frequency is important because it is not
included in the PAC-SYM. The PAC-SYM should be used
together with PAC-QOL in clinical research settings.
The CCQ [9] is the most formally and rigorously devel-
oped and validated PROM. However, its major limitation is
that it was designed for Chinese-speaking patients and has
never been validated in English-speaking populations.
Besides, the full version of CCQ is not available. These seem
main reasons why it is not widely used at present.
The CSI [10] was formally and rigorously developed in
conjunction with the CRQOL [14]. It is, however, too com-
plicated and has too many items to be used in clinical prac-
tice. The CSI can be used in clinical research settings together
with the CRQOL.
The ODS score [11] was specifically designed, devel-
oped, and validated to evaluate the symptomatic severity of
evacuation disorders. Therefore, it should be used to evaluate
symptomatic severity and treatment efficacy in patients with
evacuation disorders, including functional defecation disor-
der, rectocele, and rectal intussusception.
The BFI [12] was designed, developed, and validated to
evaluate the symptomatic severity of patients with opioid-­
induced constipation (OIC). Although it is a simple measure
with only three items and can be used for OIC, it has never
been validated in patients with constipation cause by other
pathologies.
Although the CAS [5] and KESS [8] are rarely used in
clinical studies at present, the CAS might be useful to evalu-
ate the symptomatic severity of constipation in patients
whose constipation is associated with rectal fecal impaction
causing overflow passive fecal incontinence because it
includes an item of “oozing liquid stool.”
In clinical research settings, particularly in prospective
controlled trials, both a constipation symptom severity
scale and a constipation-specific quality-of-life question-
naire should be used. The usage of both PAC-SYM and
PAC-QOL is the most recommended combination,
although a combination of CSS and PAC-QOL is accept-
able because the CSS has been widely used in the field of
colorectal surgery and is useful to compare the results with
the previous studies. For studies of evacuation disorder, a
combination of ODS score and PAC-QOL is recom-
mended. For studies of OIC, a combination of BFI and
751
PAC-QOL is recommended, although BFI alone is accept-
able because the simplicity and minimal burden seem par-
amount in the field OIC.  A combination of CSI and
CRQOL can be utilized in clinical researches, although
they have rarely been used.
61.2 Future Directions
1. Patient Assessment of Constipation Symptom (PAC-­
SYM) questionnaire and Constipation Scoring System
(CSS) will continue to be used to evaluate the symptom-
atic severity of constipation by gastroenterologists and
colorectal surgeons, respectively. Colorectal surgeons
might learn to use PAC-SYM more frequently in the
future.
2. Obstructed Defecation Disorder (ODS) score will con-
tinue to be used to evaluate the symptomatic severity of
evacuation disorders.
3. Bowel Function Index (BFI) will continue to be used to
evaluate the symptomatic severity of opioid-induced con-
stipation (OIC). BFI might be utilized in general consti-
pation other than OIC due to its simplicity.
4. Patient Assessment of Constipation Quality of Life (PAC-­
QOL) questionnaire will continue to be used to evaluate
the constipation-specific QOL in conjunction with PAC-­
SYM, CSS, ODS score, or BFI. It is expected to be trans-
lated and validated in many other languages for the
international usage.
Take-Home Messages
• In clinical practice, PAC-SYM or CSS is recom-
mended to use for the evaluation of symptomatic
severity of constipation.
• In clinical practice, ODS score is recommended
to use for the evaluation of symptomatic severity
of evacuation disorders, including functional def-
ecation disorder, rectocele, and rectal intussus-
ception.
• In clinical practice, BFI, PAC-SYM, or CSS is rec-
ommended to use for the evaluation of symptomatic
severity of opioid-induced constipation.
• In clinical research, particularly if it is a prospective
full-scale study, both a constipation symptom sever-
ity scale, such as PAC-SYM, CSS, ODS score, or
BFI, and a constipation-specific quality-of-life
questionnaire, such as PAC-QOL, should be used to
evaluate symptomatic severity and its impact on
quality of life, respectively, separately in patients
with constipation.
752 T. Mimura

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 Anorectal Manometry, Rectal Sensory
Testing and Evacuation Tests
Mitul Patel, Kumaran Thiruppathy, and Anton Emmanuel
Learning Objectives
• Discuss the methods and clinical role of anorectal
manometry and how it is evolving with high-­
resolution anorectal manometry.
• Discuss the methods and clinical role of rectal sen-
sory testing.
• Discuss the method and clinical role of balloon
expulsion tests.
• Evaluate the limitations of anorectal manometry,
rectal sensory testing and evacuation testing.
• Understand the use of integrating imaging modali-
ties (endoanal ultrasound and evacuation proctogra-
phy) with history and physiological findings.
62.1 Introduction
A plausible interpretation of current clinical practice sug-
gests that the most useful tool in assessment of patients with
faecal incontinence is the endoanal ultrasound. However, a
significant proportion of patients with symptoms of faecal
incontinence have no ultrasonographic evidence of sphincter
injury. Conversely, sphincter-involving injury complicates
0.6–2.5% of vaginal deliveries, but only 30–50% of these
patients have symptoms of anal incontinence [1, 2]. Data
from obstetric trauma studies initially suggested that anal
sphincter damage and pudendal nerve injury were the reason
for faecal incontinence; however, the onset of symptoms can
be many years post-partum [3]. We can conclude that faecal
incontinence is a complex multifactorial problem, and so
M. Patel · K. Thiruppathy
Division of Colorectal Surgery, Royal Berkshire Hospital,
Reading, UK
e-mail: mitulpateldr@gmail.com; kum.nhs@googlemail.com
A. Emmanuel (*)
GI Physiology Unit, University College Hospital, London, UK
e-mail: a.emmanuel@ucl.ac.uk
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_62
62
when investigating its cause, such an approach is required.
Given the psychological and social associations that are a
fundamental part of maintaining continence in human soci-
ety, this is perhaps unsurprising. As such, it is a moot point
whether any testing could accurately represent this complex
function.
Both endoanal ultrasound and manometry assess anal
sphincter structure and function, while rectal testing plays a
role in assessing the rectum as an organ of storage and expul-
sion of stool. Furthermore, early studies have failed to show
sensory nerves within the rectum, and it is thought that the
perception of stool is based on rectal distension [4]. Rectal
sensory testing has been used to investigate the cause of dis-
orders such as irritable bowel syndrome and ‘obstructed
defaecation’ [5, 6].
The full strategy of anorectal manometry, rectal sensory
testing and evacuation tests in conjunction with imaging
techniques are useful in investigating the aetiology of a
patient’s pelvic floor dysfunction. However, the evidence
supporting the role of each of these investigations in defaeca-
tory disorders and faecal incontinence can be unclear.
This chapter aims to review the methods and clinical role
of anorectal manometry, rectal sensory testing and evacua-
tion tests and their potential limitations. In addition, we will
review the relationship between structural (ultrasono-
graphic) and physiological (manometric and sensory physi-
ology) changes to determine whether there is any relationship
between measurable abnormalities and the development of
symptoms.
62.2 Anal Manometry
Anal manometry offers an objective and potentially repro-
ducible assessment of anal sphincter function. Resting pres-
sure broadly reflects internal anal sphincter (IAS) function,
while voluntary squeeze or bearing down pressure is a reflec-
tion of external anal sphincter (EAS) function. Functional
753
754
anal canal length and reflex responses of the sphincter to
perianal and rectal manoeuvres can also be assessed.
Anorectal manometry has traditionally been used to gain
measurements of involuntary and voluntary anal sphincter
pressures at the mid anal canal. It is performed by the place-
ment of a manometry catheter in the anal canal to ascertain
resting pressure and then asking the patient to squeeze the
anal muscles to ascertain squeeze pressure followed by rais-
ing intra-abdominal pressure (say, by coughing) to gain an
involuntary squeeze pressure.
Manometry tests can be performed with a wide variety of
devices available. These include either open-tipped or side-­
opening water-perfused catheters, direct online solid-state
microtransducers, or air- or water-filled balloons (Fig. 62.1).
Normal anal sphincter pressure values vary depending on
testing methodology, gender (males higher than females) and
age (young greater than older) [7]. The last decade has seen
the advent of high-resolution anal manometry, but the place
of this technology is in its infancy (compared to the advances
made over a similar period in understanding the clinical role
of high-resolution oesophageal manometry).
Reduced anal sphincter pressures tended to be associated
with an increase symptom load of anal incontinence. It is
estimated that about 80% of resting anal tone is contributed
Fig. 62.1  High-resolution water-perfused manometry catheter with
rectal balloon attached
M. Patel et al.
to by the smooth-muscle internal anal sphincter, while vol-
untary squeeze depends entirely on striated external anal
sphincter function. A large proportion of the data in the lit-
erature utilizing anal manometry have been based on obstet-
ric injury patients.
It is clear that in patients with symptoms of anal inconti-
nence following instrumental delivery, episiotomies, occult
or overt sphincter injury, there is a reduction in anal sphinc-
ter function [8, 9]. Episiotomy and perineal trauma (second-
or third-degree tears) are associated with a significant
decrease in maximum squeeze pressures as compared to
intact perineum [10, 11]. Data comparing women with intact
perineum and those with spontaneous perineal tear or episi-
otomies show statistically significant differences in mean
squeeze pressures of 105 ± 26 mmHg vs. 92 ± 30 mmHg [8].
When patients with incontinence are assessed, most will
be found to have identifiable structural damage. However,
there remains a group of patients who have neither structural
sphincter damage nor evidence of impairment of the nerves
of the pelvic floor, but who have symptoms and objective
evidence of dysfunction of the internal anal sphincter. Vaizey
et al. identified a group of patients with reduced resting anal
pressures and degeneration of the IAS recognized as internal
sphincter thickness of 1 mm or less on endo-anal ultrasound
[12]. This entity of internal anal sphincter degeneration
accounts for 4% of patients presenting to a tertiary care
incontinence service.
EAS atrophy is more difficult to diagnose and is now
done on MRI by demonstrating increase of fatty replacement
and thinning of the striated muscle. Atrophy of the EAS can
be associated with poor anal sphincter function [13].
Additionally, specific injuries to the anterior EAS which may
be suitable for surgical intervention can be defined on MRI
[14]. Early studies show that non-specific, decreased resting
and squeeze pressures can be found in 90% of patients with
anal sphincter injury [15].
The role of manometry in detecting abnormalities within
dyssynergic defaecation and Hirschsprung’s disease has
been shown. The recto anal inhibitory reflex is absent in
Hirschsprung’s disease and is described as being pathogno-
monic. As previously mentioned, the presence or absence of
this reflex can be elucidated using manometry to measure
anal sphincter pressure while simultaneously inflating a rec-
tal balloon—it is described in greater depth below [16, 17].
Anal manometry can be used to characterize the chief
pathophysiology of dyssynergic defaecation. To maintain
continence, the anal canal resting pressure is higher than that
of the rectum within the resting state. When a subject
attempts to defecate, there is normally a voluntary, learned
relaxation of the anal sphincter with a synchronized rise in
the rectal pressure [18]. The inability to perform this can be
due to impaired rectal contraction, paradoxical anal contrac-
tion, impaired anal relaxation or a combination of these
62  Anorectal Manometry, Rectal Sensory Testing and Evacuation Tests
D 100
Fig. 62.2  Figure showing three-dimensional reconstruction of anal sphincter pressure recording during vector manometry
mechanisms. Based on these features, at least four types of
dyssynergia have been proposed. It has been suggested that
these types of dyssynergia may form the basis of tailored
biofeedback [19]. However, this remains to be widely
demonstrated.
62.3 Vector Manometry
Vector manometry was a pioneering technique of demon-
strating a three-dimensional pressure assessment of the anal
canal. It relied on a multi-channel manometry catheter being
pulled through the anal canal at a steady speed automated
puller withdrawn at 3 and 25 mm [43]. Using advanced com-
puter software, a three-dimensional graph/image of the pres-
sure variations of the anal canal could be created (Fig. 62.2).
This image will show areas of low pressure to be identified
and correlated with clinical history (surgical interventions,
etc.) or symptoms.
62.4 H
 igh-Resolution Anal Manometry
(HR-ARM)
The introduction of high-resolution anal manometry
(HR-ARM) in 2007 has allowed for three-dimensional pres-
sure assessments of the anal canal—resulting in high-­
resolution topographical plots of the intraluminal pressure
(Fig. 62.3).
755
180
80
60
40
20
90 270
0
Radial segment: 15 - 20 mm
HR-ARM can be carried out by solid-state or water-­
perfused manometry catheter. Water-perfused manometry
requires more preparation, technical skills and training. The
dynamic performance of water-perfused systems is several
orders of magnitude less than that of solid-state systems,
limiting their accuracy; however, this does not seem to be a
limitation in the anorectum where rapidly changing pres-
sures are not observed. It is suggested that the test allows for
reduced movement artefact, simplifies data interpretation
and allows for more sophisticated analysis of the anal sphinc-
ters. HR-ARM is commonly used in research-based centres,
while traditional anorectal physiology is used elsewhere [20,
21]. High-resolution anorectal and colonic manometry pro-
vides a more comprehensive characterization of motility pat-
terns and coordinated activity, which may help to improve
our understanding of the normal physiology and pathophysi-
ology in these areas. To date, however, no published study
has conclusively demonstrated a clinical, diagnostic or inter-
ventional advantage over conventional manometry [22].
62.4.1 Rectal Sensory Testing
Though it is not fully understood how humans perceive stool
within the rectum, with early studies failing to show rectal
sensory nerves, more recent studies have shown that disten-
sion is perceived within the rectum and has a role in main-
taining continence [4]. Specialized mechanoreceptors and
nerve endings within the rectal wall are thought to mediate
756
Fig. 62.3  An eight-channel high-resolution anorectal manometry reading in a female demonstrating squeeze pressure with fatigue. EAS external
anal sphincter, IAS internal anal sphincter
this. Animal models have shown such rectal afferent nerves
and characterized for in vitro experimentation [23].
The normal rectum is capable of accommodating increases
in volume by distending with only minor alterations of pres-
sure. Rectal compliance is the volume response to pressure
distension of the rectum and can be measured using a
­barostat, a pump that is capable of delivering air into a rectal
balloon at a fixed pressure or volume [24].
To measure rectal distension sensitivity, a highly compli-
ant balloon is placed within the rectum and progressively
distended with air or water until a desired perception is
achieved. The thresholds often used are of first sensation of
fullness, urge to defaecate and maximum tolerated volume.
Investigators have either rapidly filled the balloon or used a
continuous infusion to achieve the first sensation. The type
of inflation, phasic or continuous and speed of inflation all
can produce variability, and so normal threshold ranges can
differ between laboratories. A barostat can help remove these
variations to the distension regimen.
Rectal sensory testing with distension has been used to
assess constipation with such patients having absent or high
urge to defaecate threshold and a phenomenon known as rec-
tal hyposensitivity. Twenty-three percent of those with
M. Patel et al.
chronic constipation show rectal hyposensitivity, with it
being more common in patients with dyssynergic defaeca-
tion [31]. Lowered rectal pain threshold is a hallmark of
­irritable bowel syndrome (IBS) patients. Rectal barostat test-
ing can be used in the diagnosis of IBS and to discriminate
IBS from other causes of abdominal pain. Although IBS can
have heterogeneous precipitating factors, visceral hypersen-
sitivity remains an important feature [32, 33].
Studies suggest that an important component of successful
biofeedback training for faecal incontinence is an improved
ability to sense rectal distention. The first rectal sensory thresh-
old is of value in the biofeedback training of patients with fae-
cal incontinence; normalization or reduction of the threshold
correlates with success, and poor or absent sensation to disten-
sion makes a good response to treatment unlikely [34].
It has been shown that patients with significant perineal
trauma have altered rectal sensation requiring larger volumes
to elicit the first sensation of rectal filling. Impairment of
threshold for first rectal sensation to filling has been associ-
ated with a significant risk of passive seepage of faeces [35].
To avoid the variability that rectal balloon distension and
barostat testing creates, direct stimulation of the rectum has
been used in a research setting. A barostat is a device used to
62  Anorectal Manometry, Rectal Sensory Testing and Evacuation Tests
maintain a constant pressure within a closed chamber. Due to
the exceptional capacity of the gut to expand and to sponta-
neously or by reflex contract, rapid adjustments are required
to maintain a constant pressure within it. A highly compliant
polvinyl chloride (PVC) balloon is placed within the rectum
and step-wise ­inflation by a pneumatic pump is performed. A
pressure transducer detects for changes as the rectum relaxes
or contracts and the volume of inflation is increased or
reduced accordingly. These changes in volume of the balloon
can be measured giving an indirect assessment of the tonic
changes of the luminal wall. Its main use is in the research
setting and allows rectal compliance to be assessed.
International consensus is being reached regarding the
standardization of barostat procedures for testing smooth-­
muscle tone and sensory thresholds in the gastrointestinal
tract to reduce variability among laboratories [25].
62.4.2 Rectal Sensation to Electrical
Stimulation
Rectal sensory testing using a bipolar electrode ring within the
rectum and electrical stimulus passed across the rectal mucosa
can be used to obtain a quantitative value for rectal innervation
and has been used to investigate idiopathic constipation.
Research has shown that the raised threshold to electrosensory
mucosal testing suggests the presence of a rectal sensory neu-
ropathy in patients with severe idiopathic constipation [36].
62.5 Balloon Expulsion Test (BET)
The balloon expulsion test is a cheap and effective way of
assessing pelvic floor dyssynergia (PFD), which can be a
cause of idiopathic constipation/evacuation difficulty. It is
defined as paradoxical contraction or failure to relax the pel-
vic floor muscles during attempts to defaecate.
BET is performed by placing a rubber rectal balloon with
50 mL of water in the rectum and asking the patient to evacu-
ate it. Studies have varied with artificial stool, 18-mm spheres
and air used to fill the balloon [37]. However, water-filled
rubber balloon is easily available and sufficiently stimulates
sensation of stool within the rectum in terms of weight and
size. BET was reported to have high specificity and negative
predictive value as a diagnostic tool for functional outlet
obstruction and that it should be used for screening prior to
further testing as symptoms alone were unreliable [38].
Other studies have suggested that some patients with PFD
could expel the balloon and some healthy controls could not
expel the balloon. The prevalence of positive result in BET
has also been reported variably, ranging from 23 to 67%
among constipated patients [39]. Such variability among
studies is likely due to the poor standardization of the test.
757
Studies have shown that BET is best done in a sitting
position rather than a left lateral decubitus position [40].
Performing BET in other positions may lead to over diagno-
sis as the usual anatomical and physiological changes are not
allowed for that are afforded by the sitting position.
The normal time for the balloon to be expelled has been
variable among studies ranging from 1 to 5  min [37].
Normative data conclude that expulsion should take less than
30 s for men younger than 40 years and less than 1 min above
40 years. For women, expulsion should occur in 1  min
regardless of age [41].
Findings from the BET have a high level of agreement
with those from anorectal manometry (ARM) and electro-
myogram (EMG). The level of agreement between BET and
ARM for dyssynergia was 78%, and between BET and
EMG, it was 83% [42].
62.6 Recommendation for Practice
Comprehensive assessment of pelvic floor patients is
required to get a full understanding of the aetiopathology of
patients’ symptoms. Anorectal manometry allows for an
objective and quantifiable measure of anal sphincter function
which is important in identifying anal hypo-contractility/low
anal pressures versus those who have normal sphincter func-
tion, which aids decision-making when treating continence.
Rectal sensation assessment is important in determining
rectal hyposensitive and hypersensitive as it can aid diagno-
sis and identify the best mode of treatment (biofeedback,
drugs, laxatives, etc.) of certain cohorts of patients.
Balloon expulsion tests when performed in a standardized
manner allow for a cheap and easily accessible way to asses
for dyssynergic defaecation.
62.7 Future Direction
Further, well-controlled clinical trials are still required to
assess and fully determine the feasibility, superiority and
role of certain techniques described in clinical use.
Take-Home Message
Comprehensive evaluation of patients with functional
anorectal disorders is important to supplement a good
history and examination. The tests outlined should be
used judiciously, employed by experienced gastroin-
testinal physiologists in a standardized manner to
allow for prospective. These tests can provide vital
information delineating the mechanisms causing
patients’ symptoms allowing for bespoke treatment.
758 M. Patel et al.

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 Ultrasonography in the Assessment
of Obstructive Defecation Syndrome
Marc Beer-Gabel, Ugo Grossi,
Christian Raymond S. Magbojos, and Giulio A. Santoro
Learning Objectives
• To recognize the ultrasonographic structures of the
pelvic floor with a focus on the posterior compart-
ment in patients with obstructive defecation
syndrome.
• To understand the role of ultrasound in the treat-
ment algorithm of obstructive defecation
syndrome.
63.1 Introduction
Chronic constipation is a frequent and often disabling condi-
tion affecting over 60 million American citizens [1].
Obstructive defecation is the most frequent phenotype of
chronic constipation affecting up to 50% of patients attend-
ing consultation in tertiary centers [2, 3]. Structural altera-
tions of the rectal anatomy at strain (e.g., rectocele,
intussusception) may explain, each one per se, symptoms of
obstructive defecation. Rectoceles may entrap stools, com-
press the rectum, and stimulate the receptors of pressure in
the puborectalis muscle (PRM), inducing a sense of incom-
plete rectal emptying. Intussusception is common in patients
presenting with a sense of anal blockage during rectal evacu-
ation. A non-relaxation or paradoxical PRM and external
anal sphincter (EAS) contraction may hamper or even pre-
vent the evacuation process. Obstructed defecation syndrome
(ODS) is a frequent pelvic floor dysfunction (PFD), described
in the literature under several definitions [4, 5]. All are based
on a combination of excessive straining on passing a stool,
sense of incomplete evacuation, digital assistance to aid fecal
expulsion, and overuse of laxatives or enemas [5, 6]. In the
gastroenterological literature, ODS is considered a form of
functional constipation [7].
M. Beer-Gabel (*) · U. Grossi · C. R. S. Magbojos · G. A. Santoro
Neurogastroenetrology and Pelvic Floor Unit, Laniado Medical
Center, Netanya, Israel
e-mail: marcobg7@gmail.com; giulioasantoro@yahoo.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_63
63
Chronic obstructive defecation is not only a frequent
cause of severe constipation and detriment to quality of life
but may also trigger PFD potentially affecting all compart-
ments (i.e., pelvic organ prolapse, fecal incontinence, and
urinary dysfunction) [8]. Constipation should be deemed as
important as obstetric trauma in the development of pelvic
floor damage. Hence, an adapted imaging method is recom-
mended for a dynamic assessment of pelvic organs in order
to evaluate the cause of ODS. In this scenario, it is manda-
tory to clearly distinguish between anatomical (e.g., entero-
cele, rectocele, intussusception) and functional abnormalities
(e.g., animus, dyssynergic defecation).
Current radiological methods include X-ray, magnetic
resonance imaging, and ultrasonography [9, 10]. They shall
demonstrate the effects of ODS on the three pelvic compart-
ments. As firstly described imaging method [11], X-ray defe-
cography (DEF) is currently considered the gold-standard
reference for the assessment of the posterior compartment
[12, 13]. During the procedure, a variable volume of barium
paste is inserted into the rectum to mimic stool consistency.
During simulated evacuation, rectoanal dynamics allow the
recognition of anatomical and functional abnormalities.
Patients are usually asked to drink a minimal amount of bar-
ium or gastrografin to opacify the small bowel, a step that has
been shown to improve the diagnostic accuracy for entero-
cele [14]. Likewise, vaginal opacification with barium may
reveal an anterior prolapse. Less frequently, a retrograde ure-
thral injection of contrast medium is carried out to visualize
the bladder as landmark of the anterior pelvic floor (i.e., cys-
tocolpodefecography). In such a case, antibiotics are recom-
mended for the potential risk of urinary tract infections. The
use of ionizing radiation in a sensitive area of the body rep-
resents the main drawback of DEF [14]. Magnetic resonance
defecography (MR-DEF) is an excellent although expensive
alternative. MR-DEF has the advantage of assessing both
pelvic organs and muscles in all compartments without using
radiation. However, high cost and relatively low accessibility
of MR-DEF make ultrasound (US) a promising alternative
761
762
for the assessment of PFDs. Several US modalities have been
described, all discussed in detail below.
63.2 Transperineal/Translabial/Introital
Ultrasound
Transperineal ultrasound is a noninvasive technique allowing
examination of the three pelvic floor compartments at rest,
squeeze, and strain (see Chap. 6). It is an in-office and rela-
tively inexpensive procedure that can be easily repeated.
This modality has been described under several terms in the
literature related to the position of the transducer on the
perineum/perineal body (transperineal ultrasound—TPUS),
between the labia majora (translabial ultrasound—TLUS),
or at the introitus (introital ultrasound—ITUS) [10, 15–18,
19]. By modifying the focal distance, the examiner can
obtain a panoramic view of all pelvic organs and the PRM
and dynamically assess their motion and coordination, or
even concentrate on a single organ. Furthermore, these meth-
ods allow the recognition of anatomical abnormalities of the
pelvic organs, excessive dynamic perineal descent, or failed
relaxation of PRM and EAS.
Several technical variations have been described (see
Chap. 6): (1) patient’s position varies from supine to left lat-
Fig. 63.1  Convex transducer placement for transperineal ultrasound
M. Beer-Gabel et al.
Fig. 63.2  Convex transducer placement for translabial ultrasound
eral [20–23]; (2) both 2D (allowing midsagittal or transverse
views) and 3D (showing a tomographic aspect of the pelvic
floor) probes can be used [24]; (3) in TPUS, the examination
starts by positioning a convex probe in the perineal area, ori-
ented in the sagittal plane, in contact with the perineal body
(PB) posteriorly and the labia majora anteriorly, close to the
vaginal cavity (Fig. 63.1); in TLUS, the examination starts by
positioning a convex probe between the labia majora, ori-
ented in the sagittal or transverse planes (Fig. 63.2); in ITUS,
the examination starts by positioning an end-fire probe at the
introitus, oriented in the sagittal or transverse planes
(Fig. 63.3); (4) some authors recommended the use of con-
trast in the hollow organs to enhance their visualization and
assess rectal evacuation [15], whereas others did not [17, 20].
63.2.1 Dynamic Transperineal Ultrasound
The method of dynamic TPUS (DTPUS), described by Beer-­
Gabel et al. in 2002 [15] and Unger et al. in 2011 [25], repro-
duces the same conditions of DEF, with simulating defecation
as one of the main steps of the procedure. Compared to the
DEF, DTPUS has the advantages of showing muscular com-
ponents, all pelvic organs, and their vascularity. It is per-
formed immediately after rectal cleansing with a single
low-volume enema or glycerol suppositories. Thence, patients
are given confidence that they will not involuntarily pass
stool, thus enhancing their compliance during the Valsalva
maneuver. They are asked to empty the bladder and drink a
glass of water (150 ml) prior to start the examination. During
the US scanning, the bladder partially fills. Covering the body
with a blanket and hiding the genitals give the patient a sense
of privacy. DTPUS is carried out using a convex 5–8 MHz
transducer (Profocus Ultra View, BK 3000 Herlev, BK
Medical, Denmark) upon application of acoustic gel on the
perineum. The examination is carried out with the patient in
the left lateral position and performed at rest and after specific
maneuvers (i.e., squeeze and Valsalva). Despite preventing
the gravity forces related to the sitting position on a toilet, the
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome 763

a b

Fig. 63.3  End-fire transducer placement for introital ultrasound. (a) Horizontal position for midsagittal field of view; (b) vertical position for
transverse field of view

a b

Fig. 63.4  Transperineal ultrasound by 2D convex probe. (a) Transverse view of the anal canal; (b) midsagittal view of the posterior pelvic floor
compartment (EAS external anal sphincter, IAS internal anal sphincter, PRM puborectalis muscle)

left lateral decubitus can still reproduce the angle between the
trunk and the thighs typically obtained on defecation.
The first part of the assessment (Phase 1) is performed
without contrast. The anal canal is initially assessed with the
transducer applied transversely to the PB to obtain an axial
view of the anus, using the hypoechoic ring of the internal
anal sphincter (IAS) as a landmark (Fig.  63.4). Thereafter,
the probe is turned by 90° to provide a midsagittal view of
the pelvic floor. Care is taken in order to avoid any pressures
on the perineum, which may distort the normal anatomy/
function. On the midsagittal plane, the anal canal can be seen
from posterior to anterior, drawn by the hypoechoic IAS and
its continuation in the rectum (Fig. 63.4). The EAS is seen as
a hyperechoic structure located at the distal end of the IAS. In
female patients, EAS typically appears asymmetric (i.e.,
thinner anteriorly than posteriorly) (Fig. 63.4). The posterior
anorectal angle (ARA, or anorectal junction) can be clearly
recognized by the bright hyperechoic elliptical PRM sling
(Fig. 63.4). It is measured at the level of the posterior anorec-
tal wall by the junction of a line tangent to the posterior anus
with another in the mid rectum parallel to the posterior rectal
wall (Fig. 63.5). At rest, its normal values range from 90 to
100°. The ARA opens at strain and typically closes with
squeeze efforts. The bladder neck junction is located anteri-
orly and deeply posterior to the symphysis pubis. Its position
is measured in relation to the symphysis pubis using orthog-
onal lines passing by the symphysis and the bladder neck
(Fig. 63.5). During Phase 1, the bladder is empty. The patient
is asked to squeeze the anus and strain to simulate defeca-
tion. The gross deformation of the pelvic organs and the
motion of the pelvic muscles are reported without any con-
trast. Variations in the posterior ARA and the descent of the
posterior (anorectal tip) and the anterior (bladder neck junc-
tion) pelvic floor are measured. The posterior urethro-vesical
angle is measured by the axis of the urethra and a line mark-
ing the bladder wall (Fig. 63.5).
764
Schematic representation of the pelvic floor at rest using sagittal DTP-US
(Vagina not shown)
Legend
X-axis passes through the center of the body of the pubis
Y-axis is perpendicular to the X-axis and abuts the posterior edge of the pubis
Z-axis is perpendicular to the X-axis and abuts the posterior margin of the ano-rectal junction
ARJ = Ano-rectal junction
UVJ = Urethro-vesical junction
1 = Ano-rectal angle (ARA)
2 = Posterior urethro-vesical angle (PUV)
D1 = Length of the puborectalis muscle
D2 = Position of the ARJ in relation to the X-axis
D3 = Position of the UVJ in relation to the X-axis
Z-axis
RECTUM
ARJ
ANAL
1 CANAL
D2
X-axis 90°
Fig. 63.5  Schematic representation of the pelvic floor at rest using sagittal dynamic transperineal ultrasound
The second phase (Phase 2) is performed with contrast,
inserting 10 ml of US gel into the vagina and 50 ml in the
rectum. The anal canal, already identified in the initial US
sweep for landmarks, is examined in greater detail during
maximum straining and evacuation of the intrarectal acoustic
gel. While giving a sense of rectal fullness similar to that per-
ceived prior to defecate, the use of contrast medium helps
defining the landmarks of the pelvic organs more precisely.
The volume of gel is lower than that of barium paste used for
DEF to avoid significant deformation of the rectum. Special
contrast to enhance the small bowel is no longer used as intes-
tinal loops can be recognized by spontaneous contractions.
Rectal contrast evacuation is the first end point of DTPUS. The
second end point is to evaluate the anatomical deformation at
strain, having the rectum loaded with gel prior to simulating
defecation. For patients with ODS, the intention is to try to
correlate symptoms with impaired rectal evacuation.
During the examination, the operator may change focus,
frequency, and angle of the transducer, concentrating on dif-
ferent pelvic floor regions according to patient’s symptoms
and assessment needs. The large field of view of the trans-
ducer allows visualization of all pelvic floor structures on the
M. Beer-Gabel et al.
BLADDER Y-axis
2
UVJ
PUBIS
UR
Point A
ETH
D3
Point D 90°
RA
Point C
Point B
D1
midsagittal plane at the same time. Any pelvic organ pro-
lapse may be elicited by Valsalva maneuver. Rectal and vagi-
nal contrast allows functional evaluation, which is of utmost
importance since organ deformation at strain does not neces-
sarily explain ODS symptoms. Thus, it is crucial to under-
stand both anatomical and functional changes and correlate
the dynamics of pelvic organs, perineal muscles, and sphinc-
ters to patient’s symptoms.
63.2.2 Dynamic Translabial Ultrasound
The method of dynamic translabial ultrasound (DTLUS)
was described by Santoro et  al. [15] and Dietz [24].
Differently from DTPUS, no rectal enemas/suppositories or
contrast medium are needed prior and during the procedure.
A convex transducer is placed between the labia majora of
the patient lying in the lithotomy position (i.e., supine with
hips flexed and abducted). The scanning process includes
resting phase, maximal pelvic floor contraction (MPFC),
and Valsalva maneuver. Conventional convex transducers
(3–6 MHz frequencies and field of view of 70°) provide 2D
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome 765

a b Cranial

Uterus

Rectum
Bladder

Puborectalis

Pubic
Bone

Anal
Canal Vagina Urethra

c d

Fig. 63.6  Translabial ultrasound performed by convex transducer (type 8802, BK Medical). Schematic representation of the field of view (a, b).
Ultrasound images (c, d) (A anal canal, P pubis, PB perineal body, PR puborectalis muscle, U urethra, V vagina)

imaging of the pelvic floor. In the midsagittal plane, all pel-
vic organs between the posterior surface of the symphysis
pubis and the posterior part of the levator ani are visualized
(Fig. 63.6). Using 3D transabdominal probes developed for
obstetric imaging, 3D- and 4D-TLUS may be performed
[25] (Fig.  63.7). These transducers combine an electronic
curved array of 4–8 MHz with mechanical sector technol-
ogy, allowing fast motorized sweeps through the field of
view. Compared with 2D mode, this technique provides a
comprehensive assessment of the PRM and its attachment to
the pubic rami by the acquisition of tomographic or mul-
tislice imaging (e.g., in the axial plane) (see Chap. 6). It is
also possible to measure the diameter and area of the levator
hiatus and determine the degree of hiatal distension on
Valsalva. The 4D imaging involves real-time acquisition of
volume US data, which can then be visualized instantly in
orthogonal planes or post-processing rendered volumes.
Offline analysis is possible on the actual system or on a per-
sonal computer using dedicated software.
63.2.3 Dynamic Endovaginal Ultrasound
Similar to DTLUS, dynamic endovaginal ultrasound
(DEVUS) is performed with the patient in the dorsal lithot-
omy position with hips flexed and abducted. Either an elec-
tronic biplane (linear and transverse perpendicular arrays) or
a radial electronic probe can be used (Fig. 63.8). After inser-
tion into the vagina up to the posterior vaginal fornix, the
transducer must be held in a neutral position to avoid ana-
tomical distortion. The biplane electronic probe provides 2D
sagittal (linear array) and axial (transverse array) sectional
imaging of the posterior compartment (see Chap. 7). In the
midsagittal plane, anterior and posterior rectal walls, PB,
PRM, and ARA are visualized (Fig.  63.9). Scanning is
acquired during rest, MPFC, and Valsalva. Color Doppler
mode can assess the vascular pattern of the pelvic floor struc-
tures. The rectal electronic probe allows a computer-­
controlled 3D acquisition (high-resolution 3D-EVUS)
(Fig. 63.8). Compared with 2D, 3D mode provides sagittal,
766 M. Beer-Gabel et al.

axial, coronal, and any desired oblique sectional images. A

sonographic interpretation of the Oxford prolapse grading
system [27] was used by Hainsworth et  al. [28] to grade
intussusception on posterior EVUS scanning (discussed
below).

63.2.4 Endoanal Ultrasound

and Echodefecography

Endoanal ultrasound (EAUS) is performed with a high mul-

Fig. 63.7  Convex volumetric transducer placement for 3D translabial
ultrasound [26]
tifrequency, 360° rotational mechanical probe or a radial
electronic probe, as described in Chap. 8. During the exami-
nation, the patient may lie in dorsal lithotomy, left lateral or
prone positions. However, irrespective of the decubitus, the
transducer should be rotated so that the anterior aspect of the
anal canal lies superiorly (12 o’clock position) on the screen,
the right lateral aspect to the left (9 o’clock), the left lateral
aspect to the right (3 o’clock), and the posterior aspect infe-

a b

Fig. 63.8  Dynamic endovaginal ultrasound performed by (a) biplanar transducer (convex and longitudinal arrays), (b) linear transducer,
(c) 3D-transducer
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome 767

Perineal
Cranial body

Anorectal Junction

Rectum Anal Canal

Puborectalis
Internal anal sphincter
Longitudinal
Fibres

Fig. 63.9  Endovaginal ultrasound allows a midsagittal visualization of the posterior compartment (A anal canal, ARJ anorectal junction, IAS
internal anal sphincter, PB perineal body, PR puborectalis muscle)

riorly (6 o’clock) [29]. The recording of data should encom-
pass the whole anal canal length, from the upper aspect of
the PRM to the anal verge. Dynamic endoanal ultrasound or
EDF is discussed in detail in Chap. 64.
63.3 Ultrasonographic Assessment
of Obstructive Defecation Syndrome
Ultrasound plays an important role in visualizing clinically
undetected abnormalities and/or confirming clinical findings
that may explain symptoms of ODS [30]. The descent of the
posterior pelvic floor can be easily assessed by measuring
the vertical displacement of the posterior ARA in relation to
a horizontal axis passing through the inferior symphysis
pubis (Fig.  63.10). Posterior dynamic perineal descent is
defined as a pelvic floor descent of more than 2 cm on strain
compared to rest. The measurement of the motion of the
bladder neck junction in relation to the same plane at rest,
squeeze, or Valsalva maneuver will serve to assess the ante-
rior perineal descent. Changes of the posterior ARA from
rest to squeeze or strain can serve as a surrogate of PRM
mobility. A closure of this angle on Valsalva defines anismus,
also known as a paradoxical contraction of the PRM and
EAS. A non-­relaxing perineum is a less-obvious feature of
dyssynergic defecation, defined by failed opening of the pos-
terior ARA at strain (Fig. 63.11). PRM tension can be indi-
rectly assessed by measuring its length from the symphysis
pubis to the posterior ARA: PRM normally shortens at
squeeze and lengthens at strain; it shortens at strain in
patients with anismus (Fig. 63.11). However, the presence of
pelvic organ prolapse may affect PRM length. The descended
organ occupies space, thus stretching the PRM.  This typi-
cally occurs in case of mid- or anterior compartment pro-
lapse (e.g., uterine prolapse, cystocele, or enterocele).
Consequently, detailed measurements should be provided by
reporting the presence of any pelvic prolapse. The position
of the bladder neck junction is of utmost importance for con-
tinence mechanisms. The length of the displacement along
its vertical axis may explain stress urinary incontinence. On
the other hand, an acute posterior urethro-vesical angle may
suggest a voiding disorder, with a kinking effect hampering
the passage of urine (Fig. 63.12).
Ultrasonography allows characterization of several ana-
tomical abnormalities, including rectocele, intussuscep-
tion, enterocele, and cystocele (see Chap. 48). Rectocele
768 M. Beer-Gabel et al.

a c

Y-ax
is
POINT A
RECTUM

PUBIS
ARI ANAL
CANAL
DI

X-axis

90°

b POINT B
Z-axis

POINT D
POINT C

RECTUM
W-axis
90° D2 PUBIS
ARJ
90°
X-axis

ANAL
ARJ CANAL

Fig. 63.10  Schematic representation of the posterior pelvic floor dur-
ing sagittal dynamic transperineal ultrasonography (DTPUS). (a) The
X-axis passes through the central portion of the symphysis pubis, and
the Y-axis passes perpendicularly to the X-axis abutting the posterior
aspect of the anorectal junction (ARJ). The anorectal angle (ARA) is
clearly definable on DTP-US.  The distance between points A and B
represents ARJ displacement (distance D1) between the resting position
and following maximal straining; (b) schematic representation of the
measurement of rectocele depth. The Z-axis passes through the pro-
jected anterior aspect of the anal canal perpendicular to the X-axis. The
W-axis passes at right angles to the Z-axis through the most anterior
point of the rectocele. The distance between points C and D represents
the depth of the rectocele (distance D2); (c) large rectocele visualized
as a bulging of the anterior rectal wall by transperineal ultrasound (AC
anal canal, B bladder, PR puborectalis muscle, R rectum, SP symphysis
pubis, U urethra)

depth, intussusception, enterocele, and cystocele grades are
also defined. Rectoceles are diagnosed by an anterior bulg-
ing of the rectum into the posterior vaginal wall (Fig. 63.13).
Their depth is measured perpendicular to a line projected
along the expected contour of the anterior rectal wall
(Fig. 63.10). Rectoceles of 2–4 cm in depth are considered
medium-sized, while those deeper than 4 cm are considered
large-sized. Recent evidence suggests that only rectoceles
≥4  cm in depth should be considered truly pathological
[11, 27]. Indeed, a large overlap exists between healthy
subjects and patients with ODS when considering <4  cm
rectoceles [11]. However, medium-sized rectoceles may
become clinically significant when trapping stool
(Figs.  63.14 and 63.15). Their emptying at strain is mea-
sured. The relation of the size of the rectocele with anismus
should also be determined before considering surgical cor-
rection, since paradoxical PRM contraction may improve
with physiotherapy and biofeedback [28]. Large rectoceles
are believed to be associated with difficulty or sense of
incomplete evacuation, rectal pain, and rectal bleeding.
Patients often report a sense of vaginal mass or heaviness
and low rectal blockage on defecation. Rectoceles associ-
ated with refractory ODS are often treated with surgery in
order to resolve fecal entrapment. However, the size of a
rectocele should not be deemed as the sole indication for
surgery. A recent study demonstrated that only the evacua-
tion of rectoceles correlated to their size, although with no
proved clinical significance [31].
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome
a Rest
AC
Up
ARA
R Down
Fig. 63.11  Perineal ultrasound of a patient complaining of obstructive
defecation at strain. (a) At rest, the posterior anorectal angle (ARA)
designed by a tangent line to the posterior border of the anal canal and
the posterior rectal wall is 105°. (b) At strain, there is a paradoxical
Fig. 63.12 Dynamic translabial ultrasound by convex transducer
showing an acute posterior urethro-vesical angle (PUV) with kinking
effect during Valsalva maneuver (B bladder, SP symphysis pubis, U ure-
thra, UT uterus)
According to the Oxford prolapse grading system, inter-
nal rectal prolapse is defined as the folding of the rectum into
either the rectum (recto-rectal) or the anal canal (recto-anal)
769
b Strain
AC
ARA
R
closure of the ARA to 91°. The contraction of the puborectalis muscle
at strain, showed by its imprint on the posterior anorectal junction and
by the closure of the ARA, is responsible for the obstructive defecation
(AC anal canal, R rectum)
[27]. The latter can be further subclassified into high-anal
and low-anal intussusception (Figs.  63.16 and 63.17).
Similarly, Hainsworth et  al. [28] suggested an ultrasono-
graphic method of assessment using DEVUS, with grade of
intussusception determined by the maximal limit of the
infoldings during Valsalva. The five grades are defined as
follows:
• Grades I–II: infolding rectal wall ceased prior to the infe-
rior edge of the PRM (Fig. 63.18a)
• Grade III–IV: infolding reached beyond the inferior edge
of PRM but stopped before the perineal body (Fig. 63.18b)
• Grade V: infolding rectal wall protruded beyond the peri-
neal body (Fig. 63.18c).
Enteroceles are defined as a herniation of the small bowel
anterior to the rectal wall and extending into the vagina
through the Douglas pouch [32] (Fig. 63.19). An enterocele
can compress the anterior face of the rectum and/or fill the
rectovaginal septum. Sigmoidocele is a redundant sigmoidal
loop detectable in the Douglas pouch at strain [33, 34].
During DTPUS/DTLUS/DEVUS, differentiation of a sig-
moid loop from an enterocele is made on the basis of the
anatomy of the loop(s) in the pouch of Douglas, the presence
or absence of typical small-bowel contractions, and the qual-
ity of hyperechoic contrast detectable in the prolapsed intes-
tinal loops (Figs.  63.20 and 63.21). An enterocele or a
770 M. Beer-Gabel et al.

a b

Fig. 63.13  Rectocele is defined as a herniation of the anterior rectal wall into the vagina (posterior vaginal wall prolapse). (a) Schematic repre-
sentation; (b) clinical finding

a b

Fig. 63.14  Transperineal ultrasound showing (a) prolapse of the distal appears as an enlarged hyperechoic rectovaginal septum between these
posterior vaginal wall (VP) on Valsava. Fecal residues impinging the structures. (b) Typical appearance of a rectocele as an anterior rectal
anterior rectal wall highlighted by hypoechoic gel (R). A thin layer of bulging deforming the posterior vaginal wall in a different patient
hypoechoic gel is also seen in the vagina (V). The vaginal wall prolapse

sigmoidocele can be categorized as small if extended der beyond the introitus defines a grade 3 cystocele [32]
between 3 and 6 cm below the vaginal apex, moderate if the (Fig. 63.23) (see Chap. 48).
extension is between 6 and 9 cm, and large if it is more than
9 cm [33]. Cystocele is defined as a herniation of the bladder
into the anterior vaginal wall. It can coexist with a rectocele 63.4 U
 ltrasound vs. X-ray Defecography
in the same vaginal prolapse (Fig. 63.22). The grade of the (DEF) vs. MR Defecography (MR-DEF)
cystocele is defined by the lowest position of the detrusor in in the Assessment of ODS
relation to the vaginal wall. Grade 1 cystocele reaches the
mid-vagina and is not clinically significant. Grade 2 cysto- Currently, DEF and MR-DEF are largely used as imaging
cele occurs when the bladder prolapses far enough to come modalities for the assessment of ODS, whereas pelvic floor
close to the vaginal opening. A deeper prolapse of the blad- US is yet to be implemented in clinical practice. However,
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome 771

a b

Fig. 63.15  Translabial ultrasound by convex transducer showing a large rectocele with stool entrapment (a, b) (AC anal canal, B bladder, PR
puborectalis muscle, R rectum, U urethra)

a b

Fig. 63.16  Intussusception is defined as an invagination of the rectal wall into the rectal lumen. It may be classified as intra-rectal (a, b) if it
remains in the rectum or intra-anal if it extends into the anal canal (c)
772 M. Beer-Gabel et al.

there is lack of consensus regarding the diagnostic accuracy

c
of these techniques. Most studies compared MR-DEF (per-
formed either with an open or closed magnet) and/or US
(DTPUS, DEVUS, EDF, and DAE) [35, 36] as index tests
compared to DEF, used as reference standard. A meta-­
analysis of 38 studies on 2452 females with ODS [37] eval-
uated the accuracy of imaging modalities in the assessment
of ODS [37]. For the diagnosis of rectocele, the pooled sen-
sitivities of MR-DEF (0.89), DTPUS (0.76), DEVUS
(0.71), and DAE (0.68) were significantly lower compared
to DEF (0.99) (p  =  0.032, p  =  0.002, p  ≤  0.001 and
p  ≤  0.001, respectively). The pooled sensitivity of EDF
(0.95) was not significantly different from DEF. Specificities
of the index tests were not significantly different compared
to the reference standard (0.81–0.90 vs. 0.91) (p = 0.264–
0.894). Overall diagnostic test accuracy for diagnosis of
rectocele was h­ighest for DEF (pooled diagnostic odds
ratio [DOR] 887) compared to MR-DEF (DOR 62), DTPUS
(DOR 13), DEVUS (DOR 12), EDF (88), and DAE (DOR
19). For the diagnosis of enterocele, the pooled sensitivity
of DTPUS (0.80) was lower but not significantly different
from DEF (0.93) (p  =  0.116); however, sensitivities of
Fig. 63.16 (continued) MR-DEF (0.79), DEVUS (0.38), and EDF (0.61) were sig-

a b

c d

Fig. 63.17  Dynamic transperineal ultrasonography showing (a, b) a recto-anal intussusception with gel entrapment into the rectocele (AC
rectocele at the first stage of Valsalva; at further evacuation, an anterior anal canal, B bladder, R rectocele, RAI recto-anal intussusception, RRI
rectal wall prolapse initially determining a (c) recto-rectal and then (d) recto-rectal intussusception, V vagina)
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome 773

a
Grade Defaecation Proctography - Oxford Radiological Posterior Transvaginal Ultrasound -
Classification System Sonographic Interpretation of Oxford
System

Recto – Rectal

Non – Pathological

High rectal In folding rectal wall stops prior to inferior

edge of PR (cranial half of PR)

II

Recto – Rectal

Non – Pathological

Low rectal - in folding descends onto the level of In folding rectal wall stops prior to inferior
the rectocoele edge of PR (caudal half of PR)

b
Grade Defaecation Proctography - Oxford Radiological Posterior Transvaginal Ultrasound -
Classification System Sonographic Interpretation of Oxford
System

II

Recto – Anal

Pathological

High anal In folding rectal wall stops between the

inferior edge of PR but before PB (just
beyond PR and onto anal canal)

III

Recto – Anal

Pathological

Low rectal - in folding descends onto the level of In folding stops between the inferior edge
the rectocoele of PR but before PB (into anal canal)

Fig. 63.18  Posterior endovaginal ultrasound. Sonographic interpreta- before the perineal body; (c, d) Grade V: infolding rectal wall protruded
tion of Oxford system (see text). (a) Grades I–II: infolding rectal wall beyond the perineal body. (B bladder, R rectum, RAI rectoanal intus-
ceased prior to the inferior edge of the puborectalis (PR); (b, c) Grade susception, RRI rectorectal intussusception, V vagina)
III–IV: infolding reached beyond the inferior edge of PR but stopped
774 M. Beer-Gabel et al.

c
Grade Defaecation Proctography - Oxford Radiological Posterior Transvaginal Ultrasound -
Classification System Sonographic Interpretation of Oxford
System

Overt Rectal Prolapse

Pathological

The in folding rectal wall protrudes from the anus Limit of in folding beyond the PB.

Fig. 63.18 (continued)

a b

Fig. 63.19  Enterocele is defined as a hernia of the small bowel or sigmoid colon (sigmoidocele) into the vagina. (a) Schematic representation;
(b) at the clinical assessment, an enterocele may result in a posterior vaginal wall prolapse that needs to be differentiated from a true rectocele

nificantly lower (p = 0.015, p < 0.001, and p = 0.002), with
sensitivity of DEVUS also being significantly lower than
MR-DEF and DTPUS (p < 0.001 and p = 0.003). The non-
significant difference in sensitivity of DAE vs. DEF was
likely due to the low numbers of included studies; hence,
no clear conclusions could be drawn. Specificities of all
index tests for diagnosis of enterocele were not signifi-
cantly different compared to DEF (0.96–1.00 vs. 0.96)
(p  =  0.386–0.984). Overall diagnostic test accuracy for
diagnosis of enterocele was highest for DEF (pooled DOR
268) compared to MR-DEF (DOR 181), DTPUS (DOR
161), DEVUS (DOR 19), and EDF (DOR 92) [37]. For the
diagnosis of intussusception, the pooled sensitivity of
DTPUS (0.90) was lower but not significantly different
from DEF (0.97) (p  =  0.532); however, sensitivities of
MR-DEF (0.63), DEVUS (0.64), and DAE (0.09) were sig-
nificantly lower (p  =  0.039, p  =  0.032, p  <  0.001).
Specificities of all index tests for diagnosis of intussuscep-
tion were not significantly different compared to DEF
(0.86–0.94 vs. 0.90) (p = 0.387–p = 0.791). Overall diag-
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome 775

a b

Fig. 63.20  Dynamic translabial ultrasound by convex transducer showing large enteroceles (E) (a–c) (AC anal canal, B bladder, R rectum, SP
symphysis pubis, U urethra)

nostic test accuracy for diagnosis of intussusception was
highest for DEF (pooled DOR 315) compared to MR-DEF
(DOR 24), DTPUS (DOR 104), DEVUS (DOR 18), and
DAE (DOR 1) [37]. For the diagnosis of anismus, the
pooled sensitivities of MR-DEF (0.76), DTPUS (0.89),
DEVUS (0.86), and EDF (0.87) were not notably different
compared to DEF (0.89) (p = 0.807–0.999). Specificity of
MR-DEF (0.93) was not significantly different from DEF
(0.98) (p = 0.062); however, specificities of DTPUS (0.83),
DEVUS (0.86), and EDF (0.89) were significantly lower
than DEF (p < 0.001, p = 0.001 and p = 0.015), with DTPUS
and DEVUS also lower than MR-DEF (p  =  0.001 and
p = 0.024). Overall diagnostic test accuracy for diagnosis of
anismus was highest for DEF (pooled DOR 360) compared
to MR-DEF (DOR 43), DTPUS (DOR 40), DEVUS (DOR
40), and EDF (DOR 56) [37]. For the diagnosis of pelvic
floor descent, the pooled sensitivity of MR-DEF (0.76) was
significantly lower compared to DEF (0.97) (p  =  0.009),
and the pooled specificity was lower but not significantly
different (0.76 vs. 0.97; p  =  0.085). Given the very low
number of published studies for DTPUS, DEVUS, EDF,
and DAE, no clear conclusions could be drawn for these
index tests. Overall diagnostic test accuracy for diagnosis
of pelvic floor descent was highest for DEF (pooled DOR
1121) compared to MR-DEF (DOR 10) [37]. The use of
rectal contrast significantly increased the sensitivity of
DTPUS for the diagnosis of enterocele and intussuscep-
tion, however did not change test’s accuracy for rectocele
776 M. Beer-Gabel et al.

a b

Fig. 63.21  Dynamic endovaginal ultrasound by linear transducer showing enterocele (E) and intussusception (IN) (a, b) (R rectum)

Level of ischial spine

a b

Urethra

Cystocele

Rectocele

Enterocele with
vault eversion

Fig. 63.22  Multicompartmental prolapse (cystocele, enterocele, recto- translabial ultrasound by convex transducer (AC anal canal, B bladder,
cele) into the vagina. (a) Schematic representation; (b) at the clinical C cystocele, E enterocele, R rectocele)
assessment, organs prolapsed need to be differentiated; (c) dynamic
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome 777

[37]. Including an evacuation phase and positioning the

c
patient in the left-lateral decubitus, increased the sensitivity
of DTPUS for the diagnosis of rectocele, enterocele and
intussusception, however not significantly. Studies per-
forming DTPUS with rectal contrast are predominantly
performed in the left-lateral position with evacuation phase;
therefore, it remains unclear which of these three factors is
causing this increment in sensitivity. Cutoff values did not
influence test accuracy of DTPUS.  Given these findings,
the authors concluded that MR-DEF performed with an
evacuation phase has a similar test accuracy compared to
DEF, showing to be non-inferior to this imaging technique
for the diagnosis of posterior pelvic floor disorders and
could therefore be used as an alternative. There is still the
need for larger and well-­defined studies to evaluate the
exact place of DTPUS. However, at present, given its high
specificity, DTPUS could be used as a triage tool (SpIN tri-

Fig. 63.22 (continued)

a b

Fig. 63.23  Dynamic translabial ultrasound by convex transducer showing a multicompartmental prolapse (cystocele and rectocele) (a, b)
778 M. Beer-Gabel et al.

a b c

Fig. 63.24  Laparoscopic ventral mesh rectopexy. (a) Schematic representation; (b) intraoperative view; (c) dynamic translabial ultrasound by
convex transducer showing the mesh (arrows) (AC anal canal, B bladder, R rectum, U urethra, V vagina)

Fig. 63.25 Dynamic
translabial ultrasound by
convex transducer showing a
hematoma after laparoscopic
ventral mesh rectopexy (AC
anal canal, R rectum, SP
symphysis pubis, U urethra,
V vagina)

age tool; sensitivity >50%, specificity >95%) and only
women tested could be sent for DEF or MR-DEF [37].
63.5 U
 ltrasound Assessment After Pelvic
Floor Surgery
Since the late 1990s, synthetic suburethral implants have
become very popular. Ultrasound can confirm the presence and
location of these slings, especially in the axial plane. Given
their high echogenicity, US is superior to MR-DEF in identify-
ing implants [38] and has helped clarify their way of action. For
the posterior compartment, it is very helpful to reassess patients
after ventral mesh rectopexy (Fig. 63.24). In this setting, US
will be useful in determining functional outcome and develop-
ment of mesh complications, such as erosion, support failure,
migration, and chronic pain [39] (Fig. 63.25).
63.6 Conclusions
Ultrasound imaging provides a comprehensive assessment of
patients with ODS and can define the presence and grade of
posterior compartment prolapse. Combining DTPUS,
DTLUS, DEVUS, and EAUS has the potential to comple-
ment the advantages and overcome the limitation of each of
63  Ultrasonography in the Assessment of Obstructive Defecation Syndrome
these modalities with substantial improvements on the clini-
cal management of posterior compartment disorders. The
greatest utility of this ultrasonographic “integrated approach”
is the identification of both anatomical and functional pelvic
floor abnormalities in a nonionizing office procedure.
Take-Home Messages
• Clinical examination cannot accurately determine
the pathophysiology mechanisms of ODS (often
resulting from a combination of anatomical and
functional abnormalities) and detecting multicom-
partmental anatomical defects of the pelvic floor.
• DTPUS, DTLUS, DEVUS, and EDF represent
alternative imaging modalities to DEF and MR-­
DEF for the investigation of ODS and could be per-
formed as screening method in the initial assessment
of evacuation disorders. Positive findings on US
may avoid more invasive tests, whereas negative
findings may require confirmation by DEF or
MR-DEF.
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 Echodefecography: Technique
and Clinical Application
Sthela M. Murad-Regadas, Francisco Sérgio P. Regadas,
and Steven D. Wexner
Learning Objectives
• Describe two appropriate options of dynamic ultra-
sound technique to assess pelvic floor
dysfunctions.
• Describe and interpret the echodefecography 3D
dynamic anorectal ultrasonography technique with
a 360° transducer to identify pelvic floor dysfunc-
tions related to obstructed defecation syndrome
(rectocele, intussusception, anismus, sigmoidocele/
enterocele, and perineal descent), prolapse as
descends of the uterus and cystocele, as well as
evaluate the anatomy of the anal canal and detect
sphincter defect as well as defects defined as the
detachment (discontinuity) of the pubic visceral
muscles.
• Describe and interpret the 3D transvaginal and tran-
srectal ultrasonography (TTUS) using a biplane
transducer in the diagnosis related to obstructed
defecation syndrome, as anismus, rectocele, entero-
cele/sigmoidocele, and intussusception.
S. M. Murad-Regadas (*)
School of Medicine, Federal University of Ceara,
Fortaleza, Ceara, Brazil
Anorectal Physiology and Pelvic Floor Unit,
Sao Carlos Hospital, Fortaleza, Ceara, Brazil
e-mail: smregadas@hospitalsaocarlos.com.br
F. S. P. Regadas
Department of Surgery, School of Medicine,
Federal University of Ceara, Fortaleza, Ceara, Brazil
e-mail: sregadas@hospitalsaocarlos.com.br
S. D. Wexner
Digestive Disease Center, Department of Colorectal Surgery,
Cleveland Clinic Florida, Weston, FL, USA
Florida Atlantic University College of Medicine,
Boca Raton, FL, USA
e-mail: wexners@ccf.org
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_64
64
64.1 Introduction
Recent advances in imaging technologies and development
of ultrasound equipment with 3D-acquisition have opened
new possibilities for research on anal canal, rectum, and pel-
vic floor disorders [1–3]. The advantage of 3D with auto-
matic scanning is measurement of the length and thickness
of the sphincter muscles without manual movement of the
transducer, which may potentially be more comfortable.
The volumetric image acquired from 3D anorectal ultra-
sonography allows clear identification of the entire anal
canal in several planes, demonstrating the length and the
position of all anatomic structures and anal canal configu-
ration. Muscles are parallel but are distributed in different
positions. They start and end in different levels resulting in
an asymmetric anal canal in both genders. In a previous
study, Regadas et  al. evaluated anal canal anatomy using
3D imagining and demonstrated the asymmetrical shape of
the anal canal [1]. Specifically, the anterior anal canal starts
and ends more distally and is formed by the external anal
sphincter (EAS) and the internal anal sphincter (IAS),
while the posterior anal canal starts and ends more proxi-
mally, including the puborectalis muscle as well. In the
anterior quadrant, there is a gap area, without striated mus-
cle, measured from the proximal edge of the posterior PR
to the proximal edge of the anterior EAS, the weakest area
of the anal canal (Fig. 64.1). They also evaluated the gen-
der-related differences in anal canal anatomy and the mus-
cle length, demonstrating that the anterior EAS is shorter
(mean = 2.2 cm/range) and the gap length (mean = 1.2 cm/
range) is longer in females compared with males
(EAS = 3.4 cm; GAP = 0.7 cm), providing a possible expla-
nation for the higher incidence of pelvic floor dysfunction
in women (Fig. 64.2).
Ultrasound is appealing as high-resolution images may be
obtained during office examination.
Studies using dynamic modalities, such as transrectal,
translabial, and transperineal, have been published since
781
782
Fig. 64.1  Female anal canal anatomic configuration (sagittal plane),
highlighting the asymmetrical shape of the anal canal and the positions
of the anal sphincters and gap area. EAS external anal sphincter, IAS
internal anal sphincter, PR puborectalis muscle, GAP the area in the
anterior quadrant without striated muscle, measured from the proximal
edge of the posterior PR to the proximal edge of the anterior EAS
a b
Fig. 64.2  Anal canal anatomy comparing female (a) with male (b) images (sagittal plane). GAP the area in the anterior quadrant without striated
muscle, measured from the proximal edge of the posterior puborectalis muscle (PR) to the proximal edge of the anterior external anal sphincter
(EAS). IAS internal anal sphincter
S. M. Murad-Regadas et al.
2000 comparing the results with defecography have demon-
strated high concordance in the ability to identify dysfunc-
tion [1–8].
Murad-Regadas et  al. developed the echodefecography
technique, a 3D dynamic anorectal ultrasonography tech-
nique using a 360° transducer, automatic scanning, and high
frequencies for high-resolution images, to evaluate the anal
canal and pelvic floor anatomy in patients with evacuation
disorders affecting the posterior compartment (rectocele,
intussusception, anismus), the middle-apical compartment
(grade II or III sigmoidocele/enterocele), and the anterior
compartment (cystocele). The technique of echodefecogra-
phy including parameters and reproducible values was estab-
lished [2, 9, 10].
64.2 Echodefecography (EDF) Technique
Echodefecography is performed with a 3D ultrasound device
(Pro-Focus, endoprobe model 2052, BK Medical®, Herlev,
Denmark) with proximal-to-distal 6.0-cm automatic scans.
By moving two crystals on the extremity of the transducer,
axial and longitudinal images are merged into a single cube
image, recorded, and analyzed in multiple planes.
Following a rectal enema, the patient is examined in the
left lateral position.
The dynamic assessment consists of four automatic scans
and analyzed in the axial, sagittal, and if necessary, in the
oblique plane. The result of the examination depends on the
degree of patient’s cooperation.
64  Echodefecography: Technique and Clinical Application 783

a b

Fig. 64.3  Combined external anal sphincter (EAS) and internal anal the middle anal canal. Measurements of the lengths of the residual EAS
sphincter (IAS) defects after vaginal delivery. (a) Mid anal canal—The and IAS (sagittal plane). PR puborectalis
EAS and IAS defects (axial plane). (b) The lesion compromised only

–– Scans 1, 2, and 4 use a slice width of 0.25 mm and lasts the angle size) is compared between scans 1 and 2. Normal
50 s each. relaxation is recorded if the angle increases by a minimum of
–– Scan 3 lasts 30 s with a slice width of 0.35 mm. one degree, whereas paradoxical contraction (Anismus) is
recorded if the angle decreases by a minimum of one degree
Scan 1 (at rest position without gel): The transducer is (Figs. 64.4 and 64.5). Non-relaxation is recorded if the angle
positioned at 4.0–5.0 cm from the anal margin to visualize changes less than 1°.
the anatomic integrity of the anal sphincter muscles and to Scan 3: The transducer is positioned proximally to the PR
identify any occult defect. The endovaginal approach is valu- (anorectal junction). The scan starts with the patient at rest
able in patients who underwent vaginal delivery and/or in (3.0 s), followed by maximum straining with the transducer
patients with obstructed defecation and fecal incontinence. in fixed position (the transducer does not follow the descend-
(Fig. 64.3) ing muscles of the pelvic floor). Scanning continues distally
In this scan, the anorectal angle is measured at rest. The until the PR muscle becomes visible.
angle is formed between a line traced along the internal bor- Perineal descent is quantified by measuring the distance
der of the posterior EAS-PR muscles (1.5  cm) and a line between the position of the proximal border of the PR at rest
traced perpendicular to the axis of the anal canal. and the point to which it has been displaced by maximum
All the following scans are dynamic evaluation. straining (PR descent). Straining time is directly propor-
Scan 2 (at rest—straining—at rest without gel): The tional to the distance of perineal descent.
transducer is positioned at 6.0 cm from the anal verge. The Even with patients in the lateral position, the displace-
patient is requested to keep at rest during the first 15 s, then ment of the PR muscle is easily visualized and quantified.
to maximally strain for 20 s, and then to relax again, with the Normal perineal descent during straining is defined as a dif-
transducer following the movement. The purpose of this scan ference in PR muscle position of ≤2.5  cm and perineal
is to evaluate the movement of the PR-EAS muscles during descent >2.5 cm (Fig. 64.6). The normal range values were
straining in order to identify normal relaxation, non-­ established by comparing EDF findings with DF [10].
relaxation, or paradoxical contraction (Anismus). The result Scan 4: Following injection of 120–180  mL ultrasound
of the posterior EAS-PR muscles’ position (represented by gel into the rectal ampulla, the transducer is positioned at
784 S. M. Murad-Regadas et al.

a b

Fig. 64.4  Patient with normal relaxation (sagittal plane). (a) Angle measured at rest position (lines), (b) Increased angle during straining (lines).
EAS external anal sphincter, IAS internal anal sphincter, PR puborectalis muscle

a b

EAS
EAS

PR
EAS
PR
EAS

Fig. 64.5  Patients with Anismus (sagittal plane). (a) Angle measured at rest position (lines). (b) Decreased angle (anismus) during straining
(lines). EAS external anal sphincter, IAS internal anal sphincter, PR puborectalis muscle
64  Echodefecography: Technique and Clinical Application
a b
Fig. 64.6  Perineal descent measurement (sagittal plane). (a) Puborectal descent (PD) ≤2.5 cm—normal perineal descent. (b) Puborectal descent
(PD) >2.5 cm—Perineal descent. PR puborectalis muscle
7.0  cm from the anal verge. The scanning sequence is the
same as Scan 2 (at rest during 15 s, strain maximally during
20 s, and then relax again, with the transducer following the
movement). The purpose of the scan is to visualize and quan-
tify all anatomical structures and functional disorders
(Rectocele, Intussusception, grade II or III sigmoidocele/
enterocele, and cystocele).
In normal patients, the posterior vaginal wall displaces
the lower rectum and upper anal canal inferiorly and
­posteriorly but maintains a straight horizontal position dur-
ing defecatory effort (Fig. 64.7). If rectocele is identified, it
is classified as grade I (<6.0 mm), grade II (6.0–13.0 mm), or
grade III (>13.0 mm) (Fig. 64.8). Measurements are calcu-
lated by first drawing two parallel horizontal lines along the
posterior vaginal wall, with one line placed in the initial
785
straining position, and the other line drawn at the point of
maximal straining. The distance between the two lines (vagi-
nal wall positions) determines the size of the rectocele
(Fig. 64.8). Intussusception is clearly identified by observing
the rectal wall layers protruding through the anorectal lumen.
No classification is used to quantify Intussusception
(Figs.  64.9 and 64.10). Grade II or III Sigmoidocele/
Enterocele is recognized when the bowel bulges downward
to the pelvis, between the posterior vagina and the anterior
lower rectal wall (on the projection of the lower rectum and
upper anal canal) (Fig. 64.11). Cystocele is identified using a
reference line drawn perpendicular to the proximal margin of
the puborectal muscles and measured by a displacement of
the bladder or bladder neck below the proximal margin of the
PR ≥ 0.5 cm (Figs. 64.12 and 64.13).
786 S. M. Murad-Regadas et al.

a b

Fig. 64.7  Using intrarectal gel. Patients without rectocele (sagittal plane). (a) Case 1, (b) Case 2. The vagina maintains a straight horizontal posi-
tion during defecatory effort. EAS external anal sphincter, IAS internal anal sphincter, PR puborectalis muscle

In patients in whom a prosthesis has been placed (such as
a urethral sling), it is possible to identify the position of the
prosthesis in relation to the organ (Fig. 64.14).
The main advantage of using ultrasound is the possibility
to simultaneously evaluate the morphology (anal canal and
pelvic floor anatomy), as well as any dynamic dysfunction.
In patients with obstructed defecation symptoms without
associated fecal incontinence, who underwent vaginal deliv-
ery or anorectal surgery that resulted in sphincter division,
such as fistulotomy or sphincterotomy, assessment may
reveal occult defects. Similar results may be obtained from
transvaginal placement of the same 360° rotating transducer
probe).
Endovaginal/Transvaginal technique—The patient
is kept at rest and in dorsal lithotomy position. The trans-
ducer is placed in the vagina in the neutral position and
introduced to an extent to the bladder [11, 12]. The pur-
pose of this scan is to visualize the anatomic integrity of
the levator ani muscles and measure the levator hiatus
area that is determined by the inner margins of the lateral
branches of the levator muscles and the pubic bone. The
nomenclature regarding the levator ani varies. As pro-
posed by DeLancey, the term Pubovisceral muscle (PVM)
is used, which is synonymous with the term pubococ-
cygeus/puborectalis since the two components cannot be
distinguished on imaging [13].
The scanning identifies any defects defined as the detach-
ment (discontinuity) of the pubic visceral muscles from their
insertion on the pubic ramus on each side (Fig. 64.15) and
measure the area of the levator hiatus (Fig. 64.16). Complete
detachment of the PVM involves the entire muscle, and par-
tial detachment can be either unilateral or bilateral.
64  Echodefecography: Technique and Clinical Application 787

a b

Fig. 64.8  Rectocele grade (sagittal plane) is measured by one line Patient classified as grade II rectocele (arrows). (b) Patient classified as
placed in the initial straining position (1), and the other line drawn at the grade III rectocele (arrows). EAS external anal sphincter, IAS internal
point of maximal straining (2). The distance between the two lines anal sphincter, PR puborectalis muscle
(vaginal wall positions) determines the size of the rectocele (3). (a)

a b

Fig. 64.9  Using intrarectal gel. Patient with grade III rectocele (arrows eral intussusception (axial plane, arrows). (c) Grade III rectocele and
head) and intussusception (arrows). (a, b) Anterior, right, and left lat- intussusception (sagittal with coronal plane)
788 S. M. Murad-Regadas et al.

Levator trauma has been found to have occurred in

c
between 15 and 55% of parous women after vaginal child-
birth. The most common defect identified is an avulsion
injury at the insertion of the PVM on the pubic ramus, which
has been demonstrated by MRI and ultrasonography. This
defect can be associated with pelvic organ prolapse and bal-
looning hiatal dimensions [14–20].
Murad-Regadas et al. demonstrated that the severity of fecal
incontinence symptoms is significantly related to extent of the
defect as determined by the novel 3D ultrasound score. This
assessment includes anal sphincter and pubovisceral muscle
defects in women who have undergone vaginal delivery [21,
22]. They also evaluated the position of the anorectal junction,
measuring from it to the lowest margin of the symphysis pubic
and the position of the bladder neck, and measuring from the
bladder neck to the lowest margin of the symphysis pubic [12,
23] (Fig. 64.17). In a previous study, Murad-Regadas described
a technique for assessment of perineal descent by dynamic 3D
endovaginal ultrasonography. Using this technique, excessive
perineal descent can be defined as displacement of the anorec-
tal junction >1  cm and/or its position below the symphysis
pubis on Valsalva [23] (Fig. 64.18).
Echodefecography has been validated in a multicenter study
of 86 women at six colorectal surgery centers in the United
States, Brazil, and Venezuela [9]. A high degree of agreement
was observed between echodefecography and conventional
Fig. 64.9 (continued) defecography in the diagnosis of anorectal disorders. In a
recent study, the EDF was compared with dynamic translabial

a b

Fig. 64.10  Using intrarectal gel. Patient with grade III rectocele side intussusceptions (arrows, axial plane). (b) Grade III rectocele and
(arrow head) and intussusception (arrows). (a) Anterior and right lateral intussusception (sagittal with coronal plane)
64  Echodefecography: Technique and Clinical Application 789

a b

Fig. 64.11  Patient with grade II or III sigmoidocele/enterocele—the bowel bulges downward to the pelvis. (a, b) Axial plane. (c) Sagittal plane.
PR puborectalis muscle
790
a b
Fig. 64.12  Patient with cystocele and without rectocele. (a) Axial
plane – bladder below the puborectalis muscle (PR). (b) Cystocele mea-
sures by the displacement of the bladder below (line 2) the proximal
ultrasound, and the results demonstrated good correlation for
diagnosis of anismus, rectocele, and cystocele.
The other option of dynamic ultrasound is to assess the
ODS using the 3D biplane transducer with combined trans-
vaginal and transrectal approaches. The technique was stan-
dardized comparing with echodefecography and achieved
high rates of concordance and accuracy in the diagnosis of
anismus, rectocele, enterocele/sigmoidocele, and intussus-
ception in women with obstructed defecation syndrome, as
mentioned below [24].
64.3 3D Transvaginal and Transrectal
Ultrasonography (TTUS)
Dynamic ultrasonography combining transvaginal and tran-
srectal approaches using a 3D biplane transducer has been
used in the diagnosis of anismus, rectocele, enterocele/sig-
S. M. Murad-Regadas et al.
margin of the PR (line 1). EAS external anal sphincter, IAS internal anal
sphincter
moidocele, and intussusception in women with obstructed
defecation syndrome.
64.3.1 Technique
TTUS is performed using a biplane transducer (type 8848,
BK Medical, Herlev, Denmark), diameter of 22 mm, with a
60-mm linear array and a frequency of 12 MHz. The trans-
ducer has two perpendicular arrays that could be used for
either a midsagittal view (linear array) or an axial view
(transverse array with a field of view up to 180°) of the pelvic
floor. When the 3D is activated, a sample of volume that cov-
ers a 180° view is acquired in 30 s.
After receiving an enema, 120–180 mL of gel is injected
into the rectal ampulla while the patient is in the left lateral
decubitus position. Scanning is performed by two combined
approaches and three automatic scans, with analysis in the
64  Echodefecography: Technique and Clinical Application
Fig. 64.13  Patient with cystocele and rectocele (sagittal plane). (a)
Cystocele measured by the displacement of the bladder neck below
(line 2) the proximal margin of the PR (line 1) and rectocele (arrow
head). EAS external anal sphincter, IAS internal anal sphincter,
PR  puborectalis muscle
axial and sagittal plane. The scans use spacing of 0.66° and
last 30  s each. The duration of the combined procedure is
approximately 5 min.
64.3.2 Transvaginal Approach
The transducer is placed in the vagina in the neutral position.
Longitudinal images of the inferior rectum and entire length
of the anal canal are visualized, and two scans are acquired.
The rotation of 180° is performed from 3 to 9 o’clock
position.
791
Scan 1: (at rest) evaluates the integrity of the internal and
external anal sphincters (Fig. 64.19a).
Scan 2: the patient is requested to keep at rest during the
first 10 s and then maximally strain for 20 s. The anorectal
angle is measured at the intersection of the longitudinal axis
of the anal canal, and a line is drawn along the posterior bor-
der of the rectal wall. The measurements at rest are com-
pared with those made during straining to identify normal
relaxation (Fig. 64.19) or anismus (including non-relaxation
or paradoxical contraction) (Fig. 64.20). Anismus is charac-
terized by a failure to execute the relaxation of the posterior
EAS-PR muscles that is required for a successful defecation.
Thus, anismus is recorded when the anorectal angle fails to
open during straining compared to the anorectal angle at rest.
In cases with normal relaxation, the angle increases.
64.3.3 Transrectal Approach
The rectum is refilled with ultrasound gel whenever the
patient eliminates the gel in scan 2. The transducer is placed
in the rectum and positioned at 7.0 cm from the anal verge.
The patient is requested to keep at rest position during the
first 10 s, and then maximally strain for 20 s.
The purpose of scan 3 is to visualize and quantify all ana-
tomical structures and any functional disorders such as recto-
cele, intussusception, or enterocele/sigmoidocele grade II or
III.
The rectocele size is measured by drawing two parallel
horizontal lines along the posterior vaginal wall, one in the
initial straining position and another at the point of maximal
straining, when the anterior rectal wall and upper anal canal
are maximally distended, bulging into the vaginal lumen. In
normal patients, the posterior vaginal wall displaces the
lower rectum and upper anal canal inferiorly and posteriorly
but maintains a straight horizontal position during defeca-
tory effort (Fig. 64.21a). The distance between the two vagi-
nal wall positions is used to determine the size of the
Rectocele that is classified as grade I (<6.0  mm), grade II
(6.0–13.0 mm), or grade III (>13.0 mm) (Fig. 64.21b).
Rectal intussusception is confirmed by observing the
infolding of the rectal wall into the rectum (anterior part of
the rectal circumference) (Fig. 64.22).
Grade II or grade III enterocele or sigmoidocele is diag-
nosed if the bowel bulges downward to the pelvis, between
the posterior vagina and the anterior lower rectal wall
(Fig. 64.23).
792 S. M. Murad-Regadas et al.

a b

Fig. 64.14  Patients underwent an intravaginal mesh sling procedure. The scanning assesses mesh position. (a) Mesh around the urethra (axial
plane). (b) The length of the mesh (sagittal plane). IAS internal anal sphincter, PR puborectalis muscle

a b

Fig. 64.15  3D endovaginal ultrasonography. (a) Anatomic integrity of the pubovisceral muscles (PVM). (b) Render mode – The measurement of
the levator hiatus area (black draw). AC anal canal, SP symphysis pubis, U urethra, V vagina
64  Echodefecography: Technique and Clinical Application
a b
Fig. 64.16  3D endovaginal ultrasonography. (a) Unilateral pubovisceral muscle (PVM) defect (left side, arrow). (b) Bilateral PVM defect
(arrow). AC anal canal, SP symphysis pubis, U urethra, V vagina
This type of transducer covers half of the circumference.
It is necessary to combine the transvaginal and transrectal
approaches for complete evaluation. However, the technique
is simple and generally performed within approximately
5 min. One limitation of TTUS is that it cannot be used in
patients who have never had intercourse or in male patients
with obstructed defecation symptoms.
New imaging techniques provide new options for evalua-
tion of pelvic floor dysfunction and make possible complete
clinical, anatomic, and dynamic assessment of patients with
pelvic floor dysfunctions for part of various specialists
(colorectal surgeons, gynecologists, and gastroenterologists)
since that this modality is easy to perform, quick, inexpen-
sive, and well tolerated by patients without exposure to
radiation.
793
Take-Home Messages
• Dynamic ultrasound scanning using echodefecog-
raphy technique or other options are a helpful tool
in the evaluation of patients with pelvic floor dys-
functions related to bowel function, such as incom-
plete evacuation, incontinence, and genital prolapse
as it clearly shows the anatomical structures with
high spatial resolution.
• The option of assessment should be recommended
since it is quick, performed in the office, inexpen-
sive, and well tolerated by patients without expo-
sure to radiation.
794 S. M. Murad-Regadas et al.

a b

Fig. 64.17  3D endovaginal ultrasound. Measurements of bladder neck (BN) position. Distance from the BN to the lowest margin of the symphy-
sis pubis (SP) (line 1). (a) At rest. (b) Valsalva maneuver (sagittal plane). AC anal canal, ARJ anorectal junction, B bladder, R rectum, U urethra
64  Echodefecography: Technique and Clinical Application 795

a b
a

Fig. 64.18  3D endovaginal ultrasound. Patient with perineal descent— anal canal, ARJ anorectal junction, B bladder, R rectum, SP symphysis
displacement of the anorectal junction >1cm (compared Valsalva pubis, U urethra
maneuver with at rest, line 1). (a) At rest. (b) Valsalva maneuver. AC
796 S. M. Murad-Regadas et al.

a b

Fig. 64.19  Dynamic 3D transvaginal and transrectal ultrasonography the anal canal, and a line is drawn along the posterior border of the rectal
technique (TTUS). Using intrarectal gel. Transvaginal approach. (a) At wall (lines). (b) Increased angle during straining (lines). EAS external
rest. The angle is measured at the intersection of the longitudinal axis of anal sphincter, IAS internal anal sphincter, PR puborectalis muscle

a b

Fig. 64.20  Dynamic 3D transvaginal and transrectal ultrasonography rectal wall (lines). (b) Decreased angle (anismus) during straining
technique (TTUS). Using intrarectal gel – transvaginal approach. (a) At (lines). EAS external anal sphincter, IAS internal anal sphincter, PR
rest. The angle is measured at the intersection of the longitudinal axis of puborectalis muscle
the anal canal, and a line is drawn along the posterior border of the
64  Echodefecography: Technique and Clinical Application 797

a b

Fig. 64.21  Dynamic 3D transvaginal and transrectal ultrasonography
technique. Using intrarectal gel—Transrectal approach—the vagina
maintains a straight horizontal position during defecatory effort. (a)
Patient without rectocele—the vagina maintains a straight horizontal
position during defecatory effort. (b) Patient with grade III rectocele.
Rectocele grade (sagittal plane) is measured by one line placed in the
initial straining position (1), and the other line drawn at the point of
maximal straining (2). The distance between the two lines (vaginal wall
positions) determines the grade of the rectocele (3)

Fig. 64.22  Dynamic 3D transvaginal and transrectal ultrasonography

technique. Using intrarectal gel—Transrectal approach.(a) Patient with
intussusception—rectal wall infolding into the rectum
798 S. M. Murad-Regadas et al.

a b

Fig. 64.23  Patient with grade II or III sigmoidocele/enterocele—bulges downward to the pelvis. (a) Patient without rectocele. (b) Patient with
grade II rectocele

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 Evacuation Proctography
65
Magdalena Maria Woźniak, Aleksandra Stankiewicz,
Alexander Clark, and Andrzej P. Wieczorek

Learning Objectives pacemakers, or of greater relevance to pelvic floor investiga-

• To gain an overview on how evacuation proctogra- tion, sacral nerve stimulators (SNS).
phy should be performed and interpreted
• To become familiar with normal findings and the
ways of interpretation 65.2 Patient Preparation
• To understand the most frequent pathological find-
ings which can be diagnosed with evacuation Before the procedure itself, it is very important to obtain a
proctography complete clinical history with particular attention to abdomi-
nal and pelvic surgery, clinical conditions (such as diabetes,
hypothyroidism, and systemic disorders), and drug con-
sumption. Other clinical history should be recorded as fol-
65.1 Introduction lows: the period of dyschezia, the frequency of defecation
per week, the time required for usual defecation, the sense of
Constipation is the most common digestive complaint, tenesmus or incomplete evacuation, the specific pose during
effecting up to 20% of the population, with considerable defecation, and the use of any specific maneuver (digitation),
healthcare, social, and economic implications [1]. Evacuation laxative or enema [3].
proctography also referred to as defecography has been Proctography is recognized by patients as an embarrass-
established as a particularly useful fluoroscopic examination ing and stressful examination, and thus, the patient should be
for diagnosis in patients with constipation, where constipa- informed in advance about the procedure and its particular
tion is due to obstructed defecation, because it enables a steps. To perform a correct examination cooperation with the
functional, real-time assessment of the defecation mechanics patient is essential. The entire procedure should be explained
in an almost physiologic setting. When combined with phys- to the patient first so that the patient follows actual instruc-
ical examination, evacuation proctography allows accurate tions of the examination correctly in a relaxed and comfort-
and expanded assessment of the underlying pathology and able condition [3].
helps to guide future intervention [2]. Despite recent Preparation of the bowel with laxatives or enemas is not
advances in magnetic resonance (MR) defecography, this mandatory. In some institutes, however, the patient can
technique still represents a widely available and cost-­ undertake a rectal cleansing enema at home a few hours
effective diagnostic tool [3]. Furthermore, some patients will before the examination because a limited bowel preparation
be unsuitable for MRI having implanted devices such as will be more comfortable for the patient and will also pro-
vide a more standardized examination [3]. In some centers
for the same purposes, the administration of two glycerin
suppositories to empty the rectum is recognized as useful,
M. M. Woźniak (*) · A. P. Wieczorek
although also not obligatory [4].
Department of Pediatric Radiology, Medical University of Lublin,
Children’s University Hospital, Lublin, Poland
e-mail: mwozniak@hoga.pl; wieczornyp@interia.pl
A. Stankiewicz · A. Clark
Imaging Department, University Hospitals of North Midlands
NHS Trust, Keele University, Stoke-on-Trent, UK
e-mail: Ola.Stankiewicz@uhnm.nhs.uk;
Alexander.Clark@uhnm.nhs.uk

© Springer Nature Switzerland AG 2021 801

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_65
802 M. M. Woźniak et al.

65.3 Examination Technique

Rather than actually reproducing the physiological process

of normal defecation, defecography is a study of voluntary
evacuation; hence, the term “evacuation proctography” is
often preferred [5] and will be further used in this chapter.
The concept of radiological investigation of rectal evacua-
tion in constipated patients is not new [6], although the proc-
tographic technique widely practiced today is based on the
initial description of Mahieu in the early 1980s [7, 8].

65.3.1 Small Bowel, Rectal and Vaginal

Opacification, and Defecation

In our institution (University Hospital of North Midlands),

evacuation proctography is performed as follows:
The patient drinks 400–600 ml of oral barium suspension
to opacify the small bowel and about 1 h later is taken to the
fluoroscopy room by the advanced practitioner in radiogra-
phy who will perform the test. Here, the patient is reminded
of what the procedure entails, and they have the opportunity
to ask any questions regarding the examination. Subsequently,
the patient lies on a bed in the left lateral decubitus position,
and 10 ml of barium is administered into the vagina. Then
150  ml of barium sulfate for oral suspension (E Z HD),
which is mixed immediately before use with warm water to
a “toothpaste” consistency, is injected into the rectum gently
Fig. 65.1  Evacuation proctography. Normal anatomy. A (arrow) anal
using an enema catheter. The enema catheter is removed, and
canal, R rectum, SB opacified small bowel, V (dotted arrow) vagina
the patient walks 3 m to the commode chair. The examina-
tion takes place with the patient seated, following the below
instructions: Without interruption, the evacuation process takes less
than 30 s in physiologic conditions [3, 9]. Normal anatomy is
(a) “Relax,” then “squeeze and lift,” and then “relax.” This demonstrated in Fig. 65.1.
is captured with video fluoroscopy and is an indication Most authors consider proctography to be more physio-
of pelvic floor level and puborectalis contraction. logical when performed with the patient in the seated posi-
(b) The next is to “push” out the rectal paste, also under tion, although in immobile or incontinent patients, the
fluoroscopic screening. “Push” is repeated until all the procedure may successfully be performed with the patient in
paste is evacuated or if a diagnosis of rectal prolapse is the left lateral decubitus position [10]. Indeed, comparative
made. If patients are unable to empty, they are asked to studies suggest that although static findings differ, dynamic
try to evacuate on a normal toilet in privacy before a final patterns are essentially similar [11].
fluoroscopic assessment. In some institutions, cystocolpoproctography is per-
(c) Some practitioners will obtain a post-evacuation spot formed. The bladder is first filled through a catheter, and
radiograph after full evacuation. In our practice, spot static and dynamic images are obtained during rest and max-
exposures are only acquired where there is a history of imum strain. Then the bladder is emptied, and the vagina is
rectopexy. In such cases, one spot film is acquired at rest opacified followed by the rectum, as described above [12].
and another at maximum strain. These radiographs Clearly, more invasive than basic proctography, dynamic
should show the position of clips or staples and any cystocolpoproctography has the advantage of providing a
excess movement of these when pushing to empty the more detailed assessment of pelvic floor dysfunction [13,
rectum. 14]. However, dynamic magnetic resonance imaging (MRI)
65  Evacuation Proctography
has found an increasing role in imaging multicompartment
pelvic organ prolapse [15].
65.4 Image Analysis
65.4.1 Parameters
65.4.1.1 Anorectal Angle (ARA)
The anorectal angle (ARA) is measured between the longitu-
dinal axis of the anal canal and the posterior rectal line, par-
allel to the longitudinal axis of the rectum. It can be difficult
to measure because the posterior wall of the rectum is often
not clearly delineated and the angle becomes highly subjec-
tive [16]. At rest, the physiologic range is 65–100° without
noticeable differences between men and women [9, 17].
ARA is an indirect indicator of the puborectalis muscle
activity. During muscle contraction, ARA becomes more
acute while during relaxing phase it becomes obtuse.
65.4.1.2 Anorectal Junction (ARJ)
The second important parameter for evaluation is the shift of
the anorectal junction (ARJ) during straining. ARJ is the
uppermost point of the anal canal. The line drawn between
the ischial tuberosities is called the bi-ischiatic line and can
be used as a fixed bony landmark. Another fixed reference
point is represented by the tip of the coccyx. The craniocau-
dal migration of ARJ indirectly represents the elevation and
descent of pelvic floor.
The reproducibility and reliability of these two parame-
ters as usually measured have been confirmed, but their clini-
cal significance is still controversial [9]; hence, some
experienced practitioners do not routinely measure them.
65.4.1.3 Pubococcygeal Line (PCL)
Pubococcygeal line (PCL) is the line between the inferior
margin of pubic symphysis and the sacrococcygeal
junction.
65.4.2 Normal Findings
65.4.2.1 Rest
At rest, the anal canal is closed, and the rectum assumes
its normal upright configuration [7]. The impression of
the puborectal sling is visible on the posterior wall of the
lower rectum, and the ARA is about 90° [3]. The position
of the pelvic floor is often inferred by reference to the
pubococcygeal line (PCL), although the side of the com-
mode or inferior margins of the ischial tuberosities are
useful approximations. Perineal descent is measured from
this line to the ARJ and may be up to 1.8 cm at rest [18],
although usually less in younger patients [19] and often
803
greater in the elderly [20]. Some pelvic floor descent dur-
ing evacuation is considered normal, and a descent of up
to 3 cm from the rest position to anal canal opening is
acceptable [18, 21].
The anorectal angle (ARA) has received considerable
attention, although absolute measurements are of question-
able clinical use. Qualitative assessments of changes in the
ARA in individual patients are more useful than absolute
angle measurements. The puborectalis length (PRL) can be
estimated by measuring the distance between the ARA and
symphysis pubis. However, as for the ARA, qualitative
assessment of the PRL in individuals is of greater use than
reliance on absolute measurements.
65.4.2.2 Squeeze/Strain (Push)
During voluntary contraction of the pelvic floor (squeeze),
the ARA decreases to about 75°, and the ARJ migrates crani-
ally. The puborectal impression becomes more evident
because of the contraction of levator ani [3]. While the
patient is asked to push or strain to empty, the ARA increases
with partial to complete loss of puborectal impression and
the pelvic floor descends. The degree of caudal migration of
ARJ is considered normal when less than 3 cm relative to the
resting position.
65.4.2.3 Evacuation
The emptying phase of the proctogram gives important
information about rectal structure and function. During evac-
uation, wide opening of the anal canal and funneling of the
anorectum are seen with near complete loss of puborectal
sling impression [2, 3]. In the normal patient, the anal canal
should open fully within a couple of seconds, and evacuation
should then proceed promptly and to completion. It is impor-
tant to remember that in essence, only contrast below the first
rectal fold is expected to be evacuated during the examina-
tion; retained contrast above the first fold is a normal finding
[21]. The ARA increases with the relaxation of the anal
sphincter and puborectalis muscle. Typically, the ARA
should increase by around 20–30°, and the PRL should
increase by around 3–4 cm [18], although absolute measure-
ments are of limited value for individual patients [7]. At the
end of evacuation, the rectum is empty and its walls collapse.
Eventually, the rectum is restored to its original resting con-
dition. The rate and degree of contrast emptying is highly
relevant in the diagnosis of functional disorders of
defecation.
This was described first by Mahieu et al. who divided the
normal proctogram into five elements: increase in the ARA,
obliteration of the puborectalis impression, wide opening of
the anal canal, evacuation of rectal contents, and lack of sig-
nificant pelvic floor descent [21]. Although later refined, this
initial description remains a very useful baseline of
normality.
804
65.4.2.4 Recovery
After evacuation is complete, the anal canal should close, the
ARA recover, and the pelvic floor return to its normal base-
line position. Post-toilet imaging may be required, particu-
larly in those suspected of retained barium within rectoceles
[7] and to visualize rectal prolapse previously obscured by
retained rectal barium.
65.4.3 Pathological Findings
65.4.3.1 Abnormal Pelvic Floor Descent
Pelvic floor descent is defined as the distance moved by the
ARJ at rest to the point of anal canal opening and is consid-
ered abnormal if it exceeds 3 cm. It is important to note the
resting position of the pelvic floor. In those with fixed pelvic
floor descent at rest, the ARJ commonly lies 4 cm below the
pubococcygeal line although moves little during evacuation
[22]. Excessive pelvic floor descent, or descending perineum
syndrome, is suggestive of pelvic floor weakness, although
the exact etiology and significance remain controversial. It
has been mainly attributed to pelvic/pudendal neuropathy
[23, 24], although other etiological factors have been identi-
fied such as greater parity [25, 26], elderly age [19], dysto-
cias and obstinate constipation, or even more recently genetic
factors [27]. There is also a well-described association with
anterior rectal mucosal prolapse [28] and with prolonged
straining [18], which is suggested as the underlying common
etiology for both conditions. In addition incontinence is fre-
quently associated with perineal descent syndrome [3].
Although perineal descent can be assessed clinically, evacu-
ation proctography is more reliable, not least because patients
are seated and strain maximally to the point of anal canal
opening [7]. The main radiographic feature is the caudal
migration of the anorectal junction more than 3 cm during
straining. The anorectal angle is more than 130o at rest and
increases to more than 155° during straining [29, 30]. On
balance, excessive pelvic floor descent is a common procto-
graphic finding, although its exact significance and cause is
not yet fully explained (Fig. 65.2).
65.4.3.2 Anismus (Dyssynergic Defecation)
There exist a large group of constipated patients who com-
plain of inability to evacuate but in whom no significant
underlying structural abnormality is found [31], but in whom
there is an inability for pelvic floor muscles to relax in con-
cert to allow defecation and in some there may be inappro-
priate contraction of the pelvic floor during defecation. The
phenomenon has been variously labeled anismus, spastic
pelvic floor syndrome, dyskinetic puborectalis muscle syn-
drome, and paradoxical puborectalis syndrome [32], reflect-
ing the as-yet obscure etiology. However, the frequent
success of biofeedback therapy is good evidence that the
M. M. Woźniak et al.
Fig. 65.2  Abnormal pelvic floor descent and bulging of the anterior
rectal wall (rectocele, arrow)
condition is both real and, in part, behavioral in origin. It is
thus an important diagnosis to make in constipated patients
with symptoms of rectal obstruction [7, 33]. Although the
diagnosis of animus may be suggested by anorectal physiol-
ogy, proctography has an important diagnostic role. Various
proctographic abnormalities have been described including
lack of pelvic floor descent and paradoxical contraction of
the puborectalis muscle when attempting to defecate. In
practice, elevation of the pelvic floor and reduction in the
ARA are rare, but no movement (descent or ARA widening)
of the opacified pelvic structures on attempted defecation is
a more commonly seen pattern with anismus. Also described
are a narrow anal canal and acute anorectal angulation [34].
However, these observations may be found in normal con-
trols and are in themselves unreliable distinguishing features
[35, 36]. A further finding is a prominent puborectal impres-
sion in the posterior lower rectum throughout the examina-
tion, due to failure of puborectalis to relax appropriately.
Indeed, another less specific feature is an aberrantly deep
impression of the puborectalis sling on the posterior lower
rectal wall at rest [2, 3], thought to be caused by the presence
of a hypertrophic puborectalis muscle, but this finding is also
seen in some normal individuals [36]. A more reliable assess-
ment is based on the rate and completeness of evacuation.
Patients with anismus classically demonstrate delay in anal
canal opening and prolonged incomplete evacuation [35,
36]. Evacuation time longer than 30 s is highly predictive of
dyskinetic puborectalis muscle syndrome, having a positive
predictive value of 90% [37]. Evacuation may eventually
proceed to completion in some patients, but only after
repeated straining. Care must always be taken, however,
when diagnosing anismus simply on the presence of pro-
longed evacuation. Inadequate straining and patient
65  Evacuation Proctography
embarrassment may both simulate the condition and should
be recognized by the radiologist.
65.4.3.3 Intussusception and Rectal Prolapse
Rectal intussusception is a concentric invagination or
infolding of the entire rectal wall into the rectal lumen dur-
ing straining or defecation. It may be classified as intrarec-
tal, intraanal, or total (external) rectal prolapse, where the
rectum passes through the anal canal. The etiology of rectal
intussuscepting is not clear; however, it is more common in
multiparous women [25, 26], suggesting it may be a sign of
more global pelvic floor damage. Although originally pos-
tulated as a cause of obstructed defecation [38], intussus-
ceptions seems more likely a secondary phenomenon,
occurring as it does at the end of evacuation rather than
preceding it [7]. There is, however, a very strong associa-
tion with solitary rectal ulcer syndrome (SRUS), a condi-
tion related to chronic straining. Patients with SRUS present
with rectal bleeding, mucus discharge, and symptoms of
obstructed defecation. The proctographic diagnosis is not
clear-cut, and there is often difficulty in distinguishing
from normal mucosal descent [7]. It usually begins at
6–8 cm above the anal canal as an invagination of one of
the valves of Houston [39]. Some degree of rectal intussus-
ception is seen in normal volunteers [17], although symp-
tomatic patients tend to have more advanced findings [40].
The categorization of intussusceptions into intrarectal and
intraanal is undoubtedly very useful, as it seems likely that
all intussusceptions commences in the rectum and descends
toward the anal canal. Furthermore, there is no clear defini-
tion of purely intrarectal intussusception [21]. However,
the presence of transverse or oblique infolding of abnor-
a b
Fig. 65.3  At rest (a), and pushing/straining (b, c). Moderate rectocele (R) and internal rectal prolapse Oxford grade 2 (arrows) are demonstrated.
Note clear demarcation of vagina (dotted arrow)
805
mally wide rectal wall of more than 3 mm thickness, which
is presented as a funnel or ring-­like configuration during
straining, represents intussusception [3]. Rectal collapse
may mean normal folds mimic intussusception in the lat-
eral view [40], and thus repeat examination in the AP pro-
jection may be required [7]. Minor degrees of infolding of
less than 3  mm thickness represent mucosal prolapse and
are probably not significant. Once the intussusception
enters the anal canal, diagnosis is more clear-cut. The canal
is seen to splay on both the lateral and AP views, as it is
filled by the descending intussusceptum. Perhaps a more
robust method has been recently described whereby the
ratio of the intussuscipiens diameter and intussusceptum
diameter are calculated [41]. A ratio of more than 2.5 is
highly suggestive of true intussusception. An advantage of
this technique is the relative nonambiguity of the intussus-
cipiens and intussusceptum borders and the nondependence
on technical factors. In complete rectal prolapse, dilatation
of the anal canal is evident during evacuation, and an
infolding of the rectal wall invaginates into the lumen.
Descent can be so dramatic as to pass through the anus and
prolapsed externally [3]. The Oxford grading system is
widely used to describe rectal prolapse on clinical and
imaging assessment. It divides prolapse into internal rectal
prolapse and external.
Internal rectal prolapse is further subdivided into rectal
intussusception (grade I—descent to the proximal limit of
the rectocele; grade II—descent into the rectocele) and rec-
toanal intussusception (grade III—descent to the top of the
anal canal; grade IV—descent into anal canal); while exter-
nal rectal prolapse corresponds to grade V, when rectal pro-
lapse protrudes from the anus [42] (Figs. 65.3 and 65.4).
c
806 M. M. Woźniak et al.

a b

Fig. 65.4  A 60-year-old lady with recurrent symptoms of obstructed defecation syndrome. (a) Initially, a small rectocele is seen. Note sacral nerve
stimulator (SNS). (b) In the same patient, during straining, circumferential rectal prolapse (Oxford grade 4) is also demonstrated (arrow)

a b c

Fig. 65.5 (a) During “squeeze and lift”—puborectalis contraction. (b) rectocele and a circumferential rectal mucosal prolapse (arrows)
At rest, the pelvic floor level is unremarkable. (c) On straining—pelvic descending into the rectocele, but no intussusception into the anal canal
floor descent and anorectal angle widening are noted. There is a small (Oxford grade 2)

65.4.3.4 Rectocele undergone instrumental delivery), and a defect in the recto-

Rectocele is an anterior bulge of the rectal wall wider than
2 cm in the anteroposterior diameter [4]. The depth of a rec-
tocele is measured from the anterior border of the anal canal
to the anterior border of the rectocele. A distance of <2 cm is
classified as small, 2–4 cm as moderate, and >4 cm as large
[7] (Figs. 65.5 and 65.6). This condition is more commonly
found in females because of the laxity of the rectovaginal
septum. Outpouchings smaller than 2  cm are frequently
found in asymptomatic females [17]. The condition is more
common in multiparous women (particularly those who have
vaginal septum has been suggested as the causal mechanism
[43]. There is also a clear association with symptoms of
obstructed defecation [44] although in itself, the mere pres-
ence of a rectocele has limited clinical meaning [45]. On
evacuation proctography, an anterior outpouching of the
anterior rectal wall bulges and displaces the opacified vagi-
nal lumen during straining and evacuation. A rectocele does
not necessarily impede evacuation, but retention of stool
within a rectocele may lead to a sense of incomplete evalua-
tion and the need for digitation to complete evacuation [3].
65  Evacuation Proctography 807

Fig. 65.6  Large rectocele measuring 50 mm is shown. There is pre- Fig. 65.7  A 6.5-cm rectocele (R) is formed by a loop of the rectum
dominantly posterior, rectal mucosal prolapse, which intussuscepts the (including rectosigmoid) folded anterior to the anus under a large
anal canal—Oxford grade 3 (arrow). R rectocele enterocele (E). Circumferential (posterior predominant) rectal mucosal
prolapse (arrow) is demonstrated, with intra anal intussusception to the
anal verge (Oxford grade 4)
Of more relevance, however, is barium trapping at the end of
evacuation defined as retention of >10% of the area [46] and
is related to the size of the rectocele [47]. A pressure drop
within “trapping” rectoceles has been demonstrated [46],
which explains the relief obtained by patient digitation, when
pressure is applied on the perineum and posterior vagina to
complete rectal emptying [48]. Indeed, the effect of digita-
tion may be imaged during proctography after careful dis-
cussion with the patient. Proctography has an important role
in triaging patients for surgical treatment. The patients with
an underlying functional disorder of defecation tend to
respond poorly to surgery and benefit from biofeedback.
Patients with proctographic evidence of significant looking
structural abnormalities are more likely to benefit from sur-
gery. Interestingly, however, even patients who obtain symp-
tomatic relief from surgical repair of a rectocele may still
have proctographic evidence of a rectocele on postoperative
imaging [49], suggesting that factors other than the anatomi-
cal abnormality give rise to symptoms. Rarely, the rectum
may be herniated in a posterolateral direction through a
defect in the levator ani, commonly related to childbirth [7]. Fig. 65.8  Large sigmoidocele (S). A small- to moderate-sized anterior
rectocele (R) measuring 23 mm is demonstrated. There is also a rectal
prolapse, including prolapse of the rectocele roof, which intussuscepts
65.4.3.5 Enterocele and Sigmoidocele into the anus almost to the anal verge (Oxford grade 4)
An enterocele is diagnosed when small bowel loops enter the
potential space between the rectum and vagina (rectogenital
space) (Fig. 65.7). When a loop of sigmoid enters and wid- rectovaginal space. The diagnosis of an enterocele on proc-
ens the rectovaginal septum, it is a sigmoidocele (Fig. 65.8). tography is more reliable if oral contrast has been adminis-
They result from the herniation of the peritoneal sac into the tered before the examination. On proctography, descent of
808
barium-filled ileal loops is evident during evacuation in the
space between the rectum and vagina that is widened.
Widening of this space, or the presence of air in this space, is
also an indirect sign of enterocele when opacification of ileal
loops is not achieved [2, 3]. The rectogenital space widens as
evacuation occurs (and after it) when pressure from the
­adjacent full rectum is reduced, and as such, enteroceles are
usually diagnosed at the end of the procedure [7]. Formation
can be prevented by filling of the rectogenital space with any
other structure such as a cystocele or large rectocele, and for
this reason, the bladder should be emptied prior to rectal
evacuation when performing extended proctography [7].
Enteroceles may also only become apparent after repeated
straining, and some authors recommend post-toilet strain
images to increase diagnosis [14]. Kelvin et al. found over
40% of enteroceles were diagnosed only on the post-toilet
images [50]. Prior hysterectomy is a major precipitating
cause of enteroceles, but there is also an association with
multiparity, age, obesity, and connective tissue disorders.
Patients typically complain of pelvic pressure or dragging,
but it is increasingly clear that, contrary to popular belief,
enteroceles are not a cause of obstructed defecation [51].
Herniation of the sigmoid into the rectogenital space (sig-
moidocele) is significantly less common than an enterocele,
although symptoms may be more severe. Diagnosis is based
on the barium-filled sigmoid or fecal contents within the sig-
moid seen anterior to the rectum. Unlike enteroceles, there is
some evidence that large sigmoidoceles can themselves
cause obstructed defecation. The advent of newer MRI tech-
niques hold considerable promise in the diagnoses of entero-
celes and other forms of pelvic herniation and are discussed
elsewhere [52].
The study by van Gruting et al. compared four different
imaging techniques used in the assessment of posterior com-
partment disorders in patients with obstructed defecation
syndrome. It showed that evacuation proctography is not the
best available method for all conditions but showed the high-
est diagnostic accuracy for rectal intussusception. Therefore,
evacuation proctography should remain the examination of
choice in cases of clinically suspected rectal intussusception
[53]. Furthermore, not all patients can undergo MRI having
pacemakers or SNS.
65.5 Conclusions
Evacuation proctography is a long-established reliable and
reproducible technique, as well as a cost-effective and easily
assessable procedure for evaluation of defecation disorders.
However, the diagnosis of defecation abnormalities may not
always be straightforward because the pathological imaging
findings overlap with appearances seen in normal and
asymptomatic individuals. This method has the highest
M. M. Woźniak et al.
accuracy in diagnosing rectal intussusception [53].
Moreover, controversies exist as to the interpretation and
clinical utility of the technique due to absent or imperfect
reference standards for comparison. The main limitation of
this technique is patient’s exposure to ionizing radiation in
comparison to MR defecography, but MR defecography is
limited due to its high costs and still low availability.
However, when performed in specialized centers by well-
trained and experienced personnel, this technique still plays
a very important role in management of patients with defe-
cation dysfunctions.
Take-Home Message
Evacuation proctography remains the main radiologi-
cal examination in the assessment of posterior com-
partment disorders in patients with constipation and
obstructed defecation, especially when rectal intussus-
ception is suspected.
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 The Abdominal Approach
to Rectal Prolapse
Sthela M. Murad-Regadas, Rodrigo A. Pinto,
and Steven D. Wexner
Learning Objectives
• Describe and discuss multiple surgical techniques
that have been developed to treat rectal prolapse,
each with advantages and disadvantages;
• Analyze many treatment options developing over
the years and develop an individualized plan for
management of each patient according to the sever-
ity and frequency of symptoms, full anorectal
examination, associated dysfunctions, and condi-
tions of the patient;
• Demonstrate and discuss the result in the literature
concerning multiple surgical techniques that have
been developed to treat rectal prolapse.
66.1 Introduction
Full-thickness rectal prolapse is defined as the protrusion of
all layers of the rectal wall through the anal sphincters [1]. If
the prolapsed rectal wall does not protrude through the anus,
it is called intussusception or internal rectal prolapse [2, 3].
Mucosal prolapse is the protrusion of only the rectal mucosa.
S. M. Murad-Regadas (*)
Colorectal Surgery at University Hospital, School of Medicine,
Federal University of Ceara, Fortaleza, Ceara, Brazil
Anorectal Physiology and Pelvic Floor Unit, Sao Carlos Hospital,
Fortaleza, Ceara, Brazil
e-mail: smregadas@hospitalsaocarlos.com.br
R. A. Pinto
Department of Gastroenterology, Service of Colorectal Surgery,
Hospital das Clínicas, University of São Paulo School of Medicine,
São Paulo, Brazil
e-mail: rodrigo.ambar@hc.fm.usp.br
S. D. Wexner
Digestive Disease Center, Department of Colorectal Surgery,
Cleveland Clinic Florida, Weston, FL, USA
e-mail: wexners@ccf.org
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_66
66
Complete rectal prolapse has been reported since the
Egyptian and Greek ancient civilizations [4]. The first writ-
ten report dates from 1500 BC, by Ebers Papyrus [5]. Over
the years, multiple treatments came and went. Mickulicz [6]
popularized the perineal amputation in 1888, and Lockhart-­
Mummery [7], in 1910, performed a perineal procedure for
the treatment of rectal prolapse. In 1912, Moschowitz [8]
started the abdominal repair.
The estimated incidence of rectal prolapse is 4 per 1000
population, being more common in elderly females after the
fifth decade. The female to male ratio ranges from 6:1 to
10:1. Among children, males and females are equally
affected, usually by the age of 3 years [9, 10].
66.2 Etiology
The anatomical basis for rectal prolapse is a deficient pelvic
floor through which the rectum herniates [3, 11–13]. The
exact way that the prolapse takes place is not completely
understood, thus it is based on theories.
Rectal prolapse as an intussusception of the rectal wall
was first described by Hunter [14] and confirmed by Broden
and Snellman [11] with cineradiography. Complete rectal
prolapse is thought to be a process that starts within 6–8 cm
of the anal verge, continuing through the anal canal, and
everting onto the perineum [11, 15, 16]. The lower rest and
squeeze pressures found in the anal manometries of these
patients compared to normal control subjects support this
theory [17]. However, defecographic studies have found that
in patients with intussusception, the risk of developing rectal
prolapse was small, which contradicts this theory [18, 19].
Parks et al. postulated the theory that repeated stretching
of the pelvic floor muscles can injure the pudendal nerves
and can be a part of the cause of rectal prolapse [20]. This
suggested mechanism is supported by some surgeons who
have detected a frequent association between neurogenic
fecal incontinence and rectal prolapse [12, 13]. However, the
improvement of fecal incontinence after surgery, and the
811
812
electromyographic findings of normal innervation in patients
with rectal prolapse challenge this proposal.
Lax lateral ligaments combined with an atonic condition
of the muscles of the pelvic floor and the anal canal could be
the main cause of rectal prolapse [11, 12]. In addition, the
lack of normal fixation of the rectum, with a mobile meso-
rectum and a laxity of the lateral ligaments, may predispose
to and/or be associated with rectal prolapse [12, 21, 22].
Regardless of which theory is chosen, the following ana-
tomic findings are commonly associated with rectal pro-
lapse: abnormally deep cul-de-sac, loss of posterior fixation
of the rectum, laxity of the anal sphincters, and redundant
sigmoid colon. All of the procedures described to date
attempt to correct some or all these abnormalities.
66.3 A
 ssessment of Patients with Rectal
Prolapse and Associated Symptoms
The assessment of patients with rectal prolapse is based on a
complete history including the investigation of all pelvic
floor compartment involvement, like the severity and fre-
quency of fecal incontinence and constipation/obstructed
defecation symptoms as well as urge of urinary incontinence
and pelvic organ prolapse symptoms applying score systems
and quality of life to quantify the dysfunctions before and
after treatment.
Other pelvic floor disorders may be present in 8–27% of
patients with rectal prolapse [23]. Altman et al. [23] observed
an incidence of 48% of genital prolapse and 31% of urinary
incontinence in patients with rectal prolapse (Fig.  66.1).
Gonzalez-Argente et al. [24] observed a higher incidence of
urinary incontinence (58%) and genital prolapse (24%) in
patients operated for rectal prolapse. Previous pelvic surgery,
obstetric trauma, elevated intra-abdominal pressure, increas-
Fig. 66.1  Rectal and uterine prolapse
S. M. Murad-Regadas et al.
ing age, and chronic constipation are some factors allied with
rectal and genital prolapse [23].
Up to 75% patients with rectal prolapse experience fecal
incontinence, and 25–50% have significant constipation [23,
24, 26, 27]. Metcalf and Metcalf et al. [28] supposed that an
increased external sphincter activity seen by electromyogra-
phy could be a cause of outlet obstruction and constipation.
Reducible protrusion that may be associated with mucous
discharge is a common sign of initial prolapse. Prolapse may
theoretically be due to bowel movements, straining, and
increased intraabdominal pressure. After the diagnosis of
prolapse has been made, patients may experience loss of
control of stool because of stretching of the sphincter mus-
cles and the pudendal nerves. In addition, bleeding may
develop if the rectum remains exposed and therefore becomes
traumatized.
Full anorectal examination should include inspection of
the perineum including the perineal body and urogenital hia-
tus; urogynecologists will also include the pelvic organ pro-
lapse quantification (POP-Q) [29]. The prolapse may be
easily visible on anorectal examination. Otherwise, the
patient is asked to sit down on a commode, leaning forward,
with the examiner standing behind to confirm the diagnosis.
Digital examination may reveal hypotonia or a patulous anus
and it is necessary to exclude rectal/pelvic tumor. A reduc-
ible protrusion that may be associated with mucous discharge
is a common sign of initial prolapse. Prolapse may theoreti-
cally be due to bowel movements, straining, and increased
intraabdominal pressure. After the diagnosis of prolapse has
been made, patients may experience loss of control of stool
because of stretching of the sphincter muscles and the puden-
dal nerves. In addition, bleeding may develop if the rectum
remains exposed and therefore becomes traumatized.
A search for risk factors should also be considered as well
as previous pelvic surgeries.
Evaluation of the colon with colonoscopy and barium
enema is recommended to exclude coexisting conditions,
such as polyps, cancer, and diverticular disease, which may
influence the choice of procedure. The colonic transit study
is important, especially in patients with associated
constipation.
Madoff [26] suggested that slow colonic transit time is the
primary factor associated with constipation in patients with
rectal prolapse. It has also been postulated that an increased
sigmoid transit is a significant factor associated with fecal
incontinence in patients with rectal prolapse [27].
Symptoms of obstructive defecation in those patients in
whom the prolapse cannot be reproduced during the physical
examination usually require the use of dynamic evaluation
including defecography, dynamic ultrasound with different
modalities (transperineal, transrectal, and ecodefecography),
and magnetic resonance image (MRI). The findings can
reveal associated functional abnormalities such as entero-­
66  The Abdominal Approach to Rectal Prolapse
sigmoidocele, paradoxial contraction of puborectal muscles
(anismus), cystocele and vaginal vault prolapse; such tests
are useful. The advantage of dynamic images makes it pos-
sible to visualize the anatomical structures of the anal canal
and pelvic floor. The anorectal and transvaginal ultrasound
are important methods in patients with a previous history of
vaginal delivery and anorectal and/or low colorectal surgery
to identify the anal sphincter or/and levator ani muscle
defects. Previous studies have demonstrated levator ani dam-
age in 15–55% after vaginal delivery with MRI and trans-
vaginal ultrasound as well as pelvic organ prolapse and
ballooning hiatal dimensions. [30–32]
The evaluation with anorectal manometry and electromy-
ography is useful to evaluate the pelvic floor muscles, par-
ticularly in patients with preoperative fecal incontinence;
also, patients with urinary incontinence may benefit from
urodynamic examination to complete the evaluation and
allow for concomitant surgical intervention.
Although it is not life-threatening, rectal prolapse is an
extremely distressing condition that affects patients’ quality
of life; therefore, surgical treatment should be considered
even in high-risk patients.
66.4 S
 election of Patients for Abdominal
Procedures
Surgical management of full-thickness rectal prolapse aims
to eradicate the external prolapse, limit the risk of recur-
rence, and limit any impairment to bowel function and conti-
nence. Additionally, morbidity and mortality rates should be
minimal. The lack of any one treatment as a panacea is why
multiple surgical approaches are in common use.
Perineal procedures are advocated for elderly patients
with significant comorbidity, as they are associated with lim-
ited surgical stress and relatively low postoperative morbid-
ity. Nevertheless, recurrence rates up to 58% and persistent
bowel dysfunction are commonly reported [33–35].
Conversely, the abdominal approaches are associated
with lower recurrence rates, which vary from 0 to 20%
among different surgeons [36–41]. The reason for this supe-
rior durability is not clearly known, but is attributed to the
ability to perform a complete rectal mobilization and fixation
under direct vision, with no sacrifice to the rectal reservoir. It
also offers a more accurate determination of whether to
excise or fix any additional redundant bowel that may pro-
lapse [42]. Abdominal procedures are also related to symp-
tomatic improvement and better functional results than
perineal operations [34, 37, 43, 44].
The surgical options can be summarized as suture or mesh
rectopexy, with or without sigmoid resection. The abdominal
approach can be performed with either an open or a laparo-
scopic approach. Some authors have reported higher morbid-
813
ity rates of 15% with open techniques [34, 37, 42].
Furthermore, the laparoscopic approach, first introduced by
Berman [45] in 1992, tried to integrate the surgical stress
reduction associated with the perineal approach with the
lower recurrence rates achieved with abdominal repair.
The decision as to whether to perform sigmoid resection
is based on bowel function and sphincter muscle status. If the
patient has normal bowel function, or constipation associ-
ated with normal anal tone, a resection is preferred. Whenever
diarrhea or sphincter damage is suspected, maintenance of
the sigmoid colon seems to be correlated with better func-
tional results.
Choosing the optimal repair for rectal prolapse involves
consideration of the patient’s health and the preexisting
bowel function as well as any history or physical findings
consistent with either constipation or fecal incontinence.
Lastly, the individual surgeon’s experience is always an
important factor in the decision-making process as to which
procedure is most appropriate for the individual patient. This
chapter addresses the abdominal approaches for rectal
prolapse.
66.5 Abdominal Procedures
Multiple abdominal operations for the treatment of rectal
prolapse have been described since the beginning of the past
century. The procedures that have persisted, and are mostly
commonly reported in the literature, are discussed below.
66.5.1 Ripstein Procedure (Anterior Sling
Rectopexy)
First described by Ripstein [46] in 1952, the procedure con-
sists of insertion of a synthetic mesh or fascia lata to the ante-
rior wall of the mobilized rectum, fixing the mesh to the
sacral promontory, and promoting an encirclement of the
rectum. The technique restores the posterior curve of the rec-
tum and provides a stiff anterior support (Fig.  66.2). The
major problem with this procedure is the development of
obstruction due to the anterior mesh, which can cause rectal
stenosis and erosion of the mesh into the rectal wall, fol-
lowed by fistula formation. Kuijpers [12] observed a 7%
incidence of stenosis in his experience. Aiming to reduce this
complication, Ripstein [46] modified his procedure by
including a posterior fixation of the mesh to the sacrum and
an intraoperative calibration with a proctoscope to prevent
the narrowing. Despite this modification, the complication
rate remained high, significantly limiting the use of the
technique.
Roberts et  al. [47] reviewed their experience with the
Ripstein procedure in 135 patients and reported a 52% com-
814
Fig. 66.2  Mesh placement in the Ripstein procedure. Supplied cour-
tesy of Dr Amanda M. Dantas
plication rate and an overall recurrence rate of 10%.
Furthermore, a review by Madiba et al. [48] also showed a
high complication rate, with mortality ranging from 0 to
2.8%, and recurrence rates ranging from 0 to 13%.
66.5.2 Posterior Mesh Rectopexy
First described by Wells [49] in 1959, this technique was pop-
ular in the UK.  The procedure consists of placement of a
prosthetic Ivalon® (polyvinyl alcohol) sponge between the
rectum and the promontory in either side of the rectum, after
mobilization of the posterior rectal wall (Fig. 66.3). The ante-
rior part of the rectum must stay free to prevent stenosis. The
parietal peritoneum is closed to isolate the mesh from the
peritoneal cavity. The well-built fibrous reaction promoted by
the presence of a foreign body restores the anorectal angle.
Novell et al. [50], in a prospective randomized trial com-
paring the Ivalon sponge to sutured rectopexy, showed simi-
lar recurrence rates and higher wound infection in the mesh
group. They failed to demonstrate any advantage of the
Ivalon rectopexy over the simpler sutured rectopexy.
Other nonabsorbable and even absorbable meshes have
been introduced, and have undergone evaluation with similar
results, including mortality ranging from 0 to 1% and recur-
rence rates ranging from 0 to 6%, using absorbable [51–53]
or nonabsorbable [25, 26, 50–54] meshes.
The main concern about the presence of a foreign mate-
rial is the development of infection and sepsis. Sepsis after
mesh placement has varied from 2 to 16% [11, 12, 52, 55–
61]. The performance of a resection associated with de novo
S. M. Murad-Regadas et al.
Fig. 66.3  Posterior mesh fixation of the sacral promontory in the Wells
procedure. Supplied courtesy of Dr Amanda M. Dantas
mesh insertion may be associated with an increased risk of
infection because of the presence of an anastomosis and a
new foreign body; thus, the placement of a mesh for recto-
pexy seems to be reasonable without resection, due to lower
mortality and infection rates [52, 53, 62].
The placement of a drain in the presacral space is also
recommended while inserting a mesh to prevent infected col-
lections or hematomas [45, 47, 53]. Whenever sepsis occurs,
it is worthwhile to remove the mesh [50, 52, 57, 59–61].
66.5.3 Suture Rectopexy
First described by Cutait [63] in 1959, the operation involves
a mobilization and upward fixation of the rectum to the sacral
promontory with two to three unabsorbable sutures on either
side of the rectum (Fig. 66.4). The healing process by fibro-
sis keeps the rectum fixed in the elevated position, prevent-
ing recurrence [1].
Despite the sound theory, the recurrence rates range from
0 to 27% [50, 63–67]; however, most reports have included
recurrence rates ranging from 0 to 3%.
The effect of rectopexy on constipation may include exac-
erbation of constipation and sometimes the development of a
new onset of constipation [67, 68]. Currently, the lower com-
plication rates and similar long-term outcomes associated
with the suture rectopexy compared to mesh placement have
led surgeons to prefer sutures to foreign material.
66  The Abdominal Approach to Rectal Prolapse 815

Fig. 66.4  Stitches placed

onto the sacral promontory in
suture rectopexy. Supplied
courtesy of Dr Amanda
M. Dantas

Table 66.1  Results of rectopexy with and without sigmoid resection

Author Year Resection Number Complication (%) Mortality (%) Success (%) Recurrence (%)
Solla et al. [35] 1989 Yes 102 4 0 98.1 1.9
Stevenson et al. [72] 1998 Yes 34 13 3 92 7 (MP)
Aitola et al. [54] 1999 No 112 15 1 – 6 (FT); 12 (MP)
Heah et al. [73] 2000 No 25 12 0 60 0
Lechaux et al. [69] 2005 Yes 48 5 0 72 4
Ashari et al. [74] 2005 Yes 117 9 <1 80 2.5 (FT); 18 (MP)
Carpelan Holmström et al. [75] 2006 Yes 85 0 0 84 wo; 92 w 2.3
Kariv et al. [76] 2006 No 111 – – 75 LR; 89 OR 9.3 LR; 4.7 OR
Dulucq et al. [68] 2007 No 77 0 0 89 1.3
FT full thickness, LR laparoscopic rectopexy, MP mucosal prolapse, OR open rectopexy, w with resection, wo without resection

66.5.4 Sigmoid Resection Associated higher incidence of constipation, due to an angulation

with Rectopexy
Originally described by Fryckman [36] in 1955 and champi-
oned by Goldberg, commonly known as resection rectopexy
or Fryckman-Goldberg procedure, the addition of a sigmoid
resection combines the advantages of rectal mobilization
and fixation to an excision of the redundant sigmoid. The
sutures can be applied before the bowel resection and
secured after the anastomosis. Some studies have shown
improvement in constipation compared to rectopexy alone
[38, 51]. Mckee et al. [38] associated rectopexy alone to a
between the redundant sigmoid and the rectum in the recto-
sigmoid junction. The sigmoidectomy seemed to alleviate
this possibility, which could cause delay in the passage of
intestinal content. However, there are risks of higher mor-
bidity from anastomotic complications and longer hospital
stay, due to the presence of an intraperitoneal anastomosis
[70, 71]. Table 66.1 summarizes the postoperative results of
rectopexy with and without sigmoid resection. Patients with
concomitant colonic inertia may potentially benefit from a
subtotal colectomy with ileorectal anastomosis rather than a
sigmoid colectomy with colorectal anastomosis.
816 S. M. Murad-Regadas et al.

66.6 Abdominal Surgical Techniques patient is positioned in a modified supine position to facili-
tate the exposure, retracting the small bowel, the omentum,
Patients are placed in a Lloyd-Davis position with split legs, and the redundant sigmoid from the pelvis.
and the prolapse is reduced before starting the procedure. For Either the medial to lateral or lateral to medial dissection is
an open approach, an infra-umbilical midline incision is usu- acceptable, as are diathermy scissors, harmonic scalpel (Ethicon
ally preferred, although some surgeons use a Pfannestiel Endo-Surgery, Cincinnati, OH, USA), or Ligasure (Valleylab,
incision to perform the rectopexy. Tyco Healthcare Group Lp, Boulder, CO, USA). The posterior
In the case of laparoscopy, the pneumoperitoneum is dissection is undertaken anteriorly from the promontory distal
established with a Veress needle or opened under direct to the pouch of Douglas after identifying the ureters, in a plane
vision using a Hasson trocar. The surgeon and the camera-­ surrounding the mesorectum between the parietal and visceral
holder stay on the right side of the patient, while the assistant fascial planes of the pelvis. During the dissection, care has to be
surgeon stands between the legs, and the monitor is placed in taken to identify and preserve the pelvic splanchnic nerves
the left side of the patient. Placement of three to five trocars (superior hypogastric nerves, the autonomic branches of S2, S3,
is described by different authors. Usually one 10 mm umbili- S4, and the pelvic autonomic nerve plexus). The posterior dis-
cal port is positioned for the camera, and two 5 or 10 mm section is carried down to the levator plane. The lateral liga-
ports in the right lower quadrant (12 mm if a stapler device is ments of the rectum should preferably be preserved.
used) and in the right upper quadrant. An additional 10 mm The promontory is exposed to visualize the presacral fas-
port can be placed in the left lower quadrant to help facilitate cia. If the sigmoid is going to be excised, some surgeons pre-
the exposure, particularly in obese patients (Fig. 66.5). The fer a lateral to a medial laparoscopic dissection. The superior
hemorrhoid artery may be preserved and the rectum can be
transected at the rectosigmoid junction, followed by con-
struction of a circular stapled colorectal anastomosis.
The rectopexy can be performed with the placement of a
mesh, usually when there is no resection, or by a suture rec-
topexy. The mesh is placed in the right posterior side of the
rectum, usually fixed with sutures or with staples. A simple
suture rectopexy can be an option, and two to four stitches
are placed in the posterior side of the mesorectum or in the
lateral rectal wall, and fixed to the periosteum of the sacral
promontory, taking care to avoid injury of the middle sacral
artery with the needle. At the end of the procedure, the peri-
toneum can be closed with absorbable running sutures. The
10 or 12 mm ports, or the open incision, are then closed, and
a drain may be placed into the pelvis. The open dissection is
performed similarly in an identical manner, except that most
surgeons routinely mobilize from lateral to medial instead of
medial to lateral during laparotomy.
Some technical aspects seem to be directly related to
patients’ postoperative functional outcomes, especially exac-
erbation of constipation. Some authors consider preservation
of the lateral ligaments of the rectum for normal evacuation
after surgery to avoid the parasympathetic denervation that
may be responsible for rectosigmoid dysmotility [77–81].
Bruch et al. [78] reported that preservation of the lateral liga-
ments leads to a significant improvement in constipation
after resection rectopexy and suture rectopexy. Darzi et  al.
[79] observed persistence of constipation in 18% of patients
who underwent resection rectopexy with division of the lat-
eral stalk of the rectum. A Cochrane meta-analysis of 10 ran-
domized controlled trials comprising 324 patients concluded
that division of the lateral ligaments of the colon was associ-
Fig. 66.5  Placement of ports for the laparoscopic approach. Supplied ated with less prolapse recurrence, but more postoperative
courtesy of Dr Amanda M. Dantas constipation [83].
66  The Abdominal Approach to Rectal Prolapse
Other features related to constipation may be functional
obstruction caused by kinking of the redundant sigmoid left
in place, and fibrosis related to the rectal dissection or the use
of a mesh, creating stenosis [38, 83]. Mckee et al. [38] sug-
gest that the redundant or kinking sigmoid colon could cause
delayed colonic transit, which eventually leads to persistent
constipation.
66.7 Minimally Invasive Approach
During the last 20 years, due to the advent of laparoscopy,
abdominal rectopexy for the management of rectal prolapse
has become one of the earliest procedures. The results are
comparable with the open approach, with the advantages
associated with a minimally invasive approach. Rectopexy
alone can be performed as a completely laparoscopic proce-
dure since there is no specimen to be retrieved.
Recent reports have compared laparoscopic to open pro-
cedures and have shown reduced postoperative pain, earlier
recovery, and shorter length of hospital stay for laparoscopy
[80, 84–87], despite a longer operative time and higher direct
costs [84, 86–89]. However, Salkeld et  al. [88] stated that
laparoscopy is associated with an overall cost saving per
patient from faster recovery, less use of pain medications,
and shorter stay in the hospital. Forty-four percent of the
additional operative costs for laparoscopy were attributed to
longer operative times.
Carpelan-Holmström et al. [75] addressed the abdominal
approach for elderly high-risk patients, evaluating 65 patients
operated by laparoscopy and 10 patients operated in an open
fashion. Half of the patients were American Society of
Anesthesiologists (ASA) classification III and IV. The opera-
tive time was similar overall, although the laparoscopic
resection rectopexies were more time-consuming (150 vs.
80 min; P = 0.07). The hospital stay and intraoperative bleed-
ing were significantly shorter for laparoscopic procedures.
Sixty-eight patients were selected for follow-up, after a mean
of 1.8 years, and the results were comparable between lapa-
roscopic and open procedures. Full-thickness rectal prolapse
recurrence occurred in two patients. There was no difference
in constipation after the procedures, and continence was
fully restored in 86% of patients who underwent rectopexy
and 79% of patients who underwent resection rectopexy. The
authors concluded that laparoscopic procedures can be safely
performed and well tolerated by elderly patients.
Solomon et  al. [89] performed a randomized controlled
trial with 39 patients allocated to either open (19) or laparo-
scopic (20) mesh rectopexies, and analyzed some objective
parameters related to stress response to surgery. Acute-phase
reactants, such as urinary catecholamines, interleukin-6 (IL-­
6), serum cortisol, and C-reactive protein favored laparos-
copy. Respiratory function was comparable between the
groups, whereas respiratory morbidity was greater in the
817
open group. The overall and the major morbidity incidence
also favored laparoscopy (overall 3% vs. 9% and major 0%
vs. 4%, respectively for laparoscopic and open groups).
Likewise, Stage et al. [90] observed no difference in respira-
tory function, and decreased pain scores and morphine
requirements for laparoscopy. There was also minor stress
response represented by IL-6 and C-reactive protein, and
shorter hospital stay (5 vs. 8 days for laparoscopy and open,
respectively), favoring laparoscopy. In contrast, Milsom
et al. [91] reported improvement in respiratory function with
laparoscopic rectopexy, but similar hospital stay (6 vs. 7 days
for laparoscopy and open, respectively).
Regarding constipation after surgery, Kariv et  al. [76],
reviewing the experience of Cleveland Clinic Foundation,
noticed that laparoscopic cases were related to better
improvement of constipation (74% vs. 54%, respectively in
laparoscopy and open procedures) and lower worsening of
constipation (3% vs. 17%, respectively in laparoscopy and
open procedures) compared to open cases. Postoperative
constipation rates also seemed better following laparoscopy
(35% vs. 53%, respectively in laparoscopy and open proce-
dures). However, anterior mesh placement in open cases may
contribute to higher constipation rates. Within the laparos-
copy data, resection and no resection outcomes were compa-
rable in terms of constipation (70% vs. 59% improvement,
P  =  0.53; respectively in patients without and with
resection).
The latest meta-analysis comparing open to laparoscopic
abdominal rectopexy included six studies and 195 patients
(98 open and 97 laparoscopic cases) [92]. The length of hos-
pital stay was significantly shorter in the laparoscopic group,
while the operative time was 60.38 min longer. There was no
difference in morbidity or recurrence rates in the studies
included in the analysis. Cost was addressed by two studies
that favored the laparoscopic group. The long-term func-
tional results reported with open and laparoscopic approaches
are described in Table 66.2.
66.7.1 Ventral Mesh Rectopexy
The initial description of ventral mesh rectopexy known as
Orr-Loygue procedure involved full mobilization of the
rectum with a mesh fixed to the anterolateral rectal wall and
suspended to the sacrum. A modification and adaption to
laparoscopy was proposed by one of our Cleveland Clinic
Florida alumni Professor Andre D’Hoore in 2004 [97]. The
ventral mesh retopexy (LVMR) was proposed as a nerve-
sparing procedure to manage rectal prolapse with less com-
plications. The technique was described in detail in 2006
[98] and involves a distal mobilization of the anterior rec-
tum from the rectovaginal septum to the pelvic floor mus-
cles with fixation to the sacral promontory using a mesh
(Figs. 66.6–66.8). Just anterior mobilization of the rectum
818 S. M. Murad-Regadas et al.

Table 66.2  Follow-up and functional results in open and laparoscopic abdominal approaches
Follow-up Constipation Incontinence Recurrence
Author Year N Procedure (months) improvement (%) improvement (%) (%)
McKee et al. [37] 1992 9 RR 20 50 0 0
Duthie and Bartolo 1992 29 RR 6 Yes 78 n.s.
[38]
Madoff [26] 1992 47 RR 65 50 30 FT 6; MP 8
Deen et al. [41] 1994 10 RR + PFR 17 Yes 90 FT 0; MP 10
Huber et al. [44] 1995 39 RR 54 42 65 FT 0; MP 0
Cirocco et al. [93] 1995 41 AR+FRM 72 18 48 Total 7
Benoist et al. [94]a 2001 18 LARR 20 82 100 n.s.
Kellokumpu et al. [70]a 2000 17 LARR 24 64 80 n.s.
Ashari et al. [74]a 2005 117 LARR 62 69 62 FT 2.5; MP 18
Kariv et al. [76]a 2006 136 LARR/OR 56 LR; 63 OR 74 LR; 54 OR 48 LR; 35 OR 9.3 LR; 4.7 OR
Madbouly et al. [80]a 2003 24 LARR/ 18.1 95 80 0
LWP
Lechaux et al. [69]a 2005 48 LARR 36 3 (23% worse) 31 4.2 FT; 4.2 MP
Dulucq et al. [68]a 2007 68 LWP 34 36 89 1.5
a
Laparoscopy-assisted procedures. AR anterior resection, FRM full rectal mobilization without fixation, FT full thickness, LARR laparoscopy-­
assisted resection rectopexy, LWP laparoscopic Wells procedure, MP mucosal prolapse, n.s. not specified, OR open rectopexy, PFR pelvic floor
repair, RR resection rectopexy

a b

Fig. 66.6 (a, b) A superficial peritoneal window is made over the right part of the sacral promontory and extended caudally over the right outer
border of the mesorectum down to the right side of the pouch of Douglas to start the dissection of the rectovaginal septum

Fig. 66.7  Careful dissection of the rectovaginal septum was performed Fig. 66.8  The mesh is sutured as distally as possible on the anterior
down to the pelvic floor rectal wall/perineal body with three interrupted nonabsorbable sutures
in each side
66  The Abdominal Approach to Rectal Prolapse
helps preserve the lateral stalks, preventing from postoper-
ative constipation and improving continence. The tech-
nique is indicated to treat full-thickness rectal prolapse,
rectoceles, and internal rectal prolapse. It has gained popu-
larity due to a reduced rate of recurrence of pelvic organ
prolapse at 3.4% and low postoperative morbidity of 4.8%
with no mortality. Additionally, 88% of patients reported an
overall improvement with significant decrease in fecal
incontinence, obstructed defecation symptoms, and vaginal
discomfort [98].
Recently, D’Hoore has updated the technique reviewing
405 patients operated between 1999 and 2008 for rectal pro-
lapse (43%), internal prolapse (45.9%), and rectocele
(11.1%), describing only minor postoperative complications
of 7%, low conversion rate of 2%, and median hospital stay
of 4 days. At 25 months’ follow-up the recurrence rate was
4.6% and the main complication was mesh erosion to the
vagina in five cases (1.2%), only when associated with peri-
neotomy. Symptomatic improvement was observed in 85%
of the patients with total rectal prolapse and in 70% of
patients with internal rectal prolapse (p < 0.050). The differ-
ence was mainly due to a lesser effect on obstructed defeca-
tion symptoms [99].
A multicenter collaboration including the technique’s
author enrolled 919 consecutive patients who underwent
LVMR to evaluate the long-term outcome. The estimated 10-­
year recurrence rate was 8.2%. Mesh-related complications
occurred in 18 patients (4.6%), including 7 with vaginal
mesh erosion (1.3%). Five of these patients underwent com-
bined perineotomy. The incidence of fecal incontinence
decreased from 37.5 to 11.1% and constipation rate also
decreased from 54 to 15.6% [100].
Otherwise, major complications are related to a place-
ment of a foreign body including mesh infection leading to
sepsis, vaginal/rectum, or bladder mesh erosion, and mesh
detachment [100]. Furthermore, studies have mentioned
rectovaginal fistula and sacral discitis as complications
after the procedure. On the other hand, discitis can occur
after any type of rectopexy, where a suture is applied to
secure the mesh at the site of the sacral promontory [101,
102].
Studies have mentioned factors to have good outcomes,
such as experience to perform the technique with good qual-
ity make possible a complete ventral dissection of the recto-
vaginal septum down to the pelvic floor as well as the fixation
of the mesh without tension [100, 103–106].
The type of the mesh did not interfere in the results. A
systematic review of 767 patients who had a repair with a
synthetic mesh and 99 with a biological implant compared
both types of mesh and demonstrated that neither significant
819
difference in recurrence nor mesh complications were found
[107]. The 2008 National Institute of Clinical Excellence
(NICE) review of surgery for pelvic organ prolapse demon-
strated that complications are related to the type of mesh
used and depends on the follow-up time. The erosion rate for
a biological mesh (xenografts) was zero, rising to 7% for a
synthetic mesh and to 14% for a combined synthetic and bio-
logical one. On the other hand, there was a higher failure rate
for a biologic mesh compared to the synthetic one (23% vs.
9%) [108].
Biological implants are recommended for young
patients, women of reproductive age, diabetics, smokers,
and patients with a history of pelvic radiation and inflam-
matory bowel diseases or contaminated fields with intraop-
erative violation of the rectum or vagina. [107, 108]
Superiority of one mesh over the other has not yet been
demonstrated in the literature and randomized control trials
are needed to prove the role of the different types of meshes
for rectopexy [109].
A multicenter study included 2203 patients undergoing
LVMR and compared the safety of synthetic meshes with
biological grafts. This study demonstrated mesh erosion
rates of 2% and authors identified that the polyester mesh
was associated with a significantly higher incidence of mesh
erosion compared to titanium-coated polypropylene.
However, there was no statistically significant difference in
mesh erosion rates when comparing synthetic and biological
meshes [106].
Recently, Brunner et al. [110] showed their results and a
literature compilation of LVMR with a biological graft
between 2009 and 2017, including 454 patients. The types
of mesh used were Pelvicol, Permacol, and Surgisis
Biodesign. At the long-term follow-up, the recurrence rates
varied from 0 to 5% and complication rates from 0 to 23%.
There was no mesh-related complication at any study ana-
lyzed. Functional results were good with obstructed defe-
cation improvement in most studies and only 3% worsening.
Also, for fecal incontinence, there was a significant
improvement.
Regarding functional outcomes which are expected to be
better improved after the anterior approach, Lundby et  al.
[111] studied the bowel function after sutured rectopexy and
LVMR in a randomized controlled trial including 75 patients
and found a similar reduction in obstructed defecation syn-
drome for both techniques. Gosselink et  al. [112] selected
patients without a response to maximum medical treatment
(including biofeedback) who complained of fecal inconti-
nence and grade II to IV rectal prolapse for LVMR. The
results have demonstrated an improvement in fecal
continence.
820 S. M. Murad-Regadas et al.

66.7.2 Robotic Ventral Mesh Retopexy
The use of robotic surgery has been increasing since its
development in 2006, conferring several advantages over
laparoscopic surgery, including improved dexterity of move-
ment, obliteration of hand tremor, image magnification with
three-dimensional view, and instruments with a wide range
of movements allowing for unrivalled precision. These fac-
tors are especially advantageous in confined spaces, such as
the pelvis [113]. The use of robotics in ventral mesh recto-
pexy (RVMR) has been shown to be safe and feasible [114].
A recent meta-analysis comparing RVMR to LVMR for
the management of rectal prolapse [114] including five pro-
spective nonrandomized studies and 244 patients (101
robotic and 143 laparoscopic) observed a shorter operative
time favoring LVMR with a mean weighted difference of
27.94  min, similar conversion and recurrence rates, and a
trend toward a reduction in length of inpatient stay and early
postoperative complications in the robotic group without sta-
tistical significance.
Recently, van Iersel et al. [113] reported a 5-year experi-
ence of 258 patients who underwent RVMR and were fol-
lowed for more than 2 years. There was a low morbidity of
7%, despite 0.4% mortality rate. Only one vaginal mesh ero-
sion occurred. There was a significant improvement in
obstructed defecation (78.6%) and fecal incontinence
(63.7%) and worsening symptoms were reposted in 3.9%
and 0.4%, respectively. Recurrence rates were 12.9% for
external prolapse.
New minimally invasive techniques are emerging, such as
robotic-assisted and single trocar laparoscopy; however, no
benefit has yet been proven; in fact, one study found a higher
recurrence rate after robotic compared to laparoscopic recto-
pexy [95]. Heemskerk et  al. [96] recently reviewed 14
robotic-assisted rectopexies and compared them to 19 lapa-
roscopic cases. The authors found the new approach to be
39 min longer than laparoscopy and it was associated with an
increased charge of $745 per patient, while the postoperative
morbidity was similar. The lack of experience, and hence
publications, and the influence of a learning curve process
limit further conclusions about these new procedures.
Tables 66.3 and 66.4 summarizes the results in terms of
improvement of symptomsrecurrence, morbidity and mortal-
ity of procedures for complete external rectal prolapse.
66.7.3 Combined Rectopexy and Pelvic Organ
Prolapse Approach
Recent advances in knowledge of pelvic floor dynamic anat-
omy and dysfunctions associated with the available diagnos-
tic modalities and multidisciplinary assessment and
combined treatment of complex dysfunctions have worked
together to find the appropriate surgical technique and avoid
recurrence. Studies have demonstrated a substantial propor-
tion of females with multiple pelvic floor dysfunctions.
There is a difference in the prevalence of pelvic floor dys-
functions due to heterogeneity in definition, population

Table 66.3  Follow-up and functional results of laparoscopic and robotic ventral mesh rectopexy with synthetic mesh
Constipation Incontinence
Laparoscopic studies Year N Median follow-up improvement (%) improvement (%) Recurrence (n/%)
D’Hoore [97] 2004 42 71 84.2/de novo 4.8 90.3 2 (4.8)
Auguste [115] 2006 54 12 70/de novo 17.6 72.4 4 (7.4)
Verdaasdonk [116] 2006 13 7 66 69 2 (15.4)
Cristaldi [117] 2007 63 18 78 90/ de novo 3.2 1 (1.7)
Boons [118] 2010 58 19 72 83/de novo 1.5 1 (1.5)
Formijne Jonkers [119] 2013 36 30 57.9 76.2 –
Randall [120] 2014 190 29 – 93 9 (4.7)
Gosselink [121] 2015 41 12 – 50 1 (2.3)
Tsunoda [122] 2015 19 12 52 62 –
Consten/van Iersel [100] 2015 242 33.9 63.3 73.2 –
Tsunoda [123] 2015 31 12 – – 3 (9.7)
Robotic vs. laparoscopic studies
De Hoog [95] 2009 20 R 23.4 – – 4 (20)
Wong [124] 2011 23 L 12 – – 1 (4.3)
15 R 1 (6.7)
Wong [125] 2011 40L 6 – – 0
23R 0
Mantoo [126] 2013 23L 16 – – 6 (8)
12R 3 (7)
Mäkelä-Kaikkonen [127] 2014 14L 3 36 89 1 (5)
13R 0
L laparoscopic, R robotic
66  The Abdominal Approach to Rectal Prolapse 821

Table 66.4  Summary of results, including morbidity, mortality, and recurrence, of abdominal open and laparoscopic procedures for complete
external rectal prolapse [128]
Approach Technique Year Morbidity (%) Mortality (%) Recurrence (%)
Conventional Laparotomy
Suture rectopexy Sudeck 1922 9–20 0–4 0–20
Encircled/anterior mesh rectopexy Ripstein 1963 4–33 0–3 0–12
Rectopexy and resection Frykman-Goldberg 1955 7–23 0–7 0–9
Lateral mesh rectopexy Orr-Loygue 1957 0–4 0–17 0–5
Posterior mesh rectopexy Wells 1959 0–28 0–4 0–10
Laparoscopic surgery
Suture rectopexy – – 9–19 0 0–7
Lateral mesh rectopexy – – 0–5 0 0–6
Posterior mesh rectopexy – – 0–14 0 0–4
Rectopexy and sigmoidectomy – – 8–21 0–1 0–11
Ventral mesh rectopexy D’Hoore 2004 10–36 0 0–15

s­tudied, as well as methodology applied. The combined dys-
functions have been found from 30 to 50% in the patients
with pelvic floor dysfunctions [129–131]
The combined technique as sacrocolpopexy with recto-
pexy consists of distal mobilization of the anterior rectum
from the rectovaginal septum to the pelvic floor muscles
down to the levator ani. Once the rectum is fully mobi-
lized, a 5-cm-wide piece of mesh is sutured to the vaginal
cuff anteriorly and posteriorly. This mesh is then sutured
to the presacral fascia at the S3 level. The procedure treats
the posterior compartment due to rectopexy that improves
the position and angle of the rectosigmoid junction in the
pelvis, allowing a more complete and satisfactory evacua-
tion. Additionally, obliterates the deep Pouch of Douglas
that results in reduces or eliminates the potential space for
an enterocele or sigmoidocele.
A large study including 110 women reporting functional
outcome, quality of life, and recurrence rate after combined
sacrocolpopexy and rectopexy described more than 80% of
complete resolution or improvement in constipation without
the added morbidity of a bowel resection. Furthermore, a
significant improvement in constipation, incontinence, and
quality-of-life measures was shown. A multidisciplinary
approach to repairing of both compartments at the same
operation may have a synergistic effect in prevention of
recurrence and treatment success [132]. The approach to
anterior retopexy with or without sacrocolpopexy may be
laparoscopy or robotic, depending on the surgeon’s prefer-
ence and patient’s age and comorbidity.
Recently, Jallad et  al. [45] demonstrated that combined
laparoscopic pelvic organ suspension is effective but not free
of complications. From 59 patients who underwent LVMR
with sacrocolpopexy (81.3%) or sacrohysteropexy (18.6%),
the composite success rate was 57.4% in 17 months, despite
a 25.4% rate of perioperative adverse event. The use of bio-
logic graft was associated with a higher adverse event rate of
40%, as compared to 10.3% of the synthetic mesh.
66.8 Incontinence Improvements
and Mechanisms
Fecal incontinence in patients with rectal prolapse is attrib-
uted to pudendal nerve neuropathy causing sphincter dener-
vation [89], direct sphincter trauma caused by intussuscepting
rectum, and chronic rectoanal inhibition and abnormal ano-
rectal sensations [37, 84, 94, 133, 134]. Associated factors
that may be present are impaired internal anal sphincter, pel-
vic floor muscle dysfunction, and abnormal somatic nerve
stimulation [20, 36]
The anal sphincters usually start to regain tone approxi-
mately 1 month after surgery, and responsive patients are
fully continent in 2–3 months [24]. Functional improvement
after surgery is seen in 60–90% of patients, although the
exact mechanism is not well established [51, 52, 70, 93, 94,
135–137]. Some authors have suggested that the restoration
of internal anal sphincter function and improved anorectal
sensation or rectal compliance after surgery contribute to the
patients regaining continence [37].
Different abdominal procedures have shown a similar
improvement of anal continence. Benoist et al. [94] reported
no difference in incontinence improvement among different
laparoscopic techniques (suture, mesh, and resection) in a
2-year follow-up period, with 75% of the patients having
better continence after surgery.
66.9 M
 anagement of Recurrent
Rectal Prolapse
The mean reported time period for complete rectal prolapse
recurrence is between 2 and 3 years after surgery. Early sur-
gical failures are generally attributed to technical problems
[138, 139]. The reported surgical management of prolapse
recurrence is limited. Steele et al. [138] reviewed the man-
agement of 78 recurrences in 685 patients operated for initial
822
rectal prolapse, and compared the abdominal to the perineal
approach. The incidence of re-recurrence was 29% and was
significantly higher in the perineal cases (37.3% vs. 14.8%,
P  =  0.03, respectively for perineal and abdominal
approaches). The authors concluded that abdominal repair
has consistently lower re-recurrence rates for recurrent rectal
prolapse, independently of the number of previous repairs,
and suggested that whenever possible the abdominal
approach for recurrent prolapse should be undertaken, if the
patient’s risk profile permits.
A systematic review of surgical techniques and outcomes
for recurrent rectal prolapse was unable to create guidelines
due to the heterogeneity of surgical techniques, the short-­
term follow-up in most studies, and the low quality of evi-
dence [139].
Whenever performing surgery for recurrent prolapse, it is
important to be aware of the previous procedure. If there is
any prior resection involved, either perineal rectosigmoidec-
tomy or resection rectopexy, and another resection is planned,
the surgeon must preferably excise the previous anastomosis
to avoid devitalization of the remaining colonic segment.
66.10 Conclusions
Rectal prolapse is a fairly uncommon pathology that mainly
affects female adults after the fifth decade. The etiology is
poorly understood and most patients present with an abnor-
mally deep cul-de-sac, loss of posterior fixation of the rec-
tum, laxity of the anal sphincters, and a redundant sigmoid
colon. The diagnosis is based on anorectal examination, with
the patient straining seated in a commode as needed.
Complementary exams help to access associated conditions,
such as compromise of the sphincter and pelvic floor mus-
cles, constipation, and obstructed defecation; nevertheless,
these have limited impact on decision-making for the man-
agement of rectal prolapse. Surgical treatment should be
considered even in high-risk patients, once rectal prolapse
has become a distressing condition that affects the patient’s
quality of life.
Choosing the optimal repair for rectal prolapse involves
consideration of the patient’s health and the preexisting
bowel function related to a history of constipation or fecal
incontinence, and compromise of the sphincter muscles at
the anorectal evaluation. Among the abdominal procedures,
suture or mesh rectopexies are the option for patients with
normal or increased bowel function or atonic sphincter.
Resection rectopexy is preferred for constipated patients or
those with normal sphincter tonus. Abdominal approaches
are associated with low morbidity rates, even among elderly
patients, and lower long-term recurrence rates compared to
the perineal approach.
S. M. Murad-Regadas et al.
During the last two decades, laparoscopy has augmented
the low morbidity rates and reduced the surgical stress
related to perineal approaches, maintaining the long-term
efficacy of abdominal procedures. Currently, laparoscopy is
the preferred approach for the abdominal management of
complete rectal prolapse. Robotic surgery seems to present
similar results to laparoscopic approach, with a low morbid-
ity rate, acceptable long-term recurrence rates, and a good
functional outcome.
Take-Home Messages
• Rectal prolapse is a benign disorder and causes dis-
comfort due to the prolapsing tissue both internally
and externally.
• The resections techniques for the treatment of rectal
prolapse can be divided into abdominal and peri-
neal categories. So, the condition should be com-
pletely investigated to choose appropriate
techniques for surgery and approach to treat ade-
quately and avoid recurrence.
• The decision-making should be with respect to
the  choice of specific techniques according to the
patient’s conditions and the experience of the
surgeon.
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 The Perineal Approach to Rectal
Prolapse 67
Alison Althans, Anuradha Bhama, and Scott R. Steele

Learning Objectives
• Understand the indications for perineal approach to
rectal prolapse.
• Describe the perioperative care and steps of the
Delorme procedure.
• Describe the perioperative care and steps of the peri-
neal rectosigmoidectomy (Altemeier procedure).
• Understand the historical perspective behind the
Thiersch wire (anal encirclement).
• Understand the management of recurrent rectal
prolapse and strangulated/incarcerated rectal
prolapse.

67.1 Introduction

Rectal prolapse is a condition that involves protrusion of the

rectal mucosa through the anal canal. Full-thickness prolapse
occurs when the entirety of the rectal wall protrudes through
the anus and forms concentric folds of mucosa that extend
appreciably from the anus (Fig.  67.1). Mucosal prolapse
involves only protrusion of the rectal mucosa through the
anus and frequently is not circumferential, but rather comes
out likes spokes on a wheel (Fig. 67.2).
Rectal prolapse affects approximately 1% of the popula-
tion and its incidence peaks in women aged 70 years old.
Though classically described in elderly women, it is seen in
both genders and across all age ranges. Additional risk fac-
tors for prolapse include chronic straining with defecation,
constipation, multiparity, prior pelvic surgery, and pelvic
A. Althans
Case Western Reserve University School of Medicine,
Cleveland, OH, USA
e-mail: ara5@case.edu
A. Bhama · S. R. Steele (*)
Department of Colorectal Surgery, Cleveland Clinic Foundation,
Cleveland, OH, USA
e-mail: anuradha_bhama@rush.edu; Steeles3@ccf.org
Fig. 67.1  Full-thickness rectal prolapse
floor dysfunction. Rectal prolapse is frequently associated
with concomitant pelvic floor disorders such as enterocele,
rectocele, and cystocele. In fact, up to 30% of female patients
have concomitant pelvic floor disorders, and a thorough eval-
uation should be performed to exclude their presence.
Like many pelvic floor disorders, rectal prolapse can
cause debilitating symptoms such as anal pain, bleeding,
incontinence, and constipation that have a profound impact
on quality of life. As patients may initially be too embar-
rassed to disclose the extent of their symptoms, it is impor-
tant to ask specific questions and obtain a thorough history if
the suspicion for prolapse is high. The diagnosis is usually
confirmed clinically by physical examination. A thorough
physical examination includes a digital rectal examination to
assess for sphincter tone and any other pelvic floor patholo-

© Springer Nature Switzerland AG 2021 827

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_67
828
Fig. 67.2  Mucosal prolapse
gies. Examination of the perianal skin can reveal signs of
irritation from prolapsed tissue or incontinence. If necessary,
the patient can be examined in a squatting position or given
an enema and placed on the commode and asked to strain.
Once prolapse is confirmed by physical examination, appro-
priate evaluation with colonoscopy, defecography, anal
manometry, and colonic transit studies may be performed as
indicated before proceeding with surgical intervention. A
colonoscopy should be obtained if patients are due for
screening, have new symptoms of rectal bleeding or other
concerning symptoms (i.e., changes in bowel movements,
weight loss, pain), and would tolerate intervention if malig-
nancy was identified. Defecography, while not required to
identify rectal prolapse, may be helpful to identify other pel-
vic floor pathologies and to further visualize the prolapse if
necessary or help identify obstructive defecation. Manometry
may not be completely accurate in a patient with prolapse,
but may provide a baseline measurement to assess sphincter
function. Unfortunately, with chronic prolapse, the resting
and squeeze tone may be considerably altered. If a patient
A. Althans et al.
has a history of constipation, a radiographic marker transit
study will help rule out slow transit constipation.
Surgical treatment of rectal prolapse continues to evolve,
with the goal of treatment to eliminate the prolapse and
restore proper bowel function and quality of life. Ultimately,
the surgical approaches to rectal prolapse can be divided into
perineal and abdominal operations. Traditionally, an abdom-
inal approach has been recommended for patients who are
physically well enough to undergo such a procedure while a
perineal approach is deemed more appropriate for patients
who may benefit from a procedure that can be carried out
safely under spinal rather than general anesthesia (though
not mandatory) [1]. The decreased morbidity of the perineal
approach has classically been considered a trade-off, how-
ever, for higher recurrence rates [2–4]. Yet, several large pro-
spective studies and reviews have failed to discern significant
differences in the long-term outcomes when comparing each
of the approaches [5, 6]. Given the prevalence of this condi-
tion, it is necessary for colorectal surgeons to be well versed
in both the abdominal and perineal approaches to repair.
67.2 Delorme Procedure
The Delorme operation for rectal prolapse was first described
by Edmond Delorme in 1900  in his manuscript “On the
Treatment of Total Rectal Prolapse by Excision of the Rectal
Mucosa” and was subsequently modified by other surgeons
throughout the following decades [7]. This procedure became
a favorable option for both surgeons and patients as it offered
a simple approach without major complications that could be
especially useful for elderly patients and those with multiple
comorbidities. Within this cohort, the operation is typically
best suited for patients with a short (<5  cm from the anal
verge), full-thickness prolapse.
The basis of the Delorme procedure is a mucosal resec-
tion with muscular plication (Fig. 67.3). The patient is placed
in either prone jackknife or lithotomy position. The proce-
dure can be performed under conscious sedation, general
anesthesia, or spinal anesthesia. Once the patient is properly
positioned, visualization of the anus is obtained by using
anal effacement sutures or a hook retraction system. The
redundant mucosa is manually prolapsed through the anal
canal. A submucosal injection is performed to help develop
the space between the submucosa and muscularis layers of
the bowel. Options for injection include saline or lidocaine
with or without epinephrine and are based upon surgeon
preference. If local anesthetic (with or without epinephrine)
is used, care should be taken to not exceed the maximum
dose. The dentate line is then identified, and an incision is
carried through the mucosa and submucosa approximately
1  cm proximal to the dentate line. This incision is carried
circumferentially around the rectum creating a sleeve of
67  The Perineal Approach to Rectal Prolapse 829

Table 67.1  Recurrence and morbidity rates for both retrospective and
prospective studies of Delorme procedure
Number Recurrence Morbidity
Author (year) of patients % %
Tobin (1994) [8] 43 26 –
Oliver (1994) [9] 40 22 25
Senapati (1994) [10] 32 13 6
Lechaux (1995) [11] 85 14 14
Pescatori (1998) [12] 33 21 45
Watts (2000) [13] 101 27 –
Tsunoda (2003) [14] 31 13 13
Watkins (2003) [7] 52 10 4
Marchal (2005) [15] 60 23 15
Pascual (2006) [16] 21 10 5
Lieberth (2009) [17] 76 8 15
Chen (2012) [18] 25 4 32
Fazeli (2013) [19] 52 10 10
Elagil (2016) 53 16 7
Pares (2017) 11 18 18
Fig. 67.3 Delorme procedure. (Courtesy of Cleveland Clinic
Foundation, Copyright 2001)

67.3 Perineal Rectosigmoidectomy

mucosa. Allis or Babcock clamps may be used to aide in con-
trolling the mucosal sleeve. The mucosa is peeled away as
the dissection is carried proximally. While the dissection is
carried proximally, additional injections may be required to
develop the plane. The dissection is carried proximally until
no further mucosa prolapses. At this point, the mucosa is
completely transected. Plication sutures are then placed.
Suture material should be braided and absorbable. The plica-
tion sutures are placed longitudinally across the muscle and
tied down. At least eight sutures should be placed—four car-
dinal sutures and four in between the cardinal sutures. After
the muscle has been plicated, the mucosa should be
re-­
­ approximated, again using braided absorbable simple
interrupted sutures.
Postoperative care is surgeon-dependent. While some
may choose to constipate the patient so that hard stools pass
through as soon as possible, others may choose to soften the
stools immediately or utilize mineral oil to allow smooth
passage of stools. Regardless, patients should be monitored
postoperatively for bleeding and typically remain in the hos-
pital for 1 day unless comorbidities preclude discharge
home.
Postoperative complications are typically limited to
entities such as bleeding, urinary retention, and fecal
impaction. Less commonly, more serious complications
such as anastomotic dehiscence and ischemic proctitis can
occur. Retrospective and prospective studies evaluating
outcomes of Delorme procedure with associated recurrence
and complication rates can be seen in Table  67.1.
Complication rates range from 4 to 45% and recurrence
rates range from 4 to 27%.
(Altemeier Procedure)
At the same time that the Delorme procedure was developed,
the first perineal rectosigmoidectomy was performed by a
Polish surgeon, Jan Mikulicz-Radecki. However, the opera-
tion was not popularized until the 1960s by Altemeier, whose
namesake the procedure is often referred [20]. The technique
was adopted as surgeons continued to search for the best
approach to prolapse in elderly or otherwise unfit patient.
Compared to the Delorme procedure, the perineal rectosig-
moidectomy is better suited for patients with a longer full-­
thickness prolapse.
As the name implies, this approach involves a full-­
thickness perineal resection of the rectum with colo-anal
anastomosis (Figs.  67.4–67.7). The patient is placed in
either the lithotomy or prone jackknife position. The proce-
dure can be performed under conscious sedation, spinal
anesthesia, or general anesthesia, as co-morbidities allow.
Visualization of the anus is obtained using anal effacement
sutures or a hook retractor system. The rectum is prolapsed
using Babcock clamps. The dentate line is identified, and
electrocautery is used to mark the mucosa circumferen-
tially about 1–2 cm proximal to the dentate line. This mark-
ing is then carried down through the full thickness of the
rectum and can be aided with the use of a surgical energy
device. Anteriorly, the peritoneal reflection is typically
entered, which may allow for additional prolapse. Failure
to enter the peritoneal cavity is associated with higher rates
of recurrence. The rectosigmoid junction should be with-
drawn from the abdomen until there is no further redun-
dancy. Once this maximum prolapse has been identified,
830
Fig. 67.4  Perineal rectosigmoidectomy (Altemeier procedure): pro-
lapse of rectum through anal canal. (Courtesy of Cleveland Clinic
Foundation, Copyright 2001)
Fig. 67.6 Perineal rectosigmoidectomy (Altemeier procedure): full
thickness dissection of the prolapsed bowel through the rectum is per-
formed into the peritoneal cavity. (Courtesy of Cleveland Clinic
Foundation, Copyright 2001)
A. Althans et al.
Fig. 67.5  Perineal rectosigmoidectomy (Altemeier procedure): tran-
section of mesentery after bowel has been prolapsed from the peritoneal
cavity. (Courtesy of Cleveland Clinic Foundation, Copyright 2001)
Fig. 67.7  Following transection, the Altemeier is completed with a
hand-sewn colo-anal anastomosis. (Courtesy of Cleveland Clinic
Foundation, Copyright 2001)
the rectum can be transected. Typically, only a portion of
the rectum is transected at a time so that sutures can be
placed serially, as this helps avoid the bowel from returning
to the abdominal cavity and helps keep the bowel oriented
to avoid twisting. A small segment of the bowel is often
transected and a stitch is placed. Transection of the bowel is
continued circumferentially, pausing to place sutures to
67  The Perineal Approach to Rectal Prolapse 831

Table 67.2  Recurrence and morbidity rates for both retrospective and The PROSPER trial is the only randomized control trial
prospective studies of Altemeier procedure comparing the different surgical approaches to rectal pro-
Number Recurrence Morbidity lapse. In this study, there were no statistically significant dif-
Author (year) of patients % %
ferences in recurrence rates or functional outcomes between
Altemeier (1971) [24] 106 3 24
these two perineal approaches [6]. However, this study may
Williams (1992) [25] 114 10 12
Kimmins (2001) [26] 63 6 10 have been underpowered and had potential bias in the ran-
Steele (2006) [27] 48 recurrent 39 17 domization. Therefore, the operation best suited for each
Glasgow (2008) [28] 103 9 9 patient should be selected on a case-by-case basis at the dis-
Kim (2009) [29] 38 3 18 cretion of both surgeon and patient.
Altomare (2009) [30] 93 18 9
Cirocco (2010) [31] 103 0 14
Ris (2011) [32] 60 14 12
Ding (2012) [21] 113 primary 18 17
67.4 Anal Encirclement (Thiersch Wire)
23 recurrent 39 17
Towliat (2013) [33] 28 27 – Anal encirclement was initially described in 1891 by Carl
Thiersch. The underlying principle of this procedure is to
create a tunnel around the distal anal canal and using a
keep the bowel oriented and to avoid the bowel from retract- wire, mesh, or suture through the tunnel to create a partial
ing back into the pelvis. Suture material should be braided obstruction of the anal opening. This procedure can be
and absorbable. After four cardinal stitches are placed, done under local anesthetic and is therefore preferred in
intervening sutures are placed to complete the anastomosis. patients who cannot tolerate any or minimal systemic anes-
Once the anastomosis has been completed, ensure that the thetic. In general, this procedure is rarely used currently
lumen of the proximal bowel and the anastomosis are and is only reserved for the rarest cases, typically in a pal-
widely patent. This can be done using a flexible or rigid liative setting.
scope or simply a Hill-Ferguson retractor. The anastomosis The procedure is performed with the patient in either
should easily accommodate a medium-­ sized retractor. lithotomy or prone jackknife position, whichever can be tol-
Some surgeons will choose to perform a levatorplasty prior erated physiologically and based upon surgeon preference.
to starting the anastomosis. Care must be taken not to cre- An incision is made in the skin of the posterior perineum
ate an overly tight levatorplasty as this can lead to outlet about 2–4  cm from the anal verge. A closed curved Kelly
dysfunction. A single finger should comfortably fit between clamp is used to dissect a tunnel around the anal verge in the
the colon and the pelvic floor. A levatorplasty is typically deep subcutaneous tissues. The clamp is brought all the way
performed by approximating the levator muscles anteriorly around to the anterior perineum and another incision is made.
using a monofilament absorbable suture. This is then recreated on the other side. The material of
Perineal rectosigmoidectomy, in general, carries a low choice is then passed through this tunnel circumferentially
complication rate. Complications include anastomotic leak, circling the anal opening. Several different types of materials
bleeding, stenosis, and pelvic abscess [21]. As this is a full-­ have been used to create the encirclement. This includes
thickness resection (in contrast to the Delorme), the leak can metal wire, nylon suture, prolene suture, Dacron graft, sili-
result in peritoneal sepsis and severe morbidity or even mor- cone band, or biological graft.
tality; however, this is rare. Several studies examining out- The utilization of anal encirclement has largely fallen
comes of the Altemeier operation have demonstrated success out of favor due to very high recurrence rates upwards
in improving patients’ constipation, fecal incontinence, and of 44% and problems with outlet constipation [34]. In
anal manometry metrics [22]. Retrospective and prospective modern-day use, this procedure has been reserved for
studies evaluating outcomes of perineal rectosigmoidectomy patients with permanent colostomies with rectal pro-
with associated recurrence and complication rates can be lapse with severe comorbidities that would not tolerate
seen in Table 67.2. Recurrence rates are generally lower than perineal proctectomy. Recently, the utilization of anal
those seen in patients undergoing Delorme procedure, and encirclement with biological mesh to augment perineal
morbidity rates are comparable. Recurrence rates with proctectomy was found to reduce rates of recurrent pro-
Altemeier procedure may even be further augmented by the lapse from 29% without encirclement to 8% with encir-
implementation of levatorplasty [23]. Some surgeons do pre- clement [35]. Given the problems with anal encirclement,
fer the Delorme procedure over the Altemeier as functional this procedure is rarely done in current times (Table
results may be improved with the Delorme. 67.3).
832 A. Althans et al.

Table 67.3  Recurrence and morbidity rates for anal encirclement

procedure
Number Recurrence Morbidity
Author (year) of patients % %
Sainio (1991) [36] 14 15 NR
Fengler (1997) [37] 1 n/a 100% (death)
Eftaiha (2017) [35] 25 8 NR

More recently, the Fenix®Continence Restoration System

(Torax Medical, Inc., Shoreview, MN), consisting of a mag-
netically linked titanium beads on a titanium string, was uti-
lized as a Thiersch-type procedure. Following its initial
release in 2015 and reported success, it was withdrawn from
the market and is currently not available in the United States.

67.5 M
 anagement of Recurrent Rectal
Prolapse

It is imperative to understand the treatment of recurrent rec-

tal prolapse given the high recurrence rates even with surgi-
cal treatment. There are several factors that need to be taken
into consideration when approaching a patient with recur-
rence. First and foremost, it is absolutely necessary to know
what operations have been performed in the past. Prior to
embarking on any sort of procedure involving a resection,
the current blood supply must be understood. The prior oper-
ation will dictate the remaining blood supply and therefore
dictate the surgical options for the recurrence.
In patients who have undergone a resection rectopexy
in the past, an Altemeier should not typically be under-
taken. Similarly, patients who have undergone Altemeier
in the past should not undergo a resection rectopexy.
These operations have the potential to leave an interven-
ing segment of colon between the old and new anastomo-
ses that is at risk for ischemia. If either of these scenarios
is encountered and chosen, it is imperative to resect the
prior anastomosis to avoid the risk of ischemia. In patients
who have had an Altemeier, a repeat Altemeier or Delorme
is feasible. If the patient is now felt to be a reasonable
surgical risk, a rectopexy is also an option. Similarly,
patients who have had a rectopexy in the past are candi-
dates for repeat rectopexy or a perineal procedure. Those
who had resection rectopexy in the past should be consid-
ered for redo rectopexy; any perineal procedure would
demand resection of the old anastomosis, so it is impor-
tant to get a good understanding of the patient’s anatomy
prior to any surgical repair. A flexible sigmoidoscopy can
typically be done in an outpatient setting to assess the
location of the former anastomosis and if it is involved in
the prolapsed segment. If the anastomosis is not easily
prolapsing through the anal canal, then an Altemeier pro-
cedure should be avoided.
Fig. 67.8  Incarcerated rectal prolapse
67.6 M
 anagement of Incarcerated or
Strangulated Rectal Prolapse
Patients with incarcerated or strangulated rectal prolapse
should be evaluated at the bedside immediately and the viabil-
ity of the rectum should be assessed (Fig.  67.8). First, it is
important to ensure that the prolapse is, in fact, rectal prolapse
and not internal hemorrhoid prolapse. Once it is determined
that the condition is rectal prolapse, if the rectum appears via-
ble, attempts should be made to reduce the prolapse. If the rec-
tum is quite edematous, applying a large amount of sugar may
help pull out some of the edema, allowing the prolapse to be
reduced. Coating the entirety of the rectum in a thick layer of
sugar and then wrapping it in gauze may help reduce the swell-
ing. Many of these patients have a patulous anus and reduction
is usually possible. In the case that the prolapse is not reducible
at the bedside, the patient can be taken to the operating room
where an anesthetic may allow the prolapse to be reduced. If
the rectum is strangulated and becoming necrotic, then the pro-
lapse should not be reduced but should be excised via emergent
perineal rectosigmoidectomy procedure.
67.7 Conclusion
Perineal approaches to rectal prolapse still play a large role
in the care of patients with rectal prolapse. Despite their pro-
clivity for a slightly higher recurrence rate, they are associ-
ated with low morbidity and mortality, and in general, serve
to improve quality of life.
67  The Perineal Approach to Rectal Prolapse 833

14. Tsunoda A, Yasuda N, Yokoyama N, Kamiyama G, Kusano

Take-Home Messages M.  Delorme’s procedure for rectal prolapse: clinical and physi-
ological analysis. Dis Colon Rectum. 2003;46:1260–5.
• Understanding the various perineal approach to rec- 15. Marchal F, Bresler L, Ayav A, Zarnegar R, Brunaud L, Duchamp
tal prolapse is a necessary tool for surgeons who C, et al. Long-term results of Delorme’s procedure and Orr-Loygue
treat this condition. rectopexy to treat complete rectal prolapse. Dis Colon Rectum.
• The choice of operation is patient dependent, and 2005;48:1785–90.
16. Pascual Montero J, Martinez Pente M, Pascual I, Butron Vila T,
various factors need to be considered in making that Garcia Borda F, Lomas Espadas M, et al. Complete rectal prolapse
decision. clinical and functional outcome with Delorme’s procedure. Rev
• It is necessary to have a management strategy in Esp Enferm Dig. 2006;98:837–43.
place for patients with emergent issues related to 1
7. Lieberth M, Kondylis LA, Reilly JC, Kondylis PD. The Delorme
repair for full-thickness rectal prolapse : a retrospective review. Am
rectal prolapse, including reduction of the prolapse J Surg. 2009;197:418–23.
and emergency perineal rectosigmoidectomy, if 18. Chen C, Zhang G, Yan C, Wang C. [Delorme procedure for full-­
necessary. thickness rectal prolapse: a report of 25 cases]. Zhonghua Wei
Chang Wai Ke Za Zhi. 2012;15:285–7.
19.
Fazeli MS, Kazemeini AR, Keshvari A, Keramati
MR.  Coloproctology Delorme’s procedure  : an effective treat-
ment for a full-thickness rectal prolapse in young patients. Ann
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20. Altemeier W, Giuseffi J, Hoxworth P. Treatment of extensive pro-
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 The Laparoscopic Approach to Rectal
Prolapse
Bart Van Geluwe and Andrè D’Hoore
Learning Objectives
• Pathogenesis of pelvic floor disorders needs to be
clarified.
• Prospective controlled studies are necessary to
define the optimal treatment strategy for pelvic
floor disorders
• Indications for surgery and patient selection should
be optimized.
68.1 Introduction
Pelvic floor dysfunction is the inability of the pelvic floor to
fulfill its supportive role to the pelvic organs and/or its inabil-
ity to allow these organs to function normally. The dysfunc-
tion may be limited to a single organ, but more often affect
more than one of the urinary, gynecological or anorectal
organs and necessitate a multidisciplinary approach [1].
These disorders are common and cause significant clinical
problems going from fecal incontinence, obstructed defeca-
tion syndrome (ODS) and pelvic organ prolapse (POP) [2].
Pathogenesis is complex and not completely understood but
seems to be multifactorial. Rectocele, rectal intussusception,
and perineal descent are the most frequently diagnosed ana-
tomic disorders identified in these patients. Functional disor-
ders, for example, dysregulated pelvic floor function
(anismus), may coexist, and it is not clear whether it is a
cause, consequence, or an associated symptom [3, 4].
In general, most patients will respond to conservative
treatment such as dietary modifications, fluid manipulation,
Electronic Supplementary Material The online version of this chap-
ter (https://doi.org/10.1007/978-3-030-40862-6_68) contains supple-
mentary material, which is available to authorized users.
B. Van Geluwe (*) · A. D’Hoore
Department of Abdominal Surgery, University Hospitals
Gasthuisberg Leuven, Leuven, Belgium
e-mail: andre.dhoore@uzleuven.be
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_68
68
fiber supplements, osmotic and stimulant laxatives, and/or
enemas. In the minority of patients, a selective surgical inter-
vention is necessary [2].
Several surgical approaches have been advocated for the
treatment of rectal prolapse syndrome including perineal
versus transabdominal procedures, and open versus laparo-
scopic techniques, but prospective studies comparing differ-
ent approaches and techniques are lacking [5]. A recently
published international survey showed that the treatment of
rectal prolapse syndromes clearly differed between surgeons,
continents, and regions. Therefore, there is no consensus on
the best treatment option for these conditions, nor are there
generally accepted guidelines [6].
Laparoscopy offers better anatomical exposure and surgi-
cal detail, reduces blood loss and excessive tissue manipula-
tion making it an excellent modality for performing
functional surgery. This article will review contemporary
concepts in pelvic floor anatomy, describes the various lapa-
roscopic surgical techniques currently available, and sum-
marizes currently published results of laparoscopic approach
for rectal prolapse.
68.2 Epidemiology
The prevalence of pelvic floor disorders is unclear, but gen-
erally 25% of women between the ages 40–59 show some
form of pelvic floor disorder (including urinary or fecal
incontinence or pelvic organ prolapse) [7]. Rectal prolapse
syndrome affects patients at every age and is more common
in women than in men with a ratio of 10 to 1 [8]. Male
patients have an equal incidence per decade of life whereas
women have an increased incidence as they age. The preva-
lence of these disorders will increase substantially given the
changing demographics in western civilization [9].
Predisposing factors include a history of constipation or
obstructed defecation with excessive straining. Childbearing
will certainly contribute to the development of pelvic floor
laxity; however, a big portion of the patients with rectal
835
836
p­ rolapse are nulliparous excluding birth trauma as a cause.
Psychiatric disorders are also a risk factor [2, 10].
68.3 Etiology
There are two theories postulating the etiology of rectal pro-
lapse. This is based on observations of abnormalities in local
anatomy associated with the prolapse.
1. Sliding Hernia Theory
This theory was described by Moschowitz in 1912 based
on the observation that the rectal lumen is usually poste-
riorly placed in procidentia and small bowel occasionally
present anteriorly in the “hernia sac.” The concept is that
rectal prolapse is rather a sliding perineal hernia, which
develops as a weakness in the transversalis fascia second-
ary to increased intraabdominal pressure. Hence, the pro-
lapse starts as a hernia in the pouch of Douglas and
because the perineal reflection is closely adherent to the
rectum, and the anus is relatively fixed, the hernia pro-
trudes as an intussusception toward the anal canal [11].
2. Intussusception Theory
Devadhar proposed that rectal prolapse starts as a circum-
ferential intussusception of the rectum [12]. This has been
confirmed by defecographic studies by several authors
[13]. Intussusception may due to congenital failure of fixa-
tion of the mesorectum to the sacrum with straightening
the anorectal angle or secondary to trauma, obstetric
injury, or surgical procedures. A nonrelaxing puborectal
muscle may also play a role. Whether or not this internal
intussusception represents an early finding in patients who
eventually develop full-thickness prolapse is unclear [14].
Numerous anatomic abnormalities are associated with
rectal prolapse syndrome and include an abnormally deep
pouch of Douglas, lax and atonic muscles of the pelvic
floor, weak anal sphincter muscles, nonrelaxing puborec-
tal muscle, and poor sacral and lateral ligament fixation of
the rectum. The real cause of rectal prolapse may be a
combination of disturbances in one or more of these fac-
tors [13–17].
68.4 P
 elvic Floor Anatomy and (Patho)
Physiology
The surgical approach to pelvic floor disorders is almost
always an anatomical one and therefore a thorough knowl-
edge of pelvic floor anatomy and its supportive components
before repair of disorders is attempted.
B. Van Geluwe and A. D’Hoore
The endopelvic fascia and pelvic floor muscles provide
most of the support function in female pelvis although the
support for the pelvic viscera, vagina and rectum involves a
complex interplay between muscles, fascia, nerves, liga-
ments and anatomical orientation. The anatomical pathology
of the posterior compartment is best understood in terms of
the DeLancey level of pelvic organ support [18]. Three levels
of vagina support are described:
• Level 1: The superior suspension of the vagina apex from
the lateral pelvic sidewall by the uterosacral–cardinal
complex. The cardinal–uterosacral complex provides api-
cal support by suspending the uterus and upper one-third
of the vagina to the bony sacrum. This complex can be
described as two separate entities: the cardinal ligament
and the uterosacral ligament. The cardianal ligamant is a
fascial sheath of collagen that envelops the internal iliac
vessels and then continues along the uterine artery merg-
ing into the visceral capsule of the cervix lower uterine
complex and upper vagina. The uterosacral ligament is
denser and more prominent than the cardinal ligament.
Collagen fibers of the uterosacral ligament fuse distally
with the visceral fascia over the cervix, lower uterine seg-
ment, and upper vagina, forming the pericervical ring.
Proximally, these fibers and at the presacral fascia overlie
the second, third, and fourth sacral vertebrae. This com-
plex seems to be the most suppurative structure of the
uterus and upper one third of the vagina. Disruption of the
cardinal–uterosacral complex may result in uterine
descensus or vaginal (vault-prolapse). Likewise, the most
common cause of vaginal vault prolapse is previous hys-
terectomy with failure to adequately reattach the cardi-
nal–uterosacral complex to the pubocervical fascia and
rectovaginal fascia at the vaginal cuff intraoperatively.
A vaginal vault or uterine prolapse and retropubic fixa-
tion of the anterior wall will result in an abnormal deep
pouch of Douglas. The descent of small bowel (enterocele)
or abundant sigmoid (sigmoidocele) in this space between
the posterior vaginal wall and the anterior rectum will
always be associated with at least some rectal descent, and
the clinical presentation of a bulge in the upper posterior
vagina, the sign of a recto- and/or entero/sigmoidocele.
• Level 2 provides horizontal or lateral support to bladder,
vagina, and rectum and includes the lateral attachment of
the upper two-thirds of the vagina. The anterior vaginal
wall is attached laterally to arcus tendinous fascia pelvis
while the posterior vaginal wall is attached laterally to the
fascia overlying the levator ani muscle. Posteriorly the
rectovaginal septum found between the vaginal epithe-
lium and the rectum attaches laterally to the fascia over
68  The Laparoscopic Approach to Rectal Prolapse
the levator ani muscles. The rectovaginal septum is the
most important support system of the posterior vaginal
wall and helps maintain the rectum in its posterior posi-
tion. A breech in the integrity of the rectovaginal septum
or a defect in its lateral attachments results in develop-
ment of a rectocele or may lead to a failure of the fixation
of the anterior rectum wall, creating a leading cause for a
rectal intussusception.
• Level 3: Distal Support.
The rectovaginal septum fuses distally into the fascia of the
pubococcygeal and puborectal muscles and perineal body.
A disruption of the perineal body, usually associated with a
defect of the deep portion of the external anal sphincter will
lead to the formation of a supra-anal rectocele.
68.5 Symptoms
Rectal prolapse syndromes are associated with different def-
ecation disorders going from obstructed defecation to fecal
incontinence [8]. Patients may complain of one of the fol-
lowing: pain, incomplete evacuation, the need to digitation, a
pelvic mass or prolapse, mucus or blood discharge, constipa-
tion or incontinence. Patients with an external rectal prolapse
will complain of a mass protruding from the anus with the
need to reduce the prolapsed rectum manually. Untreated
rectal prolapse inevitably leads to sphincter insufficiency and
fecal incontinence. Mucus discharge and soiling is common.
Chronic exposure may lead to rectal ulcerations and excoria-
tions (‘solitary rectal ulcer’) associated with anal bleeding,
pain and tenesmus [2]. Associated cystocele may cause uri-
nary symptoms and in situations where the pelvic floor is
extremely weak, the vaginal vault may prolapse as well.
The clinical examination should include inspection of the
perineum for scars and for protrusion of vaginal and/or rectal
mucosa or asymmetry of anal folds. The prolapsing mass
will have circular folds with a posteriorly situated lumen in
case of an external rectal prolapse. In mucosal prolapse,
these folds are radial. Rectal digital examination should be
carried out to assess sphincter tone and ascertain when a rec-
tocele is present.
68.6 Investigations
A colpo-cysto-defecography with small bowel contrast is
essential in the evaluation of pelvic floor disorders. This
examination will not only demonstrate the prolapse itself, it
can also reveal further information of the middle and anterior
compartment or can reveal functional information such as an
837
nonrelaxing m. puborectalis syndrome. A flexible endoscopy
is advisable to exclude a neoplasm, inflammatory bowel dis-
ease, or diverticular disease. Anorectal functional assess-
ment with manometry and balloon evacuation test is useful
to evaluate the anal sphincter and to exclude severe dyssyn-
ergia. In patients with a long history of constipation, transit
marker studies are necessary to identify patients with total
colonic inertia.
68.7 Indications
Surgery is the only adequate treatment for patients with total
rectal prolapse. On the other side, there has been a debate for
decades about the optimal treatment of internal rectal pro-
lapse. However, there appears to be a renewed interest in the
clinical relevance and treatment of these disorders. Rectocele,
rectal intussusception, and entero- or sigmoidocele are the
most frequently associated anatomic disorders identified in
patients with obstructed defecation and/or fecal inconti-
nence. Conservative management including pelvic floor bio-
feedback is the first-line treatment. In failure, a surgical
treatment has been shown to be beneficial in highly selected
patients. Surgical repair should be associated with minimal
morbidity and result in the lowest possible recurrence rates.
The aim of surgery is to correct anatomy with a relief of
associated symptoms [2, 8, 19].
68.8 Surgical Techniques
In 1992, Berman et  al. published the first laparoscopically
performed rectopexy [20]. The surgical principle of recto-
pexy is simple: the rectum is mobilized and returned to its
correct anatomical position within the pelvis. During the last
decades, many abdominal operations have been described.
All of these approaches essentially involve varying the
degree of rectal mobilization, reduction in the prolapse as
well as fixation of the rectum with or without sigmoid resec-
tion. Fixation can be augmented through anterior or posterior
placement of foreign material (mesh) to incite an inflamma-
tory reaction and fibrosis. Alternatively, suture rectopexy
alone can be utilized to suspend the rectum. Preservation of
the rectum (rectal capacity) is important to obtain satisfac-
tory functional outcome with regard to fecal incontinence.
1. Laparoscopic Suture Rectopexy
Since its introduction, laparoscopic suture rectopexy
gained popularity given that it is simple and easy to per-
form. The surgical technique is to mobilize the rectum
from adjacent tissues completely and to suture and anchor
838 B. Van Geluwe and A. D’Hoore

Table 68.1  Results of laparoscopic suture rectopexy

Continence Constipation Recurrence Follow-up
Authors N Pts Procedure improvement (%) improvement (%) N Pts (%) (months)
Kessler et al. [23] 32 SR NS NS 6 48
Bruch et al. [24] 72 SR 64 76 0 24
Kellokumpu et al. [25] 17 SR 82 70 7 24
Heah et al. [26] 25 SR 50 11 worsening NS NS
Benoist et al. [27] 18 SR 77 NS 0 67
Hsu et al. [28] 12 – 0 0a 0 32
Wilson et al. [29] 72 9 48
N Pts number of patients, NS not stated, SR suture rectopexy
a
Obstructive defecation syndrome in 1 patient

Table 68.2  Results of laparoscopic resection rectopexy

Continence Constipation Recurrence Follow-up
Authors Year N Pts Procedure improvement (%) improvement (%) N Pts (%) (months)
Stevenson et al. [32] 1998 34 SR + Res 70 64 0 18
Xynos et al. [33] 1999 10 SR + Res 100 NS NS 12
Bruch et al. [24] 1999 40 SR + Res 64 76 0 24
Demirbas et al. [34] 2005 23 SR + Res 85 30 0 36
Lechaux et al. [35] 2005 13 SR + Res 38 (8 worsening) 8 (8 worsening) 0 36
Rose et al. [36] 2002 124 SR + Res NS NS NS NS
Tsiaoussis et al. [37] 2005 27 SR + Res 71 92 NS 12
Laubert et al. [38] 2013 264 NS 80 NS 58
N Pts number of patients, NS not stated, Res resection, SR suture rectopexy

the rectum to the sacrum. Following full mobilization of
the rectum, the lateral stalks are sutured to the presacral
fascia using nonabsorbable suture material. Two or three
sutures are used on one or both sides of the rectum mak-
ing sure not to narrow the rectum. In this technique, adhe-
sions progresses due to fibrosis, keeping the rectum
anchored to the rectum. After surgery, incontinence is
improved but the relief of constipation varies with the
investigators [21]. Recurrence rates are reported to be low
(0–9%) (Table 68.1) [23–29].
2. Laparoscopic Resection Rectopexy (Frykman-
Goldberg) [30].
After a rectal resection, it has been commonly observed
that a strong adhesion between rectal anastomosis and
sacrum enables to fix the rectum to the sacrum. For that
reason, bowel resection has been applied to the treatment
of rectal prolapse. The technique combines direct suture
rectopexy with sigmoid resection (laparoscopic
resection-rectopexy)
The rectum is mobilized and the sigmoid colon is resected
and a tension-free anastomosis is created. Preservation of
the A. rectalis superior should be attempted. Fixation
sutures are placed from the lateral stalks to the endopelvic
fascia in a similar fashion to the suture rectopexy. The
rectum must be elevated out of the pelvis as high as pos-
sible prior placement of the sutures. The anterior cul-de-
sac is closed. Additional theoretical advantages of this
procedure include suspension of the rectum by straighten-
ing and “shortening” the left colon and the prevention of
torsion or volvulus of the abundant sigmoid colon. By
performing a resection, the mobility of the left colon
almost disappear, which also helps to prevent recurrences
[21–23].
The procedure carries the risk of anastomotic leakage;
however, it results in low incidence of recurrence (0–5%).
In most cases, both incontinence and constipation is
improved (Table 68.2). In patients with a major degree of
fecal incontinence, a resection should be avoided [31]. In
males, a wide pelvic dissection may induce serious sexual
dysfunction [32–39].
3. Laparoscopic Mesh Rectopexy
Based on the assumption that when a foreign body is used,
stronger fibrosis and adhesion than simple suture could be
induced, the mesh rectopexy was introduced [31].
Initially, the procedure involved supporting the rectum
against the sacrum with a sling of mesh attached to the
presacral fascia. Depending on the fixation site, the
method is classified as anterior sling rectopexy (Ripstein
procedure) or posterior mesh rectopexy (Well’s posterior
rectopexy) [40, 41]. In the Ripstein procedure, an anterior
sling is positioned in front of the rectum and sutured to
the presacral fascia. However, this approach was found to
be associated with significant postoperative constipation
arising from obstruction to the rectum from the sling. A
subsequent modification of the procedure to avoid this
problem involved a partial wrap of the rectum by two
sides of a piece of mesh which have been previously
attached to the presacral fascia. In the UK, a similar
68  The Laparoscopic Approach to Rectal Prolapse 839

approach was introduced, where the mobilized rectum

was partially encircled by an Ivalon sponge, which has
been fixed to the presacral fascia [42].
A second approach to fixing the rectum within the pel-
vis is to suspend it from the sacral promontory. Initially
this was achieved using strips of fascia lata attached to
the sacral promontory and the anterior wall of the rec-
tum (Loygue’s operation) [43, 44]. Very recently, lapa-
roscopic ventral mesh-rectopexy by laparoscopy, a
modification of the Loygue procedure, has been intro-
duced [43, 45].

68.8.1 Laparoscopic Ventral Mesh Rectopexy

Fig. 68.2  Peritoneal incision and sacral promontory dissection: The
mesosigmoid is retracted to the left, and a peritoneal incision is made
The aim of the dissection is to avoid autonomic nerve dam-
over the sacral promontory. Special care is taken to preserve the right
age and to limit the dissection to the rectovaginal septum hypogastric nerve. The sacral promontory should be sufficiently dis-
close to the muscular coat of the rectum preserving all areo- sected to allow safe mesh fixation
lar tissue to the posterior aspect of the vagina.
The dissection starts at the sacral promontory (Figs. 68.1
and 68.2). Care should be taken not to injure the right hypo-
gastric nerve and the left iliac vein. A temporary uterine sus-
pension can be performed to expand the field of view within
the pelvis.
An inversed J-formed incision is made over the perito-
neum close to the left side of the rectum and over the deepest
part of the Douglas fold. No pararectal dissection is per-
formed and only a flap of peritoneum is raised.
Essentially, to start the dissection of the rectovaginal sep-
tum is to reduce the prolapse and make the incision in the
deepest part of the reduced Douglas. Incision should be per-
formed 1  cm cephalad to the vaginal vault. Denonvilliers’
fascia is incised and dissection is progressed on the muscular
coat of the rectum.
Fig. 68.3  Laparoscopic view of the mesh-fixation upon the anterior
aspect of the rectum (in the rectovaginal septum), with glue and nonab-
sorbable sutures. The fixation will inhibit further rectal intussusception.
A redundant pouch of Douglas can be resected

Depending upon the indication, a more deep dissection

within the septum can be performed especially to also cor-
rect rectoceles.
Depending upon the need, a resection of the pouch of
Douglas can be performed. This will add to the adherence of
the mesh to the rectum.
Once this dissection has been performed, a strip of mesh
(normally around 4 cm × 17 cm) should be positioned flat
within the rectovaginal septum. The mesh should be fixed at
the side of the intussusception (normally at the level of the
incision where the rectovaginal dissection was started), using
nonabsorbable sutures. Today we routinely use biological
Fig. 68.1  Laparoscopic view of a deep pouch of Douglas (rectouterine
excavation). The uterus is suspended to improve exposure of the pelvis
glues to have the mesh remaining in position deeper into the
rectovaginal septum (Fig. 68.3).
840
Fig. 68.4  The mesh is fixed to the sacral promontory using an endo-
scopic “tacker” device. The position of the strip is slightly deviating to
the right side of the sacral promontory. No traction is exerted on the
rectum, which remains in the sacrococcygeal hollow
The mesh should keep the prolapse reduced but there
should not be any undue traction. Small screws are inserted
to fix the mesh to the sacral promontory. Entrapment of the
hypogastric nerve should be avoided. (Fig. 68.4).
The shape of the mesh can be adapted according to the
need, especially when there is a colpopexy to be performed.
At inspection, one should explore the utero-sacral ligaments.
If those are intact then no colpopexy should be performed as
this could lead to traction and dyspareunia. If a colpopexy is
to be performed, lateral stitches should be inserted through
the remainder of the ligament and sutured to the mesh. No
transvaginal suturing should be performed, as this would add
a risk for mesh infection.
Once this has been performed then the peritoneal flap will
completely cover the mesh. The lateral borders of the incised
peritoneum are then closed over the mesh. This elevates the
new pouch of Douglas and completely covers the mesh with
peritoneum, with an additional advantage to avoid small
bowel adhesions to the mesh and erosions (Fig. 68.5).
If inadvertently the rectum or the vagina has been entered,
a closure repair should be performed and we strongly advise
to omit any placement of mesh, and to go for a perineal pro-
cedure or re-explore the patient after 3 months. The opera-
tion is also feasible in male patients [8, 45].
68.9 What Are the Results of Rectopexy?
Many studies, both retrospective and prospective, evaluated
the outcome after surgery for rectal prolapse. The heteroge-
neity of the trial objectives, interventions, and outcome made
analysis difficult. Many review objectives were covered by
only one or two studies with small numbers of participants
B. Van Geluwe and A. D’Hoore
Fig. 68.5  The lateral borders of the incised peritoneum are then closed
over the mesh, resulting in an elevation of the “neo-Douglas” (com-
pared with the deep pouch of Douglas in Fig. 68.1)
[46]. With these caveats in mind, there is insufficient data to
say which laparoscopic approach has a better outcome.
Some further studies compare different types of recto-
pexy, performed either by open or by laparoscopy [47]. They
conclude that all types of rectopexy sufficiently repair pro-
lapse and improve incontinence. Resection suture rectopexy
is associated with less incidence of constipation, and the pro-
cedure is recommended in patients with associated preopera-
tive constipation and sigmoid colon-bearing diverticulae. For
patients with predominant fecal incontinence, prosthesis rec-
topexy is recommended. [46–50].
The above findings are further emphasized by one sys-
tematic review and one meta-analysis of studies compar-
ing open to laparoscopic approach for all types of
rectopexies in patients with external rectal prolapse [46,
51]. The systematic review also included studies with peri-
neal procedures. They both show that the laparoscopic
approach seems to be associated with faster recovery, and
similar recurrence rates and functional results as compared
to the open approach. In more detail, i) data to document
superiority of transabdominal over perineal procedures are
not strong, ii) there were no significant differences in the
outcomes between the different methods of rectopexy, iii)
division of the lateral ligaments seems to be associated
with reduced recurrence rate, but increased incidence of
postoperative constipation, and iv) resection suture-recto-
pexy is associated with less incidence of postoperative
constipation. However, due to the heterogeneity and the
poor quality of the studies included, safe results cannot be
drawn. According to the results of a more recent multi-
center study, suture rectopexy should always complement
rectal mobilization; avoidance to fix the mobilized rectum
is as associated with significantly increased recurrence
rate, after 5 years of follow-up [50, 52].
68  The Laparoscopic Approach to Rectal Prolapse 841

68.10 Role of Lateral Ligaments? feasible, and the bowel anastomosis can be avoided [8, 45,
53]. An inherent step in all other rectopexies is the full
The left colon and rectum receive retrograde innervation mobilization of the rectum. Autonomic nerve injury during
from neural efferents running through the so-called “lateral extensive posterolateral rectosigmoid mobilization may
ligaments”; thus, lateral ligament division during rectopexy lead to postoperative dysmotility and impaired evacuation
has been suggested to denervate the rectum, causing postop- (Table  68.3). Published results concerning laparoscopic
erative constipation. ventral mesh rectopexy are good, especially with regard to
A number of studies looked at the effect of the division or functional outcome even in the long term. According to
preservation of ligaments. Bachoo et al. performed a meta-­ several recent studies and one review, morbidity is low, the
analysis of articles reporting on surgery for rectal prolapse. recurrence rate is below 5%, preexisting constipation is
They concluded that division rather than preservation of the treated in almost 80% of the cases, and incontinence
lateral ligaments was associated with less recurrent prolapse improves in 90% [27, 52–66]. To avoid any complication
but more postoperative constipations, although these find- from the synthetic prosthesis, use of biological mesh has
ings were found in small numbers [48]. also been used with comparable success rates, although on
short-term follow-up. [67].
The advantage of laparoscopic ventral mesh-rectopexy
68.11 Choice of Operation? includes a correction of the posterior compartment on the
three DeLancey levels of pelvic organ support (Table 68.4)
There are many options to repair rectal prolapse syndromes, [68]: by performing the dissection into the rectovaginal sep-
and since there is no consensus on the best surgical treatment tum as deep as possible and introducing a mesh at the level
for these conditions, the choice of an optimal treatment is of the perineal body (level 3), a supra-anal rectocele can be
difficult. It is best tailored to the individual patient and sur- treated. Interposition of the mesh on the anterior surface of
geon. The skill and the surgeon’s familiarity with the proce- the rectum will reinforce the rectovaginal septum correcting
dure should be considered. a concomitant rectocele and will prevent recurrence of rectal
In our practice, we favor laparoscopic (nerve-sparing) intussusceptions (level 2). Moreover, the choice of a ventral
ventral mesh rectopexy because the procedure is safe and position for the mesh is based on defecographic data that

Table 68.3  Results of laparoscopic mesh rectopexy

N Continence Constipation Recurrence Follow-up
Authors Year Procedure Pts improvement (%) improvement (%) N Pts (%) (months)
Himpens et al. [53] 1999 Post mesh 37 92 0 (38 worsening) 0 26
Zittel et al. [54] 2000 Post mesh 29 76 0 1 (3, 4) 22
Benoist et al. [27] 2001 Post mesh 14 10 0 (21 worsening) NS 47
Lechaux et al. [35] 2005 Orr-Loygue 35 27 (4 worsening) 19 (27 worsening) 2 (5, 7) 36 (7–77)
Douard et al. [55] 2003 Orr-Loygue 31 96 26 (54 worsening) 0 28 (13–57)
Portier et al. [57] 2006 Orr-Loygue 73 62, 5 54 3 (4, 1) 27, 5 (6–84)
Marchal et al. [56] 2005 Orr-Loygue 49 73 33 (58 worsening) 2 (4, 08) 106 (14–276)
Marceau et al. [58] 2005 Orr-Loygue 28 2 (7, 1) 34 (5–82)
D’Hoore et al. [52] 2004 Ventral mesh 42 90 84 2 (4, 7) 61 (29–98)
Slawik et al. [61] 2007 Ventral mesh 80 91 80 0 54
D’Hoore [44] 2006 Ventral mesh 109 NS NS 3 (2, 75) NS
Vanden Esschert et al. [59] 2008 Ventral mesh 17 0 38
Boons et al. [62]. 2010 Ventral Mesh 65 85 (5 worsening) 72 (2 de novo) 2 19
Maggiori et al. [60] 2012 Ventral Mesh 33 90 72 (7 de novo) 2 (6) 42 ± 7 (35-52)
Wong et al. [63] 2011 Ventral Mesh 86 4.9 29
Jonkers et al. [65] 2012 Ventral Mesh 245 77 65(2 de novo) 6 (2.6) 30 (5-87)
Lauretta er al. [64] 2012 Ventral Mesh 30 100 92.8 1 (3.4) 13.9
Van Geluwe et al. [8] 2013 Ventral Mesh 405 85 57 (2.8 de novo) 4.7 25
Consten et al. [73] 2015 Ventral Mesh 667 73 73 47/667 34
Tsunoda et al. [74] 2015 Ventral Mesh 26 41 67 1/26 16
Franceschilli et al. [75] 2015 Ventral Mesh 100 92 86 14/100 20
Gosselink et al. [76] 2015 Ventral Mesh 50 NS 74 3/50 12
Albayati et al. [77] 2016 Ventral Mesh 51 30 67 2/36 23
N Pts number of patients, NS not stated
NS, meaning that these results were not available in the articles referring to
842
Table 68.4  Supporting structures in female pelvic floor
DeLancey described three levels of support axes as follows:
 Level 1: superior suspension of the vagina to the cardinal–
uterosacral complex.
 Level 2: lateral attachment of the upper two thirds of the vagina,
and
 Level 3: distal fusion of the vagina into the urogenital diaphragm
and perineal body
identified rectorectal intussusception as the leading mecha-
nism for development of a severe rectal prolapse almost
always starts anteriorly [13, 44, 52, 69]. In addition, patients
with solitary rectal ulcer syndrome predominantly have a
prolapse of the anterior rectal wall [70].
Colposuspension on the same mesh can be incorporated if
necessary to correct a vaginal vault prolapse and to elevate
the pouch of Douglas correcting an enterocele or sigmoido-
cele (level 1).
Other advantages of this operation include avoidance of
risk of bleeding of the presacral fascia, and the avoidance of
rectal mobilization with less risk of damaging the pelvic
autonomic nerve supply [44, 52, 71].
68.12 Need for Colonic Resection?
All patients with a history of obstructed defecation or consti-
pation will present with an abundant sigmoid during laparos-
copy. Only in patients with a history of diverticular disease,
one might perform a sigmoid resection at the same time as an
abdominal rectopexy. In some patients with marked redundant
sigmoid with an element of volvulus, a sigmoid resection may
be considered too. In patients with proven slow transit consti-
pation and a high degree of internal rectal prolapse, rectopexy
alone, is often sufficient. Correcting the obstructed defecation
can be enough to improve colon transit time. Only a few
patients with an isolated slow transit constipation may benefit
from a subtotal colectomy with ileorectal anastomosis.
68.13 Robotic Approach
Robotic-assisted laparoscopic techniques have been reported
with similar results as laparoscopic procedures. It has the
advantage of a three-dimensional vision with more detail,
useful to identify and spare the parasympathetic innervation
of the rectum. The use of instruments offers more flexibility
in suturing of the pelvis. Robotics are safe and feasible, but
result in increased operating time and higher costs than con-
ventional laparoscopy. [72].
B. Van Geluwe and A. D’Hoore
68.14 P
 reoperative Considerations: Urinary
Incontinence
Urinary incontinence can develop de novo or worsen follow-
ing surgery in the posterior compartment. The urethra may
be anatomically kinked in patients with revers pelvic pro-
lapse. Following prolapse repair, insufficient urethral sphinc-
ter function may result in new onset stress urinary
incontinence. Preoperative and postoperative urological fol-
low-­up is mandatory.
68.15 Postoperative Considerations:
Mesh-­Related Complications
There has been an increasing awareness on mesh-related
complications and this in view of the unacceptable high ero-
sion rates, seen after transvaginal prolapse repairs (up to
11% within 12 months of follow-up).
A recent position statement by the Pelvic Floor Society
on behalf of the Association of Coloproctology of Great
Britain and Ireland on the use of mesh in ventral mesh recto-
pexy stated that mesh morbidity is clearly significant and
lower then after transvaginal procedure but that polyester
types of mesh should be avoided and that certain suture
material especially not resorbable bradeds could contribute
to mesh morbidity [78]. The European Society of
Coloproctology (ESCP) is currently working on guidelines
of the use of a mesh in the pelvis, which will be available
soon.
In a recent Finish consecutive series of 508 patients,
only 1.4% of patients developed mesh-related complica-
tions most, five, were vaginal erosion and it has to be
noticed that in three of those vaginal perforation occurred
during surgery. None of the patients had a previous Starr
procedure. Only two patients developed a rectovaginal fis-
tula [79].
There certainly is an ongoing debate on the need for a
permanent scaffold or the use of biological meshes. The
trade-off probably will be a certain increase in recurrence
rates if biological meshes are used in comparison to syn-
thetic meshes.
In a systematic review, data were compiled on synthetic
mesh repairs in 3517 patients [80]. Only 1.87% developed a
mesh erosion and in the biological mesh group, 1 patient in
439 developed an erosion.
It also has to be noticed that there is a difference between
the different available biological meshes and especially
crosslinked meshes seem to be prone to act as a foreign
body.
68  The Laparoscopic Approach to Rectal Prolapse
68.16 Conclusion
Treatment of rectal prolapse is one of the most challenging
conditions to treat because of the poorly understood nature
of these disorders and the lack of adequate evidence to guide
the most appropriate approach for an individual patient.
There are no detectable differences between the methods
used for mobilization and fixation of the rectum. Division,
rather than preservation of the lateral ligaments was associ-
ated with less recurrent prolapse but more postoperative con-
stipation. Laparoscopic ventral mesh rectopexy has gained
wide spread global acceptance due to its results relative to
the cure of prolapse and function. The long-term outcome
17.
data support its efficacy and beneficial functional outcome,
while complications are acceptable [81].
Take Home Messages
• Laparoscopy is an excellent modality to perform
pelvic floor surgery, and seems to be superior to an
open approach.
• There is no consensus on the best surgical treatment
of pelvic floor disorders, choosing an optimal treat-
ment is difficult. It is best tailored to the individual
patient and surgeon.
• The long-term outcome data of laparoscopic ventral
mesh rectopexy support its efficacy and beneficial
functional outcome.
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55. Douard R, Frileux P, Brunel M, Attal E, Tiret E, Parc R. Functional
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 The Role of Robotic Surgery in Rectal
Prolapse 69
Adam Studniarek, Anders Mellgren,
and Johan Nordenstam

Learning Objectives likely as men to present with RP, approximately one third of
After completing this chapter, the reader should be women are younger and nulliparous at presentation [5].
able to: Thus, obstetric history is not the only risk factor for the
development of RP. Men with RP frequently suffer from
• Describe and understand the pathophysiology disordered defecation, dysmotility, psychiatric comorbidi-
behind rectal prolapse and the two theories explain- ties, and/or developmental delays [6, 7].
ing the etiology of rectal prolapse. Various anatomic variations and pelvic floor abnormali-
• Understand the indications, different approaches, ties are associated with the development of RP, including a
and complications associated with both abdominal deep pouch of Douglas, a laxity of rectal attachments, and a
and perineal operations for rectal prolapse. redundant sigmoid colon. Patients frequently have a laxity of
• Describe the most common pitfalls and complica- the anal sphincters and evidence of pudendal nerve
tions for each procedure. neuropathy can frequently be found [8, 9]. Other contributing
• Present the most current evidence regarding robot-­ factors may include a mobile mesorectum and lax lateral
assisted rectopexy techniques and both advantages ligaments [9–12].
and disadvantages that come with this approach. From an anatomic and functional standpoint, RP can be
• Define the aspects of robotic surgery that will divided into external and internal prolapse [13]. An external
require further research in order to compare long-­ rectal prolapse (ERP) extends beyond the anus, while an
term outcomes of all available surgical approaches. internal rectal prolapse (IRP) does not. Several authors have
suggested that IRP represents the first stage of a progressive
anomaly and may eventually lead to a full-thickness external
rectal prolapse (ERP) [8–10]. The Oxford group has
69.1 Introduction suggested a radiological classification with five different
degrees of prolapse (Table  69.1, Fig.  69.1) [9]. Their data
External rectal prolapse (ERP) is defined as a full-thickness
extrusion of the rectum of the rectum beyond the anal verge.
Rectal prolapse (RP) was described already in the 1500s BC in Table 69.1  Oxford rectal prolapse grade, a radiological grading
the Ebers Papyrus and in 1900 Edmond Delorme reported the system
first successful surgical treatment of RP [1, 2]. Grade
The peak incidence of RP is found in elderly women and of rectal Radiological characteristics
prolapse of rectal prolapse
may be associated with other pelvic floor disorders, such as
Internal
vaginal prolapse (enterocele, cystocele, rectocele) and/or Recto-rectal I (high rectal) Descends not lower than
urinary incontinence. The peak incidence is in women older Intussusception proximal limit of the rectocele
than 50 years  and women represent 80–90% of patients (RRI) II (low rectal) Descends into the level of the
[3, 4]. Interestingly, even though women are six times as rectocele, but not into anal canal
Recto-anal III (high anal) Descends into anal canal
Intussusception
(RAI) IV (low anal) Descends into anal canal
A. Studniarek · A. Mellgren (*) · J. Nordenstam
External
Division of Colon and Rectal Surgery,
University of Illinois at Chicago, Chicago, IL, USA External rectal V (overt rectal Protrudes outside the anus
e-mail: adamstudniarek@yahoo.com; anders.mellgren@icloud.com prolapse (ERP) prolapse)

© Springer Nature Switzerland AG 2021 847

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_69
848
Fig. 69.1  Oxford rectal OPG-1
prolapse grade (OPG), a
radiological grading system
OPG-4
demonstrate a relationship between age and prolapse grade,
supporting the view of IRP as a precursor to ERP  in the
spectrum of rectal prolapse disease.
Symptoms of rectal prolapse are variable, including
feeling of a bulge,  mucous drainage, fecal accidents,
constipation, pelvic pressure, pain, and rectal bleeding.
Symptoms can often affect the daily quality of life and result
in psychosocial distress resulting in isolation and depression
in the most extreme cases.
69.2 Preoperative Assessment
ERP can usually be diagnosed with a careful clinical exami-
nation. Patient is best examined in the sitting position on a
commode, and the prolapse can then be visualized by clini-
cal examination with the patient pushing.
Defecography and/ or pelvic floor ultrasound can assist
in diagnosing RP and may be required to diagnose an
IRP. Defecography can be performed with fluoroscopic or
MRI techniques. These modalities can also diagnose
concomitant disorders, such as enterocele or vaginal
prolapse.
Some patients are also evaluated with a norectal manom-
etry and/or ultrasound to better assess pelvic floor function.
A. Studniarek et al.
OPG-2 OPG-3
OPG-5
A multidisciplinary approach is recommended and an
urogynecological evaluation can be useful. A colonoscopy is
usually recommended in adults to exclude coexisting condi-
tions. Colonoscopy frequently demonstrates proctitis in the
distal rectum.
69.3 S
 urgical Approaches to Rectal
Prolapse
Nonoperative management of rectal prolapse with dietary
modifications, bulking agents, manual reduction, and bio-
feedback has shown to produce only limited  symptomatic
relief with lack of long-term success [14, 15]. Surgery is the
only curative treatment for rectal prolapse.
Since 1899, when Delorme reported the first successful
surgical treatment of rectal prolapse, more than a 100 proce-
dures have been described [16]. Choice of surgical approach
has usually been centered around the rate of recurrence, risk
for complications, and functional outcomes.
Surgical repair can be achieved by abdominal and peri-
neal approaches. Trans-abdominal approach can be done
with open, laparoscopic, and robotic techniques. Historically,
the perineal approach has been reserved for elderly patients
with comorbidities.
69  The Role of Robotic Surgery in Rectal Prolapse
69.4 Perineal Operations
The two most commonly performed perineal procedures are
Delorme mucosal sleeve resection and Altemeier perineal
rectosigmoidectomy [17]. Several studies have shown the
safety of a perineal approach in the elderly, high-risk patients,
but the recurrence rates are significantly higher when com-
pared with abdominal repairs [18–21].
69.4.1 Delorme’s Operation
This operation was first introduced by Delorme in 1900, and
it consists of stripping the mucosa from the prolapsed seg-
ment, plication of the muscle layers, and reapproximation of
the mucosa [18]. This procedure is typically reserved for
patients with a short segment of full-thickness rectal
prolapse.
69.4.2 Altemeier’s Operation
This procedure, which consists of a perineal proctosigmoid-
ectomy was first described by Miles in 1933 [19], subse-
quently popularized by Altemeier in 1971 [20]. It involves
excising the prolapsed segment of the rectum and creating a
low end-to-end coloanal anastomosis.
69.5 Abdominal Operations
An abdominal approach for the treatment of rectal prolapse is
suited for patients without significant comorbidities, and fit
for an abdominal operation [21]. Historically, the abdominal
approach has been reported to have longer operative times,
but lower recurrence rates, whereas perineal approach was
considered safer, but with higher recurrence rates. Since the
introduction of laparoscopic and robotic surgery to rectal pro-
lapse, abdominal procedures can be performed with relatively
low morbidity, and less physiological burden on the patient.
69.5.1 Abdominal Suture Rectopexy
Abdominal suture rectopexy is a common approach with the
goal of anchoring the rectum directly to the sacrum. This
procedure can be performed with open, laparoscopic, or
robotic techniques. Cutait et al. described this approach for
the first time in 1959, and the main steps consist of thorough
mobilization and upward fixation of the rectum to correct the
telescoping of the bowel [22]. The idea of subsequent heal-
ing and fibrosis of sutured rectum allows the bowel to remain
849
in a fixed position as adhesions formed attaching the rectum
to the presacral fascia [23]. The majority of case series report
a low recurrence rate (usually between 5 and 10%), with
most of the reports showing improvement in fecal continence
as well [24–26].
69.5.2 Abdominal Resection Rectopexy
Abdominal resection rectopexy was described by Frykman
and Goldberg in 1969 [27]. The resection was recommended
to achieve a lower recurrence rate and improved functional
outcome. Luukkonen et  al. [28] compared the abdominal
rectopexy with sigmoidectomy vs. rectopexy alone and
found that concomitant sigmoidectomy can diminish postop-
erative constipation. The American Society of Colon and
Rectal Surgeons in its 2011 Clinical Practice Guidelines sug-
gested that “a sigmoid resection may be added to rectopexy
in patients with prolapse and perioperative constipation, but
it is not necessary in those without constipation” [29].
69.5.3 Laparoscopic Ventral Mesh Rectopexy
Laparoscopic Ventral Mesh Rectopexy (LVMR) was first
described by Andre D’Hoore et al. in 2004 [28]. The initial
idea for the laparoscopic ventral rectopexy repair was derived
from the cinegraphic data of Broden and Snellman [10], who
demonstrated that the intussusception of the rectum starts
usually in the anterior aspect. LVMR aims to correct the
descent of the rectum and middle compartment by mobiliz-
ing the rectovaginal septum down to the pelvic floor between
the rectum and the vagina [30]. Once the rectovaginal sep-
tum is dissected, it is reinforced with a mesh. The mesh is
typically fixated to the promontory.
The recurrence rate after LVMR was evaluated in a meta-­
analysis of 789 patients in 12 published articles, reporting
a 3.4% recurrence rate. The overall mean decrease in fecal
incontinence score was 45% along with a significant
decrease in constipation [31]. Jonkers et al. [32] compared
LVMR with laparoscopic resection rectopexy and found
that there is a reduction in constipation and incontinence
with both approaches; however, more complications
occurred after laparoscopic resection rectopexy than with
LVMR.
LVMR achieves excellent functional results in a large
proportion of patients, and the technique has therefore gained
widespread acceptance in Europe as the treatment of choice
for rectal prolapse. The indications have expanded from
treatment of patients with ERP to also include some patients
with advanced IRP. In the USA, ventral rectopexy is gaining
an increased interest as well.
850
There is some  debate regarding which  type of mesh
should be used at LVMR. Smart et al. [33] performed a sys-
tematic review of 13 observational studies, reporting out-
comes in 866 patients undergoing LVMR. In 767 patients, a
synthetic mesh had been implanted and in 99 a biological
mesh was used. There was no difference in recurrence
(3.7 vs. 4%; P  =  0.78) or mesh-related complications
(0.7 vs. 0%; P  =  1.0). Major mesh-related complications
described at LVMR include erosion into the vagina, bladder
or rectum, mid-rectal stricture, rectovaginal fistula, and
chronic pelvic pain. In most stuies, the frequency of mesh-
related complications seems to be low, but further long-term
follow-up is warranted.
LVMR can be technically challenging and requires
advanced laparoscopic skills to be able to perform the com-
plete ventral dissection and intracorporal suturing within a
confined space. The introduction of robotic surgery in this
field and the application of robotic dexterity and angulation
may facilitate sometimes this difficult dissection.
69.6 Robotic Approach to Rectal Prolapse
Robotic surgery was implemented into the surgical arma-
mentarium in the late 1990s to expand the benefits of laparo-
scopic surgery [34]. The three-dimensional, enhanced
visualization, tremor filtering, dexterity, and precision make
the use of surgical robots particularly suitable for confined
spaces such as pelvis. The new developments of robotic sur-
gery have minimalized the limitations of conventional lapa-
roscopic surgery such as rigid instruments, lack of wrist
movement and angulation, difficult suturing, and operating
in the confines of a deep pelvis.
Robotic-assisted surgery is a rapidly developing field. In
2001, Weber et al. performed the first robotic-assisted lapa-
roscopic colectomy for benign disease [35]. Since that pro-
cedure, robotic surgery has been employed in multiple other
procedures including abdominoperineal resection, low ante-
rior resection, and rectopexy [36].
Robotic surgery is generally considered user-friendly and
can be adopted by a competent surgeon. Bokhari et al. per-
formed a retrospective analysis to look at the learning curve
in robotic colorectal surgery and found that the learning
phase was achieved after 15–25 robotic cases [36]. This
number is significantly lower than the learning curve associ-
ated with laparoscopic colorectal procedures [37].
Makela-Kaikkonen et al. [38] compared robotic-assisted
ventral rectopexy (RVMR) and LVMR and found no signifi-
cant difference in operating time, blood loss, length of hospi-
tal stay, and complication rate (5%) between the two groups.
Ventral rectopexy is ideally suited for robotic surgery.
The previously mentioned advantages of robotic surgery per-
fectly apply to this procedure, with improved visualization in
A. Studniarek et al.
the deep pelvis and easier dissection and mesh placement in
the rectovaginal septum. The ability to angulate the wrist and
perform precise movements in the small pelvic space allows
for adequate suturing technique and placement of the mesh.
69.7 Technique
Preoperative preparation for RVMR remains the same as for
LVMR and open procedures. Patients typically receive an
enema or a complete bowel preparation before the surgery,
and a single dose of appropriate perioperative antibiotics is
given according to the local hospital  standards. A urinary
catheter is usually placed after induction of anesthesia and
may be removed prior to reversal before the end of the case.
Port placement and patient’s positioning are important
aspects of a successful surgery during both laparoscopic and
robotic cases. Before RVMR, the patient is placed in a modi-
fied lithotomy position. The support column with robotic
arms is usually placed between the legs of the patient.
With the da Vinci Si® Robotic System (Intuitive Surgical,
Sunnyvale, CA), the 12-mm port is placed just above the
umbilicus in the midline for the camera robot arm #1. An
8-mm port is placed in the right lower quadrant 8 cm below
the umbilical port at the lateral edge of the rectus muscle for
the right robotic arm #2. Another 8-mm port is placed oppo-
site in the left lower quadrant for the left robotic arm #3. The
#4 arm is placed through an 8-mm port in the anterior axil-
lary line on the left at the level of umbilicus. An additional
12-mm port can be placed for assistance (Fig. 69.2). After all
the arms are securely placed and connected, the patient is
placed in a steep Trendelenburg position to allow the abdom-
inal contents to retract cranially and allow for better visual-
ization in the pelvis.
With the da Vinci Xi® Robotic System (Intuitive Surgical,
Sunnyvale, CA), the port placement is usually different. The
12-mm camera port is placed just above the umbilicus in the
midline similarly to the da Vinci Si® System (Intuitive
Surgical, Sunnyvale, CA). All four 8-mm ports are placed in
a suprapubic location with the camera inserted through the
port just lateral to the midline. An additional 12-mm port can
be placed for assistance as well (Fig. 69.3).
RVMR is done in a similar fashion as in LVMR. In a step-
wise fashion, the rectosigmoid is retracted to the left, and
peritoneal incision is made to the right of the sacral promon-
tory and extended along the rectum. Lateral and posterior
dissection should be avoided to prevent damage to the auto-
nomic nerves, which may cause increased constipation, as
well as neurogenic impairment of the urinary bladder and
genital organs. Next, the rectovaginal septum (recto-prostatic
septum in men) is mobilized to the pelvic floor, approxi-
mately 2–3 cm above the dentate line [39–43]. The curved
portion of the mesh is sutured to the ventral aspect of the
69  The Role of Robotic Surgery in Rectal Prolapse 851

distal rectum. The upper part of the mesh is fixed to the sacral
promontory by an endofascial stapler or non-absorbable
A suture. The posterior vaginal fornix may be sutured to the
anterior aspect of the mesh, and the peritoneum is closed
over the mesh [44].

C
69.8 Complications

Recurrent prolapse, mesh complications, urinary tract infec-

tions, pre-sacral fluid collections, constipation, and fecal
incontinence can be seen after RVMR. Other complications
include rectal or bowel injuries, hemorrhage, bowel obstruc-
tion, port complications, urinary retention, and wound infec-
tion [45–47]. Only limited data exist regarding complications
after RVMR.  In a meta-analysis including three available
studies, RVMR showed a non-significant minimal advantage
in terms of intra- and postoperative complications in com-
parison to LVMR [48].
- 12 mm port Blood loss at surgery is usually low at both LVMR and
RVMR. The mean blood loss is usually less than 50 ml, and
A- Assistant port
in some cases it has been considered too low to be reported
C- Camera port [47–51].
- 8 mm port The need to convert a robotic procedure to an open proce-
dure can be seen as a measurement of the difficulty of the
Fig. 69.2  Port placement in robotic ventral rectopexy using the da procedure. Mantoo et  al. [52] reported 4% of their laparo-
Vinci Si® System (Intuitive Surgical, Sunnyvale, CA) scopic procedures required conversion to open due to adhe-
sions, inability to tolerate pneumoperitoneum, and a missing
needle. Only one of their 44 robotic cases (2.2%) required
conversion to open due to poor visualization. Other authors
reported conversion rates ranging from 2 to 6% [47,
A 49–51].

69.9 R
 ecurrence Rates and Functional
Outcomes

Reported recurrence rates after RVMR are usually low. De

Hoog et al. [51] published a case–control study to compare
C open vs. laparoscopic vs. robotic recurrence rates after ven-
tral rectopexy. With an adequate follow-up reaching 90%,
they found that patients after open approach had 2% recur-
rences vs. 27% after laparoscopic and 20% after robotic
approaches [51]. In a study by Makela-Kaikkonen with a
reported short-term follow-up of 40 patients, their recurrence
rate was found to be 5% in both laparoscopic and robotic
- 12 mm port
groups [53].
A- Assistant port Short-term outcomes after RVMR, including functional
C- Camera port outcomes, appear to be similar to the laparoscopic approach
-8 mm port and open technique. Perrenot et  al. [48] have reported the
only available clinical trial with 12 months followed up, and
Fig. 69.3  Port placement in robotic ventral rectopexy using the da they reported a better functional outcome and quality of life
Vinci Xi® System (Intuitive Surgical, Sunnyvale, CA) in patients undergoing RVMR in comparison to LVMR.
852 A. Studniarek et al.

69.10 Other Aspects and in this process, RVMR seems to be a perfect operation to
introduce robotic technique in colorectal surgery.
The debate around increased operative time and costs with
robotic is an ongoing controversy. For robotic surgery, oper-
ative time is often divided into total operative time and the Take-Home Messages
time spent behind the robotic console. In general, operative • Surgery is the only curative option for patients with
experience and familiarity with the robot decreases the over- severe rectal prolapse. The decision about the type
all operating time. Makela-Kaikkonen et al. reported a mean of surgery should be based on a patient’s functional
operative time of 159 min and total time of 231 min in OR status, anatomical differences, and surgeon’s expe-
for robotic cases. The matched-pair laparoscopic cases had a rience with each method of treatment.
mean operative time of 153 min and total time of 234 min in • LVMR and RVMR are currently attractive and pop-
the OR [38]. Some authors advocate that there is still a lon- ular methods of treatment for patients with rectal
ger operative time during robotic cases when compared with prolapse due to low recurrence rates and complica-
laparoscopic technique, but limited robotic experience often tions. However, since they were introduced to prac-
negatively influences these results. Wong et  al. [34] pre- tice in the last decade, more long-term follow-up
sented their results with 40 laparoscopic ventral rectopexies studies are warranted.
vs. 23 robotic ventral rectopexies. The reported robotic oper- • Robotic platform allows for improved three-­
ative time was 221 min (setup time was 17 min) compared to dimensional enhanced visualization, tremor filter-
162 min in the laparoscopic cases. Robotic surgery requires ing, and precise dissection within the confined
the team to be familiar with the instruments and the robot spaces of the pelvis, which makes RVMR a great
itself. The operative time can be improved with adequate procedure to implement in the treatment of rectal
training of the team. prolapse. Further studies on the long-term recur-
From economic standpoint, robotic surgery is a costly rence rates and complications associated with the
investment for the institution. On the other hand, length of robotic approach also need to be performed.
hospital stay after ventral rectopexy may offset some of • With the emerging technology and the state-of-the-­art
these costs. The typical postoperative course with timely robotic systems, RVMR can be safely and success-
return of bowel function, adequate food intake, and pain tol- fully performed; however, the surgical team’s experi-
erance may allow patients to be safely discharged sooner ence and training are of paramount importance.
than open surgery. The length of stay difference between
laparoscopic and robotic is minimal, with some studies
favoring robotic approach while other studies favor laparo-
scopic approach. References
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cient, time-consuming, and costly the procedure is. rectal prolapse: differential assessment of the innervation to
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results and decrease costs. It is our firm belief that we have procidentia. Dis Colon Rectum. 1965;8:75–7.
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complete rectal prolapse: differences between continent and incon-
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13. Felt-Bersma RJ, Cuesta MA.  Rectal prolapse, rectal intussuscep-
tion, rectocele and solitary ulcer syndrome. Gastroenterol Clin N
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14. Pescatori M, Spyrou M, Pulvirenti d’Urso A. A prospective evalua-
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15. Myers JO, Rothenberger DA.  Sugar in the reduction of incarcer-
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16. Kuijpers HC. Treatment of complete rectal prolapse: to narrow, to
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17. Riansuwan W, Hull TL, Bast J, Hammel JP, Church JM. Comparison
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1847-1929. On the treatment of total prolapse of the rectum by
excision of the rectal mucous membranes or recto-colic. Dis Colon
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19. Miles WE.  Rectosigmoidectomy as a method of treatment for
procidentia recti. Proc R Soc Med. 1933;26:1445–52.
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years’ experience with the one-stage perineal repair of rectal pro-
lapse. Ann Surg. 1971;173:993–1006.
21. Madoff RD, Williams JG, Wong WD, Rothenberger DA, Goldberg
SM. Long-term functional results of colon resection and rectopexy
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22. Cutait D.  Sacro-promontory fixation of the rectum for complete
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24. Novell JR, Osborne MJ, Winslet MC, Lewis AA. Prospective ran-
domised trial of Ivalon sponge versus sutured rectopexy for full-­
thickness rectal prolapse. Br J Surg. 1994;81:904–6.
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26. Khanna AK, Misra MK, Kumar K.  Simplified sutured sacral
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27. Frykman HM, Goldberg SM. The surgical treatment of rectal proci-
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28. Luukkonen P, Mikkonen U, Javinen H. Abdominal rectopexcy with
sigmoidectomy vs rectopexy alone for rectal prolapse: a prospec-
tive, randomized study. Int J Colorectal Dis. 1992;7(4):219–22.
29. D’Hoore A, Cadoni R, Penninckx F. Long-term outcome of lapa-
roscopic ventral rectopexy for total rectal prolapse. Br J Surg.
2004;91(11):1500–5.
30. Kuijpers HC. Treatment of complete rectal prolapse: to narrow, to
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Surg. 1992;16:826–30.
31. Samaranayake CB, Luo C, Plank AW, Merrie AE, Plank LD, Bissett
IP. Systematic review of ventral rectopexy for rectal prolapse and
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32. Formijne Jonkers HA, Maya A, Draaisma WA, Bemelman WA,
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33. Smart NJ, Pathak S, Boorman P, Daniels IR. Synthetic or biological
mesh use for laparoscopic ventral rectopexy – a systematic review.
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34. Wong MT, Meurette G, Rigaud J, Regenet N, Lehur PA. Robotic
versus laparoscopic rectopexy for complex rectocele: a prospec-
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35. Weber PA, Merola S, Wasielewski A, Ballantyne G.  Telerobotic-­
assisted laparoscopic right and sigmoid colectomies for benign dis-
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38. Makela-Kaikkonen J, Rautio T, Klintrup K, Takala H, Vierimaa
M, Ohtonen P, et  al. Robotic-assisted and laparoscopic ventral
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44. Faucheron JL, Voirin D, Riboud R, Waroquet P, Noel J. Laparoscopic
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N. Robot-assisted vs. conventional laparoscopic rectopexy for rec-
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 Sacral Neuromodulation
for Constipation
Klaus E. Matzel and Birgit Bittorf
Learning Objectives
• Understand the technique and patient selection.
• Understand the clinical outcome of SNM for
constipation.
70.1 Introduction
Since the introduction of sacral neuromodulation in the field
of coloproctology, there has been an interest in its applica-
tion in patients with constipation. This interest was encour-
aged by the clinical observation that patients treated with
SNM for other pelvic organ dysfunctions reported, among
other changes, a tendency toward less constipation. Since
2001, the role of SNM in the treatment of constipation refrac-
tory to conservative treatment has been studied [1]. Overall,
the existing evidence is low, with three systematic reviews
having been published [1–4].
70.2 Technique and Its Evolution
The technique is the same as that for fecal incontinence (see
Chap. 40).
70.3 Mechanism of Action
The mechanism of action is also described in the above-cited
chapter. However, regarding the use of SNM in constipation,
an observed increase in colonic transit and anterograde con-
tractile activity and a reduction in retrograde colonic activity
were of special interest [5, 6].
K. E. Matzel (*) · B. Bittorf
Sektion Koloproktologie, Chirurgische Klinik der Universität
Erlangen-Nürnberg, Erlangen, Germany
e-mail: Klaus.matzel@uk-erlangen.de
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_70
70
70.4 Indications
Patient selection is based on the outcome of a test stimula-
tion, during which the reduction of symptoms is measured.
It is noteworthy that there is no general agreement on a spe-
cific outcome measure; a variety have been used. Also the
selection for test stimulation is not limited to a specific
pathophysiologic or morphologic cause of constipation.
Thus, the broad criteria result in heterogeneous patient
collectives.
70.5 Prognostic Factors of Outcome
As a consequence of the technique’s broad use in constipa-
tion, no prognostic factor for clinical success could be iden-
tified. As noted above, the selection for permanent
therapeutic stimulation relies on the outcome of the test
phase. However, the failure rate of test stimulation appears
to be higher and the results are less reliable than in fecal
incontinence.
70.6 Outcome
Since the introduction of SNM for constipation, outcome
reports on symptoms and quality of life have accumulated
[7–23], few with long-term follow-up (see Table 70.1). A
difference in outcome can be found between early, mainly
retrospective, studies and more recent methodologically
improved studies, which report less favorable results. The
latter and the limitation of quality outcome data have
resulted in some countries declining coverage for this use.
However, despite uncertain and relatively low clinical effi-
cacy, the technique continues to be used because of its lim-
ited invasiveness and reversibility and is considered an
alternative to more invasive, irreversible operative inter-
ventions. [24].
855
856 K. E. Matzel and B. Bittorf

Table 70.1  SNS for constipation: outcome

Follow-up monthsa Improvement
Author Year Patients (N) (range) N temporary N Permanent (intention-to-treat: %)
Kenefick et al. [8] 2002 4 8 (1–11) ns 4 3/ns
Kenefick et al. [9] 2002 2 12 2 2 2/2
Holzer et al. [10] 2008 19 11 (2–20) 19 8 8/19 (42%)
Vitton et al. [11] 2009 6 2–50 weeks 6 5 0/6 (0%)
Kamm et al. [12] 2010 62 28 (1–55) 62 45 39/62 (63%)
Maeda et al. [13] 2010 70 28 (0–70) 70 38 35/38 (54%)
Naldini et al. [14] 2010 15 42 (24–60) 15 9 6/9
Carriero et al. [15] 2010 13 22 (12–26) 13 11 6/11
Sharma et al. [16] 2011 21 38 (18–62) 21 11 10/21 (48%)
Govaert et al. [17] 2012 117 37 (4–92) 117 68 61/117 (52%)
Knowles et al. [7] 2012 13 19 13 11 9/13 (69%)
Ortiz et al. [18] 2012 48 26 s (6–96) 48 23 14/48 (29%)
Graf et al. [19] 2015 44 24 (4–81) 44 15 5/44 (11%)
Ratto et al. [20] 2015 61 51 (±15) 61 42 20/61 (33%)
Patton et al. [21] 2016 53 24 ns 53 3/53 (ns)
Zerbib et al. [22] 2017 36 12 36 20 11/36 (31%)
Maeda et al. [23] 2017 62 60 62 45 14/62 (23%)
a
Unless otherwise noted
ns not stated

Recently, there has been increased interest in the use of
this technique in constipation owing to rectal hyposensitivity
[7] in children [25–27] and in patients with low anterior
resection syndrome after rectal resection [28, 29]. For these
indications, despite limited existing evidence, the lack of
attractive alternatives renders the technique a possible thera-
peutic option.
Take-Home Messages
SNM for treatment of constipation is less effective
than for treatment of fecal incontinence. Recently, its
therapeutic effectiveness has been challenging. Despite
uncertain and relatively low clinical efficacy, the tech-
nique is continued to be used because of its limited
invasiveness and reversibility and is considered an
alternative to more invasive, irreversible operative
interventions. Patient selection for permanent stimula-
tion therapy is based on the clinical outcome of test
phase.
References
1. Ganio E, Masin A, Ratto C, et al. Short-term sacral nerve stimula-
tion for functional anorectal and urinary disturbances: results in 40
patients: evaluation of a new option for anorectal functional disor-
ders. Dis Colon Rectum. 2001;44:1261–7.
2. Mowatt G, Glazener C, Jarrett M. Sacral nerve stimulation for fae-
cal incontinence and constipation in adults. Cochrane Database
Syst Rev. 2007;(3):CD004464.
3. Thaha MA, Abukar AA, Thin NN, et al. Sacral nerve stimulation for
faecal incontinence and constipation in adults. Cochrane Database
Syst Rev. 2015;(8):CD004464.
4. Pilkington SA, Emmett C, Knowles CH, et al. Surgery for consti-
pation: systematic review and practice recommendations: results
V: Sacral Nerve Stimulation. Colorectal Dis. 2017;19(Suppl
3):92–100.
5. Dinning PG, Fuentealba SW, Kennedy ML, et  al. Sacral nerve
stimulation induces pan- colonic propagating pressure waves and
increases defecation frequency in patients with slow-transit consti-
pation. Colorectal Dis. 2007;9:123–32.
6. Patton V, Wiklendt L, Arkwright JW, et al. The effect of sacral nerve
stimulation on distal colonic motility in patients with faecal inconti-
nence. Br J Surg. 2013;100:959–68.
7. Knowles CH, Thin N, Gill K, Bhan C, et al. Prospective random-
ized double-blind study of temporary sacral nerve stimulation in
patients with rectal evacuatory dysfunction and rectal hyposensitiv-
ity. Ann Surg. 2012;255:643–9.
8. Kenefick NJ, Nicholls RJ, Cohen RG, et al. Permanent sacral nerve
stimulation for treatment of idiopathic constipation. Br J Surg.
2002;89:882–8.
9. Kenefick NJ, Vaizey CJ, Cohen CR, et  al. Double-blind placebo-­
controlled crossover study of sacral nerve stimulation for idiopathic
constipation. Br J Surg. 2002;89:1570–1.
10. Holzer B, Rosen HR, Novi G, et  al. Sacral nerve stimulation in
patients with severe constipation. Dis Colon Rectum. 2008;51:524–
9; discussion 529–30.
11. Vitton V, Roman S, Damon H, et  al. Sacral nerve stimula-
tion and constipation: still a long way to go. Dis Colon Rectum.
2009;52:752–3.
12. Kamm MA, Dudding TC, Melenhorst J, et al. Sacral nerve stimula-
tion for intractable constipation. Gut. 2010;59:333–40.
13. Maeda Y, Lundby L, Buntzen S, et al. Sacral nerve stimulation for
constipation: suboptimal outcome and adverse events. Dis Colon
Rectum. 2010;53:995–9.
14. Naldini G, Martellucci J, Moraldi L, et  al. Treatment of slow-­
transit constipation with sacral nerve modulation. Colorectal Dis.
2010;12:1149–52.
15. Carriero A, Martellucci J, Talento P, et al. Sacral nerve stimulation
for constipation: do we still miss something? Role of psychological
evaluation. Int J Colorectal Dis. 2010;25:1005–10.
16. Sharma A, Liu B, Waudby P, et al. Sacral neuromodulation for the
management of severe constipation: development of a constipation
treatment protocol. Int J Colorectal Dis. 2011;26:1583–7.
70  Sacral Neuromodulation for Constipation
17. Govaert B, Maeda Y, Alberga J, et  al. Medium-term outcome of
sacral nerve modulation for constipation. Dis Colon Rectum.
2012;55:26–31.
18. Ortiz H, de Miguel M, Rinaldi M, et  al. Functional outcome of
sacral nerve stimulation in patients with severe constipation. Dis
Colon Rectum. 2012;55:876–80.
19. Graf W, Sonesson AC, Lindberg B, et al. Results after sacral nerve
stimulation for chronic constipation. Neurogastroenterol Motil.
2015;27:734–9.
20. Ratto C, Ganio E, Naldini G, et  al. Long-term results following
sacral nerve stimulation for chronic constipation. Colorectal Dis.
2015;17:320–8.
21. Patton V, Stewart P, Lubowski DZ, et al. Sacral nerve stimulation
fails to offer long-term benefit in patients with slow-transit consti-
pation. Dis Colon Rectum. 2016;59:878–85.
22. Zerbib F, Siproudhis L, Lehur PA, et al. Randomized clinical trial
of sacral nerve stimulation for refractory constipation. Br J Surg.
2017;104:205–13.
23. Maeda Y, Kamm MA, Vaizey CJ, et  al. Long-term outcome of
sacral neuromodulation for chronic refractory constipation. Tech
Coloproctol. 2017;21:277–86.
857
24. Thomas GP, Dudding TC, Rahbour G, et al. Sacral nerve stimula-
tion for constipation. Br J Surg. 2013;100:174–81.
25. Lu PL, Koppen IJN, Orsagh-Yentis DK, et  al. Sacral nerve
stimulation for constipation and fecal incontinence in children:
long-term outcomes, patient benefit, and parent satisfaction.
Neurogastroenterol Motil. 2018;30(2).
26. Janssen PTJ, Meyer YM, Van Kuijk SMJ, et  al. Long-term out-
come of intractable constipation treated by sacral neuromodula-
tion: a comparison between children and adults. Colorectal Dis.
2018;20:134–43.
27. van der Wilt AA, van Wunnik BP, Sturkenboom R, et  al. Sacral
neuromodulation in children and adolescents with chronic consti-
pation refractory to conservative treatment. Int J Colorectal Dis.
2016;31:1459–66.
28. Ramage L, Qiu S, Kontovounisios C, et  al. A systematic review
of sacral nerve stimulation for low anterior resection syndrome.
Colorectal Dis. 2015;17:762–71.
29. D’Hondt M, Nuytens F, Kinget L, et  al. Sacral neurostimulation
for low anterior resection syndrome after radical resection for
rectal cancer: evaluation of treatment with the LARS score. Tech
Coloproctol. 2017;21:301–7.
 Part VIII
Pelvic Pain and Sexual Dysfunction
 Bladder Pain Syndrome/Interstitial
Cystitis
Mauro Cervigni
Learning Objectives
• Chronic pelvic pain is one of the world’s major
emergencies in the field of pelvic floor dysfunc-
tions. It is therefore extremely useful to have knowl-
edge from various specialists in the field in such a
complex and difficult subject that requires a very
broad vision because it is a very often chronic dys-
function involving more pelvic and extra-pelvic
apparatus with repercussions on the central nervous
system. The bladder pain syndrome/interstitial cys-
titis is an important component of this problem.
• The chapter dedicated to this pathology in this book
guides the reader on the diagnostic and therapeutic
path giving some ideas for research and reflection,
providing a useful tool even for a specialist not directly
involved in this pathology.
71.1 Introduction
Painful bladder syndrome/interstitial cystitis (PBS/IC) origi-
nally described by the International Continence Society (ICS)
has recently more precisely defined as bladder pain syndrome
(BPS/IC) according to European/International Society for the
Study of Interstitial Cystitis (ESSIC); it is a syndrome pri-
marily based on symptoms of urgency, frequency, and pain in
the bladder and/or pelvis. These collective terms describe
debilitating, chronic bladder disorders of unknown causes
with an exclusion of confusable diseases. BPS/IC is also a
disorder of the pelvic floor occurring mostly (>90%) in
women [1, 2]. A number of studies have identified the bladder
as one of major causes of chronic pelvic pain (CPP) [3–7].
M. Cervigni (*)
Female Pelvic Medicine and Reconstructive Surgery Center,
“La Sapienza” University, ICOT-Polo Pontino, Latina, Italy
e-mail: mauro.cervigni@libero.it
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_71
71
Misdiagnosis and ineffective treatments are common,
leaving patients with persistent pain and the potential for
neuropathic upregulation and allodynia. Currently, BPS/IC
is considered a diagnosis of exclusion because its etiology
until today is not thoroughly known and clinical characteris-
tics vary among patients. Voiding often relieves the typical
symptoms of pain, pressure, or discomfort involving the
lower pelvic area including gastrointestinal organs. The
symptoms have to be present for no less than 6 months, obvi-
ously in the absence of urinary tract infection (UTI). Early
recognition of BPS/IC is very important because symptoms
are quite disabling, affecting quality of life, and leading to
patients being seen by a variety of specialists (usually
between five and seven times in a period of 3–5 years). The
syndrome is also exacerbated by the high incidence of other
comorbid diseases including allergies, asthma, atopic derma-
titis, inflammatory bowel syndrome (IBS), systemic lupus
erythematosus (SLE), Sjögren’s syndrome, chronic fatigue
syndrome, and fibromyalgia [8–11]. Vulvodynia may also be
present in 20% of cases, as well as endometriosis in 45–65%
of women with pelvic pain of bladder origin. BPS/IC may
also be present in men (2.2% of the population using the
National Institutes of Health Chronic Prostatitis Symptom
Index (NIH-CPSI)), with less frequent urgency and frequent
urination (type 3 prostatitis, nonbacterial prostatitis, or
chronic prostatitis).
71.2 Definition
In 1887, Skene [12] defined the first time “an inflammation
that has destroyed the mucous membrane partly or wholly
and extended to the muscular parietes.” In 1915, Hunner [13]
outlined a peculiar form of bladder ulceration, whose diag-
nosis depends ultimately on its resistance to all ordinary
forms of treatment in patients with frequency and bladder
symptoms (spasms).
In 1990, the National Institute of Diabetes and Digestive
Kidney Diseases (NIDDK) established a set of consensus
861
862
criteria, which were developed to ensure the comparability
of patients enrolled in clinical studies [14]. These include:
• Hunner’s ulcers,
• any two of:
–– pain on bladder filling, relieved by emptying.
–– suprapubic, pelvic, urethral, vaginal, or perineal pain
for 9 months.
–– glomerulations on endoscopy or upon hydrodistension
under spinal or general anesthesia.
However, over 60% of patients with possible BPS/IC
appear to fail these criteria expanding the definition [15].
The International Continence Society (ICS) in 2002
defined the term painful bladder syndrome as “the complaint
of suprapubic pain related to bladder filling, accompanied by
other symptoms such as frequency and nocturia in the
absence of proven pathologies” [16].
In Kyoto at the ICICJ (International Consultation
Interstitial Cystitis Japan) in March 2003, it was agreed that
the term “interstitial cystitis” should be expanded to “inter-
stitial cystitis/chronic pelvic pain syndrome” when pelvic
pain is at least of 3 months duration and associated with no
obvious treatable condition/pathology [17].
Most recently, the European/International Society for the
Study of Interstitial Cystitis (ESSIC) named this disease
Bladder Pain Syndrome [18] according to the definition by the
International Association for the Study of Pain (IASP) [19]
According to ESSIC, BPS/IC is indicated by two symbols, the
first of which corresponds to cystoscopy with hydrodistention
findings (1, 2, or 3, indicating increasing grade of severity) and
the second to biopsy (A, B, and C, indicating increasing grade
of severity of biopsy findings). Although neither cystoscopy
with hydrodistention nor bladder biopsy was prescribed as an
Table 71.1  Diagnostic criteria,
classification, and nomenclature
for painful bladder syndrome/
interstitial cystitis: an ESSIC
not done
proposal. From [18]
not done XX
normal XA
biopsy
inconclusive XB
positive3 XC
1 cystoscopy: glomerulations grade
2 with or without glomerulations
3 histology showing inflammatory infiltrates and/or detrusor mastocytosis and/or granulation tissue and/or
intrafascicular fibrosis
M. Cervigni
essential part of the evaluation, by categorizing patients as to
whether either procedure was done, and if so, the results, it is
possible to follow patients with similar findings and study
each identified cohort to compare natural history, prognosis,
and response to therapy. See Table 71.1.
Sometimes a significant proportion of BPS/IC patients do
not complain of pain but relate their feelings to pressure and
discomfort [20]. In this situation, patients not complaining of
pain would remain undiagnosed for IC if only pain syn-
dromes are applicable to a diagnosis of BPS/IC; therefore, in
May 2009, the Asian Society published clinical guidelines
for IC, proposing a new definition of the syndrome as
“Hypersensitive Bladder Syndrome” (HBS)—bladder hyper-
sensitivity, usually associated with urinary frequency, with
or without bladder pain [21].
71.3 Epidemiology
The prevalence of BPS/IC is enormously variable according
to various authors and studies. The lack of an accepted defini-
tion, the absence of a validated diagnostic marker, and ques-
tions regarding etiology and pathophysiology make much of
the literature difficult to interpret. Overlapping patterns of
bladder pain, lower urinary tract symptoms, and pelvic pain
are common and present challenges for clinicians and
researchers [22]. The other major difficulty in evaluating vari-
ous prevalence studies is that some are based on unverified
self-report; others by physician diagnoses or by identification
of BPS symptoms. This confusion becomes apparent when
one looks at the variation in prevalence reports in the United
States and around the world. These range from 3.5 per
100,000 population in Japan [23] to 18.1/100,000 women in
another epidemiologic study [24]. Subsequent studies in 2002
cystoscopy with hydrodistension
Hunner’s
normal glomerulations1
lesion2
1X 2X 3X
1A 2A 3A
1B 2B 3B
1C 2C 3C
II-III
71  Bladder Pain Syndrome/Interstitial Cystitis
indicated it was 450 per 100,000 (0.45%), and more recently,
it was 680 per 100,000 (0.68%) for a probable IC and 300 per
100,000 (0.3%) for a definite diagnosis of IC [25, 26]. A
recent study of 981 urban females in Vienna showed an over-
all prevalence of 306 per 100,000 (0.3%), with the highest
number in the 40–59 years age group [27]. BPS/IC has also
been reported in children and adolescents [28–30]. Another
Japanese study showed the prevalence reported from a ques-
tionnaire survey of 300 major hospitals of only 2 per 100,000
patients [31]. The patients were older than those in Europe
and the USA [32]. This may indicate that patients have had
symptoms for a long time before diagnosis. However, a recent
epidemiological investigation in Japan found that 1.0% of the
general population experienced bladder pain every day [33].
Estimations of prevalence based on physicians’ diagnoses
may be thought to produce more accurate estimates. Bade
et al. [34] used a physician questionnaire-­based survey in the
Netherlands yielding an overall prevalence of 8–16 per
100,000 females, with diagnosis heavily dependent on pathol-
ogy and presence of mast cells. The Nurses Health Study I
and II showed a prevalence of IC between 52 and 67 per
100,000 in the United States [35].
In 2000, the European Parliament and the Council of the
European Union defined rare diseases (RD) as conditions
with a low prevalence threshold (5/10,000 inhabitants in the
EC and a high degree of complexity, differently from the
rates reported by United States (7.5/10,000) and Japan
(4/10,000).
In May 2001  in Italy, the Ministry of Health approved a
decree to officially establish a very complex national network
with reference centers for various diseases with high degree of
complexity including RD, and a National Registry of Rare
Diseases (NRRD) was established. The latter had the objective
of collecting data on epidemiology (number of cases and their
distribution nationwide) and risk factors. This would help
define the size of the problem, estimate the delay in the time to
diagnosis, and the healthcare migration pattern by patients.
Data were recorded in 5 centers and the prevalence ranged
from 1,9 to 5,1/10,000.
In 2013–2014, NRRD had 1192 patients in a population
of almost 61 million. The Italian prevalence was 1.9 out of
100,000. These results indicate that BPS/IC is not a common
occurrence in the Italian population. It is widely agreed that
a disease registry is a valuable source of information both for
epidemiology and for public health.
It is apparent that there has been no standardized method
of determining the prevalence of BPS, with wide variation of
estimates in the same study employing different definitions
or criteria for identifying the condition. Many factors includ-
ing bias, cultural differences, methodology, geographic vari-
ations in diagnostic criteria, and/or possibly real differences
in different populations lead to further variations between
countries. There is some evidence of genetic predisposition;
863
the prevalence of BPS/IC in first-degree relatives has been
shown to be 17 times higher than in the general population
[36].
71.4 Nonbladder Syndromes (NBS)
Over 75% of women with a clinical diagnosis of IC/BPS
report pain outside the pelvis (pelvic pain and beyond) [37].
Multiple observations have shown that BPS patients are
more likely than controls to have pain-related syndromes
manifesting symptoms beyond the bladder and even the
pelvis. Warren et  al. [38] demonstrated that significantly
more BPS cases than matched controls had 11 antecedent
syndromes: fibromyalgia (FM), chronic fatigue syndrome
(CFS), inflammatory bladder disease (IBS), Sicca syn-
drome (SS), chronic pelvic pain, migraine, allergies,
asthma, depression, panic disorder, and vulvodynia. Nickel
et  al. [39] found significantly higher prevalence of self-
reported FM, CFS, IBS, migraine and tension headaches,
vulvodynia, temporomandibular disorder and low back
pain in female BPS cases than in controls, as well as sig-
nificantly more with depression and anxiety in a study in
several urology practices in three continents [40]. The etio-
logical and epidemiological questions that remain unan-
swered is how are these NBS associated with BPS, do these
NBS precede or follow IC/BPS, and do multiple NBS
increase the risk of BPS. Warren et al. [41] have introduced
a number of hypotheses; however, the studies to validate
these have not yet been done. Relatives of BPS patients
appear to have an increased risk of associated conditions
including myalgia and fibromyalgia, as well as constipa-
tion, suggesting shared underlying genetic factors [42].
One other NBS that is sometime neglected or forgotten in
these epidemiological associations is the association of
BPS with sexual dysfunction. Multiple studies have shown
that women with BPS diagnoses or symptoms experience
very high levels of sexual dysfunction [43]. This is likely
related to deep dyspareunia associated with anterior vagi-
nal wall pain from a hypersensitive bladder and can also be
related to vulvodynia, a common NBS seen in female IC/
BPS patients [44].
71.5 Etiology and Pathogenesis
Several etiologic theories have been proposed in recent
years, although they remain somewhat speculative and con-
troversial, and the precise causes of BPS/IC are still unknown.
One aspect has been emphasized: the multifactorial etiology
of the disease. Interaction between nervous, immune, and
endocrine factors creates a vicious cycle, provoking and
maintaining the inflammatory effect in the bladder.
864
71.5.1 Infection
To date, no infectious etiology has been identified using
reverse transcriptase polymerase chain reaction (RT–PCR)
for Chlamydia trachomatis, adenovirus, cytomegalovirus,
herpes simplex virus, papillomavirus, or Gardnerella vagina-
lis [45, 46]. It is well known that antibiotic treatment is inef-
fective for BPS/IC. Flare-up of symptoms can occasionally
be elicited by an infection, as an associated factor that initi-
ates or exacerbates IC [47].
Recently, Siddiqui et al. using 16S ribosomal DNA data
demonstrated alterations of microbiota in urine from women
with interstitial cystitis [48]. Using culture independent
method to compare the microbiota of the lower urinary tract
in standard culture negative (for bacteria) female patient with
BPS, Nickel et al. showed that among women with BPS the
prevalence of fungi (Candida and Saccharomyces sp.) was
significantly greater in those who reported a flare compared
to those who did not [49]. Nevertheless, the possibility of a
microbial contribution to the etiology of BPS remains an
open question.
71.5.2 Mastocytosis
An increased number of activated bladder mast cells have
been reported repeatedly in BPS/IC [34, 50]. There are twice
as many mast cells in the urothelium of BPS/IC patients and
ten times more in the detrusor compared to controls [51]. In
addition, more than 70% of bladder mast cells were activated
in BPS/IC compared to less than 10% in controls. In fact, the
mast cells play a pivotal role in the inflammatory process:
they release potent inflammatory mediators such as hista-
mine, leukotriene, and serotonin and also interact with
immunoglobulin E (IgE) antibodies, other inflammatory
cells, and the nervous system [51, 52].
Hence, the mast cell-IgE system and its interaction with
other inflammatory cells and the nervous system seem to be
of importance when it comes to pathogenesis [53]. There is a
significant increase in mast cell count in subepithelial region
from BPS patients with Hunner lesions compared to non-­
Hunner lesion BPS patients or patients with overactive blad-
der syndrome [54, 55].
71.5.3 Dysfunctional Bladder Epithelium
The protective inner layer of the bladder is made up of gly-
cosaminoglycans (GAGs), chondroitin sulfate (CS), and
sodium hyaluronate (SH). This GAG component is hydro-
philic and binds a layer of water molecules that is thought to
protect the urothelium from potentially harmful agents,
including bacteria, proteins, and ions. Proponents of the
leaky endothelium theory suggest that the GAG layer may be
M. Cervigni
damaged in BPS/IC [37, 38, 56, 57]; this deficiency allows
irritants in the urine to leak through the urothelium and
causes inflammation, irritation, and numerous other reac-
tions [58].
Increased urinary levels of CS and SH have been reported
in some BPS/IC patients [59, 60] with concomitant decrease
of mucosal glycoprotein GP1 [61].
Zhang et  al. [62] demonstrated significantly increased
paracellular permeability, decreased expression of the tight
junction proteins ZO-1 and occludin, and increased expres-
sion of the adhesion protein E-cadherin from patients with
BPS. Shie et al. [63] further showed that in the urothelium of
the BPS bladder a reduced E-cadherin expression was asso-
ciated with a higher level of apoptosis.
The etiology of the defect in the GAG layer is currently
unknown. Antiproliferative factors (APFs), detected in the
urine of IC patients, downregulate expression of genes that
stimulate proliferation of bladder epithelial cells and upregu-
late genes that inhibit proliferation, leading to urothelial
undermaturation and dysfunction [64, 65].
71.5.4 Neurogenic Inflammation
BPS/IC is not an end-organ condition; it should be considered
a condition of the peripheral and central nervous systems as
they relate to acute or chronic pain. The initiating event is a
noxious stimulus such as trauma, infection, or inflammation.
Acute pain is associated with nociception, which results in
pain perception modulated in the peripheral and central ner-
vous systems. Conversion of acute to chronic pain begins
with activation of visceral silent unmyelinated C-fibers by
prolonged noxious stimulation and inflammation. The neu-
rotransmitter glutamate is released, which activates N-methyl-
d-aspartate receptors. A chronic pain cycle begins as dorsal
horn neurons are activated (wind-up), which causes exagger-
ated responses to less noxious stimuli (hyperalgesia), or a
painful response to normally innocuous stimuli (allodynia),
as small volumes of urine in the bladder are perceived as a full
bladder. The neurotransmitter substance P stimulates the
release of histamine and nitric oxide, which causes neuro-
genic inflammation. Once the dorsal horn becomes hypersen-
sitive, the pain syndrome becomes a chronic pain syndrome.
Prolonged noxious stimuli can cause dorsal horn cells to
transmit efferent signals to peripheral nerve terminals (anti-
dromic transmission). Thus, a self-­ perpetuating signal is
established as a visceral CPPS, causing expression of genes
such as c-Fos in the spinal cord and loss of inhibitory neu-
rons, resulting in a decreased threshold for activation.
Akiyama et al. [66] have demonstrated in innovative animal
studies that there is a bidirectional neural cross-sensitization
of the colon and lower urinary tract. Acute colitis sensitized
lumbosacral spinal neurons receiving input from the urinary
bladder result in spinal neuronal hyperexcitability that may
71  Bladder Pain Syndrome/Interstitial Cystitis
be involved in central cross-organ sensitization of visceral
nociception between the colon and urinary bladder. This pro-
vides information that not only supports a neurogenic etiol-
ogy but also may account for the substantial overlap of BPS
with other chronic pelvic pain disorders, especially the
inflammatory bowel disorders [67]. The brain might also play
a role in the neurobiological component of BPS/IC.  Using
contrast-enhanced magnetic r­ esonance imaging, Kairys et al.
[68] showed an increased brain gray matter in the primary
somatosensory cortex associated with increased pain and
mood disturbance in patients with BPS.
71.5.5 Reduced Vascularization
A decrease in the microvascular density has been observed in
the suburothelium in patients with BPS/IC [69]. Bladder vas-
cular perfusion is reduced by bladder filling in BPS/IC, while
it is slightly increased in controls [70].
A recent paper showed that hyperbaric therapy seems to
relieve the symptoms of BPS/IC [71], confirming indirectly
that a reduced blood supply may cause a decrease in epithe-
lial function, as well as epithelial thinning and denudation
[72]. It is reasonable that the impaired blood circulation in
the bladder is related to BPS/IC and the apoptotic activity of
microvascular endothelial cells is increased [73].
71.5.6 Pelvic Floor Dysfunction
Many patients with bladder painful syndrome/interstitial
cystitis (BPS/IC) have concomitant pelvic floor dysfunction
(PFD), with muscle tenderness and spasm also known as
hypertonic pelvic floor dysfunction (HPFD). Previous stud-
ies found that myofascial pain and HPFD are present in as
many as 85% of patients with BPS/IC and/or chronic pelvic
pain (CPP) syndrome [74]. Probably, it is the same or very
Table 71.2  Bladder painful syn-
drome/interstitial cystitis (BPS/
IC) pathogenesis: integrated
pathophysiology
Mast cell
activation
Visceral hyperalgesia/allodynia
Urinary Gynecologic
865
similar to Category IIIB chronic prostatitis/chronic pelvic
pain syndrome (CP/CCPS) in male population [75, 76].
An inflammatory or pain disorder of pelvic viscera, a
trauma, or an abnormal behavior may elicit noxious stimuli
to sacral cord that set up a pelvic floor muscle dysfunction
with sacral nerve hypersensitivity and a sacral cord wind-up
[77–81].
The “guarding reflex” is a viscero-muscular reflex acti-
vated with the aim to increase the tone of the pelvic floor
during routine daytime activity [82].
In BPS/IC patients, there is an afferent autonomic bom-
bardment that may enhance and maintain a guarding reflex
that manifests itself as a hypertonus of the pelvic floor. On
the other hand, vulvodynia, dyspareunia, scrotal, and peri-
neal pain are one of the expressions of the exaggerated mus-
cle tone activity, contributing to the maintenance of the
noxious stimuli. Approximately 15% present with pain as the
only symptom [83].
71.5.7 Autoimmunity
Many of the clinical features of BPS/IC reflect an autoim-
mune component of the disease process. Investigators have
also reported concomitant association of BPS/IC and other
autoimmune diseases, such as SLE, rheumatoid arthritis, and
Sjögren’s syndrome [84–86]. There are numerous reports on
autoantibodies in patients with BPS [85, 87]. The precise
identity of these autoantibodies has yet to be determined.
Some of the common clinical and histopathological charac-
teristics present in BPS patients show certain similarities
with other known autoimmune disturbances. Studies on
autoantibodies in BPS have shown that these mainly consist
of antinuclear antibodies, and these findings are in turn simi-
lar to the autoantibody profiles in some systemic diseases
[87, 88]. Table 71.2 summarizes the integrated pathophysiol-
ogy of the syndrome in a schematic way.
Urothelial defect
C-fiber nerve
upregulation
Spinal cord and
CNS “Wind-Up”
Pelvic floor Gastrointestinal
866
71.6 Diagnosis
It is important to keep in mind that BPS/IC patients may
present with only one of the symptoms, particularly early in
the course of the disease. Up to 30% with BPS/IC present
without pelvic pain [55, 89], and approximately 15% present
with pain as the only symptom [83].
The diagnosis of BPS/IC is symptom driven by exclusion,
but should not necessarily be organ oriented, considering the
large number of confusable diseases (Table 71.3). A compre-
hensive medical history should include suprapubic pain,
pressure, and discomfort related to bladder filling, as well as
frequency and urgency in the absence of UTI or other pathol-
ogy [90]. Table 71.2 shows which disease could be confused
with BPS/IC.
A retrospective analysis from the IC Database (ICDB)
pointed out the most common baseline pain site was lower
abdominal (80%), urethral (74%), and low back (65%),
with the majority of patients describing their pain as inter-
mittent [91].
Questionnaires can be helpful in screening for BPS/
IC. The most commonly used screening tools are the pelvic
pain, urgency, frequency symptom scale (PUF) and O’Leary–
Sant symptom and problem index [92, 93] (Table 71.4). Both
Table 71.3  Differential diagnosis of bladder pain syndrome: confusable diseases
Carcinoma and carcinoma in situ
Infection with
Common intestinal bacteria
Chlamydia trachomatis, Ureaplasma urealyticum
Mycoplasma hominis, Mycoplasma genitalium
Corynebacterium urealyticum, Candida species
Mycobacterium tuberculosis
Herpes simplex and human papilloma virus
Radiation
Chemotherapy, including immunotherapy with cyclophosphamide
Anti-inflammatory therapy with tiaprofenic acid
Bladder-neck obstruction and neurogenic outlet obstruction
Bladder stone
Lower ureteric stone
Urethral diverticulum
Urogenital prolapse
Endometriosis
Vaginal candidiasis
Cervical, uterine, and ovarian cancer
Incomplete bladder emptying (retention)
Overactive bladder
Prostate cancer
Benign prostatic obstruction
Chronic bacterial prostatitis
Chronic non-bacterial prostatitis
Pudendal nerve entrapment
Pelvic floor muscle-related pain
From [18]
M. Cervigni
surveys include questions regarding pain, urgency, fre-
quency, and nocturia and how these symptoms have an
impact on quality of life.
Physical evaluation is a critical component of diagnosing
BPS/IC.  Since the bladder is a pain generator, tenderness
with single-digit examination of the trigonal area can help
establish a diagnosis of BPS/IC [94] as pelvic floor tender-
ness at the trigger point in the levator muscles [95]. Physical
examination should also address high tone of the pelvic
floor muscles, and hypersensitivity of the perineal area
using the Kaufman Q-Tip touch sensitivity test that might
screen for the presence of vulvodynia (VS) [96]. Urine anal-
ysis can rule out hematuria, and urine culture is required to
identify bladder infection as cytology can help rule out blad-
der cancer. Several optional diagnostic tests are also used
but diagnostic evaluation varies among urologists/urogyne-
cologists, in different centers [97–99] and between the USA,
Europe, and Asia. Intravesical administration of 40 mL of a
solution of 40  mEq of potassium chloride in 100 mL of
water (potassium sensitivity test—PST), with pain and
urgency scored by the patient compared to administration of
sterile water has been proposed for BPS/IC diagnosis.
However, this test’s sensitivity and specificity is only about
75%, and the participants at the International IC Consultation
Cystoscopy and biopsy
Routine bacterial culture
Special cultures
Dipstick; if "sterile" pyuria culture for M.tuberculosis
Physical examination
Medical history
Medical history
Medical history
Uroflowmetry and ultrasound
Imaging or cystoscopy
Medical history and/or hematuria: upper urinary tract
imaging such CT or IVP
Medical history and physical examination
Medical history and physical examination
Medical history and physical examination
Medical history and physical examination
Physical examination
Postvoid residual urine volume measured by ultrasound scanning
Medical history and urodynamics
Physical examination and PSA
Uroflowmetry and pressure-flow studies
Medical history, physical examination, culture
Medical history, physical examination, culture
Medical history, physical examination, nerve block may
prove diagnosis
Medical history, physical examination
71  Bladder Pain Syndrome/Interstitial Cystitis 867

Table 71.4  Questionnaires. Pelvic Pain, Urgency, Frequency Scale (PUF)

0 1 2 3 4 Symptom Bother
score score
1. How many times do you go to the 3-6 7-10 11-14 15-19 20+
bathroom during the day?
2a. How many times do you go to the 0 1 2 3 4+
bathroom at night?
2b. If you get up night to go to the Never Occasionally Usually Always
bathroom, does it bother you?
3. Are you currently sexually active?
YES NO
4a. If you are sexually active, do Never Occasionally Usually Always
you now or have you ever had pain or
symptoms during or after sexual
intercourse?
4b. if you have pain, does it make you avoid Never Occasionally Usually Always
sexual intercourse?
5. Do you have pain associated with your Never Occasionally Usually Always
bladder or in your pelvis (vagina, labia
lower abdomen, urethra, perineum, testes,
or scrotum)?
6. Do you still have urgency after you go to Never Occasionally Usually Always
the bathtoom?
7a. If you have pain is it usually Mild Moderate Severe

7b. Does your pain bother you? Never Occasionally Usually Always

8a. If you have urgency, is it usually Mild Moderate Severe

8b. Does your urgency bother you? Never Occasionally Usually Always

O'Leary Sant Symptom and Pain Index

Interstitial Cystitis Symptoms Index during the past month: How much has each of the following been a problem for you.
How often have you felt the strong need to urinate with little or no warning: Frequent urination during the day?
0. — Not at all 0. — No problem
1. — Less than 1 time in 5 1. — Very small problem
2. — Less than half the time 2. — Small problem
3. — About half the time 3. — Medium problem
4. — More than half the time 4. — Big problem
5. — Almost always

How you had to urinate less than 2 hours after you finished urinating? Getting up at night to urinate?
0. — Not at all 0. — No problem
1. — Less than 1 time in 5 1. — Very small problem
2. — Less than half the time 2. — Small problem
3. — About half the time 3. — Medium problem
4. — More than half the time 4. — Big problem
5. — Almost always

How often did you most typically get up at night to urinate? Need to urinate with little warning?
0. — Not at all 0. — No problem
1. — Once per night 1. — Very small problem
2. — 2 times per night 2. — Small problem
3. — 3 times per night 3. — Medium problem
4. — 4 times per night 4. — Big problem
5. — 5 or more times per night

Have you experienced pain or burning in your bladder? Burning, pain, discomfort, or pressure in your bladder?
0. — Not at all 0. — No problem
1. — A few times 1. — Very small problem
2. — Fairly often 2. — Small problem
3. — Usually 3. — Medium problem
4. — Almost always 4. — Big problem
Add the numerical values of the checked entries:
Total score
868 M. Cervigni

Fig. 71.2  Hunner lesion. From M.Fall World Consensus Conference,

Rome 2012
Fig. 71.1  Typical bladder hypervascularity and glomerulations in a
patient with bladder pain syndrome/interstitial cystitis. From M.Fall
World Consensus Conference, Rome 2012

in Rome recommended that it should not be used for diag-

nostic purposes because of its low prognostic value [100].
Urodynamic studies can highlight detrusor overactivity
or reduced bladder capacity without detrusor overactivity
(bladder hypersensitivity) suggestive of BPS/IC [101–103].
A mild impaired voiding phase with detrusor-sphincter dis-
coordination is probably related to the dysfunctional pelvic
floor behavior. In females, flowmetry, postvoid residual
urine volume and pressure-flow study are optional. In males,
a flowmetry should be done for all, and if maximum flow
rate is <20 mL/s a pressure-flow study and measure of resid-
ual urine volume should be done. It is recommended to per-
form filling cystometry with a filling rate of 50 mL/s to look
for overactivity, volume at first desire to void, and cystomet- Fig. 71.3  Mucosa bleeding with cracking and fissure. From M.Fall
ric capacity. A revised potassium test can be performed World Consensus Conference, Rome 2012
using cystometric capacity and a 0.2 M KCL solution. The
so-­called revised or comparative potassium test (according Cystoscopy with hydrodistension under anesthesia is
to Daha et al.) has shown prognostic value in bladder irriga- proposed by the NIDDK research criteria but is now consid-
tion studies [104], but is considered optional by ESSIC. ered too restrictive [99]; however, it remains the most com-
Local cystoscopy is not mandatory but is a good prelimi- mon procedure performed in patients with BPS/IC especially
nary investigation to rule out other conditions (e.g., bladder in Europe [106]. Hydrodistension is also done using different
stone, hematuria, or cancer) (Fig. 71.1). Cystoscopy is also methodologies, making comparison between studies difficult
needed to identify Hunner’s lesions, [105] the positive spe- [96, 107, 108]. It may be necessary to exclude other patholo-
cific finding of BPS/IC. Typically, an ulcer is recognized as a gies and to identify the presence of “classic” BPS/IC with
well-demarcated reddish mucosal lesion lacking the normal “Hunner’s lesions,” and document urothelial bleeding (glo-
capillary structure and sometimes with a spontaneous bleed- merulations), even though these have also been noted in the
ing during inspection (Fig. 71.2). In addition, some scars or bladders of normal women undergoing tubal ligation [109].
fissures with a rich hypervascularization or a pale mucosal Bladder biopsy has to be performed after hydrodistension to
aspect may be found and are an indirect index of hypovascu- avoid the risk of bladder rupture, to prove the presence of mast
larization (Fig. 71.3). cell infiltration, and to orientate toward a more specific therapy.
71  Bladder Pain Syndrome/Interstitial Cystitis
Biopsy with histopathology may be necessary to exclude neo-
plasm and eosinophilic or tuberculosis cystitis. A count of trypt-
ase-positive bladder mast cells is recommended by the European
Society, with >28 mast cells/mm constituting detrusor mastocy-
tosis, which is considered diagnostic for BPS/IC [99, 107, 110].
An increased number of mast cells were also recently proposed
as a diagnostic criterion for vulvodynia syndrome [111].
There are no specific blood or urine markers available for
diagnosis. A major factor affecting the controversy over
accepted clinical diagnostic criteria is that the current criteria
are predominantly symptom specific. An objective biomarker
would advance the establishment of reproducible diagnostic
criteria for BPS and also aid in monitoring effects of treat-
ment. A biomarker for any disease needs to demonstrate high
sensitivity and high specificity. An antiproliferative factor
(APF), recently identified as a frizzled-8 surface sialoglyco-
peptide [112], was increased in BPS/IC urine as determined
by its ability to decrease in vitro proliferation of bladder epi-
thelial cells and could distinguish BPS/IC from other uro-
logic disorders [113]. Urine APF levels also apparently
distinguished BPS/IC from CPPS in men [114]. However,
APF still needs to be validated and independently repro-
duced. Classic BPS/IC might be differentiated from nonulcer
disease by elevated urine nitric oxide (NO) [115]. GP-51 is a
glycoprotein present in both the transitional epithelium and
urine of humans and other mammals. Moskowitz et al. have
shown that bladder biopsies of BPS patients had decreased
staining for GP-51 [116]. The same laboratory also demon-
strated that although GP-51 demonstrates a high specificity
for BPS, it is not as sensitive as APF [117].
71.6.1 Gynecological Associated/Confusable
Disease
In female population affected by BPS/IC, the gynecological
pathologies may be present in about 20% of patients, and
there is also an overlapping of musculoskeletal pathologies
in 12% of cases [118].
The associated pathologies are:
(a) Pelvic Floor Dysfunction: it affects the anterior, apical,
or posterior vaginal compartment with muscle tender-
ness, spasms, and voiding dysfunction, both manifesta-
tions of pelvic floor hypertonicity [74]. It has been
estimated that the prevalence of HPFD in patients with
BPS/IC ranges from 50 to 87% [119]. Pelvic floor dys-
function exacerbates BPS/IC symptoms and has been
reported to appear in response to events such as bladder
inflammation, gait disturbance, and trauma [120].
(b) Endometriosis is the presence of endometrial glands or
stroma outside of the endometrial cavity and affects 1–7%
of the general population [121]. Up to 70% of women
with endometriosis have some type of pain symptoms,
869
most commonly dysmenorrhea, cyclic pelvic pain, or
deep dyspareunia. In women who undergo a laparoscopy
to evaluate CPP, the prevalence of endometriosis is
30–90% [122]. There is a high prevalence and association
of IC and endometriosis. A study by Chung et al. of 178
women with CPP found that 65% of CPP patients suffered
from both active endometriosis and IC [5]. A recent sys-
tematic review estimated the prevalence of BPS/ IC, and
the coexistence of BPS/IC and endometriosis in women
with CPP. Nine studies including 1016 patients with CPP
showed the mean prevalence of BPS was 61%, of endo-
metriosis 70%, and coexisting BPS and endometriosis
48%. These data suggest the importance of considering
the bladder as the source of pain even where endometrio-
sis is confirmed, and in the case of unresolved endome-
triosis and persistent pelvic pain, patients must be
evaluated to rule out the presence of BPS/IC [123].
(c) Vulvodynia: also known as vulvar vestibulitis or vulvar
dysesthesia syndrome, it literally means pain, or an
unpleasant altered sensation, in the vulva. Pain can be
unprovoked, varying from constant to intermittent or
occurring only on provocation, such as in sexual inter-
course. Peters et al. reported that vestibulodynia affects
25% of women with BPS/IC [124]. The etiology of vul-
vodynia is presumed to involve many factors: infections
and altered vaginal acid–base balance and the upregula-
tion of pro-inflammatory immune responses.
Furthermore, a large community-based study found that
vulvodynia was strongly associated with childhood
physical or sexual abuse [125].
(d) Pudendal Neuropathy: is a common feature of syndromes
such as dysfunctional voiding, nonobstructive urinary
retention, chronic pelvic pain syndromes, and urinary
and fecal incontinence. It could be ruled out as a confus-
able disease in BPS/IC patients. Pudendal neuralgia is a
functional entrapment of the pudendal nerve, and pain
occurs during compression or stretch maneuvers, such as
repetitive microtrauma, fracture, straining with constipa-
tion and childbirth, falls onto the buttocks, and suture
entrapment during pelvic surgery. The main symptom is
pain aggravated by sitting/driving/exercise, reduced by
recumbence or standing, and relieved by sitting on a toi-
let. The quality of neuropathic pain varies and can be
induced by voiding, defecating, vaginal penetration, or
orgasm. It can occur in the perineum and urethra and
extends to suprapubic, inguinal regions and to the upper
medial thighs. Urinary symptoms and rectal dysfunction
might occur. Sexual dysfunction could be present [126].
In women affected by BPS/IC is mandatory to observe
not only the bladder but also the other components
responsible for the pain disorder. Patients with bladder
tenderness alone responded better than patients with mul-
tiple tender trigger points, possibly because in these
patients, the bladder is the only target organ and the
870 M. Cervigni

patients are less severely affected than patients with mul-
tiple trigger points. Multimodal therapy remains the gold
standard in the management of female BPS/IC patients.
71.7 Treatment
There is no curative therapy for BPS/IC [127–130]. This is
consistent with the fact that the causes of BPS/IC are yet not
understood, and the pathophysiology remains uncertain.
Therefore, the therapeutic strategy is to reduce or elimi-
nate the symptoms of BPS/IC, thereby interfering with the
potential disease mechanism and improving quality of life.
Because IC is a chronic disease, patients should be coun-
seled regarding realistic expectation of treatment. Remission
may be attained but should not be expected, and even when it is
attainable, months of medical treatment may be required [131].
Exacerbations during periods of remission are common,
and patients need to be encouraged that therapy is not failing.
See Algorithm in Table 71.5.

Table 71.5  Algorithm for diag-

nosis and treatment of Bladder BLADDER PAIN SYNDROME
Pain Syndrome (BPS)
2016 International Consultation Pain, pressure, or discomfort perceived
on Incontinence to be related to the bladder with
at least one other urinary symptom
SYMPTOMS (e.g. frequency, nocturia) Test and reassess

Urinary
History infection
Frequency/volume chart
“Complicated BPS”
Focused physical examination
BASIC Incontinence
Urinalysis, culture
ASSESSMENT Urinary infection
Hematuria
“Uncomplicated BPS” Gynecologic signs/symptoms
Conservative therapy
Stress reduction normal
Patient education Consider:
Dietary manipulation Urine cytology
Nonprescription analgesics Further imaging
1’ST LINE RX Endoscopy
Pelvic floor relaxation
Pelvic floor physical therapy Urodynamics
Consult if associated disease abnormal Laparoscopy

Treat as indicated

BPS requiring more active intervention

Consider: oral and/or intravesical therapies;

2nd line treatment Consider physical therapy;
(no hierarchy implied) Consider cystoscopy with hydrodistention under
anesthesia and treatment of any Hunner lesion

Consider if not done previously:

Cystoscopy under anesthesia
3rd line treatment with bladder hydrodistension,
fulguration, resection, or
steroid injection of Hunner lesion Improved with
acceptable quality
of life:
Follow and support
4th line treatment Neuromodulation
(no hierarchy implied) Intradetrusor botulinum toxin
Cyclosporine A
Clinical trials of new therapies

5th line Consider:

treatment Diversion with or without cystectomy
Substitution cystoplasty
71  Bladder Pain Syndrome/Interstitial Cystitis
71.7.1 Conservative Therapy
Behavioral modification including education, timed voiding
(scheduled voiding time and interval), controlled fluid intake,
pelvic floor muscle training, and bladder training (gradually
extending voiding interval) may have modest benefit for IC
patients (grade of recommendation B). It is believed that exer-
cise and bathing favorably influence the quality of life by
reducing stress; however, the effect of such nonspecific thera-
pies are difficult to assess and have not been proven in clinical
trials. It would seem reasonable to suggest, when possible, to
shorten working hours, choose a job with less stress, or create
a less stressful home environment. Involvement in patient edu-
cation programs and patient support groups is considered by
most practitioners to be beneficial [132]. Barbalias et al. [133]
looked at a type of bladder training as an adjunct to treatment
with intravesical oxybutynin in patients with IC; there was a
modest improvement in O’Leary–Sant questionnaire at
6  months. Chaiken et  al. [134] reported similar results with
diary-timed voiding and pelvic floor muscle training. There are
no randomized controlled trials (RCTs) attesting the efficacy of
pelvic floor physical therapy. Biofeedback and soft tissue mas-
sage may aid in muscle relaxation of the pelvic floor [135].
Manual physical therapy (grade of recommendation C) to
the pelvic floor myofascial trigger points twice per week for
8–12  weeks also resulted in moderate to marked improve-
ment in 7/10 BPS/IC patients [136].
Modified Thiele intravaginal massage of high-tone pelvic
floor muscle trigger points twice per week for 5 weeks has
been shown to improve the O’Leary–Sant Index [137].
Common-sense dietary changes, especially avoidance of
potential bladder irritancy as identified by individual patients
may be beneficial (grade of recommendation B).
A majority of BPS/IC patients seem to have symptom
exacerbation related to the intake of specific foods and bev-
erages: coffee, spicy foods, and alcoholic beverages [138].
However, different patients seem to be affected to differ-
ent degrees by specific foods and beverages, and patients
should avoid only those foods and beverages that they find
worsen their symptoms.
71.7.2 Medical Therapy
Medical therapies for BPS/IC include oral, subcutaneous, and
intravesical agents. These drugs are categorized according to
their intended point of action within the disease process.
71.7.2.1 Oral Therapy
Protection of the Mucosal Surface
One of the theories in the pathogenesis of IC is that deficiency
of the GAG layer causes symptoms related to the increased
871
permeability of the urothelium. Therefore, a number of agents
have been used to improve the integrity of the mucosal
surface.
• Pentosan polysulfate (PPS), a branched polysaccharide
presumably acting to “replenish” the GAG layer, is the
only oral drug approved in the USA for BPS/IC (grade of
recommendation B, level of evidence 2). One study of
PPS (300 mg/day) used for 3 years showed it was twice as
potent as placebo (18%) in reducing pain, but the placebo
response was unusually low. A randomized double-blind
multicenter study, with a range of doses (300, 600 or
900 mg per day) for 32 months, of 380 BPS/IC patients
with >6  months’ symptoms and positive cystoscopic
examination but no placebo control reported that 45–50%
of all patients were classified as responders (50% or
greater improvement on the Patients’ Overall Rating of
Symptoms Index—PORIS), irrespective of the dose
[139]. In a recent prospective study, 41 patients with B
­ PS/
IC were divided into three groups according to their
response to PPS (major, intermediate, minor); they were
administered 3 × 5000 IU subcutaneous heparin per day
for 2 days, followed by 2 × 5000 IU per day for 12 days
plus 300  mg PPS per day, compared to 17 nonmatched
patients taking PPS alone; 32% of the patients in the
minor response group reported a significant improvement
in “overall well-being” over that of PPS alone [140].
Antihistamines
Simmons first proposed the use of antihistamines in 1955
[141]. His findings of mast cells in the wall of a normal blad-
der and the edema and increased vascularity seen in the IC
bladder suggested that histamine may be responsible for the
development of interstitial cystitis.
• Hydroxyzine is a histamine-1 receptor antagonist, with
additional anxiolytic, sedative, anticholinergic, and mast
cell inhibitory properties (grade of recommendation D,
level of evidence 1). It has been shown to reduce neuro-
genic bladder inflammation [142]. Hydroxyzine has shown
mixed results in treating BPS/IC symptoms. One open-
label study showed a 55% reduction in symptoms, particu-
larly in patients who suffered from allergies [143].
• Cimetidine is a histamine-2 receptor antagonist (grade of
recommendation D, level of evidence 4). It was reported
to decrease the median symptom score in 34 BPS/IC
patients studied, but with no apparent histological changes
in the bladder mucosa [144].
Immunosuppressant
• Cyclosporine is a widely used immunosuppressive drug
in organ transplantation, has been used in a long-term
follow-­up study, on refractory IC patients, and it was
872
considered far superior to sodium pentosan polysulfate in
all clinical outcome parameters measured at 6  months.
Patients who responded to cyclosporine A had a signifi-
cant reduction of urinary levels of epidermal growth fac-
tor (EGF), [145] Forrest et  al. [146] retrospectively
summarized results from cyclosporine off-label use in 44
BPS patients. In 34 patients presenting with Hunners
lesion upon cystoscopy, the success rate was higher com-
pared to those patients without lesions (68% vs. 30%).
However, side effects were common and demand a close
monitoring of patients including blood pressure and renal
failure.
• Suplatast Tosilate: Suplatast Tosilate (IPD-1151 T) is an
immune-­regulator that selectively suppresses IgE pro-
duction and eosinophilia via suppression of helper T
cells that produce IL-4 and 5. Ueda et al. reported a small
study in 14 women with interstitial cystitis [147].
Treatment for 1 year resulted in a significantly increased
bladder capacity and decreased urinary urgency, fre-
quency, and lower abdominal pain in 10 women. Larger,
multicenter international RCTs have been completed,
and results did not justify further development for this
indication.
• Corticosteroids: reports on outcome with corticosteroid
therapy have been both promising and discouraging
[148]. The side effects of steroids can be very serious,
making it difficult to justify their use [149, 150].
Other Oral Medications
• l-Arginine is a natural substrate of nitric oxide synthase
(NOS) (grade of recommendation D). It may re-activate
NOS activity, which is suppressed in IC, and relieve
symptoms [151]. No significant effect was observed in
double-blind studies [152, 153].
• Quercetin is a bioflavenoid that has an anti-inflammatory
effect and is found in fruits, vegetables, and some spices.
In a small study of 22 BPS patients followed for 4 weeks,
all but one patient had some improvement in the O’Leary–
Sant symptom and problem scores, as well as in a global
assessment score. Further studies are necessary to deter-
mine efficacy [154].
• Sildenafil: the contraction of smooth muscle caused by
elevating potassium or adrenergic activity can be relaxed
by phosphodiesterase type 5 inhibitors (a class of drugs
approved to treat erectile dysfunction). Forty-eight
women with a clinical diagnosis of BPS were randomly
assigned to treatment or placebo for 3 months [155]. The
O’Leary–Sant IC symptom and problem indices, VAS,
and a micturition diary were recorded before treatment,
and after the treatment until 3 months. The IC symptom
and problem indices scores and urodynamic index were
significantly improved in sildenafil treatment group com-
pared with placebo group and baselines (p < 0.05). The
efficiency of treatment reached 62.5%. The adverse events
M. Cervigni
Table 71.6  Oral medications for treatment of bladder painful syn-
drome/interstitial cystitis (BPS/IC)
Drug RCT GoE: LR
Amitriptyline; tricyclic antidepressant Yes B: 2
Cimetidine Yes C: 3
Hydrocortisone No Ineffective
Cyclosporine No C: 3
Hydroxyzine Yes D: 1
l-Arginine Yes A: 1
PPS Yes D: 1
Quercetin No D: 4
Sodium pentosane polysulfate Yes D: 1
Suplatast tosilate No D: 3
GoE grade of evidence, LR level of recommendation, RCT randomized
controlled trials (Adapted from Hanno P, et al.—ICI 2013)
were mild to moderate and transient. The mode of action
of sildenafil in BPS remains unclear. Further, larger stud-
ies are necessary to confirm the results of this innovative
study. More detailed results of the use of oral drugs in
BPS/IC patients are reported in Table 71.6.
71.7.3 Intravesical Instillation
Intravesical and subcutaneous heparin has been used for
the treatment of IC since early 1960. It is either instilled
or administered subcutaneously. When instilled, heparin
does not have systemic anticoagulant effects. In one study,
48 patients with IC are self-administered intravesical hep-
arin (10,000 IU in 10 mL sterile water three times weekly
for 3  months). Fifty-six percent of the patients attained
clinical remission after 3  months. Subcutaneous heparin
has been demonstrated to produce rapid relief of symp-
toms in eight patients who reported long-term benefit over
1 year [156].
• Intravesical dimethylsulfoxide (DMSO) remains the basis
of intravesical therapy for IC (grade of recommendation
B, level of evidence 2). It has been shown to reduce symp-
toms for up to 3 months. Its multiple effects include an
anti-inflammatory and analgesic effect, muscle relax-
ation, mast cell inhibition, and collagen dissolution [157].
Patients treated with DMSO have experienced a 50–70%
reduction of symptoms, although the relapse rate is
35–40%. Administration in combination with various
other agents including hydrocortisone, heparin, and
sodium bicarbonate has been recommended to improve
the response to DMSO.
• Intravesical hyaluronic acid (grade of recommendation
C, level of evidence 1) has been used with a long-lasting
moderate efficacy with no side effects, but an RCT per-
formed by Bioniche Company reported no significant
efficacy of their preparation (40  mg or 200  mg per cc,
respectively) and neither showed significant efficacy of
71  Bladder Pain Syndrome/Interstitial Cystitis
sodium hyaluronate compared to placebo in large phase 3
trials. These negative studies have not been published in
peer-reviewed literature (http://www.medicalnewstoday.
com/articles/112053.php). Neither preparation has been
approved for use for BPS in the United States.
• Chondroitin Sulfate (grade of recommendation C, level of
evidence 1): Steinhoff et  al. treated 18 patients with
40  mL intravesical chondroitin: 46.2% showed a good
response, 38.5% had a partial or no response [158]. In
2013, a larger and long-term study was made on 213
patients. At the end of the treatment, GRA rates were
43.2% in the chondroitin group and 27.4% in the control
group, and the chance of becoming a responder with
chondroitin sulfate was 55% significantly higher than
with placebo. The small decrease in total score and urine
frequency between the two groups was less impressive
and not statistically significant.
• Combined Instillation of Hyaluronic Acid and Chondroitin
Sulfate (grade of recommendation: C, level of evidence: 2).
Recently, Cervigni et  al. [159] published a randomized,
open-label, multicenter study involving 110 women ran-
domized to receive 13 weekly instillations of HA (1.6%—
800  mg) and CS (2.0%—1  g) (Ialuril®; IBSA) or 50%
DMSO solution (RIMSO®; Bioniche), with a 2:1 alloca-
tion ratio. This study showed that treatment with HA/CS
appears to be as effective as DMSO with a potentially
more favorable safety profile. Both treatments increased
health-related quality of life, while HA/CS showed a
more acceptable cost-effectiveness profile.
• Botulinum toxin (grade of recommendation A, level of evi-
dence 1) inhibits the release of calcitonin gene-related pep-
tide and substance P from afferent nerves, and weakens
pain [160, 161]. Several studies of intravesical Botox into
the bladder wall indicated symptom relief in IC patients,
without significant adverse events. In a pilot study, repeated
injections for a total of 13 patients were followed up for
2  years, 10 patients reported a subjective improvement.
Mean VAS scores and mean daytime and nighttime urinary
frequency decreased significantly. At 1 and 2 years follow-
up, the beneficial effects persisted in all patients [162].
These results are in contrast with those in another study
from Kuo et  al. [163] of Botox-A in 10 patients with
BPS.  None of the patients became symptom-­ free; two
showed only limited improvement in bladder capacity and
pain score. Trigonal-only injection seems effective and
long lasting since 87% of patients reported improvement
after a 3-month follow-up period in a study by Pinto et al.
[164]. Further studies will be needed to obtain conclusive
evidence for its efficacy, duration of effect, and side effect.
Table 71.7 shows the results of drugs administered intra-
vesically for the treatment of BPS/IC.
• Intravesical Bacillus Calmette–Guérin (BCG) (not rec-
ommended) was initially reported to have some benefit in
BPS/IC [165]; however, a subsequent, randomized
placebo-­controlled trial of BPS/IC patients, who met the
873
Table 71.7  Intravesical medications for treatment of bladder pain-
ful syndrome/interstitial cystitis
Intravesical therapy RCT GoE/LR
DMSO Yes B: 2
BTX (intramural) Yes A: 1
BCG Yes −A: 1 ineffective
Hyaluronic acid Yes D: 1
Chondroitin Sulfate No D: 4
Hyaluronic + chondroitin Yes C: 2
PPS Yes D: 4
GoE grade of evidence, LR level of recommendation, RCT randomized
controlled trials (Adapted from Hanno P, et al.—ICI 2013)
NIDDK research criteria, showed that there was no statis-
tical difference at 34 weeks [166].
71.7.4 Pain Modulators
The long-term, appropriate use of pain medications is one of
the main step in the treatment of BPS/IC.  Many nonopioid
analgesics and the nonsteroidal anti-inflammatory drugs
(NSAIDs) and even antispasmodic agents have a place in pain
therapy.
71.7.4.1 Analgesics
(Grade of Recommendation: C—Level of Evidence: 4)
• Gabapentin, introduced as an anticonvulsant, has found
efficacy in neuropathic pain disorders, and it demon-
strates synergism with morphine in neuropathic pain
[167]. Sasaki et al. reported that 10 of 21 male and female
patients with refractory genitourinary pain had subjective
improvement of their pain following treatment with gaba-
pentin [168].
• Pregabalin has similar structure as gabapentin and might
be worthwhile to try for bladder pain syndrome, particu-
larly for those with concurrent fibromyalgia, though stud-
ies are lacking [169]. Opioids are seldom the first choice
of analgesics in chronic pain states, if less powerful anal-
gesics have failed [170]. Chronic opioid therapy can be
considered a last resort in selected patients who have dis-
abling pain and often receive inadequate doses of short-
acting pain medications. The major impediment to the
proper use of opioids when they are prescribed for long-
term nonmalignant pain is the fear of addiction. In addi-
tion to narcotics, concurrent usage of nonsteroidal
anti-­inflammatory drugs, cyclooxygenase inhibitors, acet-
aminophen, and tricyclic antidepressants may provide
better pain control [171]. The common side effects of opi-
oids include sedation, nausea, and mild confusion.
Constipation is common, and a mild laxative is generally
necessary.
• Tricyclic Antidepressants (TCAs)
Amitriptyline is known to have pain-reducing effects
(grade of recommendation B, level of evidence 2). One
874
recent RCT of amitriptyline evaluated 50 patients with
IC. Improvement in overall symptom scores was signifi-
cantly greater in the treatment group, as well reduction in
pain and urgency (P  <  0.001). van Ophoven et  al. per-
formed the first prospective, double-blind, placebo-­
controlled study of amitriptyline. Fifty patients were
randomized to placebo. About 42% of patients had greater
than 30% decrease in O’Leary/Sant symptom and prob-
lem scores at 4 months compared to 13% of patients in the
placebo group [290]. They subsequently reported a long-­
term follow-up of amitriptyline for patients who can tol-
erate the side effects and continued the medication. With
a mean follow-up of 19 months, 64% of 94 patients had
response [172]. Foster and Hanno [173] reported a second
multicenter, RCT, double-blind, placebo-controlled study
of amitriptyline in subjects with BPS/IC. Only of the sub-
group of 207 subjects who achieved a drug dose of at least
50 mg, a significantly higher response rate was observed
in the amitriptyline group (66%) compared to placebo
(47%) (p = 0.01).
Doxepin, Desipramine, and Duloxetine are other tricy-
clic antidepressants that have been used for bladder pain
syndrome are doxepin and desipramine. Wammack et al.
used the combination of doxepin and piroxicam, a cox-2
inhibitor. Twenty-six of 32 patients (81%) experienced
remission of symptoms [174]. One study reported satis-
factory outcome with desipramine [175]. Duloxetine, a
serotonin-norepinephrine reuptake inhibitor, has also
been tried but without therapeutic effects [176].
71.7.5 Multimodal Medical Therapy
To manage the multiple pathological features of IC, a multi-
modal approach, combining agents from different classes, is
suggested to improve the therapeutic response by attacking
the disease at several points. One common multimodal
approach is
1 . to restore epithelial function with heparinoid,
2. to treat neural activation and pain with TCA,
3. to control allergies with an antihistamine.
In advanced form, intravesical treatment may be required.
Combination intravesical therapy is also indicated for
patients who experience significant flare of symptoms after
remission.
71.7.5.1 Procedural Intervention
BPS/IC is a chronic and debilitating disease with an impair-
ment of quality of life due to disabling symptoms. Surgical
options should be considered only when all conservative
treatment has failed.
M. Cervigni
Laser resection, augmentation cystoplasty, cystolysis,
cystectomy, and urinary diversion may be the ultimate option
for refractory BPS/IC patients [131]. Continent diversion
may have better cosmetic and lifestyle outcome, but recur-
rence is a real possibility.
Posterior tibial nerve stimulation somewhat improved
less than half of patients [166].
Sacral nerve neuromodulation as a treatment for BPS/IC
in initial studies seems to relieve the symptoms of IC. Further
studies are needed [177].
71.8 Conclusions
Bladder pain syndrome/interstitial cystitis is a chronic, multi-
factorial disorder with symptoms of urinary frequency,
urgency, and pelvic pain, often associated with other painful
diseases, which profoundly affects patients’ quality of life
due to its disabling aspects. Pelvic pain in BPS/IC is a vis-
ceral pain syndrome with multiple pain generators, which can
make the diagnosis difficult. The knowledge of a pathology
so difficult to understand and to treat is fundamental. Patients
with a history of recurrent UTIs that are culture negative,
those with endometriosis and significant bladder symptoms,
those with overactive bladder syndrome who have responded
poorly to therapy, or those with vulvodynia or chronic pelvic
pain are all likely to have untreated BPS/IC.
An underlying principle is that, where possible, decisions
on the treatment of bladder pain syndrome should be evi-
dence based. Unfortunately, high-level evidence of efficacy
is lacking for many common treatments, either because such
studies have not been done or were done and failed to dem-
onstrate efficacy. Another principle is that we should be
guided by patient perceived and driven outcomes for BPS/IC
after exclusion of confusable diseases. Many patients prefer
noninvasive therapies (diet, behavioral modification, stress
reduction, physical therapy) associated with oral therapy.
The use of surgical therapies should be approached with
some caution in a very selected group of refractory patients.
Take-Home Messages
• Pelvic pain in BPS/IC is a visceral pain syndrome
with multiple pain generators, which can make the
diagnosis difficult.
• Patients with a history of recurrent UTIs that are
culture negative, those with endometriosis and sig-
nificant bladder symptoms, those with overactive
bladder syndrome, who have responded poorly to
therapy, or those with vulvodynia or chronic pelvic
pain are all likely to have untreated BPS/IC.
• The earlier the diagnosis is made and therapy
begun, the sooner patients with BPS/IC will experi-
ence improvement of their symptoms.
71  Bladder Pain Syndrome/Interstitial Cystitis 875

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 Pelvic Pain Associated
with a Gynecologic Etiology
Megan B. Shannon and Elizabeth R. Mueller
Learning Objectives
• Appreciate the broad differential for gynecologic
causes of pelvic pain.
• Elicit a detailed history from a patient with pelvic
pain.
• Understand the detailed physical exam required to
properly diagnosis pelvic pain.
72.1 Introduction
Understanding pelvic pain and all of its manifestations is an
essential part of clinical practice for healthcare providers
treating women. Pelvic pain (PP) is discomfort localized to
the pelvic compartment or perineum, which causes a woman
to seek medical attention or affects her ability to function.
For most clinicians in nongynecologic specialties and even
the seasoned gynecologist, the workup and management of a
woman who presents with pelvic pain can be daunting.
Historically, pelvic pain has been categorized into cyclic or
noncyclic but this description has become less reliable in
making a diagnosis. A thought process we have found help-
ful is to first categorize the pelvic pain as acute or chronic.
We triage the acute pain into emergent and nonemergent
(Fig. 72.1). In this chapter, we will provide the framework
for the evaluation and management of women who present
with pelvic pain with a gynecologic etiology. This chapter
will not focus on musculoskeletal, urinary, colorectal, or gas-
trointestinal etiologies for pelvic pain. Knowledge of these
M. B. Shannon
Female Pelvic Medicine and Reconstructive Surgery, Virginia
Women’s Center, Richmond, VA, USA
E. R. Mueller (*)
Female Pelvic Medicine and Reconstructive Surgery, Departments
of Urology, Obstetrics and Gynecology, Loyola University Stritch
School of Medicine, Chicago, IL, USA
e-mail: emuelle@lumc.edu
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_72
72
systems’ pain disorders is critical given that pelvis contains
several organs that may be individually or collectively con-
tributing to the symptoms.
Patients who present with new-onset PP and the findings
of an acute abdomen pain warrant evaluation in an emer-
gency department. They usually have a source for their peri-
toneal irritation, such as pelvic inflammatory disease,
intra-abdominal bleeding, ovarian cyst rupture, or ovarian
torsion. Although an ectopic pregnancy can present without
evidence of acute abdomen pain, it is important to rule out
this diagnosis in reproductive-aged women due to the poten-
tial for serious consequences if left untreated. This can be
done with a urine pregnancy test, and if positive, followed up
with a quantitative beta human chorionic gonadotropin
(β-HCG) level to determine next steps.
72.2 E
 valuation of Pelvic Pain
of Gynecologic Origin
72.2.1 History
The evaluation of PP involves the typical components of a
history and physical exam, and at a minimum should include
a visual analogue scale (VAS) for the assessment of pain. A
pain map is also useful to localize the pain (Fig.  72.2). A
complete history of the pain should also include the compo-
nents of the pain: location, characterization, exacerbating
and alleviating activities, and radiation pattern.
Many clinicians utilize a patient questionnaire that
includes an anatomic diagram to identify the location of the
chronic pelvic pain (CPP). Oftentimes, patients will point to
the abdomen, indicating a more likely gastrointestinal or
abdominal wall etiology. Pain localized at the site of previ-
ous abdominal surgical incisions can be caused by an inci-
sional hernia or endometrioma of the abdominal wall or
entrapped nerve. It is also possible for musculoskeletal strain
or myofascial pain disorder involving a specific muscle or
muscle group to present as pain localized to the anatomic
879
880 M. B. Shannon and E. R. Mueller

No PAIN Yes
ACUTE CHRONIC
Duration ≥ 6 months

Abnormal Vital Signs,

Emergency Room
Leukocytosis,
Yes
+ Pregnancy Test Evaluation

Physical Site Acute Chronic

Vulva Infectious (HSV, Candida) Inflammatory (Dermatosis)

Contact dermatitis Vulvodynia

Vagina Vaginitis Vaginal Atrophy

Bartholin’s abscess Bartholin’s cyst

Cervix Cervicitis Cervicitis

PAIN
Uterus Endometritis Endometriosis

Adenomyosis

Leiomyomas

Adnexa Adnexal torsion

Pelvic inflammatory disease

Tubal Pregnancy

Extra-gynecologic considerations • Gastrointestinal (constipation, • Myofascial pain (pelvic floor or

(can be acute or chronic) IBS, IBD) abdominal wall)
• Painful bladder syndrome • Skeletal pelvis (sacro-iliac joint,
hips, pubic symphysis)

Fig. 72.1  Evaluation of pelvic pain of gynecologic etiology and common causes of pain by site

location of the muscle, its tendons, and site of insertion. It is
just as important that the patient identifies the site of tender-
ness on the vulva or perineum as with the abdominal exam.
A diffuse pattern of CPP on the perineum suggests either a
chronic irritant such as dermatoses or a neuropathic cause.
Chronic recurrent painful ulcerative lesions can be found
with Behçet’s syndrome, herpes, or from the “itch-scratch”
syndrome of a nonspecific irritation.
The patient’s description of the location of radiation of
her pain can also be helpful. Pelvic structures in the posterior
portion of the pelvis can cause pain to radiate into the back;
for instance, a posterior uterine fibroid can present with a
dull backache. Pain which radiates into the lower extremities
may be originating from a musculoskeletal or neurologic dis-
ease process.
Description of exacerbating events is an important
piece of the clinical puzzle. Movement can elicit pain for
many patients. A common exacerbating event for pelvic
pain is intercourse, a complaint known as “dyspareunia”.
The pain can occur during sex or afterward. Introital
72  Pelvic Pain Associated with a Gynecologic Etiology 881

Fig. 72.2  Pain Map

pain with initial penetration is suggestive of a vulvar, fascial pelvic pain (MFPP). When an examiner can
vaginal, or muscular source. Pain with deep penetration reproduce the pain with a digital vaginal exam, this
suggests a condition that is aggravated with contact, information aids in diagnosis and subsequent clinical
such as cervicitis, endometriosis, adenomyosis, or myo- decision-making.
882
Alleviating factors are an important component of the his-
tory and may be helpful in creating a differential diagnosis.
The use of analgesics, narcotics, rest, and heat can be non-
specific therapies which help with many types of pain. It is
imperative to document any pain medications the patient has
used in the past, as well as current medications with dosing
schedule and strength.
The patient’s qualitative description of the pain can also
be helpful. It is thought that the neurophysiological mecha-
nism of pain caused by injury to an anatomic structure can
determine the type of pain experienced by the patient. For
instance, pain originating from somatic structures such as
musculoskeletal injury is described as dull or aching due to
transmission along sensory fibers. Visceral organs transmit
pain sensation via sympathetic fibers of the autonomic ner-
vous system, which is perceived as diffuse and crampy.
Patients many times use the descriptive term “burning” or
“tingling” to describe pain caused by a neuropathy [1].
History taking should include a question addressing
physical or sexual abuse, as pelvic pain can be a complex
syndrome affected by psychological and behavioral factors.
There is a high incidence of pelvic pain among those who
have been victimized by such abuse [2–4]. Questions about
bladder and bowel habits (e.g., dysuria, urinary urgency,
constipation, diarrhea, bloating) as well as prior musculo-
skeletal diagnoses (e.g., orthopedic surgeries of the pelvis
or back, arthritis, prior accidents) can aid in proper
diagnosis.
72.2.2 Physical Exam
The clinician should initiate the physical exam of a CPP
patient after establishing rapport during the interview p­ rocess.
The exam may elicit significant pain for the patient, so effec-
tive communication and trust need to be developed. It is also
important to note that patients will respond to a painful exami-
nation with guarding, which may render the remainder of the
exam difficult to interpret. We prefer a systematic, gentle
approach with maneuvers that are likely to cause pain per-
formed last. Physical examination of the patient is critical to
directing further evaluation and formulating a treatment plan,
and thus is a crucial part of the patient evaluation.
The exam typically starts with the patient seated on the
exam table. The back is carefully inspected for sacral defects,
tenderness over the spine or sacroiliac joint, and normal spi-
nal alignment. An exam of the lower extremities can then be
performed and is indicated in patients who present with a
potential neurologic cause to their symptoms.
The abdominal exam is performed with the patient in a
supine position. The examination of the abdomen begins
with visual inspection: note abdominal scars and any super-
ficial masses or skin retraction. The next step isolates the
M. B. Shannon and E. R. Mueller
anterior abdominal wall, and is initiated by asking the patient
to engage her abdominal wall muscles by lifting her head or
legs off the exam table, then palpating the abdomen. Pain
with this maneuver would be documented as a “positive
Carnett sign” and suggests an abdominal wall etiology and
less likely a visceral cause of the pain [5]. Trigger points in
the rectus muscles, abdominal wall endometriomas, or
entrapped nerves near incisions may be identified with such
palpation. The Valsalva maneuver will also elicit a bulge if
there is a hernia or diastasis recti present. Deep palpation
should begin at the point furthest away from the site of pain.
The examiner should look for an abdominal or pelvic mass,
evidence for distention caused by constipated stool in the
colon, ascites, and a full bladder as he or she is isolating the
location of the tenderness.
The postvoid residual urine volume should be measured
to rule out urinary retention which can be a cause of diffuse
suprapubic pain. This can be done by straight catheterization
or bladder ultrasound within a few minutes after voiding. If
the patient complains of dysuria, urinary incontinence, or
urinary urgency–frequency, a urine specimen should be
obtained for urinalysis and reflex culture.
Inspection of the female genitourinary structures is per-
formed in the dorsal lithotomy position with the physician
seated. The external genitalia, specifically the vulva and the
perineum, should be inspected for any lesions or skin break-
down. If the pain is localized, the patient may be asked to
point out the site of symptoms. Any suspicious skin lesion
should be biopsied or referred for consultation to rule out
malignancy. A Q-tip test is used to faintly stroke the vulva
and hymenal opening in order to note any dysesthesia found
with vulvodynia. Visual examination of the urethra may
demonstrate a small rim of urethral mucosa posteriorly,
which is called a urethral caruncle. If the mucosa appears
circumferentially around the urethra, it is referred to as ure-
thral prolapse. Both of these findings are benign, do not
cause pain, and rarely require treatment. However, patients
may attribute their symptoms to this finding, especially if
they have been performing self-examination.
The neurologic exam should include assessment of sensa-
tion of the genitalia and inner thighs. The bulbocavernosus
reflex is elicited by stroking the clitoris or looking for con-
traction of the bulbocavernosus muscles and anal sphincter
(known as the anal wink) [6]. While the presence of this
reflex assures that the reflex arc is intact, it may be absent in
patients who are neurologically intact.
A double-bladed speculum exam is indicated for women
who present for evaluation of pelvic pain. Visualization of
the vaginal walls will allow you to see erosion or extrusion
of synthetic materials used during prolapse or incontinence
procedures. The vagina and cervix can be visualized in
order to take samples for microscopy, cultures, or
cytology.
72  Pelvic Pain Associated with a Gynecologic Etiology 883

After removal of the speculum, place two fingers beneath
the cervix and elevate the vaginal apex. By gently placing the
other hand suprapubically, one can elicit uterine tenderness
and evaluate uterine size. By sweeping these digits anterolat-
erally, one can evaluate for tenderness or mass in the adnexal
region, again using the abdominal hand gently to guide these
structures for palpation. In women with obesity, guarding, or
postmenopausal status, it may not be feasible to palpate ova-
ries; the transvaginal ultrasound will allow effective and
diagnostic visualization and many clinicians make this part
of their protocol for women presenting with CPP. A simple
palpation and movement of the cervix can evaluate for pelvic
inflammatory disease (PID); nodularity and tenderness in the
cul-de-sac can raise suspicion for endometriosis. Palpation
of a circumferential mass in the anterior vaginal wall may
indicate a vaginal wall cyst, urethral diverticulum, periure-
thral leiomyoma, or urethral carcinoma [7].
Following the speculum and bimanual exams, the physi-
cian should perform a systematic examination of the pelvic
floor with a single digit inserted into the vagina. apply digital
pressure on the pelvic floor muscles through her vagina to
check for tenderness. Demonstrate the amount of pressure
you will use by firmly pushing her thigh muscles. Ask her to
rate her tenderness on a scale of 0–10, where 0 is no pain and
10 is the worst pain imaginable. Use a single digit to firmly
palpate the muscles of the posterior, lateral, and anterior pel-
vic walls, looking for trigger points or myofascial tender-
ness. Next, with 1–2 digits in the vault, ask the patient to
contract her pelvic floor muscles (commonly referred to as a
Kegel). Normally functioning muscles will move ventrally
and cranially with this contraction [8]. Next, ask her to relax
the muscles. Well-­ functioning muscles can contract and
relax, whereas oftentimes patients with MFPP have hyper-
tonic muscles that seem to be in a constant state of contrac-
tion and cannot relax. Such women require treatment with
internal myofascial manipulation with a trained pelvic floor
physical therapist.
72.3 E
 tiologies and Treatments of Pelvic
Pain by Site
72.3.1 Perineum and Vulva
When the targeted evaluation of a patient suggests a vulvar
issue, care should be taken to obtain a good vulvar hygiene
history. For example, many women wear pads that can irritate
the skin, especially if constantly damp from urinary inconti-
nence. Similarly, women have often tried many over the coun-
ter creams before presenting for care, which can exacerbate
symptoms. Many vulvar conditions are poorly understood by
clinicians, given their complexity. This section is not compre-
hensive, but is of high yield for physicians treating PP. More
information can be obtained from the International Society for
the Study of Vulvovaginal Disease’s (ISVVD) website.
Infectious causes of vulvitis that will be discussed here
are candidiasis and herpes. Vulvar candidiasis is an infec-
tion by the Candida organisms. Symptoms typically consist
of pruritus, burning, irritation, and dyspareunia may be
accompanied by vaginal discharge. Microscopy in the
absence of a vaginal discharge is less reliable, but a culture
can be taken if the diagnosis is unsure or in a patient with
complicated candidiasis who has been refractory to prior
treatment protocols [9]. Topical or oral agents can be pre-
scribed (Table 72.1). Vulvovaginal candidiasis is more com-
monly diagnosed in women with immunocompromising

Table 72.1  Evaluation and treatment of common pelvic infections

Type Method and diagnosis Treatment
Vulvitis Candida Exam: dark red erythema, moist skin Fluconazole 150 mg po × 1
Test: fungal culture Topical azole (multiple regimens available)
Herpes Exam: vesicals or ulcerations Acyclovir 400 mg po bid × 5 days
simplex Test: HSV culture of lesion Valacyclovir 1 g po orally qd × 5 days
Famcyclovir 250 mg po bid × 5 days
Vaginitis Candida Exam: thick white discharge Fluconazole 150 mg po × 1
Microscopy with KOH: blastopores/hyphae Topical azole multiple regimens
Test: fungal culture
Trichomonas Exam: thick white discharge Metronidazole 2 g po × 1
Microscopy: Trichomonas pH <4.5 Metronidazole 500 mg po bid × 7 days
Bacterial Exam: fish odor, yellow brown discharge Metronidazole 500 mg po bid × 7 days gel, 0.75%,
vaginosis Microscopy: clue cells, no lactobacilli pH <4.5 qd × 5 days (5 g) intravaginally
Clindamycin cream, 2% (5 g), intravaginally every
night × 7 days Metrogel
Cervicitis, urethritis Chlamydia Test: nucleic acid amplification (NAAT) Azithromycin 1 g po × 1 Doxycycline 100 mg po
bid × 7–10 days
Gonorrhea Test: NAAT Ceftriaxone 125 mg IM × 1 Cefixime 400 mg po × 1
Pelvic inflammatory Multibacterial Exam: purulent cervical discharge, cervical
disease motion tenderness
Test: NAAT for Chlamydia/Gonorrhea Consult CDC guideline (www.cdc.gov)
884
conditions, such as diabetes, HIV, or chronic corticosteroid
use; it may also be seen after recent antibiotic use that dis-
rupts the vaginal microbiome. Herpes simplex virus (HSV)
is a sexually transmitted infection that presents with
extremely painful vesicles and ulcerations on the vulva.
HSV-1 and HSV-2 subtypes are both capable of causing
genital herpes. The first infection may be accompanied by
fever, myalgias, and enlarged inguinal lymph nodes.
Recurrent outbreaks of HSV are usually less severe and are
characterized by similar lesions. Oral treatment can be pre-
scribed with suppression offered to those with recurrent out-
breaks or nonconcordant partners [10]. Topical lidocaine
jelly is an analgesic option for patients to use locally during
a painful outbreak.
Contact dermatitis of the vulva can occur after exposure
to external irritants or allergens, resulting in inflammation of
the vulvar skin. Symptoms of pruritus, irritation, burning, or
discharge may be present. Skin will appear raw, erythema-
tous, or even lichenified in more chronic disease [9].
Treatment includes topical corticosteroids, removal of the
offending agent, and counseling about irritants and vulvar
hygiene.
The inflammatory dermatoses—lichen sclerosus and
lichen planus—will be discussed here. Vulvar lichen sclero-
sus typically affects the labia menora with loss of a­ rchitecture
and white papules or plaques that create a thin cigarette
paper appearance, oftentimes in an hourglass pattern (around
the vaginal opening and anus). The clitoral hood and labia
menora may even fuse. Symptoms are pruritus, irritation,
pain, and sexual and voiding dysfunction [9, 11]. In contrast
to lichen planus, lichen sclerosus only affects the vulvar skin.
It is treated with long-term low-dose topical steroids.
Diagnosis can be confirmed with a punch biopsy, and should
be performed if the diagnosis is uncertain or a patient is not
responding to initial treatment. Lichen planus has similar
symptoms and physical exam findings, except that it can also
include red friable appearing lesions affecting the vulva and
vagina, sometimes resulting in complete obliteration of the
vaginal canal. Oral lesions may be present too. Topical and
intravaginal steroids are the mainstay of treatment for lichen
planus [9].
Vulvodynia is defined as vulvar pain present for at
least 3 months without a clear identifiable cause, which
may have potential associated factors [12]. See Fig. 72.3.
This syndrome has been described in women of all ages
and is not well understood. A wide range of heteroge-
neous pain descriptions may be present in women with
this disorder. Proposed etiologies include combinations
of MFPP, neuropathic pain, psychological factors, and
genetic predisposition. The Q-tip test is commonly used
in diagnosis of this disorder, with pain to light touch of
the vulva being reported by the patient. Diagnosis and
M. B. Shannon and E. R. Mueller
management of vulvodynia are best done in a multidisci-
plinary clinic with physical therapists, gynecologists who
specialize in pain, and psychologists. These women
oftentimes suffer from other pain disorders such as fibro-
myalgia. Treatments may include topical lidocaine jelly,
pelvic floor physical therapy, psychosocial therapy, and
medications such as amitriptyline, gabapentin, or prega-
balin [13, 14].
Pudendal neuralgia is a vulvar pain disorder character-
ized by neuropathic pain in the pudendal nerve distribu-
tion. Nantes criteria states the diagnosis must include pain
along the anatomic distribution of the pudendal nerve, pain
aggravated by sitting, pain that does not awaken the patient
at night, lack of objective sensory loss on clinical exam,
and pain that is improved by an anesthetic pudendal nerve
block [15]. Proposed etiologies include mechanical (child-
birth, surgery, and trauma), infectious, or immunologic.
Treatments include pelvic floor physical therapy, muscles
relaxants, neuropathic pain medications, and nerve blocks
[16].
Hidradenitis suppurtiva, syphilis, vulvar squamous cell
carcinoma, Bechet’s disease, and Paget’s disease are less
common causes of vulvar pain that will not be elaborated
upon in this chapter.
A. Vulvar pain caused by a specific disorder*
Infectious (eg, recurrent candidiasis, herpes)
Inflammatory (eg, lichen sclerosus, lichen planus,
immunobullous disorders)
Neoplastic (eg, Paget disease, squamous cell
carcinoma)
Neurologic (eg, postherpetic neuralgia, nerve
compression or injury, neuroma)
Trauma (eg, female genital cutting, obstetrical)
Iatrogenic (eg, postoperative, chemotherapy, radiation)
Hormonal deficiencies (eg, genitourinary syndrome
of menopause [vulvovaginal atrophy], lactational
amenorrhea)
B. Vulvodynia—vulvar pain of at least 3 months’ duration,
without clear identifiable cause, which may have
potential associated factors.
The following are the descriptors:
Localized (eg, vestibulodynia, clitorodynia) or
generalized or mixed (localized and generalized)
Provoked (eg, insertional, contact) or spontaneous or
mixed (provoked and spontaneous)
Onset (primary or secondary)
Temporal pattern (intermittent, persistent, constant,
immediate, delayed)
* Women may have both a specific disorder (eg, lichen sclerosus)
and vulvodynia.
Fig. 72.3  2015 Consensus terminology and classification of persistent
vulvar pain and vulvodynia
72  Pelvic Pain Associated with a Gynecologic Etiology
72.3.2 Vagina
A common cause of vaginal discomfort is vaginitis, which
the American College of Obstetricians and Gynecologists
(ACOG) refer to as a spectrum of conditions that cause vul-
vovaginal symptoms of itching, burning, irritation, and
abnormal discharge. It can affect any age group. The most
common causes are bacterial vaginosis (22–50% of symp-
tomatic women), vulvovaginal candidiasis (17–39%), and
trichomoniasis (4–35%) [17]. See Table  72.1 for treatment
considerations for each condition.
Bacterial vaginosis is a polymicrobial infection that can
occur when there is a lack of peroxide-producing lactoba-
cilli, thus leading to overgrowth of facultative anaerobic
organisms. Patients often complain of a “fishy” smelling
vaginal discharge. On exam, a thin homogenous gray dis-
charge may be seen. The pH of this discharge is often greater
than 4.5, and has a positive amine odor when a drop of KOH
is added (“whiff test”). On saline microscopy, clue cells
comprising over 20% of all squamous cells are seen.
Candidiasis, already mentioned in the vulvar section, can
present with additional symptoms when vaginal involvement
is present. In addition to pruritus, a patient may complain of
an odorless white, thick, cottage cheese-like vaginal dis-
charge, swelling, excoriations, or dyspareunia. Upon taking
a swab of the discharge, 10% KOH wet preparation show
blastopores or pseudohyphae. A fungal culture may also be
obtained to confirm diagnosis. Trichomoniasis is a sexually
transmitted disease in which women complain of a frothy,
green, foul-smelling discharge. Vaginal or cervical erythema
with or without petechiae may be present on speculum exam.
Diagnosis relies on visualization of motile trichomonads on
saline microscopy or a positive nucleic acid amplification
test (NAAT) or culture. Atrophic vaginitis is a condition seen
in postmenopausal women and characterized by dryness,
dyspareunia, irritation, and yellow or green discharge.
Vaginal pH is often > 4.7 and saline microscopy shows
increased parabasal cells and decreased mixed flora. This can
be managed with vaginal estrogen and counseling on ade-
quate lubrication use during intercourse [18, 19].
The Bartholin’s glands are pea-sized glands whose ducts
open at the 4 and 8 o’clock positions at the vaginal vestibule.
They are involved in mucus secretion. If this gland is blocked
at the level of the duct with mucus secretion, the gland may
enlarge. Patients with a symptomatic Bartholin’s gland cyst
complain of tenderness, particularly with sexual intercourse.
Treatment with a Word catheter (which will allow epitheliza-
tion of a new drainage tract) or marsupialization can be per-
formed. Anyone who is postmenopausal is more prone to a
malignancy of the gland or duct, thus biopsy of this gland
should be performed in any woman over age 40 with afore-
mentioned symptoms. If a Bartholin’s gland cyst becomes
infected, the Bartholin’s gland abscess may cause acute vagi-
885
nal pain; the abscess may even spontaneously rupture with
copious, odorous, and purulent fluid. Culture of this abscess
is often polymicrobial. Treatment with a Word catheter or
incision and drainage can be performed in this setting [20,
21]. Oral antibiotics should be considered if surrounding cel-
lulitis is present.
A Skene’s (“peri-urethral”) gland cyst or abscess,
Gartner’s duct cyst, or urethral diverticulum are other less
common cystic findings in the vagina that should be consid-
ered as a source of pain.
72.3.3 Cervix
Cervicitis can be an acute or chronic condition; it is often-
times asymptomatic and caused by the sexually transmitted
diseases, Neisseria gonorrhoeae or Chlamydia trachomatis.
These will be mentioned again in the “Adnexal” section of
this chapter. Patients may complain of an odorless vaginal
discharge, spotting, postcoital bleeding, or dyspareunia.
Pelvic exam findings include a friable, inflamed cervix with
purulent discharge. A swab of the endocervix or vagina can
confirm diagnosis with a NAAT; urine can also be tested. See
Table 72.1 for treatment [22]. Check guidelines for treatment
on the CDC’s website for optimal therapy due to many resis-
tant drug strains (www.cdc.gov).
72.3.4 Uterus
Endometriosis is the presence of endometrial tissue
implanted outside of the uterine cavity. It can be found in the
myometrium (referred to as “adenomyosis”), peritoneum,
ovaries, rectovaginal septum, and has even been found in the
brain and lungs. It is associated with chronic pelvic pain and
subfertility. Endometriosis is most commonly diagnosed in
reproductive-aged women [23]. Although it is commonly
cited that as many as 70–80% of women with chronic pelvic
pain have the disease, these numbers come from old studies;
many other etiologies of pelvic pain have been better eluci-
dated in recent years and clinicians are finding that not all
pelvic pain is caused by endometriosis. In a 2016 review of
almost 4000 women who underwent laparoscopic or abdom-
inal hysterectomy for the indication of chronic pelvic pain,
only 21.4% had endometriosis at time of surgery [24].
Endometriosis can be asymptomatic. However, patients
with this disease who present for care may present with pain-
ful periods, dyspareunia, dyschezia, or dysuria. The gold
standard for diagnosis of endometriosis is surgical assess-
ment with laparoscopy and biopsy. The American Society for
Reproductive Medicine has a classification system for
describing endometriosis by anatomic location and severity
[25]. Management of endometriosis requires a multidisci-
886
plinary approach with consideration of surgical debulking of
disease, hormonal management to suppress and delay recur-
rence and progression, and pain management. Recurrence of
disease is not uncommon [26]. The reason for pain in endo-
metriosis is not well understood. Increased macrophages and
inflammatory cytokines in peritoneal fluid of patients with
the disease have been demonstrated. Nerve growth factor is
more highly expressed in the lesions, and an increased den-
sity of nerve fibers, especially in deep infiltrating disease,
has also been described [27].
Adenomyosis is the presence of heterotopic endometrial
tissue in the myometrium. Symptoms are similar to those of
endometriosis. On exam, a practitioner may note a bulky or
globular uterus. Magnetic resonance imaging (MRI) or
transvaginal ultrasound can suggest adenomyosis, but there
are no standard diagnostic criteria for radiologists to follow.
Treatment is preferentially medical with nonsteroidal antiin-
flammatory medications (NSAIDs) and hormonal suppres-
sion because true myometrial assessment can only occur
after removal of the uterus and histologic examination.
Uterine fibroids are benign tumors of the uterine smooth
muscle and are the most common tumors of the female pel-
vis. Growth of these tumors is estrogen- and progesterone-­
dependent. Fibroids increase in prevalence during
reproductive years and their size decreases after menopause.
Symptoms depend on fibroid size and location. Many
patients are asymptomatic and fibroids are found inciden-
tally on imaging. For those who are symptomatic, abnormal
uterine bleeding, pelvic pressure, bowel dysfunction, and
urinary frequency, urgency, or retention may be present [28].
Although fibroids can undergo a degeneration process which
can cause acute pain and fever, this is usually a self-limited
process, and it is atypical for a patient with a fibroid to have
CPP as the presenting symptom. A patient presenting with
CPP and uterine fibroids should undergo a thorough evalua-
tion to rule out other causes of pain. Management algorithms
depend on symptoms, but symptomatic fibroids are generally
treated with NSAIDs, hormonal treatments, interventional
radiology-guided fibroid embolization, radiofrequency abla-
tion, myomectomy, or hysterectomy.
Postablation syndrome has been described as pain from
hematometra and/or hematosalpinx after an endometrial
ablation. This occurs because the cervical os is oftentimes
scarred after an endometrial ablation, thus leaving no path
for blood to drain into the vagina. Postablation tubal steril-
ization syndrome describes a patient who has had a tubal
ligation previously and remnant endometrium at the cornua
causes hematometra and/or partial hematosalpinx. The defin-
itive treatment for this diagnosis is a hysterectomy. In a large
retrospective cohort study of almost 300 patients who under-
went endometrial ablation, pain developed in 23% of all
patients. Risk factors for postablation pain included non-
white race, history of tubal ligation, and history of dysmen-
M. B. Shannon and E. R. Mueller
orrhea. However, a history of tubal sterilization did not lead
to increased risk of hysterectomy in this group [29].
72.3.5 Adnexa
Adnexal torsion is a surgical emergency and occurs when the
ovary and fallopian tube twist on the axis created between the
infundibulopelvic ligament and the utero-ovarian ligament.
It’s possible for the ovary or fallopian tube alone to be involved.
Patients complain of acute onset abdominal pain, which is
usually unilateral. Pain is due to the occlusion of the vascular
pedicle, thus may be constant or intermittent as the ovary
twists and untwists with changes in position. Nausea, vomit-
ing, and fever are also common symptoms. Torsion generally
occurs in women with moderately enlarged ovaries in associa-
tion with an ovarian cyst. If the ovary is very large, it is actu-
ally less likely to twist due to its weight. Common cysts
associated with torsion are follicular cysts, corpus luteui,
benign teratomas, and cystadenomas. Pelvic exam may show
an enlarged tender adnexa and abdominal exam may reveal
signs of peritonitis. A urine pregnancy test should be per-
formed. Laboratory analysis may be normal or show a leuko-
cytosis. Transvaginal ultrasound is used to aid in diagnosis.
Common findings include an ovarian mass with or without
cyst and free fluid in the pelvis. Lack of Doppler venous flow
to the ovary would support the diagnosis, but if flow is present,
the diagnosis cannot be ruled out [30]. Preservation of ovarian
function should be a priority, with surgical reduction of torsion
and ovarian cystectomy. In most cases, ovarian function will
be preserved after reperfusion [31].
Pelvic inflammatory disease (PID) is a polymicrobial
infection of the internal pelvic organs. It is diagnosed if a
woman has uterine, adnexal, or cervical motion tenderness;
diagnosis is supported by presence of fever, mucopurulent
cervical discharge, or cervical friability, white blood cells on
saline microscopy of a cervical swab, or presence of gonor-
rhea or chlamydia. Symptoms include abdominopelvic pain,
nausea, yellow vaginal discharge, dyspareunia, or dysuria.
Inflammation of the liver capsule, called Fitz-High-Curtis
syndrome, can accompany PID and may lead to right upper
quadrant pain. Patients with early PID can be treated in an
outpatient setting if they appear stable, have normal vital
signs, and can tolerate oral antibiotics. Otherwise, these
patients should be admitted for intravenous antibiotics. If no
improvement is noted within 72  h of treatment, imaging
should be performed to look for a tubo-ovarian abscess.
Interventional radiology-guided drainage should be consid-
ered in these patients. Complicated, refractory cases may
require surgical exploration with abscess drainage and
removal of necrotic tissue; such cases are uncommon. Given
changing antibiotic resistances, the CDC guidelines should
be consulted for treatment of PID [32–34].
72  Pelvic Pain Associated with a Gynecologic Etiology
Some women may complain of cyclic recurrent PP which
occurs mid-cycle. This pattern is known as “mittelschmerz”
and is thought to be related to ovulation. The pain is usually
short-lived, lasting about 24 h, and usually responds to anal-
gesics [35].
Pelvic congestion syndrome is considered a pelvic venous
syndrome. It is poorly understood and there is a paucity of
literature about the disease process. Incompetence of ovarian
vein and/or internal iliac veins has been proposed as cause of
the pain symptoms. Since incompetent and dilated pelvic
veins are commonly found in asymptomatic women on
imaging, no diagnostic criteria exist [36].
72.3.6 Musculoskeletal Considerations
MFPP is pain in the pelvic floor muscles, connective tissue,
and surrounding fascia. In a review of over 1000 women who
presented to physical therapy for CPP, 13.2% of them were
found to have MFPP [37]. This rate is similar to a previously
published similarly sized study [38]. MFPP is historically
underdiagnosed due to a paucity of literature about the dis-
ease and inadequate physical exam training in gynecologic
residency to make such a diagnosis. MFPP can be diagnosed
alone or in conjunction with other pelvic pain disorders.
Physical exam findings of muscle pain include tight bands
and trigger points, which are elicited with firm pressure of a
single digit vaginally along the muscles. The affected mus-
cles can include superficial perineal muscles or the deeper
muscles that compose the pelvic diaphragm (levator ani and
coccygeus). Pelvic floor physical therapy with a highly
trained therapist involves a variety of relaxation and length-
ening maneuvers and myofascial manipulation of trigger
points [39].
The pelvis is bound by important joints that should also
be considered when evaluating a woman with pelvic pain.
Examination of the pubic symphysis, sacroiliac joint, hips,
and lumbar spine can contribute to understanding of PP. If
you are not comfortable evaluating these joints and suspect
that skeletal pelvis could be contributing to pain, referral to a
physiatrist, orthopedist, or physical therapist may prove
useful.
72.3.7 Extragynecologic Considerations
Although other chapters in this text will address nongyneco-
logic etiologies of pelvic pain, it is important to remember
that bowel and bladder coexist with the gynecologic organs
in the pelvis, and thus should be addressed during history
and physical exam. For example, a patient with a gyneco-
logic pain disorder may also have severe constipation that is
exacerbating her symptoms.
887
72.4 Multidisciplinary Approach
to Chronic Pelvic Pain
CPP can be clinically challenging to manage as a practitio-
ner, given the multitude of possible diagnoses, and that
oftentimes the pain is not caused by a single diagnosis or
even a single organ system. Calling upon other specialists is
essential for comprehensive care. A multidisciplinary team
may include practitioners from gynecology, gastroenterol-
ogy, internal medicine, physical medicine and rehabilitation,
urogynecology or urology, psychology, and physical therapy.
Team approaches to manage complex diagnoses like CPP
may result in faster, more accurate diagnoses, and higher
patient satisfaction [40].
72.5 Summary
Evaluation and management of CPP is a difficult clinical
dilemma and may require a multidisciplinary team approach.
A thorough history that includes a patient intake question-
naire, review of records, and interview by a trained clinician
are important first steps. A detailed physical exam which
incorporates techniques of pain mapping done in a non-
threatening, reassuring manner is also key to developing a
protocol that will assist each patient with individualized ther-
apy. An office pregnancy test is important to order at the first
evaluation and at each subsequent visit when appropriate.
There is a role for vulvar biopsy if the patient’s presentation
does not provide immediate diagnosis or she is not respond-
ing to treatment. Testing for infections is paramount so that
treatable sources of pain are not overlooked.
Many patients suffering from CPP whose pain is thought
to be from vulvodynia and/or MFP usually undergo pelvic
floor physical therapy. It is important for the clinician to keep
in close contact with the physical therapist to assess whether
the patient is responding appropriately to this line of therapy.
Good communication and close follow-up are critical in tak-
ing care of any patient with CPP, as is referral to other pro-
viders if a multidisciplinary team is not set up. For example,
psychotherapists commonly assist our patients in dealing
with the stress and concomitant depression that can accom-
pany CPP syndromes.
Patients with CPP who have a “normal” evaluation or lack
of response to empiric therapy can be counseled regarding
the role of surgery for their presumed diagnosis. Laparoscopy
can offer a diagnosis and therapeutic benefit in those with
suspected endometriosis. Many patients may request hyster-
ectomy in the erroneous belief that all CPP can be cured with
removal of the uterus. Intense counseling of the patient is of
utmost importance in these situations to ensure she has real-
istic expectations regarding the outcome and relief of her
888
pain in these surgical situations. As stated before, the rela-
tionship between a woman with CPP and her healthcare pro-
vider is crucial, especially in those scenarios where the
treatment is not improving her quality of life with pain relief;
these women will require more therapy and care even if the
ultimate outcome does not result in complete pain relief.
Take-Home Messages
• Chronic pelvic pain is a common complaint, yet
may present a diagnostic challenge to even the most
experienced healthcare provider.
• A detailed history is essential to making the proper
diagnosis, as is a careful examination of all parts of
the female genitalia (vulva, vagina, cervix, uterus,
adnexa).
• Adequate knowledge of nongynecologic causes of
pelvic pain (gastrointestinal or musculoskeletal
issues) will aid in a provider’s ability to make a
comprehensive clinical diagnosis.
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 Chronic Idiopathic Anorectal
Pain Disorders
Bruno Roche and Cosimo Riccardo Scarpa
Learning Objectives
• Understand the innervation of the perineum.
• Understand classification and types of anorectal pain.
• Understand diagnostic and treatment algorithms.
73.1 Introduction
Perineal, anal, and anorectal pain is a very common clinical
manifestation, affecting 6.6% of the population [1]. However,
only one third of the subjects with anorectal pain seek medi-
cal advice. Patients most often report a decline in their qual-
ity of life, frequent absence from work, as well as major
psychological distress.
In most cases, the disease causing the pain—most com-
monly, an inflammatory condition of the anorectal region [2]
(abscess, anal fistula, solitary rectal ulcer, Crohn’s disease),
hemorrhoid thrombosis, tumors, pain of gynecologic origin
in female patients, and pain of prostatic origin in male
patients—can be easily and readily recognized.
Sometimes it is difficult to differentiate between func-
tional and organic pain disorders of the distal end of the gas-
trointestinal tract. The differential diagnosis is wide, and the
approach to the diagnostic workup is vague, unclear, and
lacking standardization. An organic cause that might explain
anorectal-perineal pain is found only in 30 out of 100 patients
presenting for consultation [3]. Recent randomized trials
have compared different treatment approaches to chronic
B. Roche (*)
Proctology Unit, School of Medicine, University of Geneva,
Clinique Hirslanden Grangettes, Geneva, Switzerland
e-mail: bruno.roche@grangettes.ch
C. R. Scarpa
Visceral Surgery Division, Yverdon Hospital, University Hospital
of Geneva, Yverdon les Bains, Switzerland
e-mail: cosimo.scarpa@ehnv.ch
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_73
73
proctalgia, demonstrating 85% excellent outcomes with
appropriate patient selection [3].
Generally, pelvic and perineal pain disorders are more
common in women [4]. The prevalence of perineal mus-
cle dysfunctions in female chronic perineal pain appears
to be a key element for managing these patients [5].
Anorectal pain is frequently associated with irritable
bowel syndrome (IBS) [6], and 35% of patients with IBS
report chronic pelvic pain [7].
According to most clinicians, anorectal pain management
is a complicated and frustrating issue, without a clear thera-
peutic solution. The etiology often remains unclear, and
some even question the existence of an actual cause of this
pain and readily associate these manifestations with psycho-
logical distress.
In most cases, the source and relevance of the pathophysi-
ological mechanisms of pelvic pain are uncertain and unclear.
This defines chronic functional idiopathic anorectal and peri-
neal pain disorders, which are the primary subject of this
article.
73.2 Definition
The basic premise of chronic idiopathic (“essential”) anorec-
tal pain disorders is that all organic causes that might explain
the symptoms have been ruled out. The second premise,
chronicity, implies that pain has evolved for at least 3 months
before consultation, and symptoms have been present for
6 months before diagnosis.
The Rome criteria for functional gastrointestinal disor-
ders are universally accepted. In their latest review (IV),
chronic anorectal pain syndromes included proctalgia fugax,
levator ani syndrome, and unspecified pain [8].
These chronic disorders are classified by mode of onset
and duration and based on the presence (or absence) of ten-
derness in the anorectal region upon examination. Rendering
a definitive diagnosis is made difficult by the anatomical and
neurological interconnection of the region [9].
891
892
73.3 T
 opographic Sensitive Innervation
of the Perineum
The pudendal nerve innervates the skin covering the anus
and the central fibrous bundle of the perineum. Innervation
of the external genital organs is more complicated, as there is
some overlap (Fig. 73.1):
–– The pudendal nerve innervates the clitoris, the labia
minora, and the labia majora.
–– The iliohypogastric nerve innervates the mons pubis and
the prepubic area.
–– The ilioinguinal nerve innervates the labia majora,
together with the genitofemoral nerve.
–– The inferior cluneal nerve, a branch of the posterior cuta-
neous nerve of the thigh, innervates the skin of the peri-
anal gluteal region, lateral to the territory of the pudendal
nerve.
–– In 8–15% of cases, the perforating cutaneous nerve
described by Schwalbe, a branch of the pudendal plexus
or nerve, supplies the perianal region, together with the
inferior cluneal nerve.
Fig. 73.1 Topographic
sensitive innervation of the
perineum
B. Roche and C. R. Scarpa
73.4 H
 istory and Physical Examination
of the Perineum
73.4.1 History
History taking in the case of pelvi-perineal pain should be
accurate and detailed and should be focused on tracing the
history of the pain. The mode of onset is most often insidi-
ous, or at times acute. All triggering factors should be noted
in chronological order. In some cases, pain may develop sud-
denly and permanently, without remission; in other cases,
pain evolves in periods. At the initial consultation, the patient
often reports one or more periods of pain, lasting a few
months and then regressing spontaneously, before pain even-
tually becomes regular and daily.
The type of pain is a key point in history taking.
Currently, there are no agreed-upon diagnostic criteria that
make it possible to relate pain to a definite injury. The use of
easily applicable neuropathic pain criteria, validated by an
expert panel under the name Neuropathic Pain Symptom
Inventory (NPSI) developed first in French as “douleurs
neuropathiques 4 questions (DN4)” [10], allows to differen-
73  Chronic Idiopathic Anorectal Pain Disorders 893

tiate between pain arising from nerve damage and other
kinds of pain. The NPSI classification combines a question-
naire and a number of clinical examination items and has
been validated in French (a translation is provided in
Table 73.1). One point is given to each affirmative answer.
The final score, greater than or equal to 4, allows for the
proper identification of 86% of patients suffering from neu-
ropathic pain, with a sensitivity of 82.9% and a specificity
of 89.9%. This questionnaire must be an integral part when
obtaining the history of perineal pain. The topography of
pain must be as accurate as possible; patients should be
asked to point out their tender points, or to draw them on a
simple anatomical diagram. The same goes for pain radiat-
ing to the back, the buttocks, or the sciatic nerve.
The circumstances of pain onset, i.e., posture as a
trigger or contributing factor, the moment of onset, and
the presence of pain during the day, at night, or both, all
provide valuable information. Whether pain is triggered
by urination, bowel movement, or sexual intercourse is
investigated, as these are all major elements of the diag-
nostic workup.
73.4.2 Associated Signs
The condition is often associated with cutaneous, mucosal,
subcutaneous, muscular, or visceral hypersensitivity. The
existence of sexual dysfunctions is hard to interpret in the
context of chronic perineal pain syndromes. Constipation is
a banal symptom, but is often present as anorectal dyschezia.
A causal relationship can be suggested if the onset of pain is
concomitant with constipation.

Table 73.1  Neuropathic Pain Patient interview

Symptom Inventory (NPSI)
- Question 1: Does the pain have one or more of the following characteristics?

Burning

Cold, painful

Electric shocks

- Question 2: Is the pain associated with one of more of the following symptoms in the same
area?

Tingling

Pins and needles

Numbness

Itching

Patient examination

- Question 3: Is the pain located in an area where the physical examination may reveal one or
more of the following characteristics?

Hypoesthesia to touch

Hypoesthesia to prick

- Question 4: Can the pain be caused or increased by brushing?

894 B. Roche and C. R. Scarpa

73.4.3 Physical Examination
The examination must be accurate and systematic. In our
usual practice, patients are placed in the lithotomy position,
relaxed. They may follow the examination live, by means of
a camera and a monitor placed on their right.
At first, patients are tested for sensory disorders at the
perineum, anal reflexes, and vasomotor disturbances of the
external genitalia or buttocks.
Afterward, the specific bone tenderness of the pelvic gir-
dle is assessed:
and internal obturator muscles). The physical examination
should also be extended to the thoracolumbar and lumbosa-
cral spine and should also include searching for fibromyalgia
tender points [11].
The assessment is then completed by radiographic, com-
puted tomography (CT) and magnetic resonance (MR) imag-
ing of the spine and of the origin of the lower extremities.
73.5 Psychologic Aspects
and Somatization of Pain

–– Tail end of the coccyx The close interconnection between somatic and visceral
–– Ischia innervation is the specific feature of the anorectal-perineal
–– Pubic symphysis region. In healthy individuals, the sympathetic nervous sys-
–– Sacroiliac joints tem (SNS) plays a key role in protecting against pain, through
medullary inhibition of nociceptive transmission.
The pelvic examination aims at assessing specific trigger Experimental studies suggest that this system may be
points, following a predetermined diagram (Figs.  73.2 and involved in regulating peripheral inflammation and nocicep-
73.3). The exam is performed using the right index finger for tion. However, the context and duration of activation of the
the right pelvis and the left index finger for the left pelvis. SNS determine the suppressive or magnifying effect of pain
The physical examination is then completed by searching control by the system itself. A very interesting study has
for myofascial trigger points in the gluteal region (piriformis shown that, whenever fear or immediate threats to the body’s

Fig. 73.2  Female pelvic

trigger point diagram. (1)
Puborectalis middle posterior.
(2) Puborectalis right branch.
(3) Puborectalis left branch.
(4) Obturator internus right.
(5) Obturator internus left. (6)
Sacrococcygeal joint (ganglio
impar). (7) Ischial spine right
(right pudendal nerve). (8)
Ischial spine left (left
pudendal nerve). (9) S4 right.
(10) Right piriformis inferior
level. (11) S4 left. (12) Left
piriformis inferior level
73  Chronic Idiopathic Anorectal Pain Disorders 895

Fig. 73.3  Male pelvic trigger

point diagram. (1)
Puborectalis middle posterior.
(2) Puborectalis right branch
prostate level. (3) Puborectalis
left branch prostate level. (4)
Obturator internus right. (5)
Obturator internus left. (6)
Sacrococcygeal joint (ganglio
impar). (7) Ischial spine right
(right pudendal nerve). (8)
Ischial spine left (left
pudendal nerve). (9) S4 right
(when possible). (11) S4 left
(when possible)

integrity are sensed, pain perception is reduced, and pain-­
related behavior is suppressed. Similarly, in a context of
chronic anxiety, pain perception can be amplified and per-
ceived as a potential threat for the future [12]. This means
that either cortical activation in response to the perceived
life-threatening situation or different effects pertaining to the
circumstances that elicit the activation of the SNS, and the
duration, will affect pain suppression or amplification. The
patient’s perception will make them unsure about their bodily
response, and in turn, uncertainty will generate anxiety,
which will result in disrupting pain regulation and pain-
related behavior [13]. Unfortunately, little is known about
the molecular mechanisms involved in the interaction
between the sympathetic system and pain. These mecha-
nisms are too specific to human beings, which limits the
development of animal study models. Knowledge of these
molecular mechanisms is paramount to develop specific
treatments targeting sympathetic activity, which causes
chronic pain [14].
Recent studies have shown the close relationship between
pain, pain regulation, and the subject’s mental state at the
time the nociceptive event occurs. Such patients should
always be investigated for signs of stress, abuse, or coercion.
Psychological assessment and support psychotherapy are
paramount in these cases [15].
73.6 Proctalgia Fugax
73.6.1 Definition
Proctalgia fugax is marked by deep, intense pain in the rec-
tum area, which lasts from a few seconds to minutes (rarely
over 30  min), and then resolves spontaneously and com-
pletely [16, 17].
The condition can be associated with tenesmus, urgency
to defecate, or neurovegetative disorders.
Pain most often occurs at night, waking the patient from
sleep. It evolves into a recurrent event and may reappear
unpredictably and at irregular intervals. Patients may experi-
ence one single episode or, conversely, repeated bouts that
might last for weeks or even months. On average, up to five
episodes a year are reported in 51% of patients [18]. Pain is
felt like a cramp, a knife stab, a bite, or muscle soreness. Pain
ranges from unpleasant to unbearable in intensity [17], and it
causes half of the patients to interrupt their activities [19].
896
73.6.2 Epidemiology
Proctalgia fugax affects 8 to 18% of the population, with no
gender differences [1, 16]. Proctalgia starts in adult life and
only rarely before puberty. However, some cases have been
reported in children [16, 17]. In these cases, we believe that
a history of abuse should be investigated.
73.6.3 Pathophysiology
Different mechanisms have been postulated [20] :
• Rectal angina with transient mesenteric ischemia
• Muscle spasms of the anorectal junction
• Neurovegetative painful manifestation
At present, the spontaneous and abnormal contraction of
the smooth muscle is believed to be the most likely cause of
this condition. A relationship between hereditary proctalgia
fugax and internal anal sphincter hypertrophy in the context
of associated constipation has been described in two trials
[21, 22].
Another study has shown a personality-related predisposi-
tion in anxious, perfectionistic, and/or hypochondriac patients
[23]. Similarly, it is observed that episods of proctalgia fugax
occur chiefly in a situation of stress and anxiety [24].
73.6.4 Physical Examination
Usually, the physical examination is entirely negative, as the
attacks resolve spontaneously and quickly. The diagnosis is
based on the presence of the hallmark symptoms that we
have already described. Any other anorectal or pelvic disor-
ders must be ruled out.
73.6.5 Treatment
In most cases, the condition occurs in quick and sporadic
crisis, leaving no room for treatment; explaining the phe-
nomenon as a benign condition is usually enough to reassure
the patient.
However, subjects suffering from repeated attacks do
require treatment. The use of nitroglycerin, papaverin, phle-
botonics, and beta-blockers has been suggested [25]. A ran-
domized trial has demonstrated the superiority of inhaled
salbutamol over placebo in shortening the duration of attacks
in patients with proctalgia episodes lasting 20 min or longer
[26]. A recent publication emphasizes the value of biofeed-
back in preventing these episodes [27].
B. Roche and C. R. Scarpa
73.7 L
 evator Ani Syndromes (Chronic
Proctalgia)
73.7.1 Definition
This clinical entity is also known as levator spasm, puborec-
talis syndrome. Pain is described as a vague or dull feeling
of pressure in the rectum. It often worsens with sitting or
lying face down. Symptoms last from a few hours to several
days.
The diagnostic criteria for levator ani syndrome must
include all of the following:
–– Chronic or recurrent rectal pain.
–– Episodes last 30 min or longer.
–– Tightness and tenderness with traction of the puborectalis
muscle.
–– Other causes of rectal pain have been excluded.
These criteria must have lasted for at least 6  months
before diagnosis was made, and persist 3 months afterward,
in a context of chronic proctalgia.
73.7.2 Epidemiology
These symptoms affect 6.6–11.6% of the general population
and mostly women [1]. Over half of the patients are aged
between 30 and 60, with a peak at the age of 45 [1].
73.7.3 Pathophysiology
The levator ani syndrome is thought to result from tightness
of the pelvis muscles with an elevation of the anal sphincter
pressures from baseline, as measured by manometry [9]. The
exact etiology is still unknown to date. A recent randomized
controlled trial has focused on the relationship between dys-
synergic defecation and tenderness of the levator ani muscle
in 85% of cases. This asynchronism was found to disappear
after a properly administered biofeedback treatment, which
would suggest that anorectal coordination disorders might be
the cause of the levator ani syndrome [3]. Other authors have
reported an association between levator ani syndrome, psy-
chologic distress, tension, and anxiety [28].
73.7.4 Physical Examination
Tenderness and even spasms of the levator ani muscles, most
often unilateral on the right, are reported upon physical
examination [29]. In our opinion, this finding does not appear
73  Chronic Idiopathic Anorectal Pain Disorders
very clear, but is most likely related to the prevalence of
right-handed physicians performing the examination. This is
why we emphasize the importance of conducting the physi-
cal examination using both the right and left index fingers
(Sect. 73.4.3).
73.7.5 Treatment
Treatment is made difficult by patient heterogeneity, as
well as by the associated psychological aspects. Treatment
should be focused on relieving pelvic floor muscle stiffness
and tenderness. It often includes a combination of Thiele
massage [30], baths or sitz baths, and muscle relaxants
such as methocarbamol, diazepam, and cyclobenzaprine.
These are mostly anecdotal treatments that were not dis-
cussed in controlled studies; only two randomized con-
trolled trials have been published to date. In the first one,
157 patients diagnosed with levator syndrome have been
randomized into 3 groups: electrogalvanic stimulation,
levator ani muscle massage plus tempered sitz baths, and
biofeedback plus psychologic counseling [3]. The results
have shown that 87% of the patients who had muscle ten-
derness upon palpation reported symptom relief following
biofeedback, compared to only 45% who reported an
improvement following electrical stimulation and 22% in
the massage group. Symptom relief was maintained at
1-year follow-up. The other trial compared injections of
botulinum toxin A to placebo in 12 randomized patients.
The injection was repeated after 90 days, showing no dif-
ference between the two kinds of injection and no signifi-
cant pain improvement [31].
Surgery has no place in treating this disease: it involves
the lateral division of the puborectalis muscle and can
result in major functional disorders, especially inconti-
nence [32, 33].
73.8 Unspecified Anorectal Pain
This third group of anorectal pain syndromes recognized by
the Rome criteria is by far the most interesting, the hardest to
treat, and, definitely, the most debated and the most question-
able one. It encompasses all the clinical manifestations that
do not meet the criteria for proctalgia fugax or levator ani
syndrome. The term “unspecified” reflects the current lack of
knowledge of anorectal and, by extension, pelvi-perineal
pain disorders.
The structure of this chapter reflects our clinical experi-
ence, with inputs from supporting literature. Specifically, we
897
will examine myofascial and coccygeal pain syndromes,
postoperative anorectal neuralgias, nerve compression neu-
ralgias, and pain of central origin.
73.8.1 Myofascial and Coccygeal Pain
Syndromes
Coccygodynia can manifest in two main forms: sacrococ-
cygeal and/or anorectal pain of coccygeal origin. In either
case, patients report pain that is triggered by pressure to,
or manipulation of, the coccyx. Pain can be exacerbated
by bowel movements or prolonged seated immobility.
Coccygodynia occurs much more frequently in women
than in men [34], in a ratio of 5:1, with no preferred age
[35]. The difference in the anatomical location of the
sacrum and coccyx between men and women explains the
female preponderance of the disease. Body weight is a
contributing factor to coccygodynia starting from a body
mass index (BMI) greater than 27.4 in female subjects and
greater than 29.4 in males [36].
73.8.1.1 History
Sacrococcygeal trauma (such as a fall onto the tailbone, con-
tusions, or fractures) is a frequent finding [36, 37]. Subjects
should also be investigated for repeated microtrauma related
to their profession (secretary, driver) or sporting activities
(horse-riding, motorcycling). Dystocic or forceps-assisted
delivery may be responsible for long-term coccygeal pain in
women [38].
73.8.1.2 Physical Examination
The rectal examination checks for tender areas at the coccyx
and surrounding structures. Digitally the palpation look for
pain at the tip of the coccyx and pain at mobilisation of the
sacrococcygeal joint. Systematically the finger palpate the
middle line of the coccyx, the lateral borders of the coccyx
location of the ischiococcygeal ligaments insertion. Then
levator ani and puborectalis muscle tendeness are evaluated.
Contraction of these muscle may be associated with tene-
mus. This direct examination is considered an essential part
of diagnosis [39].
The radiological assessment using lateral radiographs,
both standing and sitting in the painful position (Fig. 73.4a,
b), may show a luxation or pseudo-luxation of the coccyx. In
most cases, a coccyx mobility over 20–25° in the anteropos-
terior plane is identified as pathological [37].
MRI examinations are essential to rule out possible
organic causes, infections, benign tumors, and malignan-
cies [40].
898
Fig. 73.4 (a) Lateral standing position. (b) Lateral sitting position with posterior luxation of the coccyx
73.8.1.3 Treatment
The treatment for coccygodynia consists of both local and
general measures. The patient must understand the impor-
tance of adopting a proper sitting position, to relieve the coc-
cyx (Fig.  73.5a, b). Especially during the acute phase, the
treatment of coccygodynia includes nonsteroidal anti-­
inflammatory drugs and muscle relaxants at bedtime [39]. A
randomized controlled trial has demonstrated the superiority
of intrarectal coccygeal manipulation over shortwave electri-
cal stimulation of the coccygeal region [35, 41]. Perineal
reeducation is effective in improving pain in 72% of cases
[42]. This approach involving manual treatment and physical
therapy must be part of the therapeutic options for the con-
servative treatment of coccygodynia. If conservative treat-
ment fails to succeed, perineal injection of local anesthetics
is proposed. According to some prospective studies, it
appears that results are better if associated with manipula-
tion, with an 85% success rate compared to 60% for injection
alone [40, 43].
Other interventional treatments, such as intradiscal
injections, radiofrequency ablation, ganglion impar
block, and caudal block, are advised only under study
conditions [40].
B. Roche and C. R. Scarpa
If some patients are resistant to the abovementioned treat-
ments, we can propose a surgical treatment. Coccygectomy
remains an exceptional treatment and is only reserved to
cases of complete coccygeal luxation, highlighted using
dynamic X-rays [44]. The resection of the coccygeal bone is
performed by a direct approach. Neurotomy and neurolysis
must not be associated with the surgical procedure, for fear
of generating deafferentation pain, which is even harder to
control. Coccygectomy is not recommended due to the dis-
appointing long-term outcomes and to the risks associated
with surgery, such as infection of rectal perforation [40].
Neuromodulation of the medullary cone and of the caudal
or subcutaneous regions has been investigated in a publica-
tion, reporting a few isolated cases [40]. The effectiveness of
these techniques has not been demonstrated [45]. They must
be investigated in randomized prospective trials to prove
their worth.
73.8.2 Postoperative Anorectal Neuralgias
Postoperative anorectal pain syndromes are described in
women aged 50 and over, suffering from anxiety and can-
73  Chronic Idiopathic Anorectal Pain Disorders
a b
Fig. 73.5 (a) Bad position (sitting on the coccyx). (b) Good position (sitting on the ischium. Coccyx is free)
cerophoby, and who underwent multiple surgeries of the
lesser pelvis. In these cases, pain involves the entire
perineum [46].
The development of stapling techniques for the treat-
ment of hemorrhoidal disease and defecation disorders has
generated new causes of postoperative anorectal pain.
These new techniques may offer the advantage of reducing
postoperative pain, when compared to traditional tech-
niques. However, despite these encouraging results, chronic
postoperative ­anorectal pain still affects 1.6 to 31% of
patients [47]. These severe and chronic proctalgias may or
may not be related to defecation [48] and may be associated
with defecation urgency [49]. Symptoms may occur right
after surgery or in the 3–5 following weeks [50]. This
chronic pain, mainly affecting male subjects, is described
as rectal spasms or a burning sensation located at the rec-
tum, irradiating to the lower back, the buttocks, and, some-
times, the posterior surface of the lower extremities. Areas
of hypoesthesia or anesthesia can be found on the internal
surface of the thigh, indicating damage of the obturator
internus nerve. Chronic pain can be due to smooth muscle
injury during the stapling technique, to sphincter spasm, to
suture dehiscence, to sepsis, or to the presence of staples
[48, 51]. A comparative study of conventional surgery and
stapled hemorrhoidectomy has shown that 8% of patients
899
who underwent anopexy complain of spontaneous pain or
pain during defecation, compared to 0% in the conventional
surgery group [52]. The treatment of postdefecation pain
involves conservative treatment using nifedipine [50].
Hard-to-treat chronic pain is the most frequent cause for
reintervention (44%), including the removal of retained
staples and the surgical reconstruction of the anastomosis
[48, 51] (Fig. 73.6a, b).
A more conservative approach consisting of local ste-
roid and/or anesthetic infiltrations, along with endoanal
electrical stimulation, must be attempted before surgery
is proposed [48] (Fig.  73.7). In three patients suffering
from uncontrolled pain after S surgery, we succeeded in
liberating the inferior rectal nerve branch by transgluteal
access.
73.8.3 Nerve Compression Anorectal
Neuralgias
The skin that covers the anus and the central fibrous bundle
of the perineum is innervated by the pudendal nerve. The
inferior cluneal nerve, a branch of the posterior cutaneous
nerve of the thigh, innervates the skin of the perianal gluteal
region, lateral to the territory of the pudendal nerve. In
900 B. Roche and C. R. Scarpa

Fig. 73.6 (a) Resection of scar tissue and staplers. (b) Hand-sewn redo anastomosis

Fig. 73.7 Decision-making
Inflammation Staples’ Stenosis Scar
tree for chronic postoperative
retention
pain

First
line treatment Topical Nifedipine

Second Local infiltration Dilation Local infiltration

line treatment anesthesia and steroids anesthesia and steroids

Third
line treatment Agraffectomy Redo suture line

8–15% of cases, the perforating cutaneous nerve described
by Schwalbe, a branch of the pudendal plexus or nerve, sup-
plies the perianal region, together with the inferior cluneal
nerve (Fig. 73.1).
Our discussion will not include the innervation of external
genitalia, which is more complicated and made of
­intertwining innervations, as described above, and is unlikely
to cause anorectal symptoms.
73.8.3.1 Pudendal Neuralgia
The pudendal nerve (nervus pudendus) is mainly a somatic
nerve, arising from the anterior branches of the S2–S4 spi-
nal nerves. Four conflict zones are described [53]
(Fig. 73.8a–c):
–– Inferior to the piriformis muscle
–– At the ischial spine
–– At the clamp formed by the sacrospinous and sacrotuber-
ous ligaments
–– At the falciform process of the sacrotuberous ligament
and at the Alcock canal
However, considering the anatomical variability of the
path of the nerve, the localization of perineal pain can only
be a clue to localize the compression site.
Symptoms of Pudendal Neuralgia
There is a resemblance between neuralgia by pudendal nerve
compression and canal syndromes. Compression affects
women more often than men, in a 2:1 ratio. Symptoms are
caused by perineal pain, which is localized systematically
and permanently. Pain falls into the neuropathic category; is
characterized by paresthesia and, rarely, by electric shocks;
and is exacerbated by sitting or resting on the ischia (as in
cycling) [54]. Patients report a burning sensation associated
with pain, which is relieved by standing and/or while walk-
ing. Pain has been seldom reported while lying; however, it
does not usually disrupt sleep and does not occur at night.
73  Chronic Idiopathic Anorectal Pain Disorders
a b
Superior
Right
Superior
Medial
Fig. 73.8  (1) Pudendal nerve, (2) lower gluteal vessels, (3) lumbosa-
cral trunk, (4) post. cutaneous femoral nerve, (5) obturator int. muscle
et gemelli muscle, (6) piriformis muscle, (7) sacrotuberal ligament, (8)
sacrospinal ligament, (9) obturator int.fascia, (10) inf. rectal nerve, (11)
perineal nerve, (12) dorsalis penis/clitoridis nerve, (13) open levator ani
muscle, (14) ischiatic spine, (15) fossa ischioanalis, (16) ischiatic tuber-
cle, (S1, 2, 3, 4) sacral nerves. (a) Posterior view of the right gluteal
region after opening gluteus max. muscle. Path of the pudendal nerve
through the major ischiatic foramen under the piriformis muscle. The
sacrotuberal ligament is separated and supported with clamps, in order
Pain can be localized to the anal sphincter or rectum, with a
feeling of an endorectal foreign body. All these symptoms
occur mostly unilaterally. This damage might be the mirror
of a specific damage of a single branch of the nerve.
Physical Examination
Often, the physical examination does not indicate any sensory
impairment. However, the alteration of sensitivity to prick
and touch is pathognomonic of nerve injury in 92% of cases
[55]. Subjects are investigated for trigger points by palpation
of the ischial spine during the anorectal examination. The
compression of this region elicits an exquisite pain, which
901
Superior
Dorsal
to expose the nerve, which becomes visible in the place where it circles
the ischiatic spines behind the sacrospinal ligament. (b) Medial pelvic
view. Origin of the pudendal nerve sacral roots S2, S3, S4. The levator
ani muscle (13) is partially separated. One sees the sacrotuberal liga-
ment (7) and the pudendal nerve (1), which enters the pelvis along this
ligament under the sacrospinal ligament (8) fenestrated: compression
C. (c) Posterior medial view into the ischioanal fossa. Opening of the
Alcock canal. The edges are held by clamps. The nerve runs in the canal
together with the blood vessels and delivers its branches, which lead
into the ischioanal fossa
may recall the patient-reported pain, in all respects. The find-
ings from the physical examination and the medical history
become particularly relevant when they are localized unilater-
ally, or along the side showing the most symptoms.
Additional etiology of neurological lesions include damage
to the radicular plexus caused by shingles, perineal herpes or
radiation therapy, neoplastic invasion of the plexus, spinal injury,
benign or malignant tumors, neurinomas, and ependymomas.
Diagnostic Workup
As pudendal neuralgia is now recognized and accepted as a
disease entity, the condition is increasingly over- or underdi-
902
agnosed in the absence of any organ pathology. The diagno-
sis is based on the medical history and physical findings that
we have already discussed and is supported by complemen-
tary electrophysiology or imaging studies and by selective
infiltrations of the pudendal nerve.
Electrophysiological Diagnosis
In electromyography (EMG), needle electrodes are used to
look for signs of denervation in the striated muscles that
are under control of a somatic nerve. The interpretation of
perineal electrophysiology studies is often delicate and
difficult. In some pathological conditions, including previ-
ous pelvic surgery or dystocic delivery, latency is found to
be increased, although not pathognomonic of pudendal
nerve compression syndrome [56, 57]. Hence, the investi-
gation of pudendal nerve distal latency time is difficult to
interpret. As of today, this test is virtually no longer used
in our division for the diagnosis of pelvic floor neurologi-
cal disorders.
These exams should be carried out solely by specialist
physicians with extensive experience in their interpretation.
Pelvic Radiography
Pelvic radiographs, in front and lateral view, allow the exclu-
sion of neoplasia localized at the sacrum or at the ischial
spine, compressing the sacral roots or the pudendal nerve
roots. These lesions are extremely rare. A few cases of exos-
tosis of the ischial tuberosity compressing the pudendal
nerve have been described [58]. Pelvic radiography is cur-
rently integrated by MRI.
Magnetic Resonance Imaging of the Pelvis
Pelvic MRI can substantiate pelvic static disorders or
presacral tumors compressing the plexus [59]. Plexus
injuries and nerve compression are often difficult to see
in MRI.
Magnetic Resonance Imaging of the Medullary Cone
This is a fundamental examination in the diagnostic workup
of pelvic pain and may substantiate focal abnormalities such
as benign or malignant tumors (neurinomas, ependymomas)
that might cause perineal pain.
In the absence of pathognomonic imaging, biological
and electrophysiological parameter, the diagnosis of puden-
dal neuralgia remains essentially probabilistic and clinical.
It is based on a set of criteria discussed and validated by a
multidisciplinary expert group and known as the Nantes
criteria [60]. Four diagnostic domains have been defined
(Table 73.2):
B. Roche and C. R. Scarpa
Table 73.2  Diagnostic criteria for pudendal neuralgia by pudendal
nerve entrapment (Nantes criteria)
Essential criteria for the diagnosis of pudendal neuralgia
Pain in the territory of the pudendal nerve (from the anus to the penis
or clitoris)
Pain predominantly experienced while sitting
The pain does not wake the patient at night
No objective sensory impairment
Positive pudendal nerve block (subject to an irreproachable
technique)
Complementary criteria for the diagnosis of pudendal
neuralgia
Burning, electric shock-like pain, tightness, and numbness
Rectal or vaginal foreign body sensation (sympathalgia)
Worsening of pain during the day
Predominantly unilateral pain
Pain triggered by defecation
Presence of exquisite tenderness on palpation of the ischial spine
Clinical neurophysiology findings in men or nulliparous women
Exclusion criteria
Exclusively coccygeal, gluteal, pubic, or hypogastric pain
Pruritus
Exclusively paroxysmal pain
Imaging abnormalities able to account for the pain
Associated signs not excluding the diagnosis
Buttock or sciatic pain, especially on sitting
Suprapubic pain
Urinary frequency and/or pain on a full bladder
Pain occurring after ejaculation
Dyspareunia and/or pain after sexual intercourse
Erectile dysfunction
Normal clinical neurophysiology
–– Essential criteria for the diagnosis of pudendal
neuralgia
–– Complementary criteria for the diagnosis of pudendal
neuralgia
–– Exclusion criteria for the diagnosis of pudendal neuralgia
and associated signs
–– Associated signs not excluding the diagnosis of pudendal
neuralgia
Treatment
Pudendal Canal Injections
The areas of compression of the pudendal nerve are acces-
sible for infiltration with corticosteroids and long-acting
local anesthetics. These injections can be performed under
radioscopic, computed tomography [61], ultrasonography
[62], or magnetic resonance [63] guidance. Symptom
relief or reduction is achieved in 40–85% of patients after
the first infiltration, and a further set of injections (up to 3)
73  Chronic Idiopathic Anorectal Pain Disorders
may have a therapeutic effect lasting several months [55,
56, 61].
Pudendal nerve perineural injections are a key element
of the diagnostic workup. The reduction (or temporary
disappearance) of symptoms allows for the selection of
eligible patients for pudendal nerve decompression
surgery.
Decompression Surgery
Surgery can be performed using one of three approaches:
–– The perineal or transvaginal technique, described by
Shafik [64], allows the opening of Alcock canal and more
rarely of the sacrotuberous ligament clamp. It is per-
formed more easily in women, but it seems more chal-
lenging in men.
–– The posterior transgluteal technique, extensively
coded and described by R.  Robert [56], is our pre-
ferred choice. It provides a perfect visualization of the
sacrotuberous ligament clamp and allows for the exci-
sion of the ischial spine (as needed), the transposition
of the nerve in the endopelvic position, and the resolu-
tion of conflict at the aponeurosis of the obturator
nerve and at the falciform process of the sacrotuberous
ligament. This is the only approach that was studied in
a randomized comparative trial [65]. Some argue that
the transection of the sacrotuberous ligament might
entail pelvic instability. Recent studies have shown
complete healing of the ligament some time after sur-
gery [66].
–– The endoscopic approach described by Shafik [67] and
then adopted by other authors [68, 69] offers the advan-
tage of providing visual magnification through the laparo-
scopic camera and of sparing of the sacrotuberous
ligament. The technique, however, is difficult to imple-
ment because of the complex anatomy of the presacral
space, and it failed to prove superior to other approaches.
What is interesting about this technique is that it makes
sacral innervation accessible and offers the possibility of
placing an electrode right on the sacral roots to enable
targeted stimulation [70].
It should be remembered that the benefit of these puden-
dal nerve decompression surgical approaches is rarely imme-
diate. Following nerve decompression, pain is often observed
as a rebound phenomenon. Infiltrative administration of
long-acting local anesthetics is recommended for postopera-
tive pain control.
903
Multidisciplinary postoperative patient management pro-
motes a gradual decline in pain intensity. In our experience,
which reflects that discussed in literature, 65% of patients
have improved 1 year postsurgery and can discontinue their
pain-relieving medicines, and 35% see no benefit or just a
short-term benefit. There is no evidence of symptom worsen-
ing [65, 71].
73.8.3.2 Cluneal Neuralgia
The anatomy and pathology of this nerve were not known
until recently [72]. The inferior cluneal nerve originates from
the posterior cutaneous nerve of the thigh (lesser sciatic
nerve), in the lower portion of the buttock; it courses below
the ischium and innervates the lateroanal and lateral regions
of the labia majora (Fig. 73.1). Injury of the inferior cluneal
nerves results in neuropathic pain throughout the innervation
territory of the nerves. The same symptoms are found in
pyriformis syndrome. The compression of the posterior cuta-
neous nerve of the thigh by the inferior border of the pyrifor-
mis muscle translates into truncated sciatic pain at the back
of the thigh, which might also radiate into the posterior
perineum while sitting.
The ischium may compress the inferior cluneal branch
while sitting, and this is caused by a hard seat.
Physical Examination
The physical examination looks for possible signs of pyrifor-
mis syndrome by triggering typical pain upon palpation of
the inferior border of the muscle attachment at the buttock,
4 cm above the line between the greater trochanter and the
tip of the coccyx. When the inferior cluneal branch is com-
pressed, the pain caused by endopelvic examination is
reported at the attachment of the internal obturator muscle.
The differential diagnosis with pudendal neuralgia is diffi-
cult and should be considered when the pain is localized at
the perineum, more externally around the anus, or when
despite evocative neuropathic pain the subject tests negative
for Alcock canal block.
Treatment
The treatment of cluneal neuralgia is based on CT-guided
inferior cluneal nerve infiltration with local anesthetics and
corticosteroids. A retrospective study on 72 patients exhibit-
ing pain consistent with cluneal nerve compression showed a
positive block test in 68% of cases, with a therapeutic effect
over 3 weeks in 40% of responder patients [73]. Decompression
surgery of the posterior cutaneous nerve of the thigh below
the pyriformis muscle or surgery of its inferior cluneal branch
904 B. Roche and C. R. Scarpa

Decision-making tree for Chronic anorectal pain

Questions
–
DN4

+
No neuropathic
Neuropathic pain
pain

History of
anorectal surgery
Rectal pain Coccygeal or
spasm perinal muscle
pain

Nocturnal
Postoperative Constant
Nerve entrapment short-term
neuralgia pain
pain

Local infiltration
Decision- Pyriformis Proctalgia Chronic Coccygodynia
anesthesia MRI
making tree a pain fugax proctalgia myofascial pain
test +

Pain of
Pyriformis See Section
Pudendral nerve Cluneal nerve central Biofeedback
syndrome 73.8.1
origin

Decompression
surgery

Fig. 73.9  Decision-making tree for chronic anorectal pain

at the ischium may be considered after a positive anesthetic
block if the patient still experiences discomfort. This type of
surgery consists of decompressing the nerve posteriorly,
along the ischium and all the way to the pyriformis, in order
to liberate the nerve throughout its course [72].
This treatment approach yields variable results. Neither
infiltration techniques nor surgical approaches were assessed
in randomized comparative studies. Reported post-­infiltration
or surgical risk is minimal.
73.8.4 Pain of Central Origin
This term indicates nonspecific pelvi-perineal pain types, such
as paresthesia and/or dysesthesia, which can be associated
with objective sensory disorders and may also affect the lower
extremities. Any accompanying proprioceptive and urinary
disorder may be indicative of multiple sclerosis. In these cases,
the diagnostic workup should include central and peripheral
MR imaging, as described in Sect. 73.8.3 (Fig. 73.9).
73  Chronic Idiopathic Anorectal Pain Disorders
73.9 Conclusions
The complexity of chronic idiopathic anorectal pain disor-
ders requires a multidisciplinary approach for both diag-
nosis and treatment. Very often, even today, anorectal pain
syndromes continue to be an enigma for clinicians. The
duality of perineal innervation complicates the diagnosis
and results in a limited effectiveness of specific treat-
ments. A better understanding of how visceral (sympa-
thetic) innervation works, along with a prospective
randomized assessment of known treatments, will greatly
contribute to improving chronic idiopathic anorectal pain
management.
Take-Home Messages
• The type of pain is a key point in history taking.
• Evaluate pain as neurogenic or not with DN4
questionnaire.
• Surgery only in specific cases.
• Multidisciplinary treatment is mandatory.
• Chronic pain management is important.
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 Female Sexual Dysfunction
Dorothy Kammerer-Doak and Rebecca Rogers
Learning Objectives
• Identify models of sexual function with focus on the
circular model specific to female sexual function.
• Review female sexual dysfunction including preva-
lence, definitions, and categories.
• Discuss the assessment of women with sexual dys-
function including the use of sexual function
questionnaires.
• Discuss treatment of female sexual dysfunction.
• Review the effect of pelvic floor disorders and their
treatment on female sexual function.
74.1 Female Sexual Function
Many misconceptions exist regarding what embodies a good
sex life, such as what constitutes correct genital anatomy, and
that everyone has frequent sexual encounters all resulting in
orgasm. However, love, intimacy, and health may be more
important contributors to sexuality. According to the World
Health Organization, “sexual health is a state of physical,
emotional, mental and social well-being in relation to sexual-
ity; it is not merely the absence of disease, dysfunction or infir-
mity. Sexual health requires a positive and respectful approach
to sexuality and sexual relationships, as well as the possibility
of having pleasurable and safe sexual experiences, free of
coercion, discrimination and violence. For sexual health to be
attained and maintained, the sexual rights of all persons must
be respected, protected and fulfilled” [1]. In this chapter, mod-
D. Kammerer-Doak (*)
Women’s Pelvic Specialty Care of New Mexico,
Albuquerque, NM, USA
e-mail: dkd@womenspsc.com
R. Rogers
Department of Obstetrics and Gynecology, Albany Medical
School, Albany, NY, USA
e-mail: rrogers@salud.umn.edu
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_74
74
els of sexual function will be identified, female sexual dys-
function will be defined, the assessment and treatment of
female sexual dysfunction will be reviewed, and effect of pel-
vic floor disorders on sexual function will be discussed.
Masters and Johnson were pioneers who studied and
reported on both healthy sexual function and sexual dysfunc-
tion [2]. In 1966, in their publication, Human Sexual
Response, they described four phases of the human sexual
response cycle: excitement, plateau, orgasm, and resolution
(Fig. 74.1). This linear model was based on observations of
100 white middle-class couples engaging in sexual inter-
course. Inherent in this linear model of sexual function is that
desire is always present before arousal, and orgasm is neces-
sary for sexual satisfaction. This model has been criticized
because it may represent male sexual function better than
female sexual function. Both male and female sexual
responses involve psychological as well as biological path-
ways. However, the male sexual response mainly involves
the ability to obtain and maintain an erection, whereas the
female sexual response is much more complex with large
psychosocial-cultural influences in addition to the biological
response. Women’s sexual arousal is the final expression of a
complex process involving sexual stimulation, ascending
and descending control by the central nervous system with
cultural and psychosocial influences, peripheral neurovascu-
lar pathways, and hormonal involvement. Therefore, a more
contemporary, intimacy-based, female-specific model of
sexual response has been proposed that is not linear, but
rather circular. In 2000, Rosemary Basson proposed an alter-
native model for women’s sexual function that suggests for
women that sexual response is not so linear, emphasizing the
fluidity of desire and arousal, and that sexual satisfaction can
be achieved without an orgasm [3]. While spontaneous desire
exists, for many women, sexual neutrality is the starting
point for a sexual encounter [3, 4]. The decision to partici-
pate in sexual activity with a partner may be based on a
deliberate decision to enhance emotional intimacy, as a result
of seduction, or a suggestion by the partner as compared to
innate sexual desire. Once engaged in sexual activity, a
909
910 D. Kammerer-Doak and R. Rogers

Fig. 74.1  Sexual response Sexual Response Cycle

cycle. Adapted from Masters
WH, Johnson VE. Human
sexual response. Boston: ORGASM
Little, Brown; 1966 Multiple
Orgasms

PLATEAU

RE
SO
LUT
EXCITEMENT

ION
DesireArousal

Time

Traditional, linear modelmale

Fig. 74.2  Female sexual Female Sexual Response Cycle

response circle

Sexual Neutrality

Emotional
Intimacy

Emotional and
Physical Satisfaction

Spontaneous Sexual
Sexual Drive Stimuli

Arousal and
Sexual Desire
Sexual Biologic
Arousal

Psychological

Basson R, Med Aspects Hum Sex. 2001;1:41-42.

woman may then become sexually aroused and experience
reactive or secondary sexual desire. For many women, sex-
ual desire is strongly linked to intimacy, and therefore satis-
faction can be both emotional, such as enhancing the bond
with a partner, and physical responses, such as an orgasm
(Fig.  74.2). These concepts are imperative to understand,
since it is completely normal for women to have a lessening
of the initial sexual drive if reactive sexual arousal and desire
are maintained and sexual satisfaction can be achieved with-
out orgasm in every encounter. Women often have a skewed
concept of normal female sexual function based on media
portrayals, and the circular female sexual response concept
reassures that decreased spontaneous desire and lack of
­climax with every sexual encounter does not mean loss of
74  Female Sexual Dysfunction
sexuality or that a sexual partner is no longer desirable.
Sexual neutrality, or being receptive to rather than initiating
a sexual encounter, and sexual satisfaction encompassing
both the physical and emotional are considered normal
female sexual function.
Knowledge of average sexual practices is important for
understanding abnormal sexual function, although norms of
sexual activity are not well studied. While frequency of sex-
ual activity may vary, the average frequency of sexual
encounters is about 4–6/month, with 37% less than or equal
to monthly, 33% weekly, and less than 1% daily [5, 6].
Vaginal intercourse is the most common sexual activity, but
with climax infrequent solely with this route. Only 20% of
women routinely experience orgasm during vaginal inter-
course, and 80% require direct clitoral stimulation either
before or after vaginal intercourse. The ability to achieve
vaginal orgasm appears to have a strong genetic component
[7]. While most women are able to experience orgasm
through masturbation, orgasm during partnered sexual activ-
ity is less frequent [8]. Use of a vibrator during partnered sex
is relatively common, and its use and the use of erotica are
associated with increased sexual function scores in women
[9]. The National Health and Social Life Survey noted that
30% of women almost always or always achieve orgasm
with sexual relations compared to 75% of men [10, 11].
Several recent studies addressing prevalence and inci-
dence data for rates of sexual activity indicate that women
are sexually active throughout their lifetimes [6, 12–14]. In
the United States, a national probability sample published in
2010 of 2929 women between the ages of 14 and 94 years
noted that 12.4% of teenagers 14–15 years of age had ever
experienced vaginal intercourse, 31.6% of those 16–17 years,
64% of those 18–19  years, and 90.7% by 25  years of age
[13]. In a sample of 8869 women ages 16–74  years from
Great Britain, 17.4% reported heterosexual intercourse
before 16 years of age [6]. Overall, the mean number of sex-
ual encounters, vaginal, oral, or anal, was 4 per month [6].
Over the past year, 58.4% had engaged in vaginal inter-
course, 59.9% had given or received oral sex, and 10.5%
were recipients of anal intercourse [6]. Over the past 4 weeks,
32.9% had engaged in masturbation [6]. Only 6.1% reported
sexual encounter that included genital contact with another
women. A very recent study of 1046 women ages 18–91 years
from the United States noted 70% were sexually active over
the past year; 11.7% were in a partnered, monogamous, but
sexless relationship; 92.2% reported they were heterosexual,
3.6% bisexual, 1.5% gay, 1.3% asexual, and 0.9% other;
82.5% had ever given their partner and 84.6% had ever
received oral sex; and 37.3% had ever received anal sex [12].
Although the frequency of sexual activity declines with
age, population-based studies indicate continued sexual
activity in about 50% of married women between the ages
of 66 and 71 years and about 1/3 of women over the age of
911
78, with the most common reason for sexual inactivity lack
of a partner [15]. In those with and without partners, 39.3%
of women between 60 and 69 years of age and 23.6% over
the age of 70 years were sexually active [12]. A sample of
749 women from the United States between the ages of 40
and 80  years noted 69.3% sexually active over the past
12 months, with 27.8% more than once/week [14]. A survey
of middle-­aged and older women reported that about 75%
were sexually active [16]. Sexual behavior in a global evalu-
ation from 29 countries and 27,500 men and women between
the ages of 40 and 80 years found 65% of women to be sexu-
ally active within the past year, with 38% more than once/
week, and significant differences based on region [17].
Sexual activity declined from 88% in women aged
40–49 years to 21% of those 70–80 years of age [17]. Only
23% of these women felt that “older people no longer want
sex,” and 76% believed that “satisfactory sex is essential to
maintain a relationship” [17].
74.2 Female Sexual Dysfunction
Sexual dysfunction is recognized as a widespread problem,
but incidence and prevalence vary depending on population
studied as well as definition. An early and widely quoted
study, the National Health and Social Life Survey, a national
probability sample of 1749 women and 1410 men aged
18–59 years, reported on adult sexual behavior in the United
States in 1992 [18]. Low libido was the most common com-
plaint noted in 51%, followed by problems with arousal in
33% and issues with pain in 16%. Weaknesses of this evalu-
ation include no assessment in individuals more than 59 years
and the lack of evaluation as to the bother or distress of the
sexual problem(s). A recent consensus conference that
reviewed and summarized the literature reported on preva-
lence of female sexual dysfunction [19]. The consensus com-
mented that female sexual dysfunction has been poorly
studied as compared to male sexual dysfunction with varying
methodologies, including definition and severity, the ages
studied, and timeframe of the sexual dysfunction, ranging
from lifelong problems to the past 3–12  months. Despite
these variations, the prevalence of female sexual dysfunction
in most studies was 40–50%. Low desire was the most com-
mon (17–55%), and some studies showed increased prob-
lems in women over the age of 60  years (40–50%) as
compared to younger women (15–33%) [19]. Arousal dys-
function, manifested by decreased lubrication, ranged from
12 to 28%, with highest rates noted in Iran (34%). The preva-
lence of orgasmic dysfunction ranged from 11 to 25% in
western countries and again was highest in Iran (37%). While
up to 80% of women have problems with orgasm, in only
about 8–15% are the difficulties with orgasm severe.
Dyspareunia and vaginismus are the least prevalent sexual
912 D. Kammerer-Doak and R. Rogers

dysfunction, noted in most studies to be less than 10%, but objective arousal, which results in an erection. In females,
with a few reporting up to 27% [19]. there is very poor correlation between subjective and objective
While most women at some point have sexual problems, arousal in that women can experience subjective arousal with-
the definition of female sexual dysfunction requires that the out increased genital blood flow and vice versa. Women expe-
sexual problem be distressful or bothersome to the affected riencing forced sexual activity can have increased genital
woman. A woman may have no desire for sexual activity, and blood flow and lubrication without any subjective arousal indi-
even if that is bothersome to her partner, this is not classified cating a physiological response. Additionally, decreased or
as her sexual dysfunction if the lack of sexual activity is not loss of sexual desire and arousal were only FSD if there was
distressful to her. Sexual dysfunction is more common in failure to respond to appropriate stimuli, whereas reactive
younger women as sexual problems tend to cause more dis- arousal and desire were normal. Orgasmic FSD was defined as
tress in this age group. While sexual issues such as lack of failure to achieve an orgasm, or a marked delay in orgasm,
desire and lubrication increase with aging, there is less despite subjective high levels of arousal, taking into account
­distress, and overall, decreased female sexual dysfunction that sexual satisfaction can be both emotional and physical
with advancing years (Fig. 74.3). (Table 74.1).
Female sexual dysfunction (FSD) is separated into four Controversy exists in the exact definitions and categories
categories: problems with desire, arousal, orgasm, and pain of female sexual dysfunction as FSD has also been classified
that cause individualized personal distress. Problems in by two other systems, the International Classification of
more than one area are common, as women with desire dif-
ficulties usually experience issues with arousal and orgasm.
FSD can also be characterized as lifelong/primary versus 70
% LOW DESIRE DISTRESS
acquired/secondary, generalized versus situational, and
60
with etiology as organic/physical, psychosocial, mixed, or
unknown.
50
In 2000, an international consensus conference defined
four categories of FSD: female sexual arousal disorder 40
(FSAD), female orgasmic disorder (FOD), female hypoactive
sexual desire disorder (FHSDD), and sexual pain disorder, 30
which was subdivided into dyspareunia, vaginismus, and non-
coital sexual pain disorder (Table  74.1) [20]. In 2004, the 20
American Foundation for Urologic Disease Consensus group
published its own set of female sexual dysfunction definitions 10
and recommendations, taking into account the Female Sexual
Response Cycle as proposed by Basson, which led to an 0
20-29 30-39 40-49 50-59 60-70
update by the international consensus group [3, 21].
N = 3589
Importantly, sexual arousal is different in females as compared
to males with both a subjective and objective component.
Fig. 74.3 Women’s International Study of Health and Sexuality.
Objective arousal results in increases in genital blood flow. In Menopause. 2006;13:46–56 {Y axis, % with sexual problem; X axis,
males, there is a direct correlation between subjective and ages in years}

Table 74.1  Female sexual dysfunction categories

Female 2004 definitiona 2015 ICSMb
Sexual arousal disorder Absent or decreased arousal despite any type of sexual Inability to attain or maintain arousal during sexual
stimulation activity (clinical principle)
Hypoactive sexual desire Absent or decreased sexual desire, thoughts, or fantasies Absent or deficient sexual/erotic thoughts/fantasies
disorder despite appropriate stimuli, lack of responsive desire and desire for sexual activity (clinical principle)
Orgasmic disorder Absent or marked delay in orgasm despite high levels of Orgasm: markedly delayed or markedly infrequent or
subjective arousal absent or marked decreased intensity (Grade B)
Sexual pain disorder Dyspareunia: pain with vaginal penetration Difficulties with: vaginal penetration or marked
(female genital-pelvic pain Vaginismus: pain and difficulty with vaginal penetration vulvovaginal/pelvic pain during genital contact or
dysfunction)c despite wish to do so due to involuntary contraction of fear/anxiety about pain in anticipation of sexual
pelvic floor muscles activity or hypertonicity/overactivity of pelvic floor
Noncoital pain disorder: pain with non-genital sexual muscles with or without genital contact (Grade C)
stimulation
a
Basson R, Leiblum S, Brotto L, et al. Revised definitions of women’s sexual dysfunction. J Sex Med. 2004;1:40
b
McCabe MP, Sharkip ID, Atalla E, Balon R, Fisher AD, Laumann E, et al. Definitions of sexual dysfunction in women and men: a consensus
statement from the fourth International Consultation on Sexual Medicine 2015. J Sex Med. 2016;13:135–43
c
Renamed by 4th International Consultation on Sexual Medicine (ICSM) (b)
74  Female Sexual Dysfunction 913

Diseases, 10th Edition (ICD-10), and the Diagnostic and
Statistical Manual of Mental Disorder 5th Edition (DSM-V).
In addition, the International Consultation on Sexual
Medicine (ICSM) updated their definitions in 2015, and the
International Society for the Study of Women’s Sexual
Health in 2016 [22, 23]. The ICD-11 was approved by the
World Health Organization and adopted in 1992, with the
11th edition revisions planned for release in 2018. The ICD-­
10 focuses on the definition of medical conditions and cate-
gorizes FSD into organic, which includes vaginismus and
dyspareunia of medical etiology, and also has ten nonorganic
FSD codes (Table 74.2) [22].
The DSM-V defines psychiatric conditions and was pub-
lished by the American Psychiatric Association in 2015 [22].
New to the DSM-V from the 4th edition is that sexual dys-
function definitions no longer relied on the sexual response
cycle proposed by Masters and Johnson, but instead incorpo-
rated many of the recommendations of the American
Foundation for Urologic Disease Consensus group, as well
as duration, frequency, and severity of sexual problems [21,
22]. For the diagnosis of sexual dysfunction, the problem(s)
must be present for at least 6 months, occur at least 75% of
the time, cause personal distress, not be secondary to non-
sexual psychiatric disorder, not be due to severe life or rela-
tionship stressors, and not be caused by illness or medication.
The DSM-V lists six FSD diagnoses: female orgasmic disor-
der, genito-pelvic pain-penetration disorder, female sexual
interest-arousal disorder, substance- or medication-induced
disorder, and specified FSD and non-specified FSD [22]. In
the DSM-V, problems with arousal and desire are combined
into one diagnosis, female sexual interest arousal disorder,
and problems with dyspareunia and vaginismus are com-
bined into the diagnosis of genito-pelvic pain-penetration
disorder (Table 74.3).

Table 74.2  International classification of diseases 11th edition (ICD-11). Classification of female sexual dysfunction
ICD-­11 Organic (physical cause) Nonorganic
Dyspareunia Lack or loss of sexual desire that is not secondary to another sexual problem such as pain
Vaginismus Sexual aversion where sexual activity is avoided as consideration of sexual interaction causes
negative feelings and anxiety
Lack of sexual enjoyment in which normal sexual responses occur including orgasm, but without
appropriate pleasure
Failure of sexual response/lack of lubrication not organic in etiology
Orgasmic dysfunction, with orgasm either markedly delayed or absent
Vaginismus, or tightening of pelvic floor muscles inhibiting vaginal penile penetration not due to
physical cause
Dyspareunia, or pain with intercourse not due to physical cause such as infection or atrophy
Excessive sexual drive additional code is used if secondary to other medical conditions such as
dementia or affective disorder such as hypermania
Two nonspecific sexual dysfunction codes

Table 74.3  Diagnostic and statistical manual of mental disorder 5th edition (DSM-V). Female sexual dysfunction categories
Category
DSM-­V Female sexual interest-arousal disorder
– Combines arousal and desire disorders
Genito-pelvic pain-­penetration disorder
– Combines dyspareunia and vaginismus
Orgasmic disorder
Female substance or medication-induced
disorder
Other specified and non-specified female sexual
dysfunction
ALL also classified as:
Definition(s)
At least three: absent or decreased
–  Interest in sexual activity
–  Sexual thoughts/fantasies
– Initiation of or unreceptive to partner for sex
– Sexual excitement or pleasure with sex
– Sexual interest or arousal in response to any sexual stimuli (written,
verbal, visual)
– Genital or non-genital sensations with sex
Persistent or recurrent:
– Pain and/or difficulty with vaginal penetration or
– Marked fear/anxiety of pain with vaginal penetration or
– Marked tensing/tightening of pelvic floor muscles with attempted vaginal
intercourse
Orgasm: markedly delayed or markedly infrequent or absent or markedly
decreased intensity
Lifelong vs. acquired
Generalized vs. situational
Level of distress:
 Mild, moderate, or severe
914 D. Kammerer-Doak and R. Rogers

The fourth International Consultation on Sexual Medicine Table 74.4  Medications and medical conditions affecting female sex-
(ICSM) evaluated all available literature in their recom- ual function
mended definitions, giving levels of evidence [22]. FSD was Medications Psychological Antidepressants
defined as sexual problems which cause individualized dis- Antipsychotics
Barbiturates
tress, persist for at least 3 months, and occur at least 75% of
Benzodiazepines
the time. Female hypoactive sexual desire disorder and Hypnotics
female sexual arousal disorder were retained as separate dys- Hormonal Oral contraceptives
function categories, but pain disorders were combined into a Gonadotropin-­
single definition, female genital-pelvic pain dysfunction releasing agonists
(Table 74.1). New categories of FSD proposed with level of and analogues
Anti-androgens
evidence expert opinion included persistent genital arousal
Anti-estrogens
disorder (unwanted spontaneous and intrusive genital arousal Other medications β-Blockers
without sexual interest unrelieved by at least one orgasm, Spironolactone
with possible persistence for hours or days), post-coital syn- Chemotherapeutics
drome (negative feelings and/or physical symptoms after Opiates/narcotics
sexual activity), hypohedonic orgasm (lifelong or acquired Substances of abuse Controlled Opiates/narcotics
decreased or low levels of sexual pleasure), and painful Legal Alcohol
Tobacco
orgasm (pain during or shortly after orgasm) [22].
Marijuana
Illegal Heroin, cocaine, etc.
Medical illnesses Depression
74.3 Assessment Diabetes
Urinary incontinence
Assessment of FSD begins with identification of the woman (OAB)a
with FSD, determination of the primary sexual dysfunction as Neurologic disease,
spinal cord injury
there is often an overlap in categories, the amount of personal Cancer
distress experienced from the sexual problem(s), and how long Cardiovascular
the symptoms have been experienced. Evaluation and treat- disease
ment can then be tailored to the individual woman based on a Adapted from Parish SJ, Goldstein AT, Goldstein SW, Goldstein I,
medical history and physical examination focused on identifi- Pfaus, J, et al. Toward a more evidence-based nosology and nomencla-
cation of treatable causes. Screening for FSD can be accom- ture for female sexual dysfunctions—Part II.  J Sex Med.
2016;13:1888–901
plished with three simple questions easily obtained from an a
OAB overactive bladder
intake questionnaire which are as effective as a lengthy inter-
view: Are you sexually active, Are there any problems, and Do
you have pain with sexual activity [24, 25]? In-depth evalua- 74.4 Sexual Function Questionnaires
tion of FSD can also be accomplished using validated sexual
function questionnaires, covered in a separate section. Objective measures of sexual health including physical
No routine laboratory screening is recommended includ- exam, laboratory analyses, and physiologic testing are poorly
ing sex steroid levels unless endocrinopathy is suspected. correlated with sexual health. Therefore, assessment is reli-
Further evaluation includes an assessment of the motivation ant on patient-reported outcomes, including diaries and
for seeking treatment, a careful history of current life and questionnaires. Sexual diaries have been proposed as one
relationship stressors or changes, illicit drug or alcohol way to assess function. In a diary, the patient may record
abuse, prescription medications and medical illnesses which sexual thoughts, desires, and events. The Food and Drug
may effect sexual function by interference with mood/affect, Administration of the United States has in the past proposed
decrease in genital blood flow and lubrication, decrease in “sexually satisfying events” as an important outcome to
sex hormone-binding globulin and therefore free testoster- measure the efficacy of treatments for sexual health, even
one, or interference with the sexual neurological response though these diaries have not always correlated well with
(Table  74.4). Vaginal atrophy, difficult vaginal deliveries, other validated measures of sexual function.
and vaginal surgery have potential for denervation or dyspa- Other measures of sexual function include validated ques-
reunia. An assessment for possible referral for psychother- tionnaires. A variety of these measures have been used in the
apy is made based on the woman’s current life stressors/ research setting and range from self-administered question-
social situation/relationships, accompanying psychiatric ill- naires to those that are administered in an interview. Nearly
ness, and history of sexual abuse as well as type of sexual all of these measures were validated in young heterosexual
dysfunction(s). women, as these are women more likely to report sexual
74  Female Sexual Dysfunction 915

Table 74.5  Sexual function questionnaires

Condition
Instrument Description No. of items ICI gradea specific?
ICIQ-­ Female sexual matters associated with urinary symptoms and related bother 4 A Yes
FLUTSsex1 UIb
GRISS2 Anorgasmia, vaginismus, impotence, and premature ejaculation, avoidance, 28 A No
dissatisfaction and non-sensuality, infrequency, and no communication about sex
FSFI3 Assesses multiple dimensions of sexual function 19 A No
ICIQ-VS4 Assesses presence, severity, and effect of vaginal symptoms on sexual quality of life 14 B Yes
POPb
One
question UI
PISQ5 Evaluates sexual function in women with incontinence and prolapse 31 B Yes
POP and
UIb
PISQ-126 Evaluates sexual function in women with incontinence and prolapse 12 Not rated Yes
POP and
UIb
PISQ-IR7 Evaluates sexual function in women with urinary and anal incontinence and prolapse 33 Not rated Yes
and includes evaluation of women who do not report sexual activity POP, UI,
and AIb
SQOL-F8 Assesses the impact of female sexual dysfunction on quality of life 18 B No
SFQ9 Assesses the impact of OAB on sexual health function in the male and female 31 C Yes
population UI, OAB
onlyb
(1) International Consultation on Continence Questionnaire (ICIQ) - Female Lower Urinary Tract Symptoms Sex (FLUTsex); (2) the Golombok-
Rust Inventory of Sexual Satisfaction (GRISS); (3) Female Sexual Function Index (FSFI); (4) International Consultation on Incontinence
Questionnaire–Vaginal Symptoms (ICIQ-VS); (5) Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ); (6) short form ver-
sion of the PISQ-31; (7) International Urogynecology Association–revised version of the PISQ; (8) Sexual Quality of Life-Female (SQOL-F);
(9) Sexual Function Questionnaire (SFQ)
Adapted from: Rogers RG, Pauls RN, Thakar R, Morin M, Kuhn A, Petri E, Fatton B, Whitmore K, Kingsberg S, Lee J. An International urogy-
necological association (IUGA)/International continence society (ICS) joint report on the terminology for the assessment of sexual health of
women with pelvic floor dysfunction. Int Urogynecol J. 2018;29(5):647–66
a
International Consultation on Incontinence
b
AI anal incontinence, OAB overactive bladder, POP pelvic organ prolapse, UI urinary incontinence

activity. Questionnaires can be further dichotomized into
those which measure sexual function among women with
pelvic floor disorders and those which are more generalized
and measure sexual function without reference to pelvic
floor dysfunction. In general condition-specific measures are
more responsive to change than questionnaires that are not
condition specific.
The most commonly used sexual condition-specific sexual
function measure in women with pelvic floor dysfunction is
the Pelvic Organ Prolapse/Urinary Incontinence Sexual
Questionnaire (PISQ) [26]. A short-form version of the ques-
tionnaire has also been published, the PISQ-12 [27]. More
recently, the PISQ was revised by an international panel. This
new measure, the PISQ-IUGA-revised, includes the impact
of pelvic floor dysfunction on the decision to not be sexually
active, as well as measurement of the impact of pelvic floor
disorders on sexual activity [28]. This measure has undergone
validation in a number of languages, and a summary score for
the questionnaire has recently been developed [29].
Other condition-specific measure includes the
International Consultation of Incontinence Questionnaire–
Vaginal Symptoms (ICIQ-VS) which assesses the severity
and impact of vaginal symptoms, mainly prolapse, and sex-
ual matters, and the International Consultation on Continence
Questionnaire-Female Lower Urinary Tract Symptoms Sex
(ICIQ-FLUTSsex) which measures the impact of urinary
incontinence on sexual function [30, 31]. Questionnaires that
are not condition specific have also been used to evaluate
sexual function in women with pelvic floor dysfunction. A
number of these have been evaluated by the International
Consultation on Incontinence and rated (Table 74.5).
Recommendations vary on what specific aspects of sexual
function should be evaluated in women undergoing treat-
ment for pelvic floor dysfunction. At a minimum, women
should be asked if they are sexually active and if they are,
how their pelvic floor dysfunction affects their sexual life. In
addition, for those who are not sexually active, questions as
to whether or not their pelvic floor dysfunction influences
their decision to not be sexually active is important. Finally,
evaluation of a patient’s return to sexual activity following
treatment should also be assessed, and if new sexual prob-
lems arise, promptly addressed. Many pelvic floor specialists
do incorporate a sexual function questionnaire into their
assessment of patients with incontinence or prolapse.
916 D. Kammerer-Doak and R. Rogers

74.5 Treatment musculoskeletal etiology. Alterations of medical contribu-

tors to FSD such as an unhealthy lifestyle, smoking, alcohol
Evaluation and treatment of FSD requires a biopsychosocial or substance abuse, obesity, medications, and lack of sleep
approach, incorporating physical health, psychosocial-­ are also part of the treatment. In women, body image is
cultural issues, and biologic and neurologic factors. The strongly correlated to desire, and modalities to improve body
combination of psychological and biological treatments of image including counseling and improving overall physical
FSD may actually result in the development of neural path- health can improve sexual function [35]. Pelvic floor muscle
ways as evidenced by changes in brain activity on MRI lead- exercises (PFME) or “Kegels” are recommended as these
ing to changes in sexual function [32, 33]. There appears to muscles may play a role in arousal and orgasm, and stronger
be strong neuroendocrine influence on female sexual func- pelvic floor muscles and PFME training are associated with
tion, especially FHSDD, with both excitatory and inhibitory improved sexual function [4, 36–38]. A handout with this
effects [33]. Serotonin (ST), opiates, and endocannabinoids information can be useful, as well as self-help books in inter-
have an inhibitory effect, while dopamine (DA), norepineph- ested patients [33]. If warranted based on assessment and
rine (NE), oxytocin (OXT), and the melanocortin system are after discussion with the patient, mediations, devices, and/or
excitatory [4, 33]. Estrogen, progesterone, and androgens psychosexual intervention may be recommended.
have a dual role, with central neurologic role effect of orga- Medications to treat FSD can be divided into hormonal
nization and activation for the brain to be sexually receptive, and nonhormonal therapies (Table  74.6). While vaginal
and a genital effect resulting in increased genital blood flow estrogen is recommended for dyspareunia secondary to atro-
and lubricating secretions which are mediated by multiple phy, systemic estrogen and progesterone does not have a
substances including nitrous oxide and neuropeptide Y [33]. positive effect overall on FSD in most randomized placebo-­
However, a direct correlation between sex steroid levels and controlled trials (RCTs). However, testosterone has been
sexual function has not been shown probably due to genetic shown in RCTs to improve sexual function, including desire,
variation in other factors such as biosynthesis and availabil- arousal, and orgasm, with the most data for use in postmeno-
ity, receptor binding, and elimination. Additionally, there is pausal and surgically castrated women [4, 34]. A significant
no normal range of testosterone for women, and no level increase of mean 2.12 sexually satisfying events per month
below which can be used to identify FSD or those who may was noted with transdermal testosterone (TT) dose of 300 μg/
be candidates for testosterone therapy [34]. However, there day testosterone compared to 0.73 with placebo. Additionally,
does appear to be a relationship between androgen levels and TT is effective in the treatment of SSRI-induced FSD. Since
desire and arousal in most studies. Orgasm is a neurologic TT improves sexual function after about 3 weeks and effects
reflex regulated by the somatic and autonomic nervous sys- plateau at 3–4 months, continued use beyond this timeframe
tem with central nervous system input [4]. is not recommended in those who have not shown a response.
Treatment of FSD begins with education regarding aver- Minimal data on long-term use beyond 3 years exists. When
age sexual practices including frequency of sexual encoun- serum levels are in the normal premenopausal range, andro-
ters about 4/month with most women achieving orgasm genic side effects are rare, but higher levels are associated
during sexual encounters through direct clitoral stimulation with acne, hirsutism, alopecia, cliteromegaly, and voice
and not just vaginal intercourse, the relatively common prac- changes. Although postulated to have a negative impact on
tice of partnered vibrator use, and a brief discussion of the liver function, lipid profile, and cardiovascular disease, TT
differences between male and female sexual responses to does not seem to adversely affect these parameters, although
include responsive desire and arousal as normal. Treatment long-term data is lacking [4, 34]. The periodic evaluation of
of problems with desire and arousal will often result in lipid and liver profiles seems reasonable. Although methyl-
improvement with orgasm difficulty. Persistent issues with testosterone has been reported to increase the risk of breast
orgasm are addressed through education including coital cancer, this does not appear to be associated with parental
alignment techniques, or sexual positions that allow for testosterone use [4, 34]. There are no data to support the use
greater clitoral stimulation during vaginal intercourse, and of other androgens, including dehydroepiandrosterone
training in masturbation, by self, partner, or vibrator use (DHEA) for the treatment of FSD in women with normal
[33]. This education can give women medical permission for adrenal function, although vaginal DHEA may be beneficial
these practices and may overcome religious or cultural tradi- for vaginal atrophy [39, 40].
tions. In the newer definitions of sexual pain disorder, treat- Nonhormonal medications have either a central effect
able causes are not considered FSD.  Nonetheless, the through changes in neurotransmitters that play a role in sex-
importance of treating organic dyspareunia and vaginismus ual response, have a genital effect on sexual function, or a
is paramount, as desire, arousal, and orgasm will be nega- combination and may lead to improvement in desire, arousal,
tively impacted with painful sexual encounters secondary to and orgasm. Flibanserin has both ST agonist and antagonis-
atrophy, scarring, infection, or pelvic floor muscle spasms of tic properties, as well as DA and NE effects, leading to an
74  Female Sexual Dysfunction
inhibition of ST-mediated decreased sexual effect and pro-
motion of DA- and NE-mediated sexual excitement [33].
Although flibanserin received FDA approval in 2015 for the
treatment of FHSDD, a recent review of RCTs reported a
mean improvement of only 0.50 (95% CI, 0.32–0.67) in sex-
ually satisfying events per month and a 0.27 (95% CI 0.17–
.03.8) point increase in the Female Sexual Function Index
(FSFI) questionnaire desire subscale [41]. Bupropion is an
antidepressant that has no ST effects, but rather inhibits both
DA and NE reuptake, and therefore can be used in women
with antidepressant medication-induced FSD [42]. In small
RCTs, bupropion has also resulted in small-moderate
improvements in sexual function versus placebo in women
with FHSDD [33]. Trazadone, a ST receptor antagonist; bus-
pirone, a partial ST agonist; apomorphine, a DA receptor
agonist; oxytocin; and bremelanotide, a synthetic melano-
cortin modulating sexual behavior at the level of the
­hypothalamus, are all under investigation for use in FSD
involving low desire and arousal (Table 74.6).
In contrast to men, female arousal is not just objective with
increases in genital blood flow, but also subjective, modulated
by a variety of psychosocial and cultural factors including
views on sexuality, attractiveness of partner, life and relation-
ship stressors, and distraction as well as attentiveness during
sexual activity. Therefore, phosphodiesterase inhibitor medi-
cations (PDE5i) which work well for male arousal dysfunc-
tion have not been uniformly efficacious in the treatment of
FSD in RCTs due to poor correlation between increased geni-
tal blood flow and subjective arousal (Table  74.6) [33]. In
women with medical problems that cause a decreased neuro-
vascular genital response, such as diabetes, SSRI use, spinal
cord injuries, multiple sclerosis, and following radiation,
PDE5i use may play a role in the treatment of FSD. Combined
drug therapies, using testosterone and buspirone or testoster-
one and PDE5i, are under investigation [33]. These combined
drug therapies are hypothesized to stimulate desire with tes-
tosterone, and to decrease central brain sexual inhibition with
buspirone, or to increase brain sensitivity to sexual genital
arousal with PDE5i.
Tibolone is a synthetic derivative of 19-nortestosterone
that has estrogenic, progesterogenic, and androgenic proper-
ties and is available outside of the United States for treatment
of menopausal symptoms as well as FSD. Tibolone increases
genital blood flow and vaginal lubrication as well as sexual
function scores for arousal and desire in RCTs compared to
placebo and demonstrates greater improvement in sexual
function than combination hormone replacement therapy
[33]. While there are other medications available for the
treatment of FSD, they have not been well studied
(Table  74.6). Zestra (Innovus Pharmaceuticals, San Diego,
CA, USA) is an over-the-counter massage oil applied to the
genitals containing botanicals including borage and evening
primrose oil, Coleus extract, and osthole which possibly
917
Table 74.6  Treatment and evidence levels for female hypoactive sex-
ual desire disorder, female sexual arousal disorder, and female orgasmic
disorder
Type of intervention Level of evidence
Psychological interventions for FHSDD
Sensate focus 2
Cognitive behavioral therapy (CBT) 2
Mindfulness plus CBT 2
Pharmacologic interventions for FHSDD
Testosterone therapy 1
Flibanserin 1
Bremelanotide 1
Bupropion 2
Buspirone 2
Testosterone plus buspirone or PDE5i 2
Psychological interventions for FSAD
Mindfulness plus CBT 2
Pharmacologic interventions for FSADa
Tibolone 2
Bupropion 2
Testosterone therapy 1
PDE5i in specific medical conditions that 2
interfere with genital neurovascular system
Psychological interventions for FOD
Directed masturbation 2
Medications: not specifically studied for FOD, but in general,
medications which improve desire and arousal will improve orgasm
as well
FHSDD female hypoactive sexual desire disorder, FSAD female sexual
arousal disorder, FOD female orgasmic disorder, PDE5i phosphodies-
terase type 5 inhibitor
Adapted from: Kingsberg, SA, Althof S, Simon JA, Bradford A, Bitzer,
J, et al. Female sexual dysfunction—medical and psychological treat-
ments, Committee 14. J Sex Med. 2017;14:1463–91
a
Unable to confer levels of evidence because of small cohorts, inconsis-
tent and weak evidence for bibliotherapy/self-help books alone, l-­
arginine plus yohimbine, alprostadil, phentolamine, apomorphine,
Zestra, and the coital alignment technique
increases genital blood flow through prostaglandin and direct
endothelial effects [43]. Prostaglandin E1 causes smooth
muscle relaxation resulting in vasodilation and increased
genital blood flow and may improve genital sensation
through sensory afferent nerves, but its use for FSD has not
yielded consistent results [44]. Phentolamine is an alpha
receptor antagonist that can be administered orally or vagi-
nally to improve genital blood flow through relaxation of the
arterial smooth muscle and is under investigation for treat-
ment of arousal FSD. L-Arginine is the precursor for nitrous
oxide and is one of the ingredients of the oral supplement
ArginMax (Daily Wellness Co, Honolulu, HI, USA), along
with ginseng, ginkgo, damiana, and some vitamins and min-
erals. Two RCTs by the same author published more than
10 years ago noted improved desire, orgasm, genital sensa-
tion, and sexual frequency as well as improved FSFI scores
compared to placebo [45, 46].
Information regarding the prevalence, etiology, and treat-
ment of persistent genital arousal disorder is lacking. This
918
category of FSD has been associated with anatomical abnor-
malities such as peri-clitoral mass as well as with discontinu-
ation of SSRI medications, overactive bladder, and restless
leg syndrome. Improvement of symptoms has been reported
anecdotally with CBT and medications including pregabalin,
duloxetine, and varenicline [33].
Sex therapy is recommended depending on the patient’s
response to conservative and/or medical treatment, on the
stage of FSD, and the woman affected including psychiatric
issues, her relationship with her partner, as well as life stress-
ors. Women with primary FOD and with history of sexual
abuse almost always require counseling. FHSDD has the
best response to psychosocial counseling. Depression and
anxiety have a strong association with FSD as well as poor
prognosis for sex therapy, and treatment of primary psychiat-
ric issue(s) in addition to FSD is imperative to achieve best
results.
Several different strategies are employed in sex therapy
(Table  74.6). Sensate focus helps to address psychological
rather than physical factors contributing to FSD through
counseling and education regarding what is pleasurable and
ways to achieve this pleasure for the woman alone as well as
with her partner. The focus is not on arousal or orgasm with
this technique, but rather on current sensations of pleasure
and enjoyment with three steps in level of intimacy begin-
ning with non-genital touching, followed by breast and geni-
tal touching, and ultimately mutual touching with sexual
intercourse when the woman and her partner are more com-
fortable touching, being touched, and experiencing pleasure.
Another technique of sex therapy is cognitive behavioral
therapy (CBT) which involves identification and alteration of
behaviors contributing to FSD.  This includes education
about how erotic stimuli, psychological influences, and
physical stimulation can contribute to female arousal and
desire and, ultimately, orgasm. Mindfulness, the acceptance
of and being present without judgment, is often combined
with CBT to improve the ability to focus on bodily sensa-
tions and decrease problems with distraction and loss of
attention during sexual activity and ultimately improve sex-
ual arousal.
In addition to vibrator use to increase clitoral stimulation
directly during sexual encounters, there are two devices
available both designed for use prior to sexual activity to
increase arousal and orgasm by increasing genital blood
flow. EROS clitoral therapy device was approved by the FDA
in 2000 and is a battery-powered, handheld suction device
applied to the clitoris for 5–15 min at least three times/week
that can be used separately from sexual activity or as part of
fore-play. In small, non-masked, non-placebo-controlled tri-
als, EROS has been shown to increase clitoral and vaginal
blood flow as well as to improve arousal, orgasm, and satis-
faction in women with FSAD [47]. Additionally, EROS has
D. Kammerer-Doak and R. Rogers
been shown to significantly improve sexual function in
women following radiation for cervical cancer [48]. FIERA
is a suction device that attaches to the clitoris and also uses
low-level vibrations prior to sexual activity for 5–20 min to
achieve desire and arousal through increased genital blood
flow and clitoral stimulation, but not lead to orgasm. While
there are no published studies demonstrating improved sex-
ual function, FIERA use led to increased external genitalia
temperature, a marker of engorgement, as measured by ther-
mography, and all of the small cohort also experienced reac-
tive desire [49].
Vaginal laser and vulvovaginal radiofrequency may also
improve sexual function. Both vaginal laser and radiofre-
quency cause neovascularization, neoelastogenesis, and neo-
collagenesis without fibrosis, with radiofrequency also
causing retraction of existing collagen. In two RCTs involv-
ing both pre and postmenopausal women, vulvovaginal
radiofrequency demonstrated significant improvement in
sexual function using the FSFI as well as genital appearance
and vaginal laxity compared to sham treatment [50, 51].
Fractional microablative CO2 vaginal laser improved sexual
function as assessed by the FSFI in all domains as well as
total score in a small, non-blinded cohort of postmenopausal
women with atrophy [52]. A recent comprehensive review
and meta-analysis of vaginal CO2 and Er:YAG laser noted
that while these therapies seem to relieve symptoms and
improve quality of life including sexual function, the quality
of evidence is low overall [53]. More studies are needed,
including long-term risks and results with both of these
techniques.
74.6 P
 elvic Floor Disorders and Sexual
Function
Like other medical conditions, pelvic floor disorders (PFD)
and their treatment can affect sexual health [54–56]. Women
with urinary incontinence (UI) frequently experience coital
incontinence, with or without vaginal penetration. A recent
survey of 2312 women found that 47.7% of women with UI
report coital incontinence. In this study, both stress and
urgency incontinence were correlated with penetration as
well as orgasm [57]. Loss of urine during sexual activity can
cause embarrassment and diminish sexual satisfaction [55,
57, 58]. Treatment of UI results in improvement of sexual
function on condition-specific measures of sexual health,
although there is little change in desire, arousal, or orgasmic
function [59].
Prolapse can likewise negatively affect sexual function as
well as body image, with feelings of self-consciousness and
embarrassment about partners’ perception of prolapse during
sexual activity [55, 60, 61]. As body image correlates with
74  Female Sexual Dysfunction
sexual function, any negative impact may adversely effect
sexual function [35, 60, 61]. Treatment for prolapse results in
improved sexual function on condition-specific measures,
but does not in general impact other aspects of sexual func-
tion including desire, arousal, and orgasm [56, 62].
Women with anal incontinence (AI) have been more
poorly studied than women with other PFD. Anal inconti-
nence results in decreased sexual function overall as well
as poorer sexual function than women with other PFD,
especially with fecal as compared to isolated flatal inconti-
nence [63–65]. Additionally, women with double inconti-
nence, or both AI and UI, have poorer sexual function as
compared to those with isolated UI [66]. While the impact
of anal intercourse on fecal incontinence symptoms and
sexual function is understudied, women who engage in
anal intercourse are more likely to report fecal inconti-
nence [67].
Treatment for pelvic floor dysfunction including con-
servative measures such as the use of pessaries and physi-
cal therapy generally improves sexual function [38, 56,
62, 68–70]. Improvement in sexual function is seen with
pessary use, but the impact may be greater with surgery
[69]. Among women who use a pessary and are sexually
active, the majority remove the pessary during sex,
although sexual activity is possible with a pessary in
place [71]. Although surgical treatment of prolapse and
incontinence results in improved sexual function in most
studies, a small but significant number of women will
experience deterioration mainly associated with the
development of either de novo, persistent postoperative
dyspareunia or pain or worsening of or failure to resolve
preexisting pain or dyspareunia following surgical repair
[62]. This complication is possible among any woman
who has undergone pelvic reconstructive surgery, but
may be especially noteworthy following prolapse repair
with mesh. A frank discussion is warranted with women
who are planning surgery to treat their pelvic floor disor-
ders regarding sexual function following surgery. While
surgical repair of PFD improves overall sexual function
in the majority, it is unlikely to improve desire, arousal,
or orgasm, and preexisting pain or dyspareunia may con-
tinue or worsen. Women should be counseled that some
will develop pain disorders following surgical repair of
prolapse and incontinence with or without mesh use
which may be difficult to treat and may adversely affect
sexual function. While many women do not ask questions
about sexual activity following surgical repairs, both
women and their partners may have concerns regarding
the timing and safety of resuming sexual relations.
Information about when to resume sexual activity, the
need for lubricants with initial attempts, and prompt
reporting of sexual pain for either partner is
recommended.
919
Take-Home Messages
Female sexual function differs from male sexual func-
tion in that desire doesn’t always precede arousal, and
sexual satisfaction is both emotional and physical.
Female sexual problems are common, with FSD diag-
nosed when a sexual problem causes individualized per-
sonal distress. FSD is usually multifactorial with
psychosocial, vascular, neurogenic, endocrine, and ana-
tomic contributors. Evaluation of FSD includes a history
and physical to identify treatable causes of pain and
stage(s) of sexual dysfunction. Treatment is then tailored
to the individual woman and may include education,
sexual/psychosocial therapy, and medications. Unlike
male SD, which mainly involves erectile problems, FSD
is a more complex problem, and unfortunately, there are
no magic bullets. FSD is common in women with pelvic
floor disorders. For most women, treatment of their dis-
order results in improved sexual function.
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 A Myofascial Perspective on Chronic
Urogenital Pain in Women
Marek Jantos
Learning Objectives
• Understand the nature, prevalence and current man-
agement of CUP disorders.
• Recognise the pain profiles of CUP disorders, based
on the use of a validated pain mapping tool and
electromyographic assessment.
• Identify structural and functional changes in soft
tissue and how this pathology leads to chronic pain.
• Recognise the interactive kinetic chain linking muscles,
fascia and the neuronal network of organs by which
pelvic muscle dysfunction leads to organ distress.
• Explore how myofascial concepts may contribute to
improving and optimising management of CUP.
• Assess the plausibility of the myofascial model of
chronic urogenital pain through further research.
75.1 Introduction
The debilitating symptoms of chronic urogenital pain (CUP)
continue to provide a unique challenge to healthcare provid-
ers. This chapter will focus on two CUP syndromes prevalent
in women. One affects the bladder and is classified as blad-
der pain syndrome (BPS). The other affects the vulva and is
identified as vulvodynia (Vd). Women account for 95% of all
medical visits in relation to CUP disorders [1]. Both of these
syndromes are diagnosed on the basis of symptoms and the
exclusion of medical causes. In varying degrees each contin-
ues to affect the function of the urological, reproductive, gas-
trointestinal and musculoskeletal systems. Invariably
questions arise in relation to what causes the pain, how organ
dysfunction arises and why these two disorders are comorbid
to each other and to gastrointestinal symptoms.
M. Jantos (*)
Behavioural Medicine Institute of Australia,
Adelaide, SA, Australia
e-mail: mjantos@behavioural-medicine.com;
marekjantos@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_75
75
Intuitively or by training, physicians associate pain with
tissue trauma and search for pathology that might explain its
existence and severity. In the absence of pathology, the pain
is seen as a paradox. This means that CUP disorders are often
undiagnosed (due to lack of visible pathology), under-­
diagnosed (being inadequately recognised) or subject to
extensive and costly diagnostic investigations (in search of
pathology).
The failure of existing interventions to provide effective
symptom relief highlights some of the common misconcep-
tions about CUP and suggests that the pain mechanisms
being considered are obscure or altogether wrong [2–4]. This
article will explore the plausibility of a peripheral mecha-
nism of pain that links muscle (myo) dysfunction, and fascial
(fascia) restrictions, to CUP and other related comorbidities
and symptoms.
Historically, the absence of pathology has fostered the
view that CUP symptoms were psychogenic [5]. Various
post-Freudian hypotheses linking symptoms to hysteria and
psychosomatic disorders were widely accepted, and these
invariably impacted on the choice of therapy [6, 7]. In time,
as professional societies sought to improve the classification
of CUP disorders, the attention moved away from psychoso-
matic notions to organ-centred taxonomies. These created a
misleading impression that the cause of pain was known and
that symptoms stemmed from a diseased organ at the centre
of the syndrome. What followed were organ-directed inter-
ventions, which proved to be nonproductive and in many
instances harmful [3]. Each of these outcomes seems unrea-
sonable and costly to the individual and the healthcare
system.
This chapter will examine the pathophysiology of CUP
and consider myofascial changes that are known to be asso-
ciated with chronic pain. Persistent pain does not exist with-
out a cause and should not be marginalised as a sensory
system malfunction. It may, however, require a conceptual
rethink and change of perspective. Given that CUP disorders
share a common cluster of symptoms and comorbidities, it is
likely that unrecognised, non-organ-based mechanisms play
923
924
an important role in the pathogenesis of these syndromes.
This discussion will integrate pain mapping research and
electromyography (EMG) studies and explore how pelvic
muscle dysfunction impacts the integrity of the fascial sys-
tem and results in pain and organ symptoms. The concluding
remarks will consider the merits of conservative interven-
tions based on a myofascial model of CUP.
75.2 B
 ladder Pain Syndrome
and Vulvodynia
According to the American Urological Association (AUA)
Guidelines, bladder pain syndrome (BPS) is defined as “an
unpleasant sensation (pain, pressure, discomfort) perceived
to be related to the urinary bladder, associated with lower
urinary tract symptoms of more than six weeks duration, in
the absence of infection or other identifiable causes” [8]. The
incidence of BPS is higher in women than in men at a ratio
of 5:1, and the reported prevalence ranges from 5 to 16%
[9–12]. Prevalence is always difficult to establish due to
ongoing disparity in definitions and inconsistences in diag-
nostic criteria.
Anatomically, the bladder is a hollow muscular and dis-
tensible organ that stores urine. It is made up of smooth mus-
cle (the detrusor) and connective tissue (transitional
epithelium). It is enclosed by fascia, which covers the pelvic
walls and floor, and is held in place in the anterior part of the
pelvic cavity by fascial ligaments and muscles of the pelvic
floor [13]. The kidneys filter waste from the blood and pro-
duce urine, which enters the bladder through two tubes,
called ureters. The urine leaves the bladder through another
tube, the urethra. In women, the urethra is a short tube about
4.0 cm long that opens just in front of the vagina. The blad-
der neck and proximal and distal urethra are complex and
vascularised structures [14], potentially very susceptible to
changes in myofascial tension [15].
Women diagnosed with BPS commonly report symptoms
of urethral sensitivity; urinary urge and frequency; nighttime
voiding (nocturia); suprapubic pressure; abdominal, groin
and lower back pain; and painful intercourse (dyspareunia)
[10]. Bladder pain was found to have a negative impact on
quality of life with 90% of women reporting impairment in
daily activities, 88% suffering sleep disturbances, 79% expe-
riencing work impairment and 70% confirming problems in
relationships and sexual function [16].
Many hypotheses regarding the pathophysiology of BPS
have been put forward: proteoglycan layer disruption,
immune system up-regulation, neurological sensitisation and
pelvic floor dysfunction [17]. Current medical treatments
include analgesics, antidepressants, antibiotics, intravesical
treatments, bladder distention, neuromodulation, behav-
ioural bladder retraining, diet, acupuncture, hypnosis and
M. Jantos
cystectomies [18]. Some of the ineffective treatments identi-
fied in a study of 53 cases included antibiotics (55%), ure-
thral dilation (50%), anticholinergics (30%), diazepam
(22%), tricyclics antidepressants (15%), α-blockers (12.5%),
phenazopyridine hydrochloride (10%), acupuncture (10%)
and surgery in a small number of cases (5%) where it was
tried [19]. The same paper identified myofascial causes of
urge and frequency stating that “pelvic floor myofascial trig-
ger points are not only a source of pain and voiding symp-
toms, but also a trigger for neurogenic bladder inflammation
via antidromic reflexes” [19]. Muscle relaxation and release
of myofascial trigger points were associated with a signifi-
cant reduction in symptoms. The study concluded that myo-
fascial trigger points underlie the pathophysiology of bladder
pain and urinary symptoms.
Since the early 1990s, evidence has accrued confirming
an association between bladder pain and pelvic floor muscle
(PFM) dysfunctions [20, 21]. Pelvic floor spasm and myo-
fascial pain were confirmed in as many as 87% of patients
diagnosed with BPS [22]. The report concluded that “the pel-
vic floor may be a significant source of pain in women with
IC [interstitial cystitis—a form of BPS], making therapy
directed only at the bladder less effective” [22]. Physical
examination identified PFM tenderness, especially in the
levator ani muscles, referred pain to the suprapubic, bladder,
urethra, vulvar and rectal areas. These reports confirmed that
palpation of specific points in the pelvic area reproduced
symptoms of BPS, including pain and urge [23]. In one study
the present author and his collaborators reported that palpa-
tion of pelvic muscles and of the paraurethral area repro-
duced bladder pain and urge in 100% of BPS cases [24].
In general, BPS cases show lack of muscle control and
poor ability to relax the PFM [20]. Consistent with these
observations, a urology report suggested that “pain and sore-
ness, even inflammation, will develop if the muscle system is
functionally abused” and this will result in changes within
the bladder [19, 23]. It recommended that stimulation or
biofeedback-assisted retraining “can produce immediate
relief in muscle soreness” and that “urologists should be
encouraged to deal with pain on as conservative a level as
possible”, noting that “if pelvic muscle dysfunction is not
corrected, then the chances are against therapy being suc-
cessful even with the help of medication” [23]. With myofas-
cial therapy an 83% improvement was noted in terms of urge
and frequency [19].
Medical therapies frequently overlook conservative thera-
pies and ignore the myofascial pain component, remaining
reliant on medications, hydrodistention, neuromodulation
and occasionally surgery. These were found to be suboptimal
in alleviating symptoms [21]. Hydrodistention was shown to
significantly reduce symptoms of pain but the benefits
appeared to be short lived. Medication helped only half of
the patients, and heat application and relaxation strategies
75  A Myofascial Perspective on Chronic Urogenital Pain in Women
provided temporary relief in 34.6% and 25.6% of cases,
respectively. Surgery was reserved as an absolutely last
measure.
These studies influenced the formulation of the current
management guidelines proposed by the American
Urological Association (AUA). In its guidelines, myofascial
therapy and biofeedback are recommended as a second line
of treatment, preceded only by patient education [25].
Vulvodynia (Vd) is a descriptive term for unexplained
pain in the vulvar area. The International Society for the
Study of Vulvovaginal Diseases (ISSVD) defines Vd as “vul-
var pain of at least 3 months duration, without clear identifi-
able cause, which may have potential associated factors”
[26]. Anatomically, the vulva includes the external portion of
the female reproductive organs: the vestibule, hymen, ure-
thral opening, ducts of the minor and major vestibular glands,
labia minora and majora, clitoris, mons pubis and perineum
[27]. Women report generalised pain or provoked discomfort
when pressure is applied to the vulva. The most common
descriptors of pain include burning, rawness, itching and
stabbing [28].
The most widely accepted diagnostic procedure is the
Kaufman Q-tip test [29]. This test was used by Friedrich and
relied on for his proposed diagnostic criteria [30]. The criteria
included pain on vestibular touch or attempted entry, tender-
ness on Q-tip palpation of the vestibule and physical findings
confined to vestibular erythema. The third criterion proved to
be the least reliable but the first two are still relevant and
accepted [31]. Though the classification of Vd has changed
over time, the diagnostic criteria have not been revised since
they were first proposed 30 years ago. In the late 1990s, the
present author and his collaborators identified pelvic muscle
dysfunction as a feature and proposed SEMG criteria for the
confirmation of Vd [32]. SEMG assessment successfully dif-
ferentiated between Vd cases and controls on the basis of rest-
ing pelvic muscle tone, contractile potential, muscle stability
and spectral frequency of muscle fibre types [32].
The aetiology of Vd is not understood, and the disorder is
thought to be symptomatic of several disease states, poten-
tially mediated by hormonal fluctuations, immune system
dysregulation, hypertonic pelvic muscle dysfunction and neu-
roproliferative changes [2]. Common triggers that exacerbate
pain include sitting, tight clothing, tampons, physical exami-
nations, penetrative sexual activities, stress and anxiety [33].
The lifetime prevalence of Vd is estimated to be in the
order of 4–16% [11, 34] and affects women of all ages but is
most common among younger women [28, 33]. A recent ret-
rospective population study of 1143 women (age range of
18–70 years), diagnosed with Vd, found prevalence to peak
at age 25, with 76% of the cohort being under 35 years of age
[33]. By age 36, prevalence decreased noticeably and pla-
teaued from age 37 onwards. These findings were very simi-
lar to an earlier study by the present author, profiling 744 Vd
925
cases where prevalence peaked at age 24, and the average
age of symptom onset was 22.8 years (range 5.5 to 45.2 years
of age) [28]. In both studies chronic vulvar pain was not
related to parity, or commencement of sexual activity, as
over 30% of cases reported the onset of symptoms prior to
commencement of sexual activity [28].
Current treatments for Vd include topical medications,
such as lidocaine, corticosteroids, amitriptyline (topical and
oral), other antidepressants, gabapentin, botulinum toxin
injections, psychological treatments, dietary regulation and
surgical treatments in the form of vestibulectomy and peri-
neoplasty [2, 35, 36]. Management guidelines also recom-
mend the use of physical therapies and biofeedback, though
these are not widely used [35, 36]. Considering that 90% of
women who reported pain with intercourse demonstrated
pelvic floor muscle dysfunction, it would seem critical that
myofascial pathology be considered, assessed and managed
[37], especially in light of the fact that an online patient
assessment of 120 interventions by 2000 women showed that
myofascial therapies, Botox (botulinum toxin) and absti-
nence from sexual and physical activities, were some of the
most effective in reducing symptoms [38]. It is not uncom-
mon for women to present with lists of inconclusive investi-
gations and a history of unsuccessful treatments [2, 39–41].
In summary, the current medical management guidelines
for both CUP disorders follow generic algorithms [2, 35, 36].
In the absence of pathology, the most common explanations
focus on somewhat nebulous notions of central sensitisation
that further enshroud the understanding of CUP.  Though
advocating multidisciplinary therapies, the literature pro-
vides little practical guidance and direction. This protracts
suffering, disability and diminished quality of life [41].
General assessment of CUP syndromes includes a detailed
health history, medical screening and a psychosexual assess-
ment. What is notably lacking is a standardised protocol for
localising and identifying the generators of pain. The author
and his collaborators have developed the first validated pain
mapping protocol [41–44]. The practical benefits of such a
protocol include the ability to obtain an individualised pain
profile and develop a customised case management plan.
75.3 Pain Mapping
The term “pain mapping” refers to the process of localising
pain and establishing an objective relationship between the
pain source and symptoms experienced by each individual
[41, 42, 45, 46]. The author and his collaborators systemati-
cally examined points that were suspected or known to
reproduce pain, assessing the quantitative and qualitative
characteristics. Each point was assessed in terms of pain
severity, temporal characteristics and spatial distribution [42,
43]. Because pain is subjective, the clinician can only achieve
926
this goal with the cooperation of the client. Pain mapping
becomes an empowering experience for clients because it
authenticates their pain and their symptoms [47].
For research purposes three pain maps were developed to
assess the external and internal pelvic points relevant to CUP
[41–45]. Map A, the external urogenital pain map, consists
of 27 palpation points and focuses on the vulvar area, tradi-
tionally thought to be the cause of vulvodynia (see Fig. 75.1).
Map B, the pelvic muscle pain map, consists of 15 palpa-
tion points and focuses on the assessment of internal pelvic
muscles, thought to be associated with a range of disorders
attributable to the levator ani muscle (see Fig. 75.2).
Map C, a new and original map, consists of 12 palpation
points and is utilised in the assessment of pain of paraure-
thral and bladder origin, previously attributed to the bladder,
but generally unrecognised and not previously mapped (see
Fig. 75.3).
A total of 54 points were assessed in the 3 anatomical
regions. Each point was rated for severity of pain using the
numerical rating scale of 0–10, where 0 represents no pain
and 10, the maximum pain ever experienced.
A study of 320 volunteers generated a total of 960 pain
maps and over 17,000 pain scores [43, 44]. Of the 320 volun-
teers, 53 were non-pain cases (mean age 34.0 ± 11.1), and
267 CUP cases (mean age 34.7 ± 12.2). Medical specialists
screened all of the non-pain and CUP cases. On the basis of
exclusion, CUP cases were diagnosed with either Vd or BPS
or both Vd and BPS. The 53 non-pain cases consisted of 32
totally asymptomatic individuals attending a gynaecology
clinic for routine PAP tests and 21 cases presenting with gyn-
aecological problems other than pain (i.e. PAP smear abnor-
malities, lichen sclerosis, polycystic ovarian syndrome). In
the CUP group, there were 119 cases (44.57%) with the
diagnosis of Vd, 119 cases (44.57%) with Vd and BPS and
29 cases (10.86%) with a diagnosis of BPS only.
A summary of all the pain scores from Maps A, B and C
is provided in Graph A, Fig. 75.4. These show mean scores
and severity of pain ratings for each point. Graph B, Fig. 75.5,
shows the comparative mean pain ratings for each of the five
groups.
The palpation of urogenital, pelvic and paraurethral points
showed that pain is limited to very specific points that can
reliably differentiate between asymptomatic and symptom-
atic women. The pain points identified define CUP syndrome
disorders. Palpating these points not only reproduced the
pain but also the symptoms frequently reported and con-
firmed that pain is not a feature of asymptomatic women.
On Map A, both the BPS and Vd cases reported high pain
scores in the vestibular and urethral points. However, it was
noted that even among the asymptomatic control group,
some women reported discomfort and pain in the vestibule,
which indicated that the vestibule is a very sensitive area for
all women and therefore may not be diagnostically as reli-
M. Jantos
able as some of the other points assessed. In the gynaecology
group, though none were diagnosed with a CUP disorder,
some points on Map A were rated as severe pain, and points
in the pelvic and paraurethral area rated in the high range. It
would appear that a range of conditions and inflammatory
states trigger sensitivity in the vestibule and urethral areas.
On Maps B and C, both groups (BPS and Vd) rated all of
the points high in terms of pain severity (the only exception
was the piriformis muscle on Map B). On Map C, paraure-
thral points consistently provided the highest pain ratings,
making this anatomical region the most painful, even though
pain from this area was imperceptible unless palpated. Mean
pain scores in the paraurethral area increased consistently
from the distal to proximal region of the urethra, and pain
scores on the left side of the urethra were consistently higher
than on the right side.
The data analysis showed that there was no relationship
between CUP and birthing and a negative correlation
between age and pain. It was also noted that the pain profiles
of women with Vd and BPS were very similar in terms of the
location and severity of pain.
Logistic regression analysis of all pain scores showed that
the most reliable points for the diagnosis of Vd and BPS came
from two points on Map A (vestibule, V6, and urethra, U9), two
points from Map B (left ischial spine, ISL, and right puborec-
talis, RPR) and two points from Map C (left paraurethral CL2
and CL5). With 94% sensitivity (true positive diagnosis) and
87.5% specificity (correct rejection), a diagnosis of CUP can
be made reliably, on the basis of these six points. Diagnostically,
of all of the points tested, the paraurethral points most reliably
differentiated between the CUP syndromes, the gynaecology
group and asymptomatic controls [48].
While palpating paraurethral points, pain was most com-
monly described as burning, sharp, stabbing and itching.
Pain from this area reproduced urethral and bladder pain,
suprapubic pressure, referred pain to the umbilicus, pubic
area, inguinal quadrants, lower lumbar region, gluteal area,
groin and in some cases the soles of the feet (Fig. 75.6) [42].
This highlights the fact that pain arising from a very well-
defined paraurethral region, unless palpated and symptoms
reproduced, can be confused with, and attributed to, a range
of other causes, including diseased organs, irritable bowel
and endometriosis. Pain from the paraurethral area was
found to refer to distant locations well beyond the pelvic
region.
For women experiencing urinary urge (a sudden and irre-
sistible desire to void—a defining symptom of overactive or
neurogenic bladder), this can be consistently reproduced
through manual palpation of specific points [49]. Palpation of
the paraurethral area reproduced urge and desire to void in
both Vd and BPS cases. Most reported the urge to void as
more distressing than pain associated with palpation. Women
with a diagnosis of Vd or BPS rarely speak of pain originating
75  A Myofascial Perspective on Chronic Urogenital Pain in Women 927

Fig. 75.1  Map A—urogenital pain map, identifying external assessment points
928 M. Jantos

Fig. 75.2  Map B—pelvic muscle pain map, identifying internal assessment points

from the paraurethral area, yet palpation of this area repro-
duced not only their pain but also symptoms of suprapubic
pressure, burning, sharp stabbing pain as well as urge. The
paraurethral area appears to be the primary generator of CUP
symptoms yet is rarely tested during diagnostic assessments.
In the symptomatic group, a subgroup of women reported
clitoral pain (a localised form of Vd). Others reported symp-
toms of persistent genital arousal, a form of unintended sex-
ual arousal [50, 51]. Both of these symptoms were reproduced
by palpation of the paraurethral points. Even among
75  A Myofascial Perspective on Chronic Urogenital Pain in Women 929

s­ ymptomatic women who did not specifically report clitoral the paraurethral area. In none of the clitorodynia cases was
pain, palpation of these points produced pain radiating into ­clitoral pain ever reproduced by Q-tip testing of clitoral tissue
clitoral tissue. It appears that localised Vd, in the form of cli- or any other mapping points. On the basis of pain mapping,
torodynia, is a form of referred pain arising from soft tissue in clitoral pain and persistent genital arousal form part of the

Fig. 75.3  Map C—bladder pain map, identifying paraurethral assessment points

Fig. 75.4  CUP chronic urogenital pain. Mean scores and the severity of pain ratings for each point on Maps A, B and C
930
Fig. 75.5  Pain mapping score comparisons for vulvodynia (VD), VD and bladder pain syndrome (BPS), BPS only, gynaecology group (Gyn) and
controls
CUP continuum originating from the paraurethral area.
Clitoral pain and persistent genital arousal both exemplify the
fact that symptoms affecting a given organ do not necessarily
originate from the organ but from soft tissue in a related ana-
tomical region and constitute a form of referred pain.
Unfortunately, the classification terminology used in rela-
tion to clitorodynia, vestibulodynia, bladder pain syndrome
or urethral syndrome clearly implicates the organ as the
source and cause of pain. Cliterodectomies further confirmed
that these symptoms were unrelated to the organ [52].
Likewise, reports of total removal of reproductive organs in
a group of young women (16–30 years of age) did not elimi-
nate or reduce their urogenital pain, highlighting the fact that
organs are not the source of pain [53]. To identify the true
origin of CUP, all mapping points need to be examined, as
patients are not able to identify the source of their pain and
symptoms.
Medical assessments generally do not include an exami-
nation of the musculoskeletal system and of the paraurethral
area [42, 54]. In the case of Vd, they follow the traditional
assessment criteria proposed by Friedrich and focus only on
the vestibule [29, 30, 35]. Yet, as shown in the mapping stud-
ies, the vestibule should not be the sole source of diagnostic
information for differentiating asymptomatic women from
other gynaecological cases. In the case of BPS, very few
studies have focused on the paraurethral area as being of
diagnostic significance, yet it is an important source of pain,
and of diagnostic significance, and should not be overlooked
in CUP assessments [55].
M. Jantos
It is also interesting to note that the pain profiles of BPS and
Vd cases are almost identical [56, 57]. This suggests that BPS and
Vd may be one and the same disorder, varying only in terms of
the topography of pain. Current diagnostic labels may reflect
more the medical specialties consulted, than the origins and
causes of CUP. As with most chronic pain conditions that have a
myofascial basis, the source of pain can be elusive and difficult to
localise as the source of pain is rarely found at the site of pain.
Once the pain is localised, it ceases to be an illusive mystery [47].
A pain mapping protocol fills a void in the clinical and
research arena and sets a new benchmark for the study of the
origins of urogenital pain. The findings give significant cre-
dence to peripheral mechanisms of pain, in which pain of
soft tissue origin is palpable and, as such, potentially respon-
sive to myofascial therapies [41, 42]. Pain mapping is cost-­
effective and bypasses a range of costly and invasive tests in
the form of laparoscopies, ultrasounds and expensive imag-
ing investigations that are not always sensitive to fascial dys-
function. By incorporating pain mapping into initial
assessments, CUP no longer presents as a mystery and the
dreaded black box of medicine [47].
75.4 Exploring Mechanisms of Pain
Management of chronic pain is most effective when the
pathogenesis and mechanisms are understood. To identify
potential mechanisms of pain, two methods of investigation
can be used; one looks at the anatomical and functional
75  A Myofascial Perspective on Chronic Urogenital Pain in Women
Fig. 75.6  Referred pain of paraurethral origin
changes associated with a given disorder, and the second
examines treatments that are effective in resolving
symptoms.
Chronic pain can be of somatic, visceral or neuropathic
origin. Of these three sources of pain, the most common is
somatic pain. Bone, cartilage tissue and organs have very
few nociceptors, but fascia that envelops these structures and
invests into the organs is richly innervated [49, 58]. This is
often overlooked, and radical pain management measures in
the form of hysterectomies, cystectomies, colectomies, ves-
tibulectomies, hymenectomies and clitoridectomies, which
have far-reaching and disabling consequences, often do more
to “ingrain and accelerate these pain conditions than to
relieve them” [59].
931
Clitoris
3
Rectum
Vulva/Vagina 7 0
1 2
47 78 1 3
19 5
272 2
6
14 44
0
17
25 11 19
82 150
30 34 72
0 0
2 22
7
Perineum Bladder
Fig. 75.7  Overlap in symptoms in women with CUP
The ongoing presence of pain, despite organ removal,
clearly suggests other mechanisms of pain, which may be of
soft tissue origin. As an example, a young woman complaining
of dysuria was referred to the author’s clinic following multiple
urethral scrapings (where pain was assumed to originate from
a deeply embedded urethral infection). The scrapings gave rise
to intense pain and severe muscle spasm that led to multiple
emergency hospitalisations. Upon discharge, the symptoms
continued to intensify with the pain becoming unrelenting. On
the basis of a pain mapping assessment, the pain was localised
to restrictions in the paraurethral area. Upon release of the fas-
cial restrictions, the symptoms subsided, and the benefits
proved to be long-term. Clearly, pain can arise from soft tissue
and be referred and experienced elsewhere [60, 61]. The con-
cept of referred pain is central to a myofascial model of pain.
Another important feature noted in CUP is that the uri-
nary and reproductive symptoms are commonly comorbid
with each other. As many as 82% of Vd cases are positive to
a bladder potassium test (a defining test for BPS) and con-
firm a dual diagnosis of Vd and BPS, while 87% of BPS
cases meet the diagnostic criteria of Vd [62]. Furthermore,
both BPS and Vd share other common co-existing conditions
such as IBS and various musculoskeletal and immune sys-
tem dysfunctions [21].
The author’s analysis of reported pain sites in 744 CUP
cases illustrates the significant overlap of symptoms and pain
sites [28]. As per Fig. 75.7, it is rare for symptoms to affect
just one specific site or bodily system.
The overlap of symptoms, common pain profiles and
comorbidities all suggest that the endopelvic fascia may
form the structural and functional link leading to urinary and
reproductive system symptoms. If the hypothesis is to be
tested, the focus needs to shift from organs of the urinary and
reproductive systems to the integrative role of the body-wide
fascial system.
932
75.5 Structure and Function of Fascia
The fascial system invests organs, nerves, blood vessels and
muscles and creates the immediate environment that either
ensures their optimal performance or mediates pain and dys-
function [63, 64]. As a fibrous communication system, it
conveys mechanical information to every cell within the
body [65–68]. The body-wide fascial network houses the
microscopic ganglia that regulate the functioning of muscles,
organs and biological systems. For optimal performance a
tensional balance must be maintained as any imbalance
within its structure results in compensatory mechanisms that
involve the musculoskeletal system, the internal fascia, and
progressively impacts the normal mobility and motility of
organs [49, 69, 70]. When the body exhausts all possible
means of compensating, fascia loses its elasticity, and the
onset of pain can be sudden and unbearable [69]. Fascial
restrictions lead to loss of muscle coordination and affect
organ peristalsis, and with densification there is greater pres-
sure on nerve endings and mechanoreceptors involved in
proprioception, nociception and interoception [49, 71].
These changes impact each of the biological systems; the
most sensitive of these is the enteric system [49].
The fascia forms four specialised layers that are identified
as superficial, deep, visceral and meningeal (the fourth layer
will not be the focus of this discussion) [64]. These layers
may blend and overlap with each other but differ in their
structure and function. They remain linked together by reti-
nacula that transfer tensional forces between the layers [64].
Superficial fascia acts as a sensory interface between the
external environment and the internal body. Deep fascia acts
as an interface between muscles, joints and organs, and
­visceral fascia between organs, glands and the other fascial
layers. The visceral layer is directly implicated in organ dys-
function via somato-visceral reflexes. This forms the basis of
fascial manipulation therapies for internal dysfunction [49,
69]. Therapy focuses on external muscles and fascia, which
then impacts on visceral fascia. In the reverse order, organ
distress is communicated to muscles and skin via viscero-
somatic reflexes that link organs with the deep and superfi-
cial layers of fascia [49, 69].
Superficial fascia forms the subcutaneous soft tissue that
is highly malleable due to its lower density of collagenous
fibres and high adipose content [64, 72]. It provides form,
stores energy and hosts elements of the body’s endocrine and
immune system as well as the estimated 80% of peripheral
autonomic innervation which regulates the flow of blood and
lymph to the skin’s surface [64, 69]. Pain associated with the
superficial fascia is only localised and does not refer to dis-
tant locations.
Deep fascia encapsulates individual muscle fibres and
invests into muscle tissue, providing stronger support, given
its higher collagen content [58, 64]. Embedded within this net-
work are various mechanoreceptors, interstitial receptors and
M. Jantos
smooth muscle-like cells known as myofibroblasts that play a
key role in the regulation and recalibration of muscle and fas-
cial tonus. It is estimated that deep fascia contains ten times as
many sensory nerve receptors as muscle tissue itself and, on
this account, plays a significant role in nociception [73].
Based on functional imaging studies, an estimated 90%
of the slow-conducting, unmyelinated nerve fibres (C-fibre
neurons) follow different pathways to the brain than those
involved in proprioception. These are labelled as interocep-
tors, which terminate not in the sensory motor cortex but
the insular cortex [71] which provides an emotional and
motivational context to the sensory information it receives.
Pain stimuli associated with injury or inflammation evoke a
sense of ill health and motivate relief-seeking behaviour.
Positive and pleasurable stimulation, such as sensual touch,
mediates emotional, hormonal and affiliative responses. In
this way the sense of wellbeing, or illness, is directly linked
to the role of interoceptors originating within the fascial
system [71].
Visceral (or internal) fascia is formed by the pleura and
the peritoneum that extends from the cranium to the lower
torso. The normal tonus of visceral fascia is reliant on its
anchorage in the bony tissue of the shoulder and pelvic gir-
dles [49]. This layer of fascia gives form to the four major
internal cavities within the body (cervical, thoracic, abdomi-
nal and pelvic). It holds each organ in its place and forms the
conduit for the major neurovascular and lymph pathways.
Visceral fascia wraps around each individual organ in a
double layer of membranous connective tissue consisting of
insertional fascia and investing fascia [49, 63]. The outer
layer (insertional fascia) holds the individual organs in place,
attaching the organ to the wall of the cavity, and the inner
layer (investing fascia) encapsulates the organ and penetrates
its internal structure [49]. Insertional fascia is much thicker
and more closely related to the mesenteries and ligaments
that insert into the trunk wall. Embedded within its fibres are
the extramural autonomic ganglia [49, 69]. Investing fascia
is thinner and enters deep into the organ forming part of its
collagenic skeleton as it blends with the smooth muscles of
the organ. Within its structure rest the intramural autonomic
ganglia that regulate the peristalsis of the organ. By this
means myofascial tension held in postural muscles can be
relayed internally (via the somato-visceral connections), to
the organ, impacting the organs’ peristalsis and normal func-
tion [49]. In the case of organ dysfunction, the reverse hap-
pens, with the visceral fascia communicating the organ’s
distress to the fascia of the trunk (via the viscero-somatic
connections), changing the tensile characteristics of the
abdominal wall and the lumbopelvic region, making it more
restricted, rigid and irregular [49]. This close relationship
between muscle tissue and organs creates a two-way com-
munication system, which can lead to a muscle-organ- or a
muscle-systems-related dysfunction or, in the other direc-
tion, an organ-muscle dysfunction [49].
75  A Myofascial Perspective on Chronic Urogenital Pain in Women
Fig. 75.8  Continuity of the
pelvic floor with the
abdominal and lumbar regions
(Used by permission of Dr
Carla Stecco)
75.6 Continuity of Pelvic Fascia
The pelvis is a well-defined anatomical and functional
region, but not isolated from the rest of the body. From a
myofascial perspective, the musculoskeletal system and the
multiple layers of fascia provide continuity between the pel-
vic floor, the abdomen and the lower back, connecting the
pelvic region and its organs with the rest of the body. Muscle
layers may generate tension enabling movement of limbs
and maintenance of posture, but it is the fascia that forms the
primary mechanism by which this mechanical tension is
communicated with adjoining body regions, cavities, organs
and the body as a whole [64, 65].
The anatomical structure of the pelvic floor consists of
four principal layers: the endopelvic fascia, the muscular
pelvic diaphragm (the levator plate), the perineal membrane
(urogenital diaphragm) and the superficial transverse perinei
[74]. These four layers of the pelvic floor are further delin-
eated by three layers of fascia [75, 76]. Each of these three
layers forms a continuum that extends from the lower
abdominal area; incorporates the pelvic muscles, its anatom-
ical structures and organs; and traverses up to the lumber
area [75, 76], as seen in Fig. 75.8.
The fascial continuity between the pelvic floor and the
abdominal and lumbar region highlights the anatomical con-
nections and potential direction in which tension is commu-
nicated. Back, groin and limb pain are often linked to pelvic
pain [77]. Compensation patterns may arise anywhere in this
continuous sequence, in response to an initial trauma, scar
tissue, irritation or inflammation. Abdominal, pelvic or lum-
bar surgery can disrupt fascial continuity and can lead to a
933
compensatory mechanism that leads to pain. In a recent case,
a client suffered severe periumbilical and lower quadrant
pain with vomiting, caused by closed-loop small bowel
obstruction and ischemia, associated with scar adhesions,
following spinal surgery (spinal fusion on account of T11–
T12 vertebral fracture). Lumbar micro-injuries and chronic
lower back pain have been shown to lead to pelvic pain and
urinary symptoms of urge and frequency [77]. These can be
resolved by the release of restrictions and adhesions, as was
successfully achieved in the case of the patient with bowel
obstruction.
75.7 R
 ole of Fascia in Chronic
Urogenital Pain
The mechanisms of chronic pain are closely related to the
tensile properties of fascia, namely, its malleability and plas-
ticity [78]. These characteristics are influenced by tempera-
ture, hydration, metabolic fluctuations, injury, surgical
trauma, infections, inflammatory states, muscle overactiva-
tion, emotional stress, sex hormones, physical inactivity, pH
and other variables [67, 79–85]. Of this long list, the two that
form the focus of this discussion are soft tissue inflammation
and muscle overactivation.
Skeletal muscles, and to a lesser degree smooth-like mus-
cle tissue embedded in the fascia, generate most of the ten-
sion in the fascial system. In the case of endopelvic fascia, it
is closely integrated with the pelvic diaphragm, consisting of
the levator ani and coccygeus muscles [72, 86]. Tension gen-
erated by pelvic muscles sets the basal tone for the whole
934
pelvic region, including its tendons and ligaments, organs
and systems. The endopelvic fascia serves as both a conduit
over which the major organs and systems receive their blood
supply and innervation and as a tensional network. The for-
mer affects perfusion, nerve conductance and lymph drain-
age, and the latter impacts the autonomic ganglia that
regulate organ peristalsis. Ischemia and inflammation are the
most common precursors to chronic pain [79]. These changes
arise in response to a prolonged state of muscle contractility,
hypoxia and the release of sensitising substances [87].
Tension in the endopelvic fascia can be generated by both
physical and psychological triggers. It is very susceptible to
inflammation, with persistent or reoccurring inflammation
causing long-term fascial restrictions [79]. Prolonged sympa-
thetic activation stimulates the immune system to release pro-
inflammatory cytokines. The expression of the cytokine
TGF-β1 stimulates myofibroblast production that is linked to
fascial contractility. Under laboratory conditions, even very
low concentrations of this cytokine elicit tissue contraction
[79]. Myofibroblasts develop out of regular fibroblasts but
contain α-smooth muscle actin (ASMA) stress fibre bundles.
These are a special phenotype of fibroblasts, identified as pho-
tomyofibroblasts, which consist of highly contractile cells that
are four times stronger than regular fibroblasts.
Photomyofibroblasts produce crimping-like contractures
within the fascia, which impact the mechanosensory regula-
tion and motor-neuronal reflexes. Though slower and weaker
than skeletal muscle contractions, they lead to collagen remod-
elling and long-lasting tissue contracture [79]. When biopsied
tissue taken from chronic pain sites was tested, it showed two
types of cells: smooth muscle cells, which are involved in the
formation of blood vessels, and myofibroblasts, which are
commonly found in wound healing and pathological tissue
contractures [79]. These findings are consistent with CUP in
which inflammatory markers, mast cells, neuropeptides and
nerve growth factor levels, consistently differentiate between
BPS and Vd cases and controls [4, 57, 88].
Other stimulants that may increase myofibroblast con-
tractility include lower pH of interstitial fluids, sexual hor-
mone activity, consumption of acid-producing foods,
dehydration and disordered breathing (commonly associated
with emotional distress); all of these can exacerbate pain
[82]. With the half-life of collagen estimated at 300–500 days
[58], long-term change requires intensive therapy focused on
softening of fascia, followed by education and lifestyle
changes [89].
75.8 Fascial Tonicity and Organ Function
The myofascial perspective on organ dysfunction shifts the
focus from the organ to its immediate environment [63]. The
non-relaxing muscles and investing fascia of the abdomen,
M. Jantos
lumbar and pelvic region form the immediate environment
of organs and impact organ peristalsis [49, 69, 90].
The peristalsis of organs is a local phenomenon, mediated
exclusively by the microscopic ganglia in the insertional fas-
cia [69]. The extramural and intramural ganglia of the auto-
nomic nervous system act as a peripheral brain, regulating
organ and gland function. The insertional fascia is highly
reactive to changes in tension [69, 74–76]. The dysregulation
of bladder pacemaker action is a sign noted in 70% of BPS
patients [88]. Micro-motions in the bladder serve as an inter-
esting example of a potential relationship between non-­
relaxing pelvic muscles, increased tension in fascia and
peristalsis of the organ [91]. The bladder wall engages in
periodic slow movements, similar to those of gastrointestinal
peristalsis. These movements are modulated by intramural
myenteric plexuses, which regulate contracting segments,
consisting of bundles of smooth muscles working as inter-
linked functional units. An increase in micro-motions results
in exaggerated sensations from the bladder, even in the
absence of any detected changes in bladder pressure, giving
rise to pathological sensory urge. In the absence of micro-­
motions, on the other hand, there may be a decrease in sensa-
tion and increased post–void residual urine [91]. When
comparing asymptomatic women with those experiencing
increased bladder sensations (overactive bladder) and pain,
patients showed significantly higher prevalence of micro-­
motions, which were associated with increased urge. Given
that intravesicular pressure changes were not the main deter-
minant, it is likely that altered myogenic properties within
the smooth muscle cells influenced their excitability [91].
This highlights a potential relationship between the immedi-
ate environment and detrusor muscle function. Factors exter-
nal to the bladder can impact on the myenteric plexuses and
the pacemaker cells regulating the initiation and coordina-
tion of bladder function. With evidence of non-relaxing mus-
cles in an overactive bladder [21, 62], it seems likely that
increased fascial tension may be a contributor to bladder
dysfunction. Case studies of an overactive bladder, where
lack of detrusor adaptability was shown to be linked to
altered fascial tension, responded positively to fascial manip-
ulation, with symptoms of overactivity and bladder pain
resolved at the conclusion of a short period of treatment [77].
Undoubtedly, a range of other factors in the regulation of the
bladder can also have impact [92, 93].
75.9 Role of Non-relaxing Muscles
It is estimated that 50–80% of patients with any form of pel-
vic pain present with non-relaxing pelvic floor dysfunction
and myofascial pain [94]. At times, symptoms are attributed
to specific muscles (e.g. levator ani syndrome, piriformis
syndrome or obturator internus syndrome); however, overac-
75  A Myofascial Perspective on Chronic Urogenital Pain in Women
tivation of pelvic muscles goes beyond an individual muscle.
Muscles work in synergistic patterns and form continuities,
in the same manner as fascia and the resulting generalised
tension-holding patterns are best described by the term “non-­
relaxing” muscles [94, 95].
The resting tone of pelvic muscles determines the basal
tone of the overlying fascia [49]. The primary structural dif-
ference between muscle and fascia is their collagen con-
tent—muscles have less collagen but stronger contractile
mechanisms. When muscles contract, the fascial tissue in the
proximity of the contracting muscle bulks up with the mus-
cle and increases in thickness by 26% [96]. As the fascia
overlaying the muscles shortens, the adjoining fascia under-
goes a selective spatial stretching, transmitting the tension in
multiple directions both longitudinally and laterally [90].
Approximately 70% of muscle-related tension transmission
is directed through tendons, and the remaining 30% of mus-
cle force is transmitted to the connective tissue in the imme-
diate surrounding of muscles [97]. In this manner
non-relaxing pelvic muscles generate tension not only in
parallel but also laterally, and this changes the anatomical
dynamics in a nonspecific, generalised way, across the whole
pelvic region.
When non-relaxing muscles augment tension in the pel-
vic region, it impacts organs and systems, especially those in
close proximity. Pelvic organs do not function in isolation,
and simply rest on PFM, but form an integral part of the pel-
vic floor:
… the pelvic organs are often thought of as being supported by
the pelvic floor, but are actually a part of it. The pelvic viscera
play an important role in forming the pelvic floor through their
connection with structures such as the cardinal and uterosacral
ligaments. [98]
When considering this at the microscopic level, the fascia
that interacts with muscle spindles within muscle tissue also
interacts with the neuronal network of the organs, creating an
interactive kinetic chain in the pelvic region, similar to that
of every other body cavity [49, 69].
A pathology common to non-relaxing muscles is increased
stiffness and rigidity of fascial tissue. Increased uptake of col-
lagen along tensional lines and the densification of loose con-
nective tissue between fascial layers sets in motion a gradual
and insidious process, evident with the onset of pain. As non-
relaxing muscles lose their contractility and extensibility, the
fascia loses its plasticity. When all possible means of com-
pensating for localised tension have been exhausted and soft
tissue has become rigid, the onset of pain can be sharp and
sudden. Densification of tissue places pressure on the mecha-
noreceptors and free nerve endings embedded in myofascial
tissue, and this gives rise to further irritation and muscle over-
activation as well as a lowering of pain thresholds and
increased sensitivity to any external pressure application
(allodynia) as is the case with CUP disorders [49, 78, 99].
935
The overactivation of muscles has other important impli-
cations for pain mechanisms. Non-relaxing muscles create
an energy crisis within local soft tissue. As muscles shorten
and bulk up, they create an ischemic state, which results in a
sensation of burning and stabbing-like pain. A muscle con-
tracting at 30–50% of its maximum contraction closes off
arterial supply and venous blood outflow [100]. This
contraction-­ischemia cycle progressively escalates and alters
the physiology of local tissue with a functional shortening of
muscles and formation of muscle contractures [41, 101].
These morphological changes are gradual and present with a
chronology of symptoms that may date back to early child-
hood, and occur in the absence of pain but are evident in
urinary voiding and defecatory disorders. Pain may not be an
initial feature but becomes evident in time or is triggered by
a noxious event.
Triggers can include obstetric trauma and pelvic surgery
[94, 102]. Where women present with already overactive
muscles, surgery can further exacerbate this problem. Most
pelvic surgeons are aware that “… if a patient has a history
or findings compatible with pelvic floor tension myalgia and/
or hypertonic dysfunction we must avoid doing surgery that
involves attaching or anchoring the support of prolapsed
organs to these muscles” [102]. Pelvic repair mesh or place-
ment of permanent sutures in fascia or muscle tissue creates
a formidable risk of pain. Other common triggers include
stress-related bracing, poor posture and occasionally inap-
propriate physical therapy, where the focus is on muscle
strengthening rather than relaxation.
75.10 S
 urface Electromyography in Studies
of Pelvic Floor Muscles
SEMG is a noninvasive, objective technique used for a func-
tional assessment of PFM [103]. It is also a common modal-
ity used for pelvic muscle rehabilitation and reeducation.
The SEMG signal reflects the summation of all action poten-
tials that are propagated along the various muscle fibre types
in muscle tissue. If the focus is on single or multiple motor
units, the action potentials are best recorded by means of fine
needle EMG recordings [104]. If larger muscles are assessed,
the preferred means is surface electrodes. SEMG tracings
show the resting tone, recruitment and fine coordination of
various muscle fibres. No other technique makes possible an
accurate and objective functional assessment of pelvic
muscles.
In the case of BPS and Vd, intravaginal SEMG probes are
used for signal acquisition, as illustrated in Fig.  75.9. The
vaginal probe has a vertical electrode configuration that
comes in contact with fibres of the puborectalis-­
pubococcygeus muscle. The shape of the probe features a
small t-bar at the base, to ensure repeatability of measure-
936
PELVIC DIAPHRAGM - SEMG PROBE VIEW
Position of SEMG probe
Fig. 75.9  Pelvic surface electromyography (SEMG) probe in situ
(Vaginal sensor, T6065 Thought Technology Ltd, Montreal, Canada)
ment in terms of orientation and depth of sensor placement,
and a small bulb at the top of the probe for comfortable inser-
tion and consistent seating of the sensor in a prone, standing
or walking position.
Certain morphological characteristics of pelvic muscles
are pertinent to interpreting SEMG signal. As a striated mus-
cle, the levator ani muscle contains a range of muscle fibre
types. PFMs contain small, slow firing aerobic fibres,
referred to as slow-twitch fibres (type I), and medium to fast
firing, anaerobic fibres known as fast-twitch fibres (types IIa,
IIb, IIx). Type I fibres activate slowly but are capable of lon-
ger contractions and are more fatigue resistant. Type II fibres
generate faster contractions but fatigued quickly because of
their reliance on anaerobic metabolism. The composite sig-
nal derived from pelvic muscles can be analysed using spec-
tral analysis, which shows the range of fibre frequencies that
make up the SEMG signal. The normal pelvic muscle fre-
quencies range between 0.5 and 350  Hz, but, on average,
range between 5 and 140  Hz. Microvolt amplitudes range
from less than 1 uv up to 100 uv, but on average, in healthy
muscles, contractions will generate 20–50 uv. These param-
eters can vary in relation to individual anatomy, tissue fat
content and equipment specifications (electrode design and
notch filters).
The SEMG signal is analysed in terms of three specific
dimensions: amplitude, time and power spectrum. The func-
tional features of PFM that are of interest are resting tone of
muscles, responsiveness of muscles to activation and deacti-
M. Jantos
vation, coordination of muscle fibre type during muscle acti-
vation, amplitude during phasic (fast-twitch mediated) and
tonic (slow-twitch mediated) contractions, neuromuscular
stability as measured by variability of signal and muscle
endurance and fatigue as reflected in median and mean
spectral frequencies [32]. Each of these variables provides
insight into the nature of muscle dysfunction, in particular
muscle insufficiency (hypotonicity) as in the case of incon-
tinence, or muscle overactivation as seen in non-relaxing
muscles (hypertonicity), in chronic pain disorders. Patterns
of muscle substitution, co-contraction, spasms, tremors and
psychophysiological tonus (emotional arousal), these can be
appraised with the assistance of SEMG.  It is important to
emphasise that SEMG signal is not a direct measure of
weakness, muscle strength or pain, but different features of
the derived signal correlate strongly with various symptoms
[99, 103, 105].
75.11 S
 EMG Studies of Chronic Urogenital
Pain Disorders
To date, the most extensive studies have been carried out in
relation to Vd, with only a few SEMG studies on BPS. The
author and his collaborators found that SEMG functional
assessments of pelvic muscles reliably differentiated between
Vd cases and controls in the following muscle characteristics:
• Elevated resting baselines in 71% of cases, with readings
over 2.0 μV indicating non-relaxing muscles
• Poor contractile potential in 63% of cases with readings
under 17 μV being consistent with functional weakness
• Elevated resting standard deviation in 93% of the group,
with readings greater than 2 μV showing significant sig-
nal variability and neuromuscular instability
• Poor recruitment and recovery times of over 0.2 s in 86%
of cases, reflecting compromised coordination of muscle
fibres
• Spectral frequency of less than 115 Hz in 69% of cases,
associated with fatigue
As a pain group, 88% of Vd cases showed at least three of
the criteria listed above [32]. The most notable feature was
the overactivation of pelvic muscles—hence the term “non-­
relaxing muscles”. The specific features of SEMG signals
that differentiate symptomatic patients from asymptomatic
controls in the case of Vd included:
• 32% more amplitude during pretest rest
• 49% more muscle variability during pretest rest
• 46% less amplitude during 3 s phasic contractions
• 49% less amplitude during 12 s tonic contractions
 75  A Myofascial Perspective on Chronic Urogenital Pain in Women 937

a
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Elevated rested baseline
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Fig. 75.10 (a) Surface electromyography (SEMG) tracing, female
nulliparous, age 24 years, primary Vd, with an early onset of symptoms
(prior to commencement of sexual activity). The pretreatment SEMG
assessment shows two phasic and two tonic contractions, illustrating an
elevated resting baseline (approximately 50% of maximum voluntary
contraction), variability (irritability) and muscle fatigue (scale range
0–26 μV). (b) SEMG tracing of posttreatment assessment of the same
client, following biofeedback-­assisted muscle retraining, showing nor-
malisation of muscle function, with good resting baseline, excellent
recruitment and recovery, increased contraction amplitude and experi-
encing a pain-free state (scale range 0–26 μV)

Chronic overactivation of pelvic muscles progressively
leads to painful decompensating and peripheral sensitisation,
most often described as burning pain [106].
In studies of SEMG-assisted retraining, patients reported
an 83% reduction in symptoms [107]. In a study conducted
by the author involving 529 Vd patients, SEMG-assisted
retraining, in conjunction with myofascial therapy, alleviated
or totally resolved symptoms of Vd, in 80–90% of patients
[101]. The normalisation of pelvic muscle function is illus-
trated in Fig. 75.10a, b showing the pretreatment and post-
treatment SEMG tracings.
When SEMG findings were compared with manual assess-
ments carried out by trained physical therapists, women with
Vd symptoms presented with superficial and deeper pelvic
 938 M. Jantos

26
24
22
20
Low level of contraction
18
16 Fatigue
14
12
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6
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Elevated resting baseline
2 (non-relaxing muscle) Poor recovery & instability
0
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Fig. 75.11  Female, nulliparous, 22 years of age, adolescent onset of bladder pain syndrome symptoms. Pretreatment surface electromyography
assessment of two phasic contractions and two tonic contractions (scale range 0–26 μV)

floor muscle hypertonicity, reduced muscle strength, inability
to relax and restrictions in the degree of vaginal stretch [108].
The study found that 90% of the women experiencing pain
with intercourse demonstrated pelvic floor pathology and
associated comorbidities that included irritable bowel, evacu-
ation difficulties and anal fissures.
There are very few SEMG studies profiling patients with
bladder pain. The studies that used SEMG assessments and
physical exams found the same dysfunctional muscle pat-
terns including overactivation, inadequate voluntary control,
muscle shortening and trigger point referred pain [19, 103].
These features were not only seen as associated with bladder
pain syndrome but were seen as causing symptoms of blad-
der pain [19]. These findings were confirmed by a study of
BPS, where a physical examination was carried out by
trained nurse practitioners, who identified non-relaxing mus-
cles, and myofascial trigger point pain which reproduced the
patients’ symptoms. The study noted that levator muscle ten-
derness and palpable taut muscle bands elicited pain in the
bladder, vagina, vulva and perineum [62]. The pain mecha-
nisms were similar to those reported in Vd studies.
Figure 75.11 illustrates the level of PFM overactivation as
seen in a SEMG assessment of a female patient with a history
of bladder pain symptoms, with urge and frequency. The
22-year-old patient had undergone two hydrodistentions, both
reported as very painful, but provided no symptom relief.
Non-relaxing pelvic muscles as seen in this BPS case are
characterised by a continuous state of mild contraction. The
level of overactivation is approximately 50–70% of that of a
maximal voluntary contraction. A reduction of BPS symp-
toms was associated with progressive relaxation of pelvic
muscles, with a 65% reduction in SEMG resting tone (from
9.73 to 3.61 μv) [19]. Both BPS and Vd cases share similar
SEMG profiles, confirming that the disorders constitute the
same regional pain syndrome.
Advanced SEMG intravaginal probes and customised soft-
ware systems can add further sophistication enabling multi-
channel assessments of PFM. Measures of muscle asymmetry,
and dynamic studies evaluating the impact of movement and
posture on pelvic muscle function provide more insight. In
postpartum women, asymmetries at multiple muscle sites are
associated with birth-related muscle dysfunction as illustrated
in Fig. 75.12. These tracings were obtained from a 60-year-
old, following two pregnancies and two births in her mid- to
late 20s. The most evident pattern is a 50–70% asymmetry in
muscle tone, reflecting weakness in the right pelvic muscles
(the right pubococcygeus and right iliococcygeus).
Four-channel SEMG assessments of the pelvis comple-
ment assessments carried out with ultrasound or scanning
technologies.
75.12 Conclusion
CUP is a prevalent problem that affects a disproportionately
high number of women. Traditionally, care providers have
looked for tissue trauma or pathology to explain the symp-
toms. With the development of a pain mapping protocol, a
more pragmatic, mechanisms-focused approach to assess-
ment is possible. Pain mapping, as a tool, can assist in local-
75  A Myofascial Perspective on Chronic Urogenital Pain in Women
A: EMG RMS 5.58 % asymmetry
30
20
10
0
00:00:00 00:00:05 00:00:10 00:00:15 00:00:20 00:00:25
C: EMG RMS 2.21 % asymmetry
30
20
10
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Fig. 75.12  Four-channel surface electromyography tracing exemplifying asymmetries: (a) right pubococcygeus; (b) left coccygeus; (c) right
iliococcygeus; and (d) left iliococcygeus. EMG RMS electromyography rigth muscles
ising the source of pain and linking symptoms to peripheral
soft tissue anomalies. Historically, the association of dys-
functional pelvic muscles and CUP has been well estab-
lished. Whether by means of manual assessment, scanning or
SEMG technologies, studies consistently confirm the pres-
ence of non-relaxing muscles in CUP disorders. However,
the question of how non-relaxing muscles relate to organ
dysfunction and symptoms of pain has not been addressed
and requires a closer examination of the body-wide fascial
system.
Fascia has been the most overlooked anatomical structure
in relation to chronic pain. Its various layers (superficial,
deep and visceral) are densely innervated with interstitial
and mechanoreceptors. The free nerve endings communicate
nociceptive information to the sensory motor cortex, but,
more importantly, target the insular cortex, shaping proac-
tive, health-related behaviour and influencing the individu-
al’s sense of illness or wellbeing.
939
- 47.85 B: EMG RMS 8.26
00:00:30 00:00:35 00:00:40 00:00:45 00:00:50 00:00:55 00:00:60
- 68.95 D: EMG RMS 3.74
00:00:30 00:00:35 00:00:40 00:00:45 00:00:50 00:00:55 00:00:60
Traditionally, the presence of comorbidities and the over-
lap of CUP symptoms were explained on the basis of central
sensitisation and nerve-mediated cross-talk. Though not dis-
counting a central component in chronic pain, the fascial ten-
sional system, conceptually and clinically, provides a more
logical mechanism in terms of organ pathophysiology,
comorbidities and concurrent symptoms in the urinary,
reproductive, digestive and musculoskeletal systems.
Histology findings identifying the presence of ischemic
and inflammatory markers at chronic pain sites establish a
link between fascial, the limbic and immune systems.
Triggers, whether iatrogenic, mechanical, infectious, chem-
ical or emotional, set in process morphological changes that
lead to peripheral sensitisation and central nervous system
involvement. The pathophysiological progression of chronic
pain requires that intervention be directed first and foremost
to peripheral mechanisms. Any frontline intervention which
bypasses the peripheral mechanisms and focuses only on
940 M. Jantos

GENERAL TRIGGERS
latrogenic
Mechanical/Chemical/Metabolic
Infectious/Hormonal/Emotional
(Sensory Interface – Fascia System)

NON-RELAXING MUSCLES
Generate Tension
Energy Crisis
Neuromuscular Instability/Fatigue SOM
IC ATO
MAT Muscular Contracture
-SO
-SO MA
ERO (Sensory Interface – Deep Fascia)
TIC
SC
VI
ORGAN DISTRESS FASCIAL PLASTICITY
Restriction in Visceral Mobility CHRONIC Restrictions /Densification/Remodelling
Dysregulation of Peristalsis Compression of Mechanoreceptors
Referred Pain /Autonomic Reactions UROGENITAL Motor-neuronal Excitation
(Sensory interface - Visceral Fascia) PAIN Autonomic Dysregulation
Organ/Gland Distension (Sensory Interface – Fascial System)
VI
SC PATHOPHYSIOLOGY L
ER RA
O- Pro-inflammatory Mediators E
VIS SC
CE Neuroproliferative Changes -VI
RAL ATO
Hypervascularity SOM
Peripheral & Central Sensitization
Pain

THERAPY
Myofascial Assessment
Pain Mapping & SEMG
Normalize Muscle Function
Myofascial Mobilization
Education and Stress Management

Fig. 75.13  Myofascial model of chronic urogenital pain. SEMG surface electromyography

surgical or central mechanisms (be they psychological or

pharmaceutical) is likely to have limited effect.
Based on these premises, a new perspective is proposed
that reflects a paradigm shift away from the traditional
diseased-­organ concepts to a model focusing on peripheral
soft tissue mechanisms. Evolving evidence gives credence to
a model of CUP where the musculoskeletal and fascial sys-
tems become central to the understanding of chronic pain. A
range of triggers may generate muscle reflex reactions, but
it’s the persistent tension, generated by non-relaxing mus-
cles, that gives rise to pathophysiology mediated by fascia
and impacts the function of organs and systems. These
changes progressively and insidiously give rise to CUP, as
illustrated in Fig. 75.13.
Management needs to focus on restoring fascial plasticity
and normalising of muscle function with the aid of SEMG.
The most pressing requirement in the management of
CUP is not so much for new techniques but rather for new
premises that lead to new strategies. Useful new premises are
a lot harder to come by than seemingly new techniques [65].
Research on the efficacy of the myofascial model continues
to expand, and further work is needed examining the struc-
tural and functional aspects of fascia, its role in propriocep-
tion and in particular the impact of sexual hormones on its
responsiveness and plasticity. It is an emerging field in anat-
omy, one that has been overlooked. Conceptually and bio-
logically, the myofascial model of CUP is plausible and well
supported by current science.
Take-Home Messages
• CUP is a prevalent but overlooked women’s
health issue, in which the current generic medical
guidelines are suboptimal in providing symptom
relief.
• The shift from the traditional diseased-organ con-
cepts of pain to a myofascial model directs greater
focus to the interactive kinetic chain linking mus-
cles, fascia and the neuronal network of organs.
Fascial pathology (densification and loss of plastic-
ity) takes on an important role and helps to better
explain the concurrent symptoms and multiple
comorbidities.
• The body-wide fascial system, as a fibrous commu-
nication system (akin to the central nervous and cir-
culatory systems), invests organs, nerves, blood
vessels and muscles, creates the immediate environ-
ment for organs and systems and either ensures
their optimal performance or mediates pain and
dysfunction. As such it must be central in assess-
ment and management.
• The myofascial model of CUP reflects a paradigm
shift in which peripheral pain mechanisms take on
greater significance. Though plausible conceptually
and biologically, the model requires and encourages
further research.
75  A Myofascial Perspective on Chronic Urogenital Pain in Women
Acknowledgments The author wishes to acknowledge fellow
researchers and colleagues. Special thanks and appreciation to Drs
Sherie Johns and Ewa Baszak-Radomańska for their research contribu-
tion to pain mapping and to Professors Carla Stecco and Robert Schleip
for their reviews and comments.
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 Pharmacological Treatment of Chronic
Pelvic Pain
Ashish Shetty, Oscar Morice, and Sohier Elneil
Learning Objectives
• To review the mechanisms of action and efficacy of
traditional analgesics, including aspirin, NSAIDs,
paracetamol, and opioids in chronic pelvic pain.
• To assess the use of hormonal therapy in the local
and systemic relief of pelvic pain.
• To evaluate the potency and side effect profile of
sodium channel blockers, membrane stabilisers, as
well as antidepressants and anxiolytics in the atten-
uating pelvic pain.
76.1 Introduction
Chronic pelvic pain (CPP) is defined as non-malignant pain per-
ceived in structures related to the pelvis that may be constant or
recurrent for a period exceeding 6 months [1]. The worldwide
prevalence of this condition is estimated at 2–24% in women,
accounting for over 20% of gynaecological consultations, and a
decrease in work productivity evaluated at 45% [2, 3]. Men also
suffer from this condition, known as chronic pelvic pain syn-
drome, with urological pain and/or discomfort often associated
with urinary symptoms and sexual dysfunction [4].
Gynaecological pain syndromes may be divided into
those affecting the external genitalia, such as vulvar pain
syndrome or vestibular pain syndrome, and those affecting
internal tissues, such as endometriosis-associated pain syn-
drome or dysmenorrhoea. In men this is mirrored in condi-
tions such as scrotal pain syndrome or prostate pain
syndrome, respectively [5]. When pain is perceived before/
during/after sexual intercourse, then often the pelvic floor
A. Shetty (*) · S. Elneil
Division of Pain Medicine, University College London Hospitals,
London, UK
e-mail: drashshetty@gmail.com; s.elneil@btconnect.com
O. Morice
University College London Medical School, London, UK
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_76
76
muscles are thought to be contributing to the problem. But,
regardless of the name of the condition, in all cases the
pathogenesis remains the same – a combination of peripheral
and central pain mechanisms. A diagnosis is made after an
assessment of a specific disease-associated pelvic pain and
of functional, emotional, behavioural and other quality of
life issues. Only after such an assessment can therapy be
instituted.
Targeted therapy is recommended if a specific diagnosis
is made. Chronic pelvic pain seldom stems from a single
cause; however, it usually arises from multiple organ sys-
tems, with a combined gynaecological, gastrointestinal, uro-
logical, neuronal and/or musculoskeletal aetiology.
Treatment therefore consists in an empiric trial of therapies
based on diagnostic probabilities that aims at relieving symp-
toms. As a mixture of nociceptive, neuropathic, inflamma-
tory and visceral pain, chronic pelvic pain is treated with a
combination therapy that acts on the different types of pain
and targets both peripheral and central generators. This chap-
ter outlines the current pharmacological regimens used to
treat this spectrum of conditions.
76.2 Traditional Analgesics
Traditional analgesics may be used alone, or in combination,
to reduce the severity of acute exacerbations of chronic pel-
vic pain and provide long-term pain relief. These include
aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs),
paracetamol and opioids.
Mechanistically, aspirin irreversibly inhibits cyclooxy-
genase 1 enzymes (COX-1) and acts as an allosteric modula-
tor of cyclooxygenase 2 enzymes (COX-2). The former
catalyse the formation of pro-inflammatory prostaglandins
and thromboxane from arachidonic acid; its analgesics
effects are therefore thought to be secondary to a reduction in
inflammation [6, 7]. This agent effectively reduces pain asso-
ciated with primary dysmenorrhoea, though its effects are
moderate and not long-lasting [8–10].
945
946 A. Shetty et al.

Nonsteroidal anti-inflammatory drugs (NSAIDs), revers- endometriotic tissue and the suppression of ovarian func-
ible inhibitors of COX-1 and 2 enzymes, also relieve pain tions; COCPs come as pills, transdermal patches or vaginal
around menses, as well as menstrual flow, and moderate rings [21]. A large cohort study following an approximate
chronic pelvic pain [9, 11, 12]. Interestingly, despite the 17,000 women for over 20 years estimates the risk reduction
diversity of molecular derivatives that constitute NSAIDs, noof endometriosis with women taking the pill at 60%, demon-
specific subtype is more effective at reducing primary dys- strating the effectiveness of this treatment in suppressing
menorrhoea than others [9]. Chronic use is however associ- endometriosis and the pain associated with it [22]. Oral con-
ated with substantial cardiovascular, gastrointestinal, renaltraceptive pills are also effective in relieving noncyclic
and hepatic side effects [13]. Traditional NSAIDs inhibit chronic pelvic pain, dyspareunia and dysmenorrhoea follow-
both classes of cyclooxygenases and are therefore deemed ing surgical excision of endometriomas, with their continuous
nonselective; the inhibition of COX-2 enzymes is thought to use superior at relieving pain associated with menses [23].
mediate the anti-inflammatory effects, whereas the gastroin- Progestogens and synthetic progestogens (progestins)
testinal side effects appear to be related to the inhibition of
may be used for those who fail to tolerate combined hor-
COX-1 enzymes. Selective COX-2 inhibitors have therefore monal contraceptives. Preparations are available orally, par-
been developed, reducing significantly the risk of peptic enterally, as an implant or as an intrauterine delivery system,
ulceration. One such agent, celecoxib, improves pain scores with a wide variety of chemically related compounds avail-
in men diagnosed with chronic pain pelvic syndrome, though able. These agents inhibit the transcription of angiogenic
symptomatic relief is limited to the duration of treatment factors, suppress matrix metalloproteinases-mediated endo-
[14]. There is growing evidence that this class of NSAIDs metrial growth and induce intrauterine and extrauterine atro-
increases cardiovascular risks in the management of chronic phy of endometrial tissue [24, 25]. Norethindrone acetate, a
pain in the elderly, further limiting their use [15]. 10-nortestosterone progestin, relieves pain associated with
Paracetamol, whose mechanism of action remains largely rectovaginal endometriosis, whilst subcutaneous depot
unknown, does not provide effective relief when used on its medroxyprogesterone acetate effectively controls
own; evidence suggests that this compound may have a endometriosis-­associated pain [26, 27]; the levonorgestrel
cumulative effect when used with caffeine or a NSAID, pro- intrauterine system on the other hand provides a route to
viding moderate relief of menstrual pelvic pain [16, 17]. deliver progestogen directly into the uterine cavity at a steady
Chronic use of this compound is however associated with rate for a 5-year period and has proved effective in treating
substantial hepatic and gastrointestinal complications [18]. menorrhagia, adenomyosis and pelvic and rectovaginal
Opioids are increasingly discouraged in chronic non-­ endometriosis, with a low side effect profile due to reduced
malignant pain as the risks likely outweigh the benefits, as a
systemic levels [28, 29].
result of significant adverse effects including sedation, con- Gonadotropin-releasing hormone agonists work by con-
stipation, urinary retention, falls and reinforcement disorders
tinuously stimulating the anterior pituitary, initially trigger-
[19]. These compounds act on three types of G-protein-­ ing a burst of luteinising (LH) and follicular stimulating
coupled receptors (μ, κ, δ), expressed pre- and postsynapti- hormones (FSH), to inhibit their production; this induces a
cally in the brain and spinal cord, thus affecting nociceptive
hypogonadotropic hypogonadal state akin to menopause,
transmission along the pain neuroaxis. There is currently no resulting in amenorrhoea and endometrial atrophy [30]. This
evidence to support the use of this class of compounds in class may be given intramuscularly, intranasally or subcuta-
chronic pelvic pain [20]. neously. GnRH agonists relieve 50–90% of endometriosis-­
related pain, with an efficacy comparable to surgical
treatment in alleviating dysmenorrhoea and dyspareunia
76.3 Hormonal Treatment associated with endometriosis [31, 32]. GnRH agonists are
however associated with significant vasomotor symptoms,
A range of hormonal treatments are available to treat condi- sleep disturbances and accelerated bone loss related to the
tions associated with chronic pelvic pain, including combi- hypoestrogenic state; combined oestrogen and progestin hor-
nation formulas of oestrogens and progestogens, in the form mone add-back regimens reduce these adverse effects with-
of the combined oral contraceptive pill (COCP), the out compromising efficacy [33, 34].
progesterone-­only pill, slow-releasing levonorgestrel-­ Androgens, deemed as effective as GnRH agonists at
containing intrauterine systems (IUS), gonadotrophin-­ relieving pain associated with menses and pelvic pain, sup-
releasing hormone (GnRH) agonists and androgens. These press the release of pituitary gonadotrophins, steroid ovarian
agents are generally deemed safe, affordable, reversible and production and the growth of endometriotic implants [30,
convenient, with a relatively low side effect profile. 35]. Their systemic use induces a hyperandrogenic state,
The commonly used combined oral contraceptive pill associated with acne, hirsutism, deepening of the voice, cli-
relieves pain by inducing the decidualisation and atrophy of macteric hot flushes, oedema and weight gain [36]. To reduce
76  Pharmacological Treatment of Chronic Pelvic Pain
systemic effects, topical preparations of danazol, a 17-­ethinyl
testosterone derivative, have been developed: vaginal or
intrauterine applications effectively reduce menorrhagia and
the size of the lesions in recurrent deeply infiltrating endo-
metriosis, with a lower side effect profile [37].
76.4 Local Anaesthetics
Local anaesthetics (LAs), commonly used in neuropathic
pain conditions, interfere with the generation and conduction
of action potentials in the nervous by blocking the pore of
voltage-gated sodium channels and have shown beneficial for
pelvic pains [38]. Trigger points are cutaneous or muscular
areas that generate neuralgic or referred musculoskeletal pain
when stimulated, which may be injected with LAs in a series
of weekly treatments to significantly reduce the pain experi-
enced in those regions [39–41]. Local anaesthetics may also
be used to induce a nerve block, targeting common culprits of
pelvic pain, such as the ilioinguinal, genitofemoral and
pudendal nerves. This technique has proved effective in the
short-term, though its long-term impact remains controversial
[42, 43]. Of note the addition of corticosteroids to local anaes-
thetics does not provide additional therapeutic benefits and is
associated with an increased risk of necrosis [44].
76.5 Antidepressants
The analgesics properties of antidepressants have been
reported for over 40 years and constitute a standard regimen
for the treatment of chronic and neuropathic pain disorders
[45]. Though well-established for a range of chronic pain
conditions, the evidence regarding their effectiveness in
chronic pelvic pain remains relatively scarce [46].
Tricyclic antidepressants (TCAs) are indeed a first-line
therapy for many neuropathic pain conditions. They act pri-
marily by blocking the reuptake of serotonin and noradrena-
line, increasing the synaptic concentration of these
neurotransmitters in descending pain modulatory pathways
of the spine [47]. One such TCA, amitriptyline, effectively
relieves pain associated with interstitial cystitis and urgency
frequency in men, with pain scores also reduced by an esti-
mated 70% in female patients that suffer from chronic pelvic
pain refractory to surgical treatment and antinociceptive phar-
macotherapy [48–50]. Tricyclic antidepressants display how-
ever potent antimuscarinic side effects, including fatigue, dry
mouth, constipation, urinary retention and cognitive and
memory impairment, limiting their chronic use. Secondary
amine tricyclics nortriptyline and desipramine present a lower
anticholinergic profile and are usually better tolerated [51].
Other antidepressants have been tried to alleviate chronic
pelvic pain, though the evidence regarding their efficacy is
947
very limited. The selective serotonin-noradrenaline reuptake
inhibitor (SNRI) duloxetine increases centrally available
noradrenaline and serotonin in descending modulatory pain
pathways and has proved effective in urological pain disor-
ders in men and women [52]. On the other hand, sertraline, a
selective serotonin reuptake inhibitor (SSRI), fails to improve
pain scores in women with chronic pelvic pain in a small
crossover trial [53].
76.6 Membrane Stabilisers
Calcium channel blockers are used in a wide range of neuro-
pathic pain conditions including diabetic neuropathy, post-­
herpetic neuralgia and spinal cord injury [54]. N-type
calcium channels, localised in superficial laminae of the dor-
sal horn, are expressed on synaptic nerve terminals and their
opening results in the release of excitatory neurotransmitters
such as glutamate and substance P in the spinal cord, whilst
T-type voltage-gated calcium channels, expressed on nerve
endings, contribute to electrogenesis; calcium channel block-
ers therefore act on both central and peripheral components
of neuronal excitability [55, 56].
One such agent, gabapentin, is more effective than ami-
triptyline at relieving chronic pelvic pain, with a reduction of
80% in pain scores 12 months after intervention, compared
to 70% with the tricyclic antidepressant [50]. In another
small trial, nearly half of patients with refractory genitouri-
nary pain, including interstitial cystitis, pain following blad-
der suspension surgery and genital pain related to lumbosacral
neuropathy, respond to gabapentin, despite failing on a range
of prior treatments [57]. Gabapentin also relieves chronic
pelvic pain in women with no obvious pathology, with a con-
comitant reduction in anxiety scores [58]. Whether all cal-
cium channel blockers may alleviate CPP remains
controversial; pregabalin, for instance, fails to reduce pain
scores in men with chronic pelvic pain/chronic prostatitis,
despite a 6-week course [59].
76.7 Anxiolytics
Evidence is emerging for the use of benzodiazepines in the
management of pelvic floor and urogenital pain conditions;
these act as positive allosteric modulators of GABAA recep-
tors, hyperpolarising the neuronal membrane potential [60,
61]. Their systemic use is however associated with severe
adverse effects such as confusion, amnesia, ataxia and
dependence. To circumvent this issue, vaginally adminis-
tered diazepam has been developed, effectively relieving
patients with levator ani and vulvar pain that failed prior
treatments, with serum levels not elevated despite a month of
daily treatment [62]. Diazepam suppositories also improve
948
pelvic floor pain and dyspareunia when used as an adjunct
treatment to physical therapy and intramuscular trigger point
injections for high-tone pelvic floor dysfunction [63].
76.8 Conclusion
Chronic pelvic pain is currently managed with an armamen-
tarium of agents that aim at reducing, rather than curing, pain
and present with a range of adverse effects that need to be
considered with a prolonged use. Present guidelines and
expert opinion algorithms are essentially derived from
empirical knowledge due to the scarcity of the literature,
warranting the need to conduct larger randomised clinical
trials to establish the efficacy profile of most agents currently
used in clinic. Long-term use of analgesics alone is not opti-
mal in management of chronic pain conditions. For now, a
multidisciplinary approach incorporating pharmacotherapy,
physical therapy, psychotherapy, lifestyle changes and neu-
romodulation remains the mainstay of optimal management
for this spectrum of conditions.
Take-Home Messages
The aetiology of chronic pelvic pain syndromes
remains largely unknown, impeding the targeting of
the mechanisms that underlie the development and
16. Ali Z, Burnett I, Eccles R, North M, Jawad M, Jawad S, Clarke G,
maintenance of pelvic pain syndromes. Effective pain
relief currently relies on a multidisciplinary approach,
using an armamentarium of analgesics that act locally
and/or in a systemic fashion to affect both central and
peripheral mechanisms. The unravelling of the precise
mechanisms that underlie pelvic pain syndromes
should allow to develop more specific therapeutic regi-
mens, and thus provide greater symptomatic relief for
chronic sufferers.
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 Idiopathic Chronic Pelvic Pain:
A Different Perspective
Peter Petros and Yuki Sekiguchi
Learning Objectives
• “Idiopathic” chronic pelvic pain (CPP) co-occurs
with bladder and bowel symptoms and is mainly
caused by inability of lax uterosacral ligaments
(USLs) to support the Frankenhauser and sacral
plexuses.
• Gentle insertion of the lower blade of a bivalve
speculum into the posterior fornix will partially
relieve the pain in approximately 70% of women,
demonstrating USL causation.
• A high cure rate for CPP in younger women can be
expected by USL plication. Older women are less
likely to be cured by USL plication and may require
a posterior sling.
77.1 Introduction
The International Continence Society defines chronic pelvic
pain syndrome as “Genitourinary pain syndromes are all
chronic in their nature. Pain is a major complaint but con-
comitant complaints are of lower urinary tract, bowel, sexual
or gynecological in nature where there was no infection or
other obvious pathology” [1]. Chronic pelvic pain occurs in
19% of adult Europeans [2]. The health costs of chronic pain
to the community are significant: hundreds of millions of
P. Petros (*)
University of NSW Professorial Department of Surgery,
St Vincent’s Hospital, Sydney, NSW, Australia
School of Mechanical and Chemical Engineering,
University of Western Australia, Perth, WA, Australia
e-mail: pp@kvinno.com; http://www.integraltheory.org
Y. Sekiguchi
Women’s Clinic LUNA, Yokohama, Japan
Yokohama City University Graduate School of Medicine,
Yokohama, Japan
e-mail: dumbo-ys@d9.dion.ne.jp
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_77
77
dollars p.a.; the reported time lost from paid work was 15%
with 45% reduced work productivity [3].
The pathogenesis of “idiopathic” chronic pelvic pain
(ICPP) is still not well understood. One theory is that ICPP
is thought to be associated with changes in the central ner-
vous system which may maintain the perception of pain in
the absence of acute injury. Such changes may magnify per-
ception: nonpainful stimuli are perceived as painful (allo-
dynia); painful stimuli are perceived as more painful than
expected (hyperalgesia) [4]. It is hypothesized that there is
both peripheral and central hypersensitization [4]. Peripheral
hypersensitization describes augmented sensory pain input
from the peripheral nervous system. Central hypersensitiza-
tion describes a predisposition to dysfunctional central regu-
lation of the sensory input [5]. In parallel, there are
accompanying symptoms, for example, urinary symptoms
or, frequently, psychosocial symptoms.
According to the Cochrane database, the main treatments
at present available include counseling, psychotherapy,
physical therapy, medications, psychosomatic therapy, lapa-
roscopic uterine nerve ablation, presacral neurectomy, and
hysterectomy, with or without removal of the ovaries [6]. Not
mentioned is the role of lax uterosacral ligaments (USLs) in
the causation of ICPP. This has been known since 1996 [7] in
the English literature and since 1938 in the German literature
[8]. In 1938 Heinrich Martius stated that “in about 30% of
cases, backaches are provoked by damaged suspending or
supporting ligaments of the pelvic organs” [8].
Idiopathic chronic pelvic pain is part of a specific symp-
tom complex known as the “posterior fornix syndrome” [9].
It is caused by lax apical support. This syndrome, reported
for the first time in 1993, (variously) encompasses chronic
pelvic pain, bladder symptoms of urgency, abnormal empty-
ing, and nocturia [9]. Such patients rarely present with single
symptoms. These symptoms occur in predictable groupings
(Fig. 77.1). A detailed description of lower abdominal pain
was reported in 1996 by ANZJOG [7]: “In its acute state of
manifestation, the pain was invariably severe, frequently
one-sided, situated low in the right or left iliac fossa, usually
951
952 P. Petros and Y. Sekiguchi

Fig. 77.1  Simplified pictorial

diagnostic algorithm. Relates
structural damage (prolapse)
to symptoms: (1) stress
incontinence, (2) cystocele,
(3) uterine prolapse, and (4)
rectocele. The size of the bar
gives an approximate
indication of the prevalence
(probability) of the symptom.
Ligaments which can be
repaired are pubourethral
ligament (PUL), CX ring/
cardinal ligament (CL), arcus
tendineus fascia pelvis
(ATFP), uterosacral ligament
(USL), and perineal body
(PB). The main symptom for
“tethered vagina syndrome” is
massive urine loss
immediately on getting out of
bed in the morning. The cause
is excessive tightness in the
bladder neck area of the
vagina. Because pain and
urgency have a peripheral
neurological origin, even
minimal vaginal prolapse may
cause major symptoms
77  Idiopathic Chronic Pelvic Pain: A Different Perspective 953

relieved on lying down, frequently relieved by insertion of a
ring pessary, and reproducible on palpating the cervix and
displacing it posteriorly with the patient in the supine posi-
tion. Although the pain was chronic in nature, it varied con-
siderably from time to time as concerns intensity. Six patients
(two of whom were nulliparas) entered the study through the
Emergency Department. The pain had become sufficiently
acute as to seek emergency care. Almost all patients com-
plained of tiredness and irritability by the end of the day. A
ring pessary considerably relieved the symptoms in approxi-
mately half of the patients, but on occasions, if the pessary
was too small, it fell out, or no effect was noted: if too large,
the symptoms frequently worsened.” Significant cure of
these symptoms was achieved by plication of the uterosacral
ligaments (Fig. 77.2) [7]. Initial cure rate for these different
pain manifestations by USL “native tissue” repair performed
under local anesthesia/sedation was 85% but subsequently
fell rapidly. This was attributed to collagen defect in the
ligaments.
77.2 T
 he Present Scope of ICPP: Presence
of Other Symptoms

We have found that vulvodynia and classical interstitial cys-

titis patients almost invariably have other posterior fornix
syndrome symptoms, urge, nocturia, and abnormal bladder
emptying. But there are also other pelvic symptoms. In a
study of 198 women, Goeschen et  al. [10] presented their
version of the “Pescatori Iceberg” (Fig.  77.3). In 2007
Pescatori et al. [11] described their “iceberg” concept: pelvic
symptoms (including psychologic and psychosomatic symp-
toms) occurred in groups, with one major symptom being the
“tip” of the iceberg and many others below the surface which
surfaced when Goeschen used the validated Integral Theory
System Questionnaire [12] to guide specific questioning to
identify other pelvic symptoms.

77.3 Anatomical Pathway to ICCP

Chronic pelvic pain is perceived in the various nerve distri-

Fig. 77.2  “Native tissue” approximation of uterosacral ligaments
(USL). A 5-cm-long transverse full-thickness incision is made in the
posterior vaginal wall 3–4 cm below the cervix (CX) (A–B). The loose
USLs are approximated (arrows) with No. 1 Vicryl sutures
butions, T11-L2, S2-4 (Fig.  77.4): lower abdomen, groin,
lower sacrum [13], introitus [14], paraurethral [15], intersti-
tial cystitis [16], and deep dyspareunia [7].
Inability of the weakened muscles to tension the uterosac-
ral ligaments may cause unsupported nerve plexuses within
the USLs to fire off to cause ICPP (Fig. 77.5).

Fig. 77.3  Pescatori Iceberg

applied to chronic pelvic pain. Chronic Pelvic Pain & Apical Prolapse
The symptom prevalence is 198
graphically indicated in the
iceberg diagram, latent
symptoms below the
waterline. All symptoms cy
derived from the Integral uen
eq
ng

127
Fr
e

Theory Symptom
yi

nc
pt

Questionnaire (ITSQ).
ne
Em

e
nc
nti

Numbers indicate combined

er

ine
co
d

total of the hysterectomy and

R

nt
ad
N

l In
es

oc

co
Bl

non-hysterectomy patients.
SU
i

ca

68
du

t
O

In
ur
D

I
al

Fe
ia

ODS obstructed defecation

ge
S
U

63 66 56
Ur
rin

syndrome, SUI stress urinary 61 55

e

incontinence 44
954
Sacral
pathway
Ganglion
Frankenhäuser
Fig. 77.4  The uterosacral nerve ganglia—the pathways to idiopathic
chronic pelvic pain. Left figure. The hypogastric nerve emerges from the
superior hypogastric plexus at the level of the sacral promontory. Its fibers
run anteriorly and distally, to merge with the pelvic splanchnic nerves to
form the inferior hypogastric plexus (ganglion of Frankenhauser). Right
figure. The sacral nerve roots leave the sacral foramina and run over the
piriformis muscle to merge and form the nerves of the sacral plexus
77.4 USL Laxity as a Cause of CPP
The etiology of USL laxity is generally attributed to age- or
birth-related collagen damage or hormone-induced depoly-
merization during pregnancy; the weakened ligament is then
stretched during childbirth; if there is failure of the ligament
to return to normal length and strength in the post-op period,
it may result in the prolapses and symptoms depicted in
Fig. 77.1.
The concept that ICPP originates in the sacral (S2-4) and
Frankenhauser nerve plexuses is not new. The anatomical
basis for this pain was described in the 1930s by Professor
Heinrich Martius from Gottingen, Germany [8] (Fig. 77.4).
Competent USLs support the nerve plexuses. They also pro-
vide a firm contraction point for the posterior pelvic muscle
vectors. These stretch the ligaments, further enabling USL
support of the nerve plexuses. How USL causation of CPP
was “rediscovered” is described in the September 2017
Editorial in Pelviperineology Journal [17]: WWII was cata-
strophic for German science and especially for the German
P. Petros and Y. Sekiguchi
Ganglion
Frankenhäuser
Fig. 77.5  Pathogenesis of chronic pelvic pain. The ganglions of the
Frankenhauser and the sacral plexuses are supported by competent
uterosacral ligaments (USLs) at their uterine end. “L” indicates liga-
ment laxity. The posterior directional forces are weakened and cannot
stretch the USLs sufficiently for them to support the nerves. The nerves
may be stimulated by gravity or by the prolapse or by intercourse to fire
off and be perceived as pain by the cortex
language as a vehicle of science. Many important historical
writings became unavailable to the now dominant Anglophone
scientific community. Amongst the lost and forgotten works
were the pre-war German language writings of Heinrich
Martius on the role of loose uterosacral ligaments in the cau-
sation of chronic pelvic pain. It is an accident of fate that
these writings were recently brought to the surface by
Professor Klaus Goeschen [21]. Goeschen was trained in
gynecological surgery by Gerhard Martius, son of Heinrich.
He had the knowledge and access to the literature needed to
recover these ‘lost’ writings. In 2015 Goeschen wrote: “Since
some decades, Heinrich Martius published in the German lit-
erature that in about 30% of cases, backaches are provoked
by damaged suspending or supporting ligaments of the pelvic
organs. The paired “Ligamenta recto-uterina”, which are
connected via paraproctium to the bony sacrum und therefore
in general are termed “plica or ligamenta sacro-uterina” or
“USL”, are placed in the centre of numerous pathophysiolog-
ical considerations. Unfortunately, Martius’s concepts have
remained largely unknown in the English literature. In 1993,
77  Idiopathic Chronic Pelvic Pain: A Different Perspective 955

Petros and Ulmsten i­ndependently described ICPP as being
caused by lax uterosacral ligaments as part of the “Posterior
Fornix Syndrome”, along with other pelvic symptoms, noctu-
ria, urgency, abnormal emptying. They reported a significant
cure rate of ICPP and other posterior fornix symptoms fol-
lowing repair of the uterosacral ligaments. Petros wrote a
classic description of this pain in 1996. Heinrich Martius
wrote detailed d­ escriptions of the role of uterosacral ligament
laxity, Frankenhauser and Sacral ganglia in the causation of
ICPP”.
77.5 P
 retreatment Diagnosis That USL
Laxity Is the Cause of ICPP
Use of the diagnostic pictorial algorithm (Fig.  77.1) is the
first step in any diagnosis. Other posterior pelvic symptoms,
bladder, bowel, are almost invariably present. In 1993, idio-
pathic CPP was described as being part of the “posterior for-
nix syndrome” [9]. ICPP was almost invariably associated
with nocturia, urgency, and abnormal bladder emptying, all a
consequence (for different reasons) of laxity in the uterosac-
ral ligaments (Fig.  77.1). Later a further association was
found with obstructive defecation and fecal incontinence
(Fig. 77.1). Two office tests help to confirm USL as a cause
of ICPP and help predict results of surgery. Later Goeschen
and Gold [10] extended associated symptoms with their
“Pescatori Iceberg” adaptation (Fig. 77.3).
77.5.1 Confirmation of USL Origin of Pain by
Vaginal Examination
A gentle vaginal examination where the cervix is gently
touched generally reproduces the particular pelvic pain. It
can only do this once, as the pain provoked even with gentle
examination can be severe. Some degree of USL laxity is
present, even in nulliparas. USL laxity may seem absent dur-
ing vaginal examination. One technique to reveal it is to gen-
tly elevate the anterior vaginal wall with the lower blade of a
bivalve speculum and ask the patient to strain. Generally an
enterocele becomes obvious. In the OR, a uterine or apical
prolapse, often only to the halfway mark, is revealed on pull-
ing the cervix downward in the OR. Attempting this in the
clinic is not advised as it can provoke considerable pain.
holding forceps with a gauze or a large menstrual tampon
and observing the change in pain symptoms. The key prin-
ciple is to gently support the USLs as they enter the cervical
ring, not to stretch them. Any pushing usually worsens the
symptoms, which is, of course, another type of proof that the
pain originates in the anatomical position of the nerve
plexuses.
Wu et al. [15] reported relief of pelvic pain and subure-
thral tenderness by insertion of the lower part of a bivalve
speculum to support the posterior fornix. Bornstein relieved
vulvodynia pain by local anesthetic injection into the cervi-
cal part of the ULSs [14] as did Petros in three patients with
interstitial cystitis, abdominal pain, and suburethral tender-
ness [16]. Gunnemann reversed anterior rectal wall intussus-
ception with a cylindrical vaginal pessary, inserted under
ultrasound control [18], and also pain and nocturia overnight
in 70% of women with the pessary (Gunnemann personal
communication).
77.5.3 Confirmation of USL Origin of Pain by
the Bornstein Test
The “Bornstein test” is a definitive test for determining
whether ICPP may be caused by lax USLs. The question of
loose USL as an etiological factor was tested in ten patients
with chronic extreme vulvodynia in 2005 [14]. Two mL of
2% lidocaine (5–10 mL of weaker solution can also be used)
was injected transvaginally at the junction of USL to the cer-
vix. On retesting after 5  min, eight patients reported com-
plete disappearance of introital sensitivity, and this was
confirmed by two separate examiners. In the other two
patients, direct testing confirmed that the allodynia (exagger-
ated sensitivity) had disappeared on one side, but remained
on the other. Retesting the patients at 30 min confirmed that
the blocking effect on the pain had disappeared. The
Bornstein test was applied to three patients with ICPP and
symptoms of bladder pain syndrome. The abdominal, ure-
thral, introital, and cervical tenderness which were demon-
strated objectively pretest in all three patients disappeared
entirely, or were substantially improved, within 5 min of the
LA injection [16].
77.6 I mprovement of CPP by Squatting-­
Based PFR

77.5.2 Confirmation of USL Origin of Pain In 2004, Patricia Skilling [19] introduced the first new
with “Simulated Operations” method for pelvic floor rehabilitation (PFR) since Kegel in
1948. The Skilling PFR method is a squatting-based method;
These consist of mechanically supporting the USL by gently it works by strengthening the three directional muscles
inserting the lower blade of a bivalve speculum into the pos- which control urethral closure, its evacuation; the same three
terior fornix of the vagina, or a roll gauze, or a sponge-­ muscle forces stretch the vagina in opposite directions to
956
Table 77.1  Fate of individual symptoms (n = 60)
Condition >50% improvement
Stress incontinence (n = 42) 78%
Urge incontinence (n = 39) 61%
Frequency only (n = 53) 62%
Nocturia (n = 24) 75%
Pelvic pain (n = 20) 65%
Leakage (n = 50) 68%
Bowel problems (n = 28) 78%
Table 77.2  Fate of individual symptoms (n = 78)
Condition >50% improvement
Stress incontinence (n = 69) 57 (82%)
Urge incontinence (n = 44) 33 (68%)
Frequency only (n = 12) 10 (83%)
Nocturia (n = 32) 29 (90%)
Pelvic pain (n = 17) 13 (76%)
support the bladder base stretch receptors, thereby prevent-
ing urine loss by premature activation of the micturition
reflex (urge incontinence). Both the initial data (Table 77.1)
[20] and the later data (Table 77.2) [19] indicate that all these
functions can be improved with this method, not just the USI
which the Kegel method addresses.
77.6.1 How the Skilling Squatting-Based PFR
Method Evolved
By 1995 it was evident from the surgical data that a substan-
tial percentage of chronic pelvic pain and bladder and bowel
dysfunctions in the female could be cured by surgical repair
of the pelvic suspensory ligaments. It was hypothesized that
a squatting-based regime would strengthen the three direc-
tional muscle forces and the ligaments against which they
contract; this would improve urethral closure (incontinence)
evacuation (bladder emptying) and support of the bladder
base stretch receptors (urge incontinence) and enable the
now strengthened USLs to better support the Frankenhauser
and sacral nerve plexuses, thereby alleviating ICPP.  The
standard regime comprised four visits in 3 months. HRT was
administered to all patients, electrotherapy 20  min per day
for 4 weeks with a 50 Hz probe placed into the posterior for-
nix of the vagina, squeezing 3 × 12 per day, reverse push-
downs 3  ×  12 per day, and squatting or equivalent up to
20 min per day as part of daily routine (such as household
tasks). Of 147 patients (mean age 52.5  years), 53% com-
pleted the program. Median QOL improvement reported was
66%, mean cough stress test urine loss reduced from 2.2
(range 0–20.3) to 0.2 (range 0–1.4), p < 0.005, and 24-h pad
loss from a mean of 3.7 (range 0–21.8) to a mean of 0.76
(range 0–9.3), p  <  0.005. Frequency, nocturia, and pelvic
pain were significantly improved (p < 0.005). Residual urine
P. Petros and Y. Sekiguchi
reduced from mean 202 to mean 71  mL (p  <  0.005). This
method extends indications for nonsurgical therapy beyond
stress incontinence, and the results appear to encourage this
approach. Approximately 3% of patients reported worsening
of their stress incontinence and these were referred for sur-
gery. Unlike the Kegel exercises, the patients do not need to
“squeeze upward” prior to a cough or sneeze. Urethral clo-
sure occurs spontaneously and reflexly, because the three
reflexly acting closure muscles are strengthened (m.pubo-
coccygeus, levator ani, conjoint longitudinal ani muscle), not
the puborectalis “Kegel” muscle.
77.6.2 The Simplified Skilling PFR Method
Both PFR trials [19, 20] had a dropout rate of 50% within
3 months. Subsequent to these trials, Skilling began a simpli-
fied PFR method consisting only of 10–20 squats morning
and night. The trial was not completed, but the preliminary
clinical data indicated a virtually zero dropout rate and very
promising improvement rates for all symptoms, especially in
younger women.
77.7 Surgical Repair Option
Initially, an 85% cure rate was reported at 3 months follow-
ing approximation of the uterosacral ligaments (USLs) [7]
(Fig. 77.2). These operations were all performed under local
anesthesia/sedation. However, the cure rate deteriorated to
70% at 12 months and further in the next 2 years. On this
basis, a posterior sling was introduced to reinforce the USLs,
much in the way of the midurethral sling [21–24].
77.7.1 USL Native Tissue Repair Technique
The posterior vaginal wall is grasped by two Littlewood’s
forceps 4 cm below the cervix. Under tension, a full-­thickness
5 cm transverse incision is made. Using a strong needle with
No1 Vicryl suture, the tissues just below the vagina are pen-
etrated to a depth of 2 cm laterally, approximated, and tied
and the incision closed. Two such sutures are usually suffi-
cient (Fig. 77.2).
77.7.2 Posterior Sling Repair of USL
This operation (Fig.  77.6), known as the “infracocygeal
sacropexy” or “posterior IVS” (PIVS), was first performed
in 1992 at Royal Perth Hospital, Western Australia, under
LA/sedation on a patient with major pain and incontinence
symptoms. Twenty-month data was published in 1997 [21].
77  Idiopathic Chronic Pelvic Pain: A Different Perspective 957

Fig. 77.6 Infracoccygeal
sacropexy or “posterior IVS.”
The apex is suspended to the
sacrospinous ligaments with a
polypropylene tape. IS ischial
spine, LP m.levator plate, PB
perineal body, PC
m.pubococcygeus, PS pubic
symphysis, R rectum, S
sacrum, V vagina

Table 77.3  Symptom outcome—67 patients

Odds Ratio USL laxity Symptom change with surgery % Cure in brackets
Frequency Nocturia Urge incontinence Abnormal
Fecal incontinence >10/day >2/day >2/day emptying Pelvic pain
0.34 0.40 0.70 0.54 0.79 0.69
n = 23 n = 27 n = 47 n = 36 n = 53 n = 46
(87%) (63%) (83%) (78%) (73%) (86%)
P < 0.005 P < 0.005 P < 0.005 P < 0.005 P < 0.005 P < 0.005
Mean age 65 years. USL uterosacral ligament

A transverse incision is made in the posterior vaginal wall
1 cm below the hysterectomy scar line. A channel is made in
the direction of the ischial spine sufficient to insert the index
finger. The ischial spine is located and the point of entry of the
instrument marked by the index finger. Bilateral skin inci-
sions 0.5 cm long are made in the perianal skin at the 4 and 8
o’clock positions halfway between the coccyx and external
anal sphincter (EAS) in a line 2 cm lateral to the external bor-
der of EAS. The tunneler is pushed 3 to 4 cm into the ischio-
rectal fossa (IRF) keeping the plastic tip parallel to the floor.
The index finger guides the tip of the tunneler which is then
brought to the point of penetration 1 cm medial to the ischial
spine (Fig. 77.6). At this point, the tunneler is safely sited well
away from the rectum and peritoneum. The tapes are inserted
from the vagina end and pulled downward. This corrects the
uterine/apical prolapse, mechanically supports the USLs, and
creates a neo-cervical ring anteriorly or posteriorly depending
on where the tape has been placed. A rectal examination is
made to ensure there has been no perforation.
77.7.3 USL Tensioned TFS Sling
A less invasive posterior sling, posterior TFS (tissue fixation
system) sling, was first reported in prototype form in 2005
[24] and with associated symptom cure in 2010, Tables 77.3
and 77.4 [25]. ICPP co-occurred with bladder and bowel
symptoms. The odds ratio for pain and other symptoms rela-
tive to lax USLs is shown in Table 77.3. Along with ICPP,
other symptoms were simultaneously cured or improved
with a posterior sling as per Table 77.3. In Table 77.4, there
are similar results in 28 patients who had only minimal first-­
degree uterine prolapse. This validated the integral theory’s
statement that major symptoms may be caused by only
958
Table 77.4  Symptom outcome—1st degree vault/uterine prolapse (n = 28)
Symptom change with surgery
Frequency Nocturia
Fecal incontinence >10/day >2/day
n = 8 n = 8 n = 17
(100%) (63%) (76%)
­ inimal prolapse and these are surgically curable with USL
m
repair.
The cervix is pulled downward so as to allow easier iden-
tification of the USLs. The ligaments are identified. A trans-
verse incision is made 1–3 cm below the cervix dependent on
the degree of prolapse. A tunnel is made into the USLs to
about 5  cm with Metzenbaum scissors. The applicator is
inserted into the tunnel. The anchor is released. The applica-
tion is repeated on the contralateral side and the tape is
adjusted until a resistance is felt. This indicates return of
muscle tone in the muscles which act on that ligament. The
tape is cut. The musculo-elastic layer of the vagina is attached
to the vaginal ends of the ligament. The vagina is closed.
Tables 77.3 and 77.4 [25] show early results from CL/
USL TFS ligament repair. The odds ratios, Table  77.3,
confirm the close association between the pelvic symp-
toms and USL laxity. Wagenlehner et  al. [26] compared
TFS and PIVS. Both achieved high cure rates for chronic
pelvic pain and bladder and bowel symptoms. Abendstein
et al. [27] reported cure of obstructed defecation, chronic
pelvic pain, and fecal incontinence with a posterior sling
(Fig. 77.7).
Fig. 77.7  TFS cardinal/uterosacral ligament (USL) repair. The trans-
verse TFS tape is the cardinal ligament tape. It “reglues” the displaced
anterior vaginal wall to the cervix and reattaches the often dislocated
arcus tendineus fascia pelvis to a site 2 cm above the ischial spine (IS).
The uterosacral TFS tape shortens and reinforces the elongated USLs to
their presacral fascial origins
P. Petros and Y. Sekiguchi
% Cure in brackets
Urge incontinence Abnormal
>2/day emptying Pelvic pain
n = 17 n = 19 n = 18
(76%) (73%) (82%)
77.8 Discussion
Heinrich Martius described two pathways for CPP, visceral
and mechanical (Fig.  77.4). The pain originating from the
visceral pathway was transmitted from Frankenhauser plexus
which is situated approximately 2 cm lateral to the cervix. It
lies at the distal end of the hypogastric plexus. The second
pathway originates from stimulation of the sacral plexus.
These pains radiate mainly to the lumbosacral region, the
anterior and lateral abdominal wall, the inguinal region, and
the thighs and are characterized by low dragging abdominal
pain or deep sacral backache. The pelvic pain addressed by
this study is consistent with both of these descriptions.
According to the theory, loose USLs fail to support the
Frankenhauser and sacral plexuses, and these can fire off
whenever tension is applied, either by gravity, intra-­
abdominal contents, or during intercourse (“contact dyspa-
reunia”). The results of Sekiguchi et al.’s study [13] do not
support peripheral and central hypersensitization. Cure,
when it occurred, was almost invariably immediate, usually
by the following day. The data (Tables 77.3, 77.4 and 77.5)
confirm that ICPP co-occurs with bladder and bowel symp-
toms and these are usually, but not always, cured at the same
time as cure of ICPP.
77.9 Conclusions
Chronic pelvic pain of no obvious cause almost invariably
co-occurs with other symptoms, bladder and bowel dysfunc-
tions (Fig.  77.1). This is an important diagnostic point.
Symptoms of isolated pelvic pain with no symptoms of blad-
der and bowel dysfunction very rarely are associated with
USL laxity. Along with ICPP, very significant cure/improve-
ment was noted in bladder symptoms such as nocturia, fre-
quency, urgency, and non-sphincteric fecal incontinence by
reinforcing the apical ligamentous supports of the vagina.
According to the Skilling data (Table  77.2), in premeno-
pausal patients with good tissues, squatting-based PFR can
provide an up to 50% improvement in pain symptoms in up
to 90% of women. Native tissue repair by USL plication can
give a high improvement rate for ICPP and other posterior
zone symptoms, at least initially. Unfortunately, due to col-
lagen deterioration, there will likely be reoccurrence of
Table 77.5  Signs and symtoms (pelvic pain, nocturia, urge incontinence, frequency, fecal incontinence, apical prolapse) at baseline and after 12 months in patients operated by Infracoccygeal
Sacropexy (PIVS) or Tissue Fixation System (TFS)
Number of patients with symptom or condition/total patients Confidence interval difference between
77  Idiopathic Chronic Pelvic Pain: A Different Perspective

(%) proportiona Probability (two-tailed)b

Pre-PIVS vs.
Pre-PIVS Pre-­TFS Post-­PIVS Post-­TFS pre-TFS Post-PIVS vs. post-TFS Pre-PIVS vs. pre-TFS Post-PIVS vs. post-TFS
Pelvic pain 405/809 (50) 197/611 (31) 131/809 (16) 42/611 (7) 0.13 to 0.23 0.06 to 0.12 <0.0001 <0.0002
Nocturia 286/809 (35) 254/611 (41) 59/809 (13) 77/611 (7) 0.011 to 0.11 0.021 to 0.085 0.017 0.0008
Urge incontinence 233/809 (40) 317/611 (52) 100/809 (12) 51/611 (8) 0.069 to 0.17 0.007 to 0.071 <0.0002 0.0015
Frequency 233/549 (42) 310/611 (51) 48/549 (9) 55/611 (9) −0.015 to 0.094 0.03 to 0.035 0.0047 0.87
Fecal incontinence 69/324 (21) 93/532 (17) 17/324 (5) 34/532 (6) −0.015 to 0.094 −0.023 to 0.042 0.167 0.49
Apical prolapse 809/809 (100) 611/611 (100) 56/809 (7) 63/611 (10) −0.006 to 0.005 0.0047 to 0.064 //0.022
a
No continuity correction
b
Z-test comparing PIVS vs. TFS, before or after surgery (www.vassarstarts.net)
959
960
symptoms with age, especially after the menopause. It is
futile therefore to proceed with “native tissue repair” in older
women, especially when tapes precisely placed along the
cardinal/uterosacral ligaments can give proven long-term
5-year surgical results in 70-year-old women [28] and with
very minimal tape erosions. Using third-generation light-
weight individually knitted tapes, tensioned slings have been
inserted for both USI and prolapse with no erosions reported
at 12 months [29, 30] or even at 3 years [31].
Take-Home Messages
• Idiopathic pelvic pain is not idiopathic. It usually
co-occurs with bladder and bowel symptoms which
need to be located by specific questioning.
• All these symptoms can potentially be improved by
the Skilling PFR method or cured by surgically
shortening and reinforcing the uterosacral
ligaments.
• A positive speculum test indicates surgical inter-
vention may be successful.
References
1. Abrams P, Cardozo L, Fall M, et al. The standardisation of terminol-
ogy of lower urinary tract function: report from the Standardisation
Sub-committee of the International Continence Society. Neurourol
Urodyn. 2002;21:167–78.
2. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey
of chronic pain in Europe: prevalence, impact on daily life, and
treatment. Eur J Pain. 2006;10:287–333.
3. Mathias SD, Kuppermann M, Liberman RF, Lipschutz RC, Steege
JF. Chronic pelvic pain: prevalence, health-related quality of life,
and economic correlates. Obstet Gynecol. 1996;87:321–7.
4. Fall M, Baranowski AP, Elneil S, et al. EAU guidelines on chronic
pelvic pain. Eur Urol. 2010;57:35–48.
5. Kairys AE, Schmidt-Wilcke T, Puiu T, et al. Increased brain gray
matter in the primary somatosensory cortex is associated with
increased pain and mood disturbance in interstitial cystitis/painful
bladder syndrome patients. J Urol. 2015;193:131–7.
6. Stones RW, Mountfield J.  Interventions for treating chronic
pelvic pain in women. Cochrane Database Syst Rev. 2000;4:
CD000387.
7. Petros PE. Severe chronic pelvic pain in women may be caused by
ligamentous laxity in the posterior fornix of the vagina. Aust NZ J
Obstet Gynaecol. 1996;36:351–4.
8. Martius H. Über einen häufigen gynäkologischen,
Symptomkomplex. Arch Gynecol Obstet. 1938;166:332–5.
9. Petros PE, Ulmsten U. The posterior fornix syndrome: a multiple
symptom complex of pelvic pain and abnormal urinary symptoms
deriving from laxity in the posterior fornix. Scand J Urol Nephrol.
1993;27:89–93.
P. Petros and Y. Sekiguchi
10. Goeschen K, Gold DM.  Surgical cure of chronic pelvic pain,
associated bladder and bowel symptoms by posterior sling in 198
patients validates the Pescatori iceberg principle of pelvic symptom
co-occurrence. Pelviperineology. 2017;36:84–8.
11. Pescatori M, Spyrou M, Pulvirenti d’Urso A. A prospective evalua-
tion of occult disorders in obstructed defecation using the ‘iceberg
diagram’. Colorectal Dis. 2007;9:452–6.
12. Wagenlehner FM, Fröhlich O, Bschleipfer T, Weidner W, Perletti
G.  The Integral Theory System Questionnaire: an anatomically
directed questionnaire to determine pelvic floor dysfunctions in
women. World J Urol. 2014;32:769–81.
13. Sekiguchi Y, Inoue H, Liedl B, et al. Is chronic pelvic pain in the
female surgically curable by uterosacral/cardinal ligament repair?
Pelviperineology. 2017;36:74–8.
14. Zarfati D, Petros PE. The Bornstein test—a local anaesthetic tech-
nique for testing uterosacral nerve plexus origins of chronic pelvic
pain. Pelviperineology. 2017;36:89–91.
15. Wu Q, Luo L, Petros PE. Case report: mechanical support of the
posterior fornix relieved urgency and suburethral tenderness.
Pelviperineology. 2013;32:55–6.
16. Petros PE.  Interstitial cystitis (painful bladder syndrome) may,
in some cases, be a referred pain from the uterosacral ligaments.
Pelviperineology. 2010;29:56–9.
17. Weintraub A, Petros PE. Editorial dedicated to Professor Heinrich
Martius, pioneer in the ligamentous origin of chronic pelvic pain in
the female. Pelviperineology. 2017;36:66.
18. Gunnemann A, Petros PE.  The role of vaginal apical support in
the genesis of anterior rectal wall prolapse. Tech Coloproctol.
2014;18:517–8.
19. Skilling PM, Petros PE.  Synergistic non-surgical manage-
ment of pelvic floor dysfunction: second report. Int J Urogyn.
2004;15:106–10.
20. Petros PE, Skilling PM. Pelvic floor rehabilitation according to the
integral theory of female urinary incontinence—first report. Eur J
Obstet Gynecol. 2001;94:264–9.
21. Petros PE.  New ambulatory surgical methods using an anatomi-
cal classification of urinary dysfunction improve stress, urge and
abnormal emptying. Int Urogynecol J Pelvic Floor Dysfunct.
1997;8:270–7.
22. Farnsworth BN. Posterior intravaginal slingplasty (infracoccygeal
sacropexy) for severe posthysterectomy vaginal vault prolapse—a
preliminary report on efficacy and safety. Int Urogynecol J Pelvic
Floor Dysfunct. 2002;13:4–8.
23. Sivaslioglu AA, Gelisen O, Dolen I, et al. Posterior sling (infracoc-
cygeal sacropexy): an alternative procedure for vaginal vault pro-
lapse. Aust N Z J Obstet Gynaecol. 2005;45:159–60.
24. Petros PE, Richardson PA. Tissue Fixation System posterior sling
for repair of uterine/vault prolapse—a preliminary report. Aust N Z
J Obstet Gynaecol. 2005;45:376–9.
25. Petros PE, Richardson PA.  TFS posterior sling improves overac-
tive bladder, pelvic pain and abnormal emptying, even with minor
prolapse—a prospective urodynamic study. Pelviperineology.
2010;29:52–5.
26. Wagenlehner F, Muller-Funogea IA, Perletti G, et al. Vaginal api-
cal prolapse repair using two different sling techniques improves
chronic pelvic pain, urgency and nocturia—a multicentre study of
1420 patients. Pelviperineology. 2016;35:99–104.
27. Abendstein B, Brugger BA, Furtschegger A, Rieger M, Petros
PE.  Role of the uterosacral ligaments in the causation of rectal
intussusception, abnormal bowel emptying, and fecal inconti-
nence—a prospective study. J Pelviperineol. 2008;27:118–21.
77  Idiopathic Chronic Pelvic Pain: A Different Perspective
28. Inoue H, Kohata Y, Fukuda T, et al. Repair of damaged ligaments
with tissue fixation system minisling is sufficient to cure major
prolapse in all three compartments: 5-year data. J Obstet Gynaecol
Res. 2017;43(10):1570–7.
29. Sekiguchi Y, Kinjo M, Maeda Y, Kubota Y. Reinforcement of sus-
pensory ligaments under local anesthesia cures pelvic organ pro-
lapse: 12-month results. Int Urogynecol J. 2014;25:783–9.
961
30. Shkarupa D, Kubin N, Pisarev A, Zaytseva A, Shapovalova E. The
hybrid technique of pelvic organ prolapse treatment: apical sling and
subfascial colporrhaphy. Int Urogynecol J. 2017;28(9):1407–13.
31. Nakamura R, Yao M, Maeda Y, Fujisaki A, Sekiguchi Y. Outpatient
mid-urethral tissue fixation system sling for urodynamic stress uri-
nary incontinence: 3-year surgical and quality of life results. Int
Urogynecol J. 2017;28(11):1733–8.
 Part IX
Fistulae
 Urogenital Fistulae
78
Andrew Browning

In the developing world, iatrogenic fistula have cer-

Learning Objectives tainly been on the rise in the last decade, being the cause
• To determine the incidence, different aetiologies of a urogenital fistula in approximately 25% of cases in
and classifications of urogenital fistula. some series from sub-Saharan Africa [4–7]. Uretero-
• To understand the broad range of injuries that occur vaginal fistula are also on the rise, invariably caused by
in the obstructed labour injury complex; physical, caesarean, hysterectomy or caesarean hysterecomty [8].
mental and social. Interestingly there seems to be an increasing incidence of
• To understand the different surgical approaches to repair fistula due to hysterectomy in the developed world as the
a urogenital fistula, knowing the shortfalls and potential number of hysterectomies, and perhaps skills, is decreasing,
complications of such treatments and to realize that uro- whilst with more access to caesareans and hysterectomies in
genital fistula is almost entirely preventable. the developing world are also causing more urogenital fistula
but undoubtedly saving lives [9].
However, it is still the case that the majority of fistula in
the developing world is caused by long obstructed labour.
78.1 Introduction The two groups differ in aetiology and certainly in clas-
sification or type of fistula. The iatrogenic cases not caused
Female urogenital tract fistula leads to complete and devas- by a broad ischaemic insult leading to wide tissue loss. They
tating urinary incontinence. No one knows for certain how are usually higher in the genital tract, they are significantly
many women suffer from this condition. A review of 19 smaller with less scarring and hence are easier to cure
papers concluded that overall there are 0.29 fistula sufferers (Fig.  78.1). Those caused by obstructed labour are lower,
per 1000 women of reproductive age. The highest incidence often involving the urethra, they are larger and more scarred,
being 1.57 women of reproductive age per 1000 women in
sub-Saharan Africa [1]. Others have estimated that there are
up to two million women suffering this condition worldwide
with approximately 50,000–100,000 new cases occurring
each year, mostly in lower resourced settings [2]. Either way
it is a significant public health problem.
Female urogenital tract fistula can be broadly divided
between those seen in the developed world, where safe
obstetric care is abundant and those seen in the developing
world, where safe obstetric care is less available.
In the developed world they are more commonly seen
after pelvic surgery with 0.1–4% of cases of surgery in the
pelvis inadvertently causing a urogenital fistula [3].
Urogenital tract fistula can also be caused by other patholo-
gies, e.g. cancer or even radiotherapy.
Fig. 78.1  Small iatrogenic intracervical fistula after caesarean (Dr
Andrew Browning, used with permission)
A. Browning (*)
Medical Director, Barbara May Foundation, Bowral, Australia
e-mail: andrew_browning@hotmail.com

© Springer Nature Switzerland AG 2021 965

G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_78
966
Fig. 78.2  Large circumferential obstetric fistula. The metal catheter is
in the small distal remnant of the urethra and the rest of the vagina and
bladder base has sloughed. The view is straight into the remaining blad-
der (Dr Andrew Browning, used with permission)
making the corrective surgery more difficult (Fig.  78.2).
These have a higher chance of ongoing incontinence despite
successful closure [6, 10, 11].
Although these differences are present, the patient pres-
ents with the same incontinence and misery, leaking urine
day and night.
78.2 Aetiology and Epidemiology
Urogenital fistula occurs more commonly in the developing
world so the focus will be here. As stated above the most are
caused by long unrelieved obstructed labour, lasting
3–4 days. The presenting part compresses against the moth-
er’s pelvis and the soft tissues between undergo ischaemic
necrosis. Eventually the unborn child dies, 90–98% having a
still-born delivery. If she has not reached a hospital for an
assisted, destructive or operative delivery, she may well die.
If she does survive, the now collapsing foetal skull is expelled
leaving her moribund with exhaustion. The ischaemic tissues
in the pelvis, which include some or all of bladder, urethra,
ureter, uterus, cervix, vagina and also rectum, anus and pel-
vic muscles, all slough away after 3–10 days (Fig. 78.3) leav-
ing a urogenital fistula (79–100%), or combined urogenital
and recotvaginal fistulae (1–23%) or rarely a recto vaginal
fistula in isolation (1–8%) [12].
The women with obstetric fistula are usually young,
poorly educated, and in 45–62.7% of cases they are pri-
miparous, the injury occurring in the first delivery [13–17],
but many are multiparous when they get their fistula [18].
They are often short, less than 150 cm in height although
height is a poor indicator of having an obstructed labour
[19–21]. Interestingly they have a narrow intertuberous
space, perhaps this could be a crude marker of those
women at risk [21].
A. Browning
Fig. 78.3  Necrotic bladder sloughing. The vaginal side has already
sloughed (Dr Andrew Browning, used with permission)
The common factor, however, is the long obstructed labour.
There are many factors contributing to this; lack of awareness
to get help in labour, needing permission from the mother-in-
law or husband to go to hospital, lack of transport of funds to
get to the hospital, a reluctance to go to hospital for the fear
that they will be abused physically or verbally at hospital.
There is also a common belief (often correct) that they will
receive poor quality care as the local health facilities are under-
resourced and staff unmotivated, having not been paid for
months on end. When they get to the health institution, it
would take an hour or two before a health professional will see
them, they might not have funds to pay for the service and in
two-thirds of patients they would have to be referred to another
health institution to deliver anyway because of lack of
resources, skilled people or funds. All of these combine to
cause genitourinary fistula and even maternal deaths [22–25].
78.3 Associated Conditions
The main symptom of a patient with an obstetric genitouri-
nary fistula is the total incontinence of urine (and if they have
a rectovaginal fistula, total incontinence of stool and flatus as
well). However, the ischaemic process of the long labour is
not confined to the urinary tract, reproductive tract and rec-
tum, it affects all the tissues in the pelvis leading to a field
injury. This has been termed the ‘obstructed labour injury
complex’ [26], which includes the following.
• Genitourinary fistula—anywhere along the genital and
urinary tract, but often in combination, for example, often
involving the cervix and vagina, bladder and urethra and
ureter.
78  Urogenital Fistulae
Fig. 78.4 Vagina almost completely closed by scar (Dr Andrew
Browning, used with permission)
• Fistula from the genital tract to the rectum and or anus.
Perineal tears are commonplace.
• The vagina can be completely destroyed being replaced
by dense scar and making intercourse and menses impos-
sible [27, 28] (Fig. 78.4).
• The pelvic bones are affected in 32% of women leaving
bony spurs, areas of erosion or separation of fusion on the
symphysis pubis [29].
• Nerves are affected causing some degree of foot drop in
up to 20% of women [30, 31].
• In severe cases all the levator muscles slough away leav-
ing what has been termed an empty pelvis [31].
Adding to this are conditions that arise secondarily as a
consequence of being incontinent and from the pelvic
pathology;
• Social consequences. This varies greatly between differ-
ent cultures, but largely the women themselves feel
ashamed, embarrassed and fear interaction with others.
Divorce is common and there are many stories of women
living in isolation for years with this condition.
• Mental health. Up to 100% of women living with fistula
screen positive for psychological ill health, namely
depression. Suicide and suicidal ideation is common,
although it has been documented that when a patient is
cured, rates of depression revert to the normal rate for the
background population [32–36]. However, this early
euphoria seems short lived and longer term follow-up
papers reveal that returning home and trying to regain
their previous position in society is problematic. They
have suffered symptoms of post-traumatic stress disorder,
they are often divorced, no living children, can have some
residual physical weakness and the reproductive abilities
967
are diminished. Ongoing mental health issues remain
[37–40].
• Limb contractures. Some women lie on the floor of their
huts for months or years with their injury. Usually the
ones with leg pain and foot drop. About 2% of cases from
a personal series in Ethiopia got lower limb contractures
from disuse; in severe cases the lower limbs were locked
in the foetal position.
• Upper renal tract damage. Lower term scarring in the
pelvis can lead to partial or complete ureteric obstruction.
Nearly half of all fistula patients have upper renal tract
damage with anything from hydro-ureter to a non-­
functioning kidney [41].
• Urine dermatitis. The constant presence of urine on the
vulval and perineal skin can cause areas of sensitive
hyperkeratosis.
• Bladder/ vaginal stones. Stagnation of urine forms
stones in some women. They have been anecdotally
reported as large as a foetal head.
• Reproductive outcomes. Despite a cured fistula, only
17–21% of fistula survivors will be having a successful
pregnancy. Many women have ongoing amenorrhoea and
infertility, and if they become pregnant they have a higher
rate of miscarriage, stillbirth, prematurity and perinatal
mortality [42–44]. Nearly all women want to have more
children. They are concerned if they can or not and 65%
are afraid of trying [45].
78.4 Diagnosis
For the majority of urogenital fistulae the diagnosis is unmis-
takable; there is a history of a long-obstructed labour, usually
a stillbirth and then continuous leakage of urine. A simple
digital examination reveals the communication between the
vagina and urinary tract. The average size of the defect is
around 2.5–3 cm and easy to detect on palpation.
Smaller fistula can be more difficult to diagnose. Very
small fistulae, such as those iatrogenic ones seen after a hys-
terectomy are nothing more than pinhole in size and the
symptoms can mimic stress urinary incontinence. If there is
a history of leaking urine after an operative intervention and
there is any doubt whether there is a fistula or not, all that is
needed to make the diagnosis is a dye test. The traditional
three-swab dye test has a number of variations, but the basic
concept is to place three swabs into the vagina, one at the
apex, one at mid vagina and one at the introitus. Then install
60–100 mL of dilute methylene blue into the bladder via a
foley catheter, wait some minutes and remove the swabs one
by one. A fistula is present if there is staining on the swab.
The swab that is stained reveals the approximate location.
968
Sometimes if the fistula is very small or if the fistula is from
the bladder to the cervix or bladder to uterus after a caesar-
ean, the urine can take a long time to track through the fis-
tula. If there is doubt, insert the swabs and dye, remove the
catheter and have the patients walk about for 30 min to an
hour and remove the swabs. You’ll be surprised at how many
patients test positive in this way. This can also reveal a ure-
teric fistula—if the apical vaginal swab is wet with clear
urine and not dye, then the urine is clearly coming from the
ureter, and not the bladder and a ureteric implantation is
needed. In most fistula units in the world, imaging is not
available, nor is it needed. The bladder can be explored
abdominally, the ureter visualized or probed and the one that
is not draining and/or cannot be probed is the offending side
and should be re-implanted. The affected ureter is invariably
dilated as compared to the normal side.
In more resourced areas, imaging such as CT urogram can
give this information prior to the operation.
78.5 Classification
There is as yet no standardized urogenital fistula classification.
There has been numerous studies confirming attributes of the
fistula that will lead to a poor outcome [11, 46]. The main
outcomes of treatment are to close the fistula and maintain
continence. Unfortunately, just closing the fistula does not
mean that the patient will be continent, she might have ongo-
ing incontinence through the urethra. The risks for ongoing
urethral incontinence after fistula repair are the following:
• The urethra has been affected by the ishaemic process. In
the worst cases the whole of the urethra has sloughed away.
• The larger the fistula the higher the risk.
• There is significant vaginal scarring (e.g. if the operation
has to begin with making relaxing incisions through hard
bands of scar on the posterior and sometimes anterior
vagina, just to be able to insert a speculum and expose the
fistula).
• The remaining bladder volume is small. It is not uncom-
mon to find that most of the bladder has been destroyed,
and after closing the defect the remaining bladder volume
can be as little as 20 mL.
Classifcation systems should try and incorporate prog-
nostic indicators. The two most commonly used systems are
the Waaldijk and the Goh.
Both systems pay attention to urethral involvement. This
is the strongest predictor of a poor outcome.
Waaldijk also includes if the fistula is circumferential or
not, that is, the whole circumference of the bladder and ure-
thra has sloughed away, leaving a small urethral remnant
detached from the bladder (Table 78.1).
A. Browning
Table 78.1  Waaldijk classification system of genitourinary fistula
Type 1
Not involving the
closing mechanism
Type 2 A. Without (sub) total B. With (sub) total
Involving the urethral involvement urethral involvement
closing mechanism
a. Without b. With circumferential
circumferential defect defect
Table 78.2  Goh Classification of genitourinary fistula
Site
Type 1 Distal edge of fistula >3.5 cm from the external urinary
meatus
Type 2 Distal edge of fistula 2.5–3.5 cm from the external urinary
meatus
Type 3 Distal edge of fistula 1.5 to <2.5 cm from the external
urinary meatus
Type 4 Distal edge of fistula <1.5 cm from the external urinary
meatus
Size
a Size <1.5 cm in the largest diameter
b Size 1.5–3 cm in the largest diameter
c Size >3 cm in the largest diameter
Scarring
i None or only mild fibrosis (around fistula and/or vagina)
and/or vaginal length >6 cm, normal capacity
ii Moderate or severe fibrosis (around fistula and/or vagina)
and/or reduced vaginal length and/or normal capacity
iii Special consideration, e.g. post-radiation, ureteric
involvement, circumferential fistula, previous repair
The Goh system looks at the site, size and scarring of the
fistula, and the circumferential defect is a subset of scarring
(Table 78.2). There has only been one study comparing the
systems, and the Goh system was found to be more predic-
tive [47].
78.6 Treatment
Treatment is primarily surgical; however, if a fistula is seen
early, within 2–4 weeks of the injury, prolonged catheteriza-
tion with free drainage may cure up to 40% of small vesico-
vaginal fistula [48, 49].
There has been some debate over the timing of the opera-
tion. Traditionally it was said to wait for 3 months after the
obstructed labour for the ischaemic tissue to slough away
and the oedema in the surrounding tissues to resolve before
attempting an operation. Some more experienced surgeons
do operate earlier and with good success [48], but the tissues
are more difficult to handle and sutures can tear through, so
waiting 3 months is prudent for the less-experienced urogen-
ital fistula surgeon.
If a urological injury occurs during a pelvic operation, it
would be best to repair it at the time, but if it is revealed only
78  Urogenital Fistulae 969

after the operation, it would be possible to operate earlier as

the surrounding tissue inflammation is mild as compared to
those caused by an obstructed labour. Clinical judgment is
needed to ascertain when the tissues appear healthy enough
to be able to operate.
Urogenital fistula can be approached by either the vaginal
or the abdominal route. With experience, most, if not all fis-
tulae, can be confidently repaired vaginally with the patient
in steep trendelenburg and the patient’s thighs flexed and
externally rotated with a weighted speculum in the vagina.
This will bring the anterior vaginal wall and fistula into view.
High vault and utero-vesical or cervical-vesical fistula can
also be operated on in this way, but some surgeons may find
the repair easier via the abdominal route, but it is largely Fig. 78.5  Ureters on the edge of the fistula. It would be easy to cut and/
determined by the surgeon’s experience and preference. or ligate these unless you stent them (Dr Andrew Browning, used with
Urogenital fistulae vary greatly and no two fistulae are permission)
exactly the same. Most obstetric fistulae have widespread tis-
sue destruction, and often extensive reconstructive surgery is
needed. However the surgical principles can be reduced to
the following steps.

• Adequate exposure
• Protecting the ureters
• Adequate mobilization

If the above three principles are applied then the ongoing

incontinence rate will decrease to around 15% depending on
what type of fistula are seen.

• Tension-free closure
• Checking the closure with a dye test.

Following these basic steps, the closure rates should sur-

pass 90%, but the patients may still remain incontinent. This
is especially true if the urethra was involved in the fistula
(Goh type 2–4 or Waaldijk type 2). Overall, after fistula sur-
gery, ongoing incontinence rates can be up to 33–45% [50].
When the urethra is involved, it can be as high as 46% for
Goh type 4 [51]. To reduce this, three further principles can
be followed.
• Maintain the anatomical length and width of the urethra
• Reconstruct the pubourethral ligament.
• Ensure a tension-free closure of the vagina.
To elaborate;
• Adequate exposure. Using steep trendelenburg as
described above with a weighted Auvards speculum in
posterior vagina and retracting the labia with sutures gives
adequate exposure to the anterior vaginal wall. If the
vagina it too scarred and will not admit a speculum, some
relaxing incisions might be needed. Some surgeons rou-
tinely use episiotomies.
Fig. 78.6 Circumferential diagram in cross section (Dr Andrew
Browning, used with permission)
• Protect the ureters. Except for very small fistulae or those
isolated to the urethra, for all other fistulae it is essential
to identify the ureters. If they are within about 2 cm from
the edge of the fistula, the standard practice is to catheter-
ize the ureters (usually done through the fistula). This
helps prevent injury or ligation to the ureter during the
repair and obstruction by oedema after the repair
(Fig. 78.5).
• Adequate mobilization of the bladder and or urethra from
the genital tract to ensure a tension-free closure. The
mobilization is extensive in the case of circumferential
cases. These are the most challenging cases, and mobili-
zation of the whole bladder, anterior, posterior and lateral,
is essential to advance the bladder down to anastomose it
to the urethral remnant (Figs. 78.2 and 78.6).
970
Fig. 78.7  A small distal fistula has been repaired and the dye test
revealed a second intracervical fistula. Note dye coming through the
cervix (Dr Andrew Browning, used with permission)
• Tension-free closure. If there is tension on the repair, it is
at risk of breaking down. Sutures should be about 4 mm
apart, interrupted in one layer to the bladder.
• Check the closure with a dye test to see if there are any
leaks on the suture line and also to exclude a second fis-
tula (Fig. 78.7).
• In all fistulae involving the urethra, maintain the length and
width of the urethra. This can be as simple as closing a ure-
thral defect vertically or in cases of partial or complete cir-
cumferential loss of the urethra, it may mean the
reconstruction of the urethra. This is done by mobilizing the
bladder anteriorly off from scarred attachments to the pubic
bone and into the cave of Retzius. This can be done by the
vaginal route and then the anterior bladder is advanced down
to where the urethral meatus should be, sutured to the back
of the pubic bone and the anterior bladder is tuburalized into
a urethra. It is difficult to get the correct urethral length and
width and a secondary procedure may be needed after the
anterior bladder flap has healed in its new position.
• Reconstructing the pubourethral ligament. All fistulas
involving the urethra (Goh type 2–4 and Waaldijk II) have
a high chance of ongoing incontinence despite an anatomi-
cal closure. This is because the continence mechanisms
have been destroyed as well and the urethra that has been
recreated has no physiological function. To improve out-
comes, autologous slings can be used at the time of repair,
either a sling of pubococcygeal/ levator muscle (Fig. 78.8),
or if there is no muscle remaining, simply use scar tissue
from the pelvic wall. Alternatively, use fascia, namely rec-
tus sheath or fascia lata. An earlier study from 2004 showed
that the application of the pubococcygeal halved the ongo-
ing incontinence rates [50] in these patients and a recent, as
yet unpublished, trial comparing the muscle to a sling of
rectus sheath placed around the urethra and tied to the
abdominal wall showed that the use of the rectus sheath led
to more breakdowns of the fistula but was equivalent in
cure, although a longer follow-up it might be slightly ben-
eficial. (Wilkinson, Pope unpublished data, 2018) It is the
author’s practice to use a muscle sling at the primary repair
A. Browning
Fig. 78.8  Suburethral pubococcygeal sling made for a small urethral
fistula. Note the urethral fistula repaired longitudinally (Dr Andrew
Browning, used with permission)
or a secondary continence operation, and if that fails, a
sling of rectus sheath can be used.
• Ensure a tension-free closure of the vagina. Fistula sur-
gery is evolving and the results are by no means perfect.
One step forward is the recent realization that recon-
structing the vagina correctly seems to be just as impor-
tant as reconstructing the bladder and urethra. The
ischaemic process obviously affects the vagina, so there
is vaginal tissue loss as well. If at the end of the operation
you just pull the vagina together, it will just lead to scar-
ring, tension on the anterior vaginal wall which in turn
just pulls the urethra open making it incompetent
(Figs. 78.9 and 78.10). There are several ways to recon-
struct and repair a vagina if there has been signficant
vaginal tissue loss. Either with series of 52 patients by
the author. In the most severe cases of fistula (4ciii Goh
and with multiple previous operations), the cure rate
improved from a dismal 19% of being dry to 66% [52,
53]. The Singapore flap is a vascular cutaneous flap with
its pedicle based medial to the ischial tuberosity. A flap
of 15 by 6 cm can be used and tunneled into the vagina
just superficial to the inferior pubic ramus. It can be hair
bearing and any remaining follicles can be diathermied at
a later date (Figs. 78.11 and 78.12).
78.7 Post-operative Management
and Results
The vagina is packed at the end of the operation and the pack
is removed the next day. The patient is encouraged to drink
to ensure good bladder irrigation and the catheter left on free
drainage.
There is no uniform agreement on how long to leave the
indwelling catheter in place and surgeons vary in their prac-
tice, from 5 to 21 days, even longer in some cases. It has been
traditionally taught to leave the catheter for 14  days. Two
papers recommend leaving the catheter for 10 days for all but
78  Urogenital Fistulae 971

Fig. 78.9  Fistula closed,

urethral reconstructed, sling
in place, but there is a large Bladder pulled down
gap in the vaginal tissue
(Dr Andrew Browning, used
with permission)

Sling

{
Gap

Fig. 78.10  If you just pull

the vagina together it merely
scars and pulls the urethra
open, making it incompetent
(Dr Andrew Browning, used
with permission)

Pulled inside/open

Tension on anterior
vagina Cervix pulled toward Introitus
972
Fig. 78.11  Fistula closed but there is a large gap in the vagina that
needs to be bridged (Dr Andrew Browning, used with permission)
Fig. 78.12  Singapore cutaneous flap harvested from the right grion
crease and tunneled into the vagina to bridge the gap (Dr Andrew
Browning, used with permission)
the large circumferential cases and repeat cases [54, 55].
Another large study recommends that the catheter can be
removed quite safely at 7 days for simple cases, but the defi-
nition of a simple case was not clear [56].
Most surgeons secure the catheter to the patient’s thigh or
abdomen with some tape. This is to prevent the balloon of
the Foley catheter pulling against the repair when the patient
is mobile.
If the patient is wet from a fistula recurrence, the catheter
is generally left for some days to weeks in order to divert as
much urine away from the healing fistula as possible. Some
fistula will close secondarily.
There is also no standard practice of assessing patients
after the catheter is removed. All patients should have their
residual urine volumes checked several times on the day of
catheter removal and in the ensuing days. Up to 7–8% of
patients will have urinary retention with overflow. About
15–25% of patients will have ongoing incontinence through
A. Browning
their urethra. This is poorly understood, but when examined
urodynamically roughly half will have urodynamic stress
incontinence, 3% have detrusor overactivity, 43% have DO
and USI and 7% have retention (over 150 mL) [57].
However, many fistula patients have a reduced bladder
capacity, with 150 mL may well be the whole bladder vol-
ume. A better way to check for retention is to measure the
voided amount and then the residual. If the residual is greater
than 50% of the voided amount, it should be treated as
retention.
78.8 Ongoing Incontinence
Every fistula surgeon knows of the problem of ongoing
incontinence despite a successful fistula closure. It is poorly
understood and it responds to treatment differently to women
in incontinence without a history of obstetric fistula. Indeed,
treatment with synthetic slings has yielded poor results and
high complications [58]. The key to beginning to understand
the condition is to realize that the obstetric injury causes tis-
sue destruction, and you need to reconstruct the normal anat-
omy if there is any hope of regaining continence.
Ongoing incontinence invariably occurs in those fistulae
in which the continence mechanisms are destroyed, namely
those fistulae involving the urethra [11]. There is no stan-
dardized way of managing the problem, but to date the author
gets the best results by following three basic principles, that
build on the principles used in fistula closure:
• Restore normal urethral length and width.
• Reconstruct the pubourethral ligament.
• Reconstruct a normal vagina.
To elaborate:
• To restore the normal urethral length and width. Many
patients with ongoing urethral incontinence after fistula
repair have very short urethras, 1.3  cm [59]. This can be
elongated by either mobilizing the urethra off from the pubic
bones and plicating it and the distal bladder in the midline or
by excising a posterior strip of urethra and repairing it.
• Reconstructing the pubourethral ligament. This can be
done with either pubococcygeal muscle (Fig.  78.8) or
autologous fascia. The fascial strip can be looped around
the urethra and sutured to the rectus sheath. This needs
some degree of caution as the Cave of Retzius is often
obliterated in these patients and re-opening the fistula is a
very real risk. An easier alternative is to suture the strip of
fascia to the arcus tendineus either side.
• Reconstruct a normal vagina. After mobilizing the vagina
and releasing the urethra from scarred attachments and
then reconstructing it, it is common to find a gap of
2–3  cm in the vagina. Pulling the vagina together just
78  Urogenital Fistulae
pulls the urethra open again, undoing the good work of
the first two steps. The gap in the vagina needs to be filled
with flaps, either the Singapore, labia minora or rotational
flaps from the labia (Figs. 78.9–78.12). In a recent series
of 36 of the most severe cases of ongoing incontinence,
failing several previous operative repairs, 83% where dry
compared to an expected 26% if no vaginal reconstruction
was used [52, 53].
78.9 The Future
Prevention is clearly better than a cure. The developed
world has all but eradicated obstetric urogenital fistula and
has few iatrogenic fistula. The goal should be complete
eradication. In the developed world, this can be achieved by
meticulous surgery, ensuring adequate identification and
protection of the urinary tract in any pelvic surgery. In the
developing world, the task is more challenging. The iatro-
genic fistula can be eradicated in a similar way but eradica-
tion of obstetric fistula needs much more effort. Obstetric
fistula will only become history when all women have
access to safe obstetric care, improved access to family
planning, better education and empowerment for women
and reaching gender equality [60].
78.10 Conclusion
Although the future should be a world without urogenital fis-
tula, this is still a long way coming. In the meantime, there is
still much to do and develop to better the lot of women suf-
fering from urogenital fistula.
Take-Home Messages
• Urogenital fistulae can be broadly divided into iat-
rogenic and obstetric. Iatrogenic fistulae are usually
smaller, higher in the reproductive tract and have a
much better surgical prognosis than fistula caused
by obstructed labour.
• Urogenital fistulae caused by obstructed labour are
not a fistula in isolation. They are a part of the
‘obstructed labour injury complex’ resulting in a
wide array of pathologies, from physical to mental
to social. All need to be addressed in any fistula
treatment program.
• The main difficulty with surgical repair of an obstet-
ric urogenital fistula is ongoing incontinence. This
973
invariably occurs if the urethra has been damaged
or completely destroyed.
• There have been several developments in surgical
treatment leading to better outcomes with respect to
ongoing incontinence after repair, which are as fol-
lows: to reconstruct the urethra with an anatomical
length and width, to reconstruct the puboreuthral
ligament (using autologous material) and lastly to
reconstruct a more normal vagina in women with
severe vaginal tissue loss.
• The final take-home message is that both iatrogenic
and obstetric fistulae are preventable with universal
access to safe obstetric care and with meticulous
surgical techniques.
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 Rectovaginal Fistulae
A. Muti Abulafi and Abdul H. Sultan
Learning Objectives
• Rectovaginal fistula can be classified according to
etiology and location of the fistula.
• Obstetric trauma and Crohn’s disease account for
over two-thirds of all fistulae.
• Multidisciplinary management is essential for a
successful outcome.
• Surgery is the mainstay treatment.
• Choice of surgery depends on location and etiology
of fistula as well as status of sphincters and sur-
rounding tissues.
79.1 Definition
Rectovaginal fistulae (RVF) are abnormal communications
between the rectum and vagina (Fig.  79.1). They must be
distinguished from anovaginal fistulae, which are more distal
communications between the anal canal and vagina and are
considered as a rare type of anorectal fistulae. Fistulae can be
either congenital or acquired. This chapter focuses on the
management options and also outlines the etiology, presenta-
tion, diagnosis, and classification of acquired recto- and ano-
vaginal fistulae.
A. M. Abulafi (*)
Department of Colorectal Surgery, Croydon University Hospital,
Croydon, Surrey, UK
e-mail: muti.abulafi@nhs.net
A. H. Sultan
Urogynaecology and Pelvic Floor Reconstruction Unit,
Croydon University Hospital, St George’s University of London,
London, UK
e-mail: asultan29@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_79
79
79.2 Etiology
Rectovaginal fistulae are rare and account for less than 5% of
all anorectal fistulae [1, 2]. The causes of recto- and anovagi-
nal fistulae are listed in Table 79.1 [1].
The most common cause of RVF is obstetric trauma,
which represents between 50% and 90% of RVF presenting
clinically, and occurs in 0.1% of all vaginal deliveries [2].
However, the incidence of RVF in women who sustain a
fourth-degree tear is higher and ranges between 0.4% and
3% [3]. In the developing world, it is most frequently related
to prolonged obstructive labor due to feto-maternal dispro-
portion and failure of timely intervention. Consequently, tis-
sue ischemia and necrosis lead to the development of a
fistula. In a case series of patients presenting with vesico-
vaginal fistulae, between 6 and 24% had concurrent RVF [3,
4]. Other obstetric causes relate to an unidentified fourth-­
degree obstetric tear at delivery, inadvertent insertion of a
rectovaginal suture during repair of perineal trauma, and
severe perineal infection, particularly following a repair of a
third- or fourth-degree perineal tear. The problem may mani-
fest immediately after delivery due to failed recognition of a
fourth-degree tear or inappropriate repair, or more com-
monly after 7–14  days due to secondary infection of the
wound. A more recent US study has shown that surgical
repair as a surrogate marker of RVF has declined in recent
years due to improved obstetric management [5].
The second commonest cause of RVF is Crohn’s disease,
occurring in up to 23% of patients [6], a figure that varies
depending on the referral pattern of the institution. The prob-
lem seems to occur more frequently with large bowel
involvement, especially the rectum [7]. Ulcerative colitis is a
mucosal disease that rarely causes fistulation unless as a
complication of surgery rather than the disease itself, or if it
is complicated by tumor. Recurrent RVF following surgery
should raise the possibility of underlying occult Crohn’s dis-
ease, which must be excluded in this situation.
Trauma to the rectum, perineum, or vagina may cause
RVF. The commonest form of trauma is during or following
975
976 A. M. Abulafi and A. H. Sultan

Table 79.1  Etiology of rectovaginal fistula (RVF), adapted from [1]

Category Condition Mechanism
1. Traumatic
  Obstetric Obstructed labor Pressure necrosis of
rectovaginal septum
Midline episiotomy Extension directed
into rectum
Third/fourth-degree Unrecognized RVF
lacerations or breakdown of
repair
  Foreign body Vaginal pessaries Pressure necrosis
Violent coitus Mechanical
perforation
Sexual abuse Mechanical
perforation
  Iatrogenic Hysterectomy Injury to anterior
rectal wall
Stapled colorectal Staple line includes
anastomosis vagina
Transanal excision of Deep margin of
anterior rectal tumor resection into vagina
Enemas Mechanical
perforation
Anorectal surgery such as Mechanical
incision and drainage of perforation
intramural abscesses
2. Inflammatory Crohn’s disease Transmural
inflammation-­
perforation
Fig. 79.1  Rectovaginal fistula 6 months after delivery
Pelvic radiation Early-tumor
necrosis
Pelvic abscess Late transmural
surgery, although blunt or penetrating trauma to the perineum inflammation
or use of a foreign body in the vagina or rectum are well-­ Perirectal abscess
recognized causes [8–10]. The use of surgical stapling Bartholin’s abscess
3. Neoplastic Rectal tumor Local tumor growth
devices during construction of ileo-anal pouches [11, 12], into neighboring
low anterior resections [13–15], stapled hemorrhoidectomy structure
[16], and stapled transanal rectal resections (STARR) [17, Cervical tumor
18] have been implicated. In addition, vaginal or transanal Uterine tumor
rectocele repair (particularly with the use of mesh) [19–21], Vaginal tumor
transanal excision of rectal tumors [22], and vaginal hyster- Primary or recurrent
tumors
ectomy [23] can potentially cause RVF. 4. Miscellaneous Fecal impaction Pressure necrosis/
Tumors of the perineum, vagina, and anorectum may erosion into vagina
infiltrate and erode the nearby organs and cause fistula for-
mation. In addition, perianal cryptoglandular infection, par-
ticularly abscesses and fistulae situated anteriorly, may erode anus, and rectum, particularly those that are locally advanced,
into the vagina to cause an anovaginal fistula. Similarly, have all been implicated. In these situations, one of the first
Bartholin’s abscess [24, 25], particularly those extending priorities in management is to rule out recurrent disease.
posteriorly on the perineum or rectovaginal septum, can
cause a fistula. The use of bevacizumab (Avastin®) has also
been implicated [26]. 79.3 Classification
Finally, one of the most challenging fistulae to treat is
radiation-induced fistula, which usually occurs a few years There are several classifications reported in the literature,
after completing the treatment [27–31]. Thankfully, the inci- which reflects a lack of unanimity about how best to describe
dence has reduced recently with advances in radiotherapy the condition. The two most commonly used classifications
delivery [32]. Radiation therapies of tumors of the cervix, are based on the etiology and location of the fistula.
79  Rectovaginal Fistulae
Table 79.2  Classification of rectovaginal fistulae, modified from [35]
Simple rectovaginal fistula Complex rectovaginal fistula
Low- or mid-vagina (check High vagina
rectum)
≤2.5 cm >2.5 cm
Traumatic or infectious cause Inflammatory bowel disease,
irradiation, neoplastic causes
Prolonged obstructed labor
Failed prior repair
RVF classified according to location is as follows:
• Anovaginal—the anal opening of the fistula is situated at
or below the dentate line and the fistula tract opens at the
posterior fourchette or lower third of the vagina.
• Rectovaginal—this is further divided into two types, a
low and a high fistula. A low RVF is located between the
lower third of the rectum and the lower half of the vagina.
A high fistula is located between the middle or upper third
of the rectum and the posterior vaginal fornix.
RVF classified according to their cause is as follows:
• Type I—RVF with or without anal sphincter disruption.
• Type II—RVF due to inflammatory bowel disease.
• Type III—RVF due to radiation injury.
• Type IV—RVF due to postoperative injury.
Obstetric trauma is the most common cause for RVF type
I, with an incidence of up to 74% [33]. The incidence of RVF
type 4 following previous surgical procedures is reported at
7% of all fistulae [33].
Both classifications are of relevance when planning treat-
ment, and some authors argue for the use of one over the
other [34]. We would advise that both etiology and location
are used when planning treatment; the etiology takes into
account the status of the local and adjoining tissues, while
the type of surgical approach will depend on the location of
the fistula. A convenient classification that takes account of
both was proposed by Rothenberger and Goldberg [35]
(Table 79.2). They grouped RVF into two categories: simple
and complex. Simple fistulae include those that are in a low-
or mid-zone location, are of traumatic or infective nature,
and are of <2.5  cm in diameter. Complex fistulae are high
fistulae due to Crohn’s disease, pelvic irradiation, or tumors,
and are >2.5 cm in diameter.
79.4 Presentation
Typically, the presenting symptoms of RVF are those of con-
stant passage of liquid stool, foul-smelling brown discharge,
or flatus per vagina. This is in contrast with anovaginal fistu-
977
lae when the above symptoms occur only during or shortly
after defecation. In addition, patients may complain of dis-
comfort in the pelvis/perineum and during sexual inter-
course. Other modes of presentation include recurrent attacks
of urinary tract infection, thrush, perineal and vulval irrita-
tion, and difficulty keeping the area clean. In addition,
patients may also present with other symptoms relating to
the underlying etiology of the fistula. For instance, patients
with Crohn’s disease may present with abdominal pain, diar-
rhea, and rectal bleeding. Patients with anorectal cancers
may present with rectal bleeding and change in bowel habit.
Radiation proctitis patients may present with rectal bleeding,
diarrhea, and pelvic pain.
79.5 Assessment and Investigations
The aim of assessment is to determine the location and etiol-
ogy of RVF, classify them into simple or complex, and hence
determine the mode of surgical intervention. In our opinion
this should be undertaken jointly by both a colorectal and
gynecological specialist, as is the case in our practice [36].
Clinical assessment starts by taking a careful history, noting
the severity of symptoms, previous operations on the anorec-
tum and vagina, mode of vaginal delivery, and whether the
patient has had pelvic irradiation or is known to have had
inflammatory bowel disease. Assessment should also take
note of the degree of continence to both urine [37] and stools
[38], and take account of any associated comorbidities that
could influence management. The degree of symptom inter-
ference with daily life is best determined by quality-of-life
questionnaires [39]. For instance, patients may have signifi-
cant comorbidities but minor symptoms that are not interfer-
ing with their lifestyle, as is the case with some anovaginal
fistulae, and therefore the consequences of surgical interven-
tion need to be weighed against potential risks. It is also
important to include assessment of prior sexual function,
especially dyspareunia, and remember to counsel women
who are considering surgery about risks of de novo
dyspareunia.
Clinical examination includes careful inspection of the
perineum and perianal area for skin rash/excoriation due to
constant soiling of liquid stools. Scars from previous anorectal
surgery, episiotomy, or perineal tears should be noted. Perianal
dimpling and/or a “dovetail sign,” which consists of perianal
folds posterior to the anal opening with smooth mucosa ante-
riorly, may indicate a disrupted anal sphincter as well as the
presence of a fistula [3]. An external opening of the fistula may
be seen at the vaginal introitus/fourchette. The anus should be
examined to determine the status of anal sphincter function by
checking the resting and squeeze pressures. When an anovagi-
nal fistula is present, a defect within the anal canal may be felt
978
at this point, whereas in low RVF a defect or thinning may be
felt in the lower rectum. Bimanual palpation of the perineum
and anal sphincter anteriorly may indicate disruption to the
anal sphincter and/or perineal body. In addition, any indura-
tion, stenosis, or strictures within the anal canal, rectum, or
vagina should be noted. These are usually confirmed on rigid
proctosigmoidoscopy or flexible sigmoidoscopy and vaginal
speculum examination. Often, examination in the clinic is
uncomfortable, making adequate assessment impossible, and
in these situations an examination under anesthetic is extremely
useful. On rare occasions, the fistula is very fine (pinhole), and
therefore may not be easily detected even during examination
under anesthetic. Various techniques have been devised to
delineate it, including instillation of diluted hydrogen perox-
ide or mildly soapy water into the rectum and observing bub-
bles on the vaginal side.
The methylene blue pad test involves injecting dye into
the rectum via a Foley catheter and inserting a tampon in the
vagina, which is usually stained within 30 min if a fistula is
present.
Complex RVF invariably require further investigations,
not only to confirm the diagnosis but also to help deter-
mine the underlying pathology. Contrast studies of either
the rectum or vagina [40] are useful in high RVF: com-
puted tomography (CT) with rectal contrast, endoanal
ultrasound scan with or without contrast enhancement
with hydrogen peroxide [41, 42], or MRI scan with or
without endocoil [43].
We would strongly advocate the routine use of endoanal
ultrasound scan in these patients not only to delineate the
fistula if possible but also, more importantly, to identify any
associated anal sphincter defects that would influence man-
agement. If the diagnosis remains unclear, or if there is dis-
crepancy between imaging and clinical findings, an
endoanal/endovaginal/perineal scan can be performed dur-
ing the examination under anesthesia. Ultrasonographic
imaging techniques have already been described in Parts II
and VI.
Table 79.3  Surgical approaches for rectovaginal fistulae
1. Local 2. Abdominal
(a)  Rectal route (a) Simple closure with interposition of
   •  Transrectal advancement flap omentum
   • Layered closure (b) Anterior resection with colorectal/coloanal
  • Rectal sleeve anastomosis
   •  Surgisis™ mesh repair (c) Proctectomy/abdominoperineal excision of
   •  Transanal endoscopic microsurgery rectum and anus
(b)  Vaginal route (d)  Diversion colostomy/ileostomy
  •  Transvaginal advancement flap (e)  Laparoscopic vs. open
   • Layered closure
  •  Surgisis™ mesh repair
(c)  Perineal route
   •  Perineo-­proctotomy
  • Sphincteroplasty
  •  Tissue transposition
A. M. Abulafi and A. H. Sultan
79.6 Treatment
In a few situations, where symptoms are mild and not inter-
fering with lifestyle (as is the case in small anovaginal fistu-
lae), conservative treatment should be considered,
particularly if there are significant associated comorbidities
[44, 45]. In fistulae associated with active Crohn’s disease,
initial management involves medical treatment aimed at sta-
bilizing the inflammation [46]. The vast majority of patients
with RVF have significant and disabling symptoms, and
therefore surgical repair is the mainstay treatment. The suc-
cess of surgical treatment depends on adhering to the known
and accepted principles of good surgery, namely accurate
diagnosis, choice of appropriate operation, and meticulous
surgical technique. The later includes excision of diseased
and fibrous tissue, avoiding tension on the suture line, achiev-
ing good hemostasis, and ensuring adequate blood supply, if
necessary by interposing vascularized tissues.
79.6.1 Surgical Techniques
There are a large number of operations described, reflecting
the many combinations of RVF presentations, which depend
on the location and diameter of the fistula and the underlying
disease process. The operations can be grouped into three
main categories, depending on the surgical approach, as
shown in Table 79.3.
The patient must be counseled about the benefits, poten-
tial risks, and success rates of the proposed surgery.
Functional outcomes including sexual function should also
be discussed. In abdominal operations, the potential need for
a stoma needs to be discussed and agreed.
In general, there has been a recent move away from using
mechanical bowel preparation prior to bowel surgery, except
where an ultra-low colorectal anastomosis is contemplated.
Instead, the rectum is prepared with suppositories or enemas
a few hours prior to the surgery, to help exposure and ensure
3. Tissue interposition
(a) Sphincteroplasty
(b)  Labial pad of fat (Martius graft)
(c) Gracilis
(d) Sartorius
(e)  Gluteus maximus
(f) Rectus
(g) Omentum
(h) Colon
(i)  Bricker’s onlay colonic patch
79  Rectovaginal Fistulae
an uncontaminated operative field. Antibiotic prophylaxis is
given at induction of anesthesia and continued for 48 h. Deep
vein thrombosis (DVT) prophylaxis with low molecular
weight heparin is continued until discharge from hospital. In
the case of major abdominal or pelvic surgery, DVT prophy-
laxis should be continued for 28  days [47]. The patient is
placed either in modified lithotomy, Lloyd Davies, or prone
jack-knife position, depending on the type of surgery. The
abdomen is prepared with alcohol- or water-based antiseptic
solution, while the rectal and vaginal lumen are cleansed
with water-based antiseptic solution. A Foley catheter is
inserted in abdominal operations. For local repair, the area is
infiltrated with 1:300,000 adrenalin solution, which will not
only reduce the amount of bleeding but also facilitate dissec-
tion in natural planes.
A stoma is raised either as the first step in treating the
fistula or during definitive surgical treatment to cover the sur-
gical repair/anastomosis. The indications for either will be
discussed below for each surgical technique.
On discharge, the patients are prescribed bulking agents
and fecal softeners to reduce the impact of stool trauma on the
repair. Patients should refrain from strenuous physical exer-
cise but continue with gentle exercises. Sexual intercourse
and use of tampons should be avoided for 6 weeks after repair.
Flap Mucosa
Internal
Sphincter
Probe in Recto
Vaginal Fistula
Internal
Sphincter
Approximated
Fig. 79.2  Endorectal advancement flap. Reproduced from [48], with permission
979
79.6.1.1 Endorectal Advancement Flap
This technique is most suited for a simple low fistula with the
opening above the dentate line. The patient is placed in the
prone jack-knife position and the anal canal exposed by
opening the anus with an Eisenhammer or Parks’ retractor.
The fistula is identified by passing a fistula probe through the
vaginal opening into the rectum. An adrenalin solution of
1:300,000 is infiltrated into the submucosa around the fistula
and cephalad. A U-shaped incision is made around the fis-
tula, with the base a few centimeters cephalad of the fistula
and at least twice the width of the apex to ensure adequate
blood supply. The flap is raised by deepening the incision
through the mucosa, submucosa, and superficial layers of the
circular muscle. Usually, raising the flap is easy and should
start laterally, moving medially towards the fistula where dis-
section and identification of the tissue planes become diffi-
cult due to scar tissue around the fistula opening (Fig. 79.2)
[48]. Once the flap is raised, the attenuated rectovaginal sep-
tum (site of fistula) is exposed. The lateral edges of the rectal
mucosa are dissected off the submucosa and internal sphinc-
ter muscle, so that these structures are approximated to the
midline, with Vicryl sutures closing the fistula defect without
any tension. The flap is then advanced over the repaired area
and sutured in place after excising the excess flap distally
Rectal
Mucosa
Elevated
Attenuated
Perineal Body
Internal
Sphincter
Mobilized
980 A. M. Abulafi and A. H. Sultan

including the site of fistula. The vaginal mucosa is left open
for drainage.
The reports in the literature (Table  79.4) [49–66] show
mixed results, with healing rates of 41–100%. It is difficult
to know conclusively why such variation in results exists but
it is possible that it is related to inclusion of complex,
Crohn’s, and recurrent fistulae. MacRae et al. [49] reported
success rates of 85% after first repair, which fell to 55% after
a third failed repair. Jones [50] reported healing rates of 77%
for fistulae without Crohn’s disease, which fell to 60% for
fistulae with Crohn’s disease. Moreover, Gagliardi and
Pescatori [51] reported that in their hands the incorporation
of a sphincteroplasty in the repair routinely resulted in 100%
success rates compared to 73% for repairs without sphinc-
teroplasty. However, other authors do not recommend the
routine use of sphincteroplasty in the repair unless there is
evidence of sphincter disruption, so as not to compromise
continence [49, 52].

79.6.1.2 Transvaginal Flap

Table 79.4  Summary of surgical outcomes of endorectal advance- Transvaginal repairs are performed in the lithotomy position.
ment flaps in the treatment of rectovaginal fistulas The principles are as follows (Fig. 79.3).
Number Success
Author Year of cases rate (%) Comments
• Invagination of fistula tract: after infiltration of a dilute
Greenwald and 1978 20 100
Hoexter [53]
solution of adrenalin (epinephrine) in saline (1:300,000),
Rothenberger 1982 35 91 10 with concomitant an elliptical incision is performed around the fistula ori-
et al. [52] sphincteroplasty fice. The vaginal epithelium is elevated circumferentially
Hoexter et al. 1985 15 100 around the opening and is then mobilized from the under-
[54] lying rectovaginal fascia for at least 2 cm from the mar-
Jones et al. [50] 1987 23 70 10 patients had
Crohn’s disease
gins of the fistula opening. The opening in the rectovaginal
Lowry et al. 1988 81 83 25 with concomitant fascia is then closed by placing a series of purse string
[33] sphincteroplasty sutures (Vicryl 3–0), such that it becomes invaginated into
Wise et al. [55] 1991 40 85 15 with concomitant the rectum. A second purse string suture inverts the first.
sphincteroplasty The vaginal epithelium is then closed with a continuous
Kodner et al. 1993 71 93
[56]
or interrupted suture. A modification of this technique
Khanduja et al. 1994 16 100 (the Latzko procedure) is performed for high
[57] RVF.  Essentially, this technique incorporates both ante-
MacRae et al. 1995 28 29 Repair for recurrent rior and posterior vaginal walls in the inversion of the fis-
[49] fistulae tula into the rectum and closes a portion of the proximal
Mazier et al. 1995 19 95
vagina. This technique may therefore not be suitable for a
[58]
Watson and 1995 12 58 woman who is sexually active.
Phillips [59] • Excision of fistula tract: a modification to the above tech-
Tsang et al. [60] 1998 27 41 nique is to completely core out the fistula tract and repair
Hyman [61] 1999 12 91 the rectal mucosa, the rectovaginal fascia, and vaginal
Joo et al. [62] 1998 20 75 Repair for Crohn’s skin in separate layers. Bhome et al. reported on 15 cases
fistulae
(nine recurrent) using this technique with a success rate of
Baig [63] 2000 19 74 7 with concomitant
sphincteroplasty 67% at 2-year follow-up, which is similar to that reported
Mizrahi et al. 2002 32 56 using an endorectal advancement flap [73]. However the
[64] transvaginal approach allows for better surgical access
Sonoda et al. 2002 37 43 and allows for reconstitution of the perineal body and anal
[65]
sphincter repair.
Zimmerman 2002 21 48 7 with concomitant
et al. [66] sphincteroplasty and • Vaginal flap: following infiltration with adrenalin solu-
12 with labial fat tion, a curvilinear U-shaped incision is performed below
Gagliardi and 2007 35 76 10 with layered the fistula opening. The rectovaginal fascial layer is then
Pescatori [51] closure and undermined and mobilized. The margins of the rectal
12 sphincteroplasty opening are freshened and closed with 3–0 Vicryl sutures.
Ellis [67] 2008 44 65.9%
The rectovaginal fascia is then closed as an intervening
Rodriguez-­ 2009 16 87.5%
Wong [68] layer between the rectal and vaginal epithelium. Some
Pinto [69] 2010 75 56.3% 10 with surgeons prefer to approximate the levator ani muscles
sphincteroplasty instead, but this can lead to dyspareunia. The fistula is
De Parades [70] 2011 23 65% then excised from the vaginal skin flap which is then
Jarrar [71] 2011 15 46.7%
sutured with interrupted sutures.
79  Rectovaginal Fistulae
a b
d e
Fig. 79.3  Transvaginal repair of a small rectovaginal fistula. (a) A cir-
cular incision is made through the vaginal mucosa around the fistula
orifice. (b) The vaginal mucosa is dissected free circumferentially for
approximately 2 cm from the margin of the fistula orifice. (c) A purse
79.6.1.3 Excision of Fistula and Layered Closure
A fistula located at or within 1  cm of the dentate line is
treated by a modification of the above flap technique as
described by Hoexter et  al. [54], to avoid the potential of
drawing the secreting rectal mucosa into the anal canal and
causing the so-called wet anus. In this situation, the steps are
exactly as described above, but a transverse elliptical inci-
sion is made around the fistula instead of the U-shaped inci-
sion (Fig.  79.4). The fistula tract and a button of vaginal
mucosa are excised (Fig. 79.5). The resulting defect is closed
with Vicryl in two layers after freeing the lateral edges of the
mucosa, as described above, to reduce tension. The rectal
981
c
string suture is placed around the fistula orifice and tied. (d) The mus-
cularis tissues are approximated with sutures. (e) The vaginal mucosa is
closed with a continuous suture. Reproduced from [72], with
permission
mucosal flap is now advanced over the septal repair and
sutured. The vaginal mucosa is left open to drain.
79.6.1.4 Rectal Sleeve Advancement Flap
This is a complex operation and should be considered in
patients with complex and multiple fistulae, particularly
those associated with Crohn’s disease. The technique was
first described by Berman in 1991 [75] and modified slightly
by Marchesa in 1998 [76]. It involves circumferential mobi-
lization of the distal rectum with excision of the diseased
rectal mucosa. The patient is positioned in the prone jack-­
knife position and the anal canal exposed. A circumferential
incision is made in normal mucosa, usually below the d­ entate
982
a b
Fig. 79.4  Excision of fistula with layered closure. (a) A transverse elliptical incision is made around the fistula, and the tract with a button of vagi-
nal mucosa is excised. (b) The resulting defect is closed with Vicryl in two layers after freeing the lateral edges of the mucosa. (c) The rectal
mucosal flap is now advanced over the septal repair and sutured with Vicryl sutures. Reproduced from [74]
Fig. 79.5  Local excision of the fistula tract
line, after infiltrating the area with an adrenalin solution of
1:300,000. A full-thickness sleeve flap made of the mucosa
and submucosa is then raised to expose the underlying inter-
nal sphincter (Fig. 79.6). Invariably, a few fibers of the inter-
nal sphincter are included in the raised flap due to associated
inflammation from the fistula and Crohn’s disease. The sub-
mucosal plane is entered and then developed in a cephalad
direction circumferentially, passing the anorectal ring and
levator ani muscle. Further dissection in this plane at the
A. M. Abulafi and A. H. Sultan
c
supralevator space will allow the full thickness of rectum to
be mobilized. This is continued if necessary to the level of
the peritoneal reflection until healthy rectal tissue can be
pulled downward to reach the dentate line without tension.
The diseased rectal mucosa is excised, and before suturing
the normal rectal mucosa to the dentate line with Vicryl
sutures, the underlying fistula tract is excised/cored out and
the anal opening is closed (as described earlier for the
endorectal advancement flap), leaving the vaginal end open
for drainage. It may be necessary to cover the repair with a
stoma, especially in patients with Crohn’s disease. Reports
in the literature describe healing rates of 54–87%, with fol-
low-­up longer than 2 years in one study [62, 77].
79.6.1.5 Episio/Perineoproctotomy
This technique is ideally suited for fistulae with associated
sphincter disruption, absent perineal body (cloacal defects),
or recurrent or failed local (transanal or transvaginal) repair.
The principle of the operation consists of identifying the fis-
tula and laying it fully open, followed by layered closure of
the divided tissues. The patient is positioned in the lithot-
omy position, which offers good exposure of both the anus
and vagina. The fistula is identified by inserting a fistula
probe via the anal canal opening and into the vagina. The
tissues superficial to this are then divided fully, thus, in
effect, creating a wound similar to that encountered by
obstetricians in a fourth-degree perineal tear (Fig.  79.7).
The edges of the primary tract are excised and any associ-
ated secondary tracts, if present, are identified and excised.
The rectal and vaginal mucosa are then freed from the
underlying tissues. The edges of the internal and external
anal sphincter as well as the perineal muscles are all identi-
fied and mobilized laterally.
The operation is concluded by approximating the rectal
mucosa with Vicryl sutures, followed by approximating the
79  Rectovaginal Fistulae
a b
Fig. 79.6  Rectal sleeve advancement flap. (a) Dissection begins at the
dentate line with a 90–100% circumferential mucosectomy of ulcerated
mucosa and submucosa of the anal canal and is carried cephalad until the
supralevator space is breeched. After sufficient rectal mobilization has
been accomplished, the fistula tract is cored out and then closed with
internal sphincter to create a high-pressure zone within the
anal canal. The external sphincter is then repaired using the
overlap technique. Next, the perineum is reconstituted by
approximating the perineal muscles and the vaginal mucosa.
The final step is to close the perineal skin from the vagina
down to the anus.
Reported success rates are good, ranging from 68 to 100%
[49, 58, 78, 79]. Exposure is generally excellent with this
approach, and it should be considered the first-line approach
for those fistulae with associated sphincter/cloacal defects. It
should also be considered in patients who have undergone
previous failed repairs where exposure via the transanal
route may be limited.
79.6.1.6 Tissue Interposition
The principle of this repair is to excise the fistula and inter-
pose healthy vascularized tissue in the space between the
rectum and vagina. The surgical approach is performed
either through the perineum or the abdomen.
Approaching the fistula via the perineum, the patient is
usually in the jack-knife prone position and the perineum is
infiltrated with 1:300,000 adrenalin solution. A transverse
incision is made on the perineum close to the fourchette.
The incision is deepened, and dissection is carried out in the
plane between the rectum and vagina, taking particular care
to avoid making a button hole in either structure. The fistula
is gently separated, and dissection is carried out in this plane
cephalad. The rectal and vaginal openings of the fistula are
983
absorbable suture, and the vaginal mucosa is left open; (b) The diseased
distal margin of the tissue is trimmed, and the cuff of rectum is advanced
down and sutured to the ridge of anoderm using absorbable sutures.
Reprinted with permission, Cleveland Clinic Center for Medical Art and
Photography © 1999–2014. All Rights Reserved. Courtesy of [78]
then closed with Vicryl sutures. The chosen tissue is then
interposed between the sutured vaginal and rectal defects.
The skin is then closed. The most common tissue interposed
is an overlapping sphincteroplasty [33, 51, 52, 55, 63, 66],
similar to that described above and in Chap. 37. This tech-
nique is utilized particularly when there is associated
sphincter disruption. In the presence of an intact anal
sphincter, this technique of dividing and then performing an
overlapping sphincteroplasty should be avoided due to the
effect on continence. Other tissues that have been interposed
include the gracilis [69, 80, 81], sartorius [82], and rectus
abdominis [83] muscles, and labial pad of fat (Martius graft)
[84–88]. If Martius graft is used, the patient is positioned in
the modified lithotomy position (Fig. 79.8) [89].
Approaching the fistula via the abdomen (see also below),
the healthy colon is interposed by undertaking an anterior
resection with removal of the diseased rectum beyond the
fistula. The vaginal opening is closed and the healthy colon
is brought down and anastomosed with the healthy lower
rectum directly (an end-to-end or end-to-side colorectal
anastomosis or via construction of a colonic J pouch), or
with the anal canal if the whole rectum is removed (coloanal
anastomosis or via a colonic J pouch or via the Parks’ colo-
anal anastomosis [49, 90, 91]. The omentum is another struc-
ture usually interposed in the space between the rectum and
vagina. Bricker reported a technique where the sigmoid
colon and rectum are mobilized fully with the division of the
fistula. The sigmoid is then transected at the midpoint and
984
Fistulous Tract
Vaginal Mucosa
Anal Canal
Rectal
Mucosa
Approximated
Fig. 79.7  Perineoproctotomy (see text). Reproduced from [48], with permission
the distal end folded on itself, and anastomosed to the
debrided rectal opening of the fistula.
The proximal end of the transected sigmoid is brought out
as a colostomy. Once healing is confirmed by a contrast
study, the colostomy end is attached to the folded sigmoid
loop as an end-to-side anastomosis [92, 93].
79.6.1.7 Use of Biomaterials
Surgisis™ Mesh Repair
This is a novel technique reported initially by Pye and col-
leagues in 2004 [94] and more recently modified by
Schwandner et al. [95]. The technique involves exploring the
fistula via a combined transvaginal and transrectal approach.
With the patient in lithotomy position, the posterior vaginal
wall is opened and the fistula tract identified with a fistula
probe. The vagina is then dissected off the rectum within the
rectovaginal space, approximately 1 cm proximal and distal
to the fistula tract. The fistula tract is then completely excised
via a combined transvaginal and transrectal approach includ-
ing a complete “coring-out” of the fistula tissue. The rectal
component of the operation consists of an advancement flap
A. M. Abulafi and A. H. Sultan
Internal
Sphincter
Approximated
Vaginal Mucosa,
Perineal Body,
External Sphincter
Approximated
in Layers
repair using PDS 2–0 (muscle layer) and Vicryl 3–0 (rectal
mucosa and submucosa) sutures. After completion of the
transrectal advancement flap repair, the rectovaginal space is
irrigated with antiseptic solution and then a 2  ×  2  cm
Surgisis™ mesh is placed in the rectovaginal space and fixed
with Vicryl 3–0 at each corner. Finally, the posterior vaginal
mucosa is closed over the mesh with interrupted Vicryl 3–0
sutures. In the study by Schwandner and colleagues [95], 19
out 21 patients with RVF, most of whom had recurrent fistu-
lae, remained healed at a median period of 12 months; four
of those patients healed after a second operation. In another
study by Ellis [67], 22 out of 27 patients, half of whom had
recurrent fistulae, remained healed at a median period of
12 months (range 6–26 months).
Surgisis™ Fistula Plug
Ellis [67] analyzed seven patients treated with this technique,
with a median follow-up of 6 months (range 3–12 months).
Six out of seven healed (86%). Goncalves et al. treated 12
patients and reported 58% success rate [96]. However, lon-
ger term follow-up of 20 patients showed that only 20% of
fistulae remain closed at 2  years [97]. In any case, a large
79  Rectovaginal Fistulae
Fig. 79.8  Martius graft. The Martius graft begins with standard peri-
neal dissection followed by longitudinal incision over the labia majora.
Skin flaps are raised medially and laterally until the entire fat pad with
bulbocavernosus muscle is mobilized. A subcutaneous, subvaginal tun-
clinical trial with longer follow-up is required before this
procedure can be recommended as a standard approach.
79.6.1.8 Abdominal Operations
These operations are indicated for high fistulae and in the
case of post-irradiation fistulae, even if the fistula is of the
low type, since healthy tissues should be employed to achieve
a successful repair. In this era of minimally invasive surgery,
most abdominal operations are undertaken laparoscopically
where appropriate.
Direct Closure with Interposed Omental Graft
This operation is undertaken in the case of a simple high
fistula due to benign and traumatic causes, particularly those
occurring following surgery. The operation involves full
mobilization of the rectum posteriorly and anteriorly. In the
anterior plane, the rectovaginal plane is entered and the
vagina separated from the rectum. At this point, the fistula is
encountered, entered, and then divided. The fistula edges are
refreshed and then both the rectal and vaginal defects are
985
nel is made, and the flap is pulled through the tunnel after the anterior
end is divided and then sutured to the posterior vaginal wall. Reprinted
with permission, Cleveland Clinic Center for Medical Art and
Photography © 1999–2014. All Rights Reserved. Courtesy of [78]
closed primarily with interrupted Vicryl sutures. The repair
is supported by interposing omentum in the intervening
space, thus separating the suture lines.
In this operation, the rectum is healthy and is not excised.
Van der Hagen et  al. reported a prospective series of 40
patients treated by the above technique laparoscopically with
95% success rate at a median follow-up of 28 months [98].
Rectal Excision (Anterior Resection) with Colorectal/
Coloanal Anastomosis
This operation is performed in complex high fistulae where
the rectal tissue is involved by a pathological process such as
cancer, Crohn’s disease, or radiation-induced fibrosis. When
performing the anterior resection, the dissection is carried
out beyond the pathology and fistula until healthy tissues are
exposed. This may require removal of only the upper and
middle third of the rectum, but may also require removal of
the whole of the rectum (low anterior resection).
Reconstruction is achieved by performing an anastomosis,
either stapled or sutured between the descending colon,
986
which is mobilized and brought down into the pelvis without
tension and with good blood supply, and the lower rectum or
the anus. The defect in the vagina is closed and omentum is
interposed in the space between the vagina and rectum.
The Parks’ coloanal sleeve anastomosis [91] is another
technique that, in addition to excision of the rectum, involves
performing a mucosectomy via the transanal route, then the
healthy colon is pulled down the muscular tube of the rectum
past the fistula, and a handsewn anastomosis with the anus at
the level of the dentate line is performed.
Proctectomy
This involves the removal of both the rectum and anus and
has been recommended by Goligher [99] as the gold stan-
dard to treat inflammatory rectovaginal fistula. However,
with advances in surgical techniques, this operation has been
used with decreasing frequency, but is mentioned here as a
last-resort option when all else has failed, particularly if
symptoms are troublesome and debilitating and patients’
quality of life is poor. The technique involves excising the
rectum, as described above, via the abdominal route. The
anus is excised via the perineal route using the intersphinc-
teric approach [100], which involves dissection of the inter-
sphincteric plane and removal of the anus with the internal
sphincter while leaving the external sphincter behind. Next,
the vaginal defect is excised and closed with interrupted
Vicryl sutures. The perineal wound is then closed in layers
by approximating the levator ani and external anal sphincter
muscle. In the presence of sepsis, all tracks should be opened
and the perineum left open, to close by secondary intention
or by tissue grafting.
Diversion Ileostomy/Colostomy
This is an option that was employed in the past as a primary
treatment of a fistula but is now recognized as an option to
cover surgical repair whether undertaken via the perineal or
abdominal routes. It should be considered in complex and/
or repeat repairs. Corte et al. reporting on 79 patients with
RVFs undergoing 289 procedures found that employing a
diverting stoma early was an independent variable for suc-
cess and improved the per-procedure healing rates from 6%
following procedures without a diverting stoma to 32% with
a stoma [101].
79.6.1.9 Other Techniques
There are several interesting techniques that have been
reported in the literature as a small case series or case
reports, and the common theme is the use of minimally inva-
sive techniques to repair the fistula. The use of fibrin sealant
was reported, but the results are conflicting [102, 103]. The
A. M. Abulafi and A. H. Sultan
transanal endoscopic microsurgery (TEM) technique was
used in 13 patients with a reported closure rate of 92.3% at
25 months [104].
Laparoscopic mobilization and interposition of the omen-
tum was combined with a perineal approach to the fistula in
two small studies of 6 and 7 patients with a reported closure
rate of 100% at 22 and 15 months, respectively [105–108].
Once again, these are case reports or small series, which, if
anything, proves that these treatments are technically feasi-
ble but long-term outcomes are lacking. As such, they are
worth considering as a last resort but are not recommended
for routine use except in the context of a clinical trial.
79.6.2 Choice of Surgery
There are no comparative studies or randomized trials com-
paring different operations, and therefore the choice of treat-
ment depends largely on the experience of the surgeon and,
as alluded to above, the etiology and location of the fistula,
and status of the anal sphincter and anorectum.
79.6.2.1 Peripartum Rectovaginal Fistula
Rectovaginal fistulas secondary to obstructed labor develops
after “sloughing” of vaginal tissue that has become necrotic
from pressure of the fetal head. Typically, the sloughing fol-
lows a week after the delivery of the fetus, after a prolonged
labor lasting more than 2 days. A fistula “field injury” includ-
ing rectovaginal and/or vesicovaginal fistula, global pelvic
floor dysfunction, and foot drop has been described and is
indicative of widespread pelvic tissue and neurological dam-
age [3]. A fistula also results following inappropriate/ incom-
plete repair of perineal tears/episiotomy.
As described earlier, it is essential to assess the anatomy
and function of the anal sphincter with appropriately directed
questions, anal manometry, and endoanal ultrasound scan.
Debridement of the infected wound, removal of residual
suture material, and antibiotic therapy should be commenced
prior to attempting repair of these fistulae. There is some evi-
dence to suggest that small anovaginal and rectovaginal fis-
tulae may close spontaneously. Rahman et al. [109] reported
that in their series of 42 women with RVF, 11% healed spon-
taneously but all these women had an RVF of less than 5 mm.
Although the traditional practice of waiting at least
3–6 months before attempting repair was widely followed,
there has been recent evidence to the contrary. Waaldijk
[110] reported on 1716 Nigerian women with a vesicovagi-
nal fistula or genital fistula, of whom 211 had a concomitant
RVF, presenting between 3 and 75  days after delivery.
Successful primary closure was achieved in at least 90%.
79  Rectovaginal Fistulae 987

Invariably, a fistula associated with obstetric trauma is a 79.6.2.2 Crohn’s Disease

simple low fistula and the commonest operation employed is
the advancement flap—either endorectal or transvaginal.
Most evidence support approaching the repair via the rec-
tum, as this is the site of high pressure. A large number of
patients will have an associated sphincter disruption [41, 57,
60], and in these instances a concomitant repair of the
sphincter using the overlapping sphincteroplasty technique
is advised. Chew and Reiger [111] reported one recurrence
out of six operations with a mean follow-up of 24 (range,
11–35) months. Five patients whose Wexner incontinence
score was assessed improved from a preoperative mean of
13.4 to 5.6 postoperatively. MacRae et  al. [49] used this
approach for recurrent fistulae, and six out of seven healed
completely.
An alternative to this is the use of the perineoproctotomy
technique which allows excellent exposure of the structures
and meticulous layered repair. Hull et  al. [79] reported an
overall success rate of 74% (100% for those with a cloacal
defect and 68% for those with anterior sphincter defect).
However, this approach should not be considered if the
sphincter is intact or significant anterior muscle is to be
divided.
In Crohn’s disease, RVF are usually a local manifestation of
a systemic disease process, and this should be taken into con-
sideration during management. There is a wealth of reports
in the literature addressing the subject (Table  79.5) [77,
112–122].
Thus, the initial focus of the treatment should be directed
at controlling the active disease and any local infective pro-
cess associated with the fistula, such as abscesses or second-
ary tracts. In this respect, it is essential to obtain a detailed
medical and physical history. The entire gastrointestinal
tract, sphincter, and anorectal disease status must be assessed
prior to consideration of treatment options. A stepwise
approach to management as recommended by Hannaway
and Hull [46] should start with conservative medical thera-
pies, ideally with involvement of medical gastroenterologists
with interest in the disease, and then progress to surgical
intervention as needed or when local conditions allow. An
exception to this rule is when severe sepsis such as an abscess
is present at the initial presentation. In this situation, the
abscess should be treated with antibiotics and immediate sur-
gical drainage and, if appropriate, a loose seton should be
inserted for drainage.

Table 79.5  Published articles specific to or including the treatment of Crohn’s-related rectovaginal fistula (RVF), adapted from [46]
Author Study period Total n Crohn’s na RVF na Study type
Surgical treatment
Morrison et al. [112] 1973–1986 12 12 12 Retrospective
O’Leary et al. [113] 1991–1996 10 10 10 Retrospective
Penninckx et al. [114] 1993–1999 32 32 32 Retrospective
Marchesa et al. [76] 1991–1995 13 13 11 Retrospective
Joo et al. [62] 1991–1995 26 26 20 Retrospective
Garcia-Olmo et al. [115] 2003 1 1 1 Case report
Scott et al. [7] 1971–1991 67 67 29 Prospective database review
Simmang et al. [77] 1997 2 2 2 Case report
Loungnarath et al. [116]b 1999–2002 39 13 3 Retrospective
Zmora et al. [117]b 1997–2000 37 7 4 Retrospective
Ellis [67]b 2003–2006 78 7 78 Retrospective review of
prospective cohort
Medical treatment
Sands et al. [118] 2000–2001 25 25 27c Post hoc analysis of randomized,
double-blind, placebo-controlled
trial
Korelitz et al. [119] 2 yearsd 34 34 6 Retrospective review of cohort
from randomized, double-blind
study
O’Brien et al. [120] 1980–1989 35 35 6 Retrospective
Parsi et al. [121] 1998–2001 60 60 22 Retrospective
Rusche et al. [122] d 6 6 6 Retrospective
a
Numbers reflect those of all subjects and not only those with both Crohn’s disease and RVF
b
Fibrin glue or plug therapy
c
Number of fistulae treated
d
Dates not stated
988
Table 79.6  Results of medical treatment of rectovaginal fistula caused by Crohn’s disease, adapted from [123]
Study Agent
Korelitz et al. (1985) [119] 6-Mercaptopurine
Hanauer and Smith (1993) [124] Ciclosporin
Present and Lichtiger (1994) [125] Ciclosporin
Ricart et al. (2001) [126] Infliximab
van Bodegraven et al. (2002) [127] Infliximab
Ochsenkuhn et al. (2002) [128] Infliximab
Bell et al. (2003) [129] Infliximab
Topstad et al. (2003) [130] Infliximab
Rasul et al. (2004) [131] Infliximab
Parsi et al. (2004) [121] Infliximab
Ardizzone et al. (2004) [132] Infliximab
Specific medical therapy for Crohn’s disease includes
treatment with steroids and immunomodulators (Table 79.6)
[123–132]. This will not only result in controlling the sys-
temic disease but may also result in complete healing of the
fistula, or at least may optimize and decrease inflammation
in perineal tissues in preparation for surgery. Once sepsis is
under control and the active disease is in remission, the type
of surgery will depend on the location of the fistula and the
presence or absence of sphincter defects, as well as the pres-
ence and extent of active disease in the anorectum. In the
absence of any sphincter defect and active disease, a fistula
in the lower rectum should be closed primarily using the
endorectal advancement flap. If a sphincter defect is present
but no active disease, an overlapping sphincteroplasty or
perineoproctotomy should be considered.
There are no direct comparative studies of these two oper-
ations, and therefore the choice of operation depends on the
surgeon’s own preference and expertise. If mild active dis-
ease exists in the rectum, then an advancement sleeve opera-
tion should be considered. In a high fistula with or without
active disease, an anterior resection with a defunctioning
stoma should be considered. If the anorectum is severely dis-
eased with active disease/strictures, or in recurrent fistulae,
consideration should be given to either an abdominoperineal
excision of the anus and rectum, proctectomy with preserva-
tion of the anus if it is not involved with a view to restoring
intestinal continuity later on, or even a diverting colostomy/
ileostomy.
Although there is no strong evidence to support the use of
anal fistula plugs in the treatment of Crohn’s RVF, Hannaway
and Hull suggested that this could be considered in a simple
low fistula with minimal active disease [46]. A systematic
review by Kaimakliotis et al. of 16 studies reporting on the
medical treatment of 137 RVFs showed a complete healing
in 38.3%. Three studies reporting on a combination of medi-
cal and surgical treatment of 43 RVFs, showed complete
A. M. Abulafi and A. H. Sultan
Number of patients Closure Improvement Recurrence
6 2 1
5 4 1 2
2 1
15 5 1
4 0 1
1
2 1
8 1 5 2
8 6
14 2 9
7 2
healing in 44.2% [133]. The authors concluded that it was
difficult to draw any conclusions and larger high-quality
clinical trials are required to determine the role of medical
and surgical treatment in Crohn’s RVF. However, the above
principles and stepwise approach are recommended for suc-
cessful management.
79.6.2.3 RVF Due to Radiation
Radiation-induced fistulae are a challenging entity to man-
age. The fistula usually develops several years after radio-
therapy, and often patients are middle-aged or elderly with
considerable comorbidity. Consequently, they may not be
suitable for a major operation and therefore require careful
preoperative assessment. In addition, since radiation would
have been delivered to treat cancer, it is essential to rule out
recurrent disease by taking a biopsy of the fistula and sur-
rounding tissue. Once the diagnosis is made, initial treatment
starts by raising a defunctioning colostomy, which not only
will help the patient cope with the debilitating symptom of
fecal incontinence but also help resolve any inflammatory
process associated with the fistula and surrounding tissues.
Often, a colostomy is all that is needed and hence it is impor-
tant to manage patients’ expectations from the beginning. In
younger and fitter patients who wish to have definitive treat-
ment, the surgical options, as in Crohn’s disease, depend on
the location of the fistula and extent of the radiation damage
in the rectum. More importantly, any repair should involve
interposing well-vascularized tissue, as the blood supply to
the surrounding tissues is usually compromised by the radio-
therapy. Low fistulae with no or mild radiation damage in the
rectum are usually approached via the perineum, with inter-
position of the anal sphincter muscle (if a defect exists) or a
labial fat pad (Martius graft) or the gracilis/sartorius muscle.
In a high fistula with no or mild damage, repair is approached
via the abdomen with interposition of omentum or colon
(Bricker’s graft). Bricker reported that 19 out of 26 patients
79  Rectovaginal Fistulae
with radiation-induced fistula were healed [92]. If the rectum
is severely damaged by radiotherapy (for example the pres-
ence of stricture and fibrosis), then an anterior resection/
proctectomy should be performed with or without restora-
tion of intestinal continuity, and with interposition of the
omentum.
79.6.2.4 RVF Due to Malignancy
Management of RVF associated with malignancy is directed
at treating the cancer, which is otherwise a progressive con-
dition. The cancers that may cause RVF are locally advanced
tumors arising from the rectum, anus, or cervix. They may be
associated with metastases, and therefore patients must be
fully staged with magnetic resonance imaging (MRI) of the
pelvis and CT scan of the chest, abdomen, and pelvis, and a
management plan discussed and agreed in a multidisci-
plinary setting involving surgeons, oncologists, radiologists,
and histopathologists. The initial treatment would involve a
defunctioning ileostomy or colostomy with benefits as
alluded to above. This is followed by neoadjuvant downstag-
ing chemoradiotherapy along the accepted regimens of the
tumor being treated. If the tumor is in the upper or mid-­
rectum, an anterior resection is undertaken using the tech-
niques described earlier. If the tumor is in the lower rectum,
an abdominoperineal excision of the rectum and anus is the
treatment of choice. If the tumor is a squamous cell cancer of
the anus and it resolves fully on treatment but the fistula is
still present, then a consideration is made for a local repair
along the lines discussed for radiotherapy-induced fistula
earlier. Ultimately, it may be necessary to undertake a sal-
vage abdomino-perineal excision of the anus and rectum
with the use of muscle graft by plastic surgeons to fill the
defect in the perineum. In the case of cervical cancer, an
anterior resection with en-bloc radical hysterectomy would
be required.
79.6.2.5 Postoperative (Iatrogenic) RVF
The commonest causes of postoperative RVF are incorporat-
ing the posterior vaginal wall with either sutures or a stapling
device during hemorrhoidectomy [18], treatment of
obstructed defecation by STARR [18], and reconstruction of
the intestinal continuity following low anterior resection or
an ileo-anal pouch construction [12, 13]. A leaking anasto-
mosis may result in pelvic sepsis and, rarely, this can lead to
fistula formation especially in the irradiated pelvis. Fistulae
can also occur following vaginal hysterectomy. In the vast
majority of patients, the problem becomes apparent a week
or two after initial injury, by which time local sepsis would
have set in. In these situations, the treatment starts by raising
989
a defunctioning stoma if one is not already raised to help
control the sepsis. Rarely, small fistulae may close spontane-
ously, but if the fistula persists, a low one is treated by an
endorectal or transvaginal advancement flap and a high one
by a repeat anterior resection and anastomosis with interpo-
sition of omentum. In a low fistula with sphincter disruption,
an overlapping sphincteroplasty is used to separate the two
suture lines, but interposition of other tissues may be required
particularly in recurrent/failed repairs. In the rare situations
where the injury/fistula is recognized at the time of surgery,
as may happen during STARR surgery or stapled hemor-
rhoidectomy, the repair of the fistula should be attempted
immediately by undertaking layered closure with repair of
the vaginal fascia.
79.6.2.6 Recurrent RVF
The principles of management are similar to those
employed in the management of complex fistulae as dis-
cussed earlier. However, the initial choice of treatment
should take into account the type of previous failed repair
and the surgeon’s experience, in addition to other factors
such as the location and etiology of the fistula. The two
reports in the literature dedicated to this subject employ a
variety of techniques via both the local and abdominal
routes, with success rates of up to 72% in simple fistulae
and 40% in complex ones [49, 103]. It is suggested that
repair of fistulae should not be attempted soon after the
recurrence develops, but delayed for a few months to allow
any inflammatory process to resolve, infection to be
treated, and the current status of the fistula to be evaluated.
Advancement flaps should not be considered if a previous
flap repair has failed and in complex fistulae, because of
low success rates of approximately 40%. However, some
suggest that this can be considered if only one, or perhaps
two, flap repairs have failed.
The success rate of 85% after first failed repair fell to 55%
after the third failed repair [33]. Perineoproctotomy, rectal
sleeve advancement, and tissue interposition operations
should be considered as the initial choice in low fistulae, and
rectal resection with or without reconstruction and with and
without tissue interposition in high fistulae.
79.6.3 Suggested Algorithm
Figure 79.9 shows a suggested algorithm to the management
of rectovaginal fistula. Although rather complex, it provides
a quick but concise overview of diagnosis and treatment of
the condition.
990 A. M. Abulafi and A. H. Sultan

Rectovaginal Fistula

Obstetric Crohn’s disease Post-Radiotherapy Postoperative Cancer

Medical treatment + Defunctioning Defunctioning Treat cancer:

Law High drainage of sepsis stoma stoma chemotherapy,
radiotherapy,
surgery
Abdominal approach
Direct closure + Rectal disease Healed Not healed Rectal disease
omental graft

Sphincter Sphincter No Mild Severe Severe Mild No

intact disruption disease disease disease disease disease disease

Endorectal or Law High Law High Law High High Law High Law
Endorectal or transvaginal
transvaginal advancement flap
advancement flap + sphincteroplasty
Anterior
Treat as Rectal sleeve resection
Perineoproctotomy Proctectomy with or
low advancement without anastomosis
obstetric
Sphincter
Sphincter intact
Anterior
resection disruption
Healed Not healed
Treat as
Local repair + low
vascularised tissue obstetric
interposition

Fig. 79.9  Suggested algorithm for the management of rectovaginal fistula

lished studies on operative techniques for RVF calling for a

79.7 Conclusions
RVF is a rare condition and potentially a difficult problem to
manage. Although it is clear that treatment of all fistulae,
particularly the complex ones, is best undertaken in special-
ized units with experience in the condition, we cannot over-
emphasize the importance of a multidisciplinary approach
to management by both gynecologists and colorectal sur-
geons and, where appropriate, gastroenterologists, clinical
oncologists, and plastic surgeons. Unfortunately, there are
no comparative studies on the efficacy of various treatment
modalities, and the published reports to date are either
observational studies or case series, deemed low-quality
evidence as was noted in the American Society for Colon
and Rectal Surgeons practice guidelines for RVF published
in 2016 [44], Gottgens et al. already noted this fact in their
systematic review entitled the disappointing quality of pub-
prospective multicenter clinical trial to show “the Holy
Grail of RVF” and address not only the efficacy of the vari-
ous techniques but also the quality of life, continence, and
sexual function [134]. Until such evidence becomes avail-
able, treatment of RVF should adhere to the principles
reported earlier in this chapter and should be tailored
according to the location, etiology, and status of the sphinc-
ter and surrounding tissues, as well as the number of previ-
ous repairs. The aim should be to make the first procedure
the most appropriate one, as it provides the best chance of
success and minimizes the risk of recurrence. Counseling
patients regarding outcome and complications is of utmost
importance. Although there are no randomized studies, gen-
eral recommendations are that women who have undergone
previous successful continence or vaginal prolapse/fistula
surgery should be offered a cesarean section in any subse-
quent pregnancy [135].
79  Rectovaginal Fistulae
Take Home Messages
• RVF is rare and causes can be multifactorial.
• Multidisciplinary approach to management is
essential to treatment success.
• Treatment should be tailored according to location,
etiology, and status of sphincters and surrounding
tissues.
• Appropriate counselling of patients particularly
regarding outcome and complications is essential.
• Best chance of cure is to make first operation the
most appropriate one.
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 Emerging Concepts in Classification
of Anal Fistulae
Arun Rojanasakul and Charles B. Tsang
Learning Objectives
• To understand the limitations of the available fistula
classification.
• To understand anogenital anatomy.
• To understand natural anal abscess/fistula patterns.
• To understand new fistula classification.
• To gain familiarity with Anal Fistula Map.
80.1 Introduction
Classification of anal fistula is the grouping of anal fistula
patterns. It is an essential tool in the development of anal
fistula management. However, the available anal fistula clas-
sifications have many limitations and are becoming less
applicable.
An ideal classification should have the following
characteristics:
1. Correct description of anal fistula patterns based on the
integrated knowledge of anogenital anatomy, imaging
studies and operative findings.
2. Simple, clear and easily adopted by multidisciplinary
users, including surgeons, radiologists and other health
practitioners.
3. Should cover variants of anal fistula but should not
include extremely rare cases.
4. Guide treatment options.
5. Reflect and predict treatment outcomes.
A. Rojanasakul (*)
King Chulalongkorn Memorial Hospital, Bangkok, Thailand
e-mail: todrarun@gmail.com
C. B. Tsang
Department of Surgery, Yong Loo Lin School of Medicine,
National University of Singapore, Singapore, Singapore
e-mail: drcharlestsang@colorectalclinic.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_80
80
6. Most importantly, provide the basis for comparison of
treatment outcomes and complications between
­techniques, surgeons and institutions.
The new anal fistula classification must be built upon cor-
rect understanding of anal fistula patterns that relate to anat-
omy and pathology of the disease. Simplified anatomy and
pathogenesis of anal fistula are described below.
80.2 Anatomy
In reflection of the importance of anatomy in anal fistula,
Parks once said, “It is impossible to perform operation with-
out accurate anatomical knowledge, and this is particularly
true in the case of fistula-in-ano where intemperate surgery
can lead to such disaster results” [1].
To understand the whole spectrum of anal fistula, it is
vital to understand the entire anatomy of anogenital area, not
only anatomy around the anus. The essential anatomy of the
anogenital area includes the anatomy of muscles, fasciae and
spaces.
80.2.1 The Anogenital Muscles
The internal anal sphincter muscle is the inferior continua-
tion of the circular muscle of the rectum. It increases in
thickness when it descends below the anorectal ring.
The longitudinal muscle is the downward continuation of
the longitudinal layer of the upper rectum. It is a thin muscle
that adheres to the internal anal sphincter.
The anogenital striated muscles can be simplified into
three levels (Fig. 80.1).
1. The upper level: is the levator ani, which is a single,
broad and thin muscle. It attaches to the lower part of
pubic bone near pubic symphysis anteriorly, arcus tendi-
nous laterally, coccyx and distal sacrum posteriorly. The
995
996
Fig. 80.1  Anogenital striated muscle anatomy. BbC bulbocavernosus,
LvA levator ani, PnM perineum membrane, ScE subcutaneous external
sphincter, SpE superficial external sphincter, STP superficial transverse
perineii
SPL
IFLS
DPA ISAS
ITSS
PRN
PRA
Fig. 80.2  Anogenital spaces. DPAS deep post-anal space, IFLS infral-
evator space, ISAS ischioanal space, ITSS intersphincteric space, PRAS
perianal space, PRNS perineum space, SPLS supralevator space
horizontal parts of the levator ani are named pubococcy-
geal and ileococcygeal according to the locations to
which they are attached. The vertical part of levator ani is
the puborectalis, which is considered to be the deep por-
tion of the external anal sphincter complex.
2. The middle level: consists of superficial external sphinc-
ter, superficial transverse perineii and deep transverse
perineii (perineum membrane).
3 . The lower level: consists of subcutaneous external
sphincter posteriorly and bulbocarvernosus anteriorly.
80.2.2 The Anogenital Spaces (Fig. 80.2)
Anal sepsis spreads between anogenital muscles to spaces
around the anogenital organs. Some spaces are large, such as
perianal space, superficial perineum space, ischioanal space
A. Rojanasakul and C. B. Tsang
and infralevator pace. Others are potential spaces, such as
intersphincteric space, deep post-anal space, deep perineum
space and supralevator space.
1. Perianal space is the space between skin, subcutaneous
external sphincter and transversalis fascia.
2. Superficial perineum space is the space anterior to super-
ficial transverse perineii, and below the perineum mem-
brane. In males, infection in this space can extend to the
scrotal area.
3. The ischioanal spaces are located at both sides of anal
canal. The boundaries of this space are superficial trans-
verse perineii anteriorly, external anal sphincters medi-
ally, obturator internus laterally, gluteus maximus and
sacrotuberous ligament posteriorly. The lower and upper
boundaries are the transversalis fascia and the levator ani
respectively.
4. The infralevator space is the space between the levator
ani and the ischioanal fossa fascia.
5. The intersphincteric space is the space between the longitu-
dinal muscle and fascia of the external sphincter muscles.
6. The deep post-anal space is located posteriorly between
the posterior extension of the superficial external sphinc-
ter and levator ani muscle. This space is located just out-
side the external sphincter ring and next to the
intersphincteric space. An abscess in the deep post-anal
space can extend into one of the ischioanal space to
become a semi-horseshoe abscess or extend into both
ischioanal spaces to form a complete horseshoe abscess.
Based on our cadaveric study, the deep post-anal space is
not in the same location as subsphincteric space described
by Courtney [2]. The subsphincteric space of Courtney,
which was previously accepted as the isthmus of both
ischioanal spaces, does not exist and needs correction.
7. The deep perineum space is located anterior to the anus
between the perineum membrane and the levator ani. It is
the continuation of the high ischioanal (infralevator)
space. Hence, infection in the infralevator space can
extend to the deep perineum space.
8. The supralevator space is the continuation of the inter-
sphincteric space above the levator ani. It is in fact a retro-
peritoneal space and in extreme case, infection in this space
can spread to the lower abdominal and perinephric area.
80.2.3 The Fasciae (Fig. 80.3)
There are three important fasciae which are related to ano-
rectal sepsis:
1. The intersphincteric fascia
The concept of intersphincteric fascia is controversial
[3]. In our cadaveric studies, this is the fascia of levator
80  Emerging Concepts in Classification of Anal Fistulae 997

Fig. 80.3  Fasciae around the

anus

2.Ischioanal fascia

1.Intersphincteric fascia

3.Transversalis fascia

ani and superficial external sphincter muscle. This fascia Table 80.1 Acute anal abscess (personal data from Bumrungrad
does not fuse with the longitudinal muscle. It descends International hospital 2010–2016)
down and separates the subcutaneous external sphincter Number of
muscle into small bundles. Type of abscess cases Percent
1.  Low intersphincteric 4 3.8
2. The transversalis fascia
2.  Low transphincteric (perianal abscess) 28 26.9
The transversalis fascia separates perianal space from 3.  Anterior high transphincteric (perineal 29 27.9
ischioanal space. abscess)
3 . The ischioanal fossa fascia 4.  Posterior high transphincteric (deep post 33 31.7
The ischioanal fossa fascia separates the ischioanal anal and ischioanal abscess)
space into low ischioanal and high infralevator 5.  High intersphincteric (supralevator 10 9.6
abscess)
space [4]. 104 100

80.3 Pathogenesis
According to the cryptoglandular theory, it is generally
accepted that the cause of anal sepsis is infection of the anal
gland. However, the origin of anal abscess is still debatable.
Parks [5] and Eisenhammer [6] popularised the concept
that anal abscess originates in the intersphincteric space
and then spreads to other spaces. On the contrary, Goligher
[7] reported that among 28 acute perianal/ischioanal
abscess operations, only 8 (28%) had an intersphincteric
component. Recently, we have used the LIFT procedure for
acute anal abscess and found that intersphincteric abscess
was detected in only one-fifth of all acute anal abscess
cases. We concluded that the majority of anal glands pass-
ing from the internal opening to intersphincteric space,
which then pass outside external anal sphincters to form
primary abscess. Another evidence that supports this find-
ing is the study of anal glands by Seow Choen [8], which
reported that only 2% of anal glands reach the intersphinc-
teric plane and 1% of anal glands extend outside the exter-
nal anal sphincter.
The anorectal sepsis spreads between the anogenital mus-
cles instead of penetrating them to reach anorectal spaces.
Since the anatomy of the muscles and spaces are constant,
the natural patterns of anal fistula which relate to these mus-
cles and spaces should also follow a constant pattern.
80.3.1 Natural Anal Abscess Patterns
(Table 80.1 and Fig. 80.4)
The internal opening is the entrance of sepsis and it extends
to the anogenital spaces, leading to different types of abscess:
1. Low intersphincteric pattern: This abscess originates in
the intersphincteric plane below the dentate line and
extends between internal anal sphincter and subcutaneous
external sphincter to reach perianal space.
998 A. Rojanasakul and C. B. Tsang

Fig. 80.4  Natural anal

abscess patterns. DPAA deep
post anal abscess, IFLA
infralevator abscess, ISAA
ischioanal abscess, ITSA SPLA
intersphincteric abscess,
IFLA
PRAA perianal abscess, PRNA
perineum abscess, SPLA
supralevator abscess
DPAA
ISAA
PRNA
ITSA

PRAA

Fig. 80.5  Posterior high

intersphincteric abscess
extends to infralevator and
ischioanal cavity

Levator ani muscle

Infralevator abscess

Superficial external
High intersphincteric
sphincter
abscess

Ischioanal abscess

2. Low transphincteric pattern: Sepsis from internal open-

ing (primary sepsis) crosses between bundles of
­subcutaneous external sphincter or between subcutaneous (5) High intersphincteric
and superficial external sphincter to enter the perianal
space to become perianal abscess. (4) Posterior high
3. Anterior high transphincteric pattern: The primary sep- Anterior high
transphincteric
transphincteric (3)
sis crosses above superficial external sphincter into the
(1) Low intersphincteric
perineum space.
4. Posterior high transphincteric pattern: The primary sep- Low transphincteric (2)
sis from internal opening at posterior midline extends to
deep post-anal space, ischioanal space and infralevator
space, without having an intersphincteric abscess Fig. 80.6  Natural anal fistula patterns (see text)
component.
5. Posterior high intersphincteric pattern: There are three three pathways results in the complexity of posterior high
possible pathways in this intersphincteric pattern. In the intersphincteric abscess.
first pathway, the intersphinteric abscess spreads upwards
to form a supralevator abscess. In the second pathway, the
intersphincteric abscess spreads posteriorly to deep post-­ 80.3.2 Natural Anal Fistula Patterns (Fig. 80.6)
anal space and ischioanal fossa. In the third pathway, the
intersphincteric abscess spreads laterally above superfi- Anal fistula forms after acute anal abscesses drain to the
cial external sphincter at 5 and 7 o’clock direction to the perianal skin. The natural patterns of the anal fistula are simi-
ischioanal space (Fig.  80.5). The combination of these lar to the patterns of anal abscess as described earlier:
80  Emerging Concepts in Classification of Anal Fistulae
1. Low intersphincteric pattern: The fistula tract passes
between internal anal and subcutaneous external anal
sphincters. This pattern can occur in all directions around
the anus.
2. Low transphincteric pattern: The fistula tract passes
between the bundles of subcutaneous external anal
sphincter. The highest tract passes between subcutaneous
and superficial external anal sphincter. This type of fistula
can occur in all directions around the anus but occurs
more commonly in the posterior and anterior directions.
3. Anterior high transphincteric pattern: The internal
opening of this type is located anteriorly at 11, 12 or 1
o’clock position. The fistula tract from internal opening
passes above superficial external anal sphincter to
perineum space to external opening. In certain cases, the
anterior high transphincteric fistula extends laterally to
ischioanal space at 1 and 11 o’clock position.
4. Posterior high transphincteric pattern: The internal
opening is at posterior midline (6 o’clock). The fistula
tract passes between superficial external anal sphincter
and levator ani to deep post-anal and ischioanal space.
This pattern does not have intersphincteric abscess or
intersphincteric granulation tissue.
5. Posterior high intersphincteric pattern: At the core of
this pattern is the intersphincteric infection. There are
three possible pathways. In the first pathway, the inter-
sphincteric abscess spreads upwards to form a supraleva-
tor abscess and may become a chronic abscess without
external opening. In the second pathway, the intersphinc-
teric abscess spreads laterally above superficial external
sphincter at 5 and 7 o’clock direction to the ischioanal
space to external opening. In the third pathway, the inter-
sphincteric abscess spreads posteriorly to deep post-anal
space and ischioanal fossa to external opening. These
three patterns can occur in combination and result in
complex fistula. These patterns almost always have inter-
nal opening at 6 o’clock.
Note:
1. The high transphincteric fistula is generally accepted as a
fistula involving more than one-third of the external
sphincter complex, but in reality the high transphincteric
fistula is the fistula that passes above the superficial exter-
nal anal sphincter.
2. Parks’ supra- and extrasphincteric are iatrogenic sequelae
of type 4 and 5 patterns and should be classified as fol-
lows: (1) posterior high transphincteric pattern with
extrasphincteric tract and (2) high intersphincteric pattern
with suprasphincteric tract.
999
Table 80.2  Anal fistula classification
Anal fistula classification
1.  Low intersphincteric type
2.  Low transphincteric type
3.  Anterior high transphincteric type
4.  Posterior high transphincteric type
5.  High intersphincteric type
80.4 A
 Proposed Anal Fistula Classification
(Table 80.2)
We have previously reported our outcomes of the LIFT pro-
cedure according to natural fistula patterns [9, 10]. We have
recently expanded the indication of LIFT procedure for acute
anal abscess. With this practice, we have a better understand-
ing of the patterns of the anal abscess and anal fistula. The
following is the anal fistula classification that we currently
use for both acute anal abscess and anal fistula.
80.4.1 Characteristics and Benefits of the New
Classification
1 . Focuses only fistula of cryptoglandular origin.
2. Applies to both anal fistula and acute anal abscess.
3. Includes only basic natural anal fistula patterns and forms
the foundation to understanding more complex fistula.
4. Conversion to other classifications is possible but not vice
versa.
5. Guides surgical options and decision-making.
6. Can reflect different outcomes between types of fistula,
techniques and surgeons.
7. Parks’ supra and extrasphincteric types are not included
in this classification but can be recorded as type 4 and
type 5.
For example: Type 4 posterior high transphincteric with
extrasphincteric tract and type 5 high intersphincteric with
suprasphincteric tract.
80.5 Anal Fistula Map
Anal fistula map is a recording and reporting template for
anal sepsis.
A major problem of any new fistula classification is the
difficulty in gaining widespread acceptance amongst users.
The other problem is the lack of common language between
1000
IO (internal opening): clock face 1-12
Intersphincteric space: abscess(a), cavity(c), tract(t)
Level at anal sphincters: IT (intersphincteric),
LT (low transphicnteric), HT (high transphincteric)
Anogenital spaces: (a,c,t)
End point: clock face 1-12
EO (external opening), BE (blind end), 2IO (secondary IO)
Distance: IO to End point - cms
Diagram 80.1  Algorithm of Anal Fistula Map
surgeons and radiologists. One way to solve these is the
introduction of “The Anal Fistula Map”. It is a standardised
recording and reporting template using standardised nomen-
clature and sequence. It allows a clear description of the
route of any fistula, and takes into account any associated
abscess/cavity/tract in each location. This recording system
is an adjunct to the classification system and does not seek to
replace it. (Diagram 80.1).
The benefits of the “Anal Fistula Map” are the following:
1. Any anal fistula classification can be extracted from the
“Anal Fistula Map”.
2. It acts like a map to guide surgeons for surgical
decision-makings.
3. It facilitates communication between surgeons perform-
ing clinical examination, recording intra-operative find-
ings, and radiologists documenting MRI and endoanal
ultrasound findings.
80.5.1 Abbreviations, Pathway and Recording
Format Used in Anal Fistula Map
80.5.1.1 Abbreviations
1. Internal opening (IO): Internal opening is the starting
point of anal fistula, recorded by location using clock
face, where anterior midline of the anus is 12 o’clock.
Other internal openings (if any), can be recorded by num-
ber in front of the IO (e.g. 2IO, 3IO and so on).
2. End point (End): There are three end points.
(a) External opening (EO): recorded by location using
clock face, where anterior midline of the anus is 12
o’clock. Other external openings (if any) can be
recorded by number in front of the EO (e.g. 2EO,
3EO and so on).
A. Rojanasakul and C. B. Tsang
(b) Blind end (BE): recorded by location using clock
face, where anterior midline of the anus is 12 o’clock.
This blind end can either be abscess (a), cavity (c) or
tract (t).
(c) Secondary internal opening (2IO).
3. Distance: The distance is the shortest measurement
between IO and End, in centimetres.
4. Stage of sepsis process (a, c, t):
a = abscess,
c = cavity,
t = tract.
5. Level which the primary fistula tract crosses the external
sphincter:
IT = Intersphincteric.
LT = Low transphincteric.
HT = High transphincteric.
6. Spaces:
ITS = Intersphincteric space.
PRA = Perianal space.
PRN = Perineum space.
DPA = Deep post-anal space.
ISA = Ischioanal space.
IFL = Infralevator space.
SPL = Supralevator space.
80.5.1.2 Recording Pathway
The recording starts from the internal opening (IO) to inter-
sphincteric space (ITS), crosses external sphincters at differ-
ent levels; low transphincteric level (LT) or high
transphincteric level (HT) or intersphincteric (IT); enters
anal spaces (PRA, PRN, DPA, ISA, IFL, SPL) and ends at
external opening (EO), second internal opening (2IO) or
blindly in any space.
Note: If there are more than one pathways, each can be
recorded separately as second or third set, as in the
example.
This example has two pathways. The first pathway is a
tract that passes from IO to intersphincteric space, above
superficial external anal sphincter into deep post-anal space.
Then it extends to the cavity in the ischioanal space and ends
at EO at 9 o’clock position. Distance between IO and EO is
5 cm. The second pathway starts from IO to intersphincteric
space then into deep post-anal space. From this, it passes into
cavity in the infralevator space and breaks through the leva-
tor ani muscle to 2IO at 9 o’clock position. Distance between
IO to 2IO is 4 cm (Fig. 80.7).
The recording of “Anal Fistula Map” for this example is:
1 . IO6 – ITSt – HT – DPAt – ISAc – EO9, 5 cm.
2. IO6 – ITSt – HT – DPAt – IFLc – translevator – SPLt –
2IO9, 4 cm.
80  Emerging Concepts in Classification of Anal Fistulae 1001

is a mixture of true intersphincteric and low transphinc-

teric type. The other important drawback of Parks’ type 1
2IO is that the much more complex high intersphincteric
supralevator type is also included in this type.
IFL 2. Parks’ type 2 (transsphincteric type): This is an overlap of
low transphincteric and high transphincteric types. Parks
did not separate low transphincteric from high trans-
phincteric fistula, but these two types are different in all
DPA aspects and should not be placed together.
ISA 3. Parks’ type 3 (suprasphincteric type) and type 4

IO
(extrasphincteric type) are questionable and need further
discussion.
(a) These types of fistulae are extremely rare and no
other surgeon has reported the high number of cases
EO as per Parks’ (20% and 5%).
(b) The illustrations of Parks’ supra and extrasphincteric
Fig. 80.7  Example of Anal Fistula Map recording. DPA deep post-anal
space, EO external opening, IFL infralevator space, IO internal open- types are misleading. In reality, these types of fistulae
ing, ISA ischioanal space always have primary internal opening at posterior
midline, but Parks’ illustration shows the internal
The use of proforma for this example is shown below. opening in the lateral direction. These incorrect illus-
trations have been demonstrated repetitively in vari-
ous literatures.
1. IO ITS Level Spaces End Distance (c) These types could be over-diagnosed. Parks noted that
[1] “in cases where the fistulas were initially thought
6 a c t IT PRA a c t EO 9 5
LT PRN a c t BE to be suprasphincteric, there was doubt to its exact
HT DPA a c t 2IO tract, either because fibrosis prevented adequate assess
ISA a c t
IFL a c t or because of unclear charting”. He also noted that it
SPL a c t
is “impossible to ascertain the location of some fistu-
las in relation to the puborectalis. The fibrosis some-
2. IO ITS Level Spaces End Distance times so obscures the anatomy that it is impossible to
be sure of the exact position of the puborectalis”. In
6 a c t IT PRA a c t EO 4 fact, the true anal fistula type can sometimes be diffi-
LT PRN a c t BE
HT DPA a c t 2IO 9 cult to identify with confidence, especially in complex
ISA a c t
IFL a c t fistula. Currently, we are able to establish the correct
SPL a c t diagnosis with the use of advanced imaging studies.
(d) These types of fistulae are not natural. They are the
results of incorrect drainage of intersphincteric supral-
evator or infralevator abscess. Eisenhammer [11] wrote
80.6 Discussion “many complex fistula described by Parks … result
from faulty surgical treatment leading to iatrogenic dis-
80.6.1 Limitations of Current Classifications ease”. Fucini [16] wrote “As in other clinical experi-
ences [11, 17, 18], this one also seems to confirm
There are many anal fistula classifications [11–15], but the Eisenhammer’s view of the non-existence of supra- or
most widely used is the Parks’ classification [5], which extrasphincteric tracks of cryptoglandular origin which
describes four major types of fistulae: intersphincteric (45%), primarily loop the external sphincters and the puborec-
transphincteric (30%), suprasphincteric (20%) and extrasphinc- talis muscles”. The recent MRI-based study reported
teric (5%). There are also 14 minor types, which are not gener- that there were no extrasphincteric fistulae found in
ally used. Parks’ classification has many limitations: their large case series of complex fistulae [14].
(e) Many surgeons fail when treating these types of fistu-
1. Parks’ type 1 (intersphincteric type): A true intersphinc- lae because they do not understand the correct
teric type in which the fistula tract passes between inter- ­pathology. Proper treatment should include manage-
nal anal sphincter and subcutaneous external sphincter, ment of the primary internal opening at the posterior
which is not common. In fact, Parks’ intersphincteric type midline, as well as iatrogenic translevator tracts.
1002 A. Rojanasakul and C. B. Tsang

Table 80.3  Comparison of St. James University Hospital MRI classi- References
fication and Parks’ classification
St. James University Hospital MRI 1. Parks AG, Stitz RW. The treatment of high fistula-in-ano. Dis Colon
classification Parks’ classification Rectum. 1976;19(6):487–99.
Grade 0 Normal appearance N/A 2. Courtney H. The posterior subsphincteric space; its relation to pos-
Grade 1 Simple linear intersphincteric fistula Type 1 terior horseshoe fistula. Surg Gynecol Obstet. 1949;89(2):222–6.
Grade 2 Intersphincteric fistula with Intersphincteric 3. Lunniss PJ, Phillips RK. Anatomy and function of the anal longitu-
intersphincteric abscess or secondary fistulous High dinal muscle. Br J Surg. 1992;79(9):882–4.
track intersphincteric 4. Kurihara H, Kanai T, Ishikawa T, Ozawa K, Kanatake Y, Kanai
Grade 3 Transphincteric fistula Type 2 S, et al. A new concept for the surgical anatomy of posterior deep
Transphincteric complex fistulas: the posterior deep space and the septum of the
Grade 4 Transphincteric fistula with abscess or
ischiorectal fossa. Dis Colon Rectum. 2006;49(10 Suppl):S37–44.
secondary track within the ischioanal fossa
5. Parks AG. Pathogenesis and treatment of fistuila-in-ano. Br Med J.
Grade 5 Supralevator and translevator Type 3 1961;1(5224):463–9.
Suprasphincteric 6. Eisenhammer S.  The internal anal sphincter and the anorectal
Type 4 abscess. Surg Gynecol Obstet. 1956;103(4):501–6.
Extrasphincteric 7. Goligher JC, Ellis M, Pissidis AG.  A critique of anal glandular
infection in the aetiology and treatment of idiopathic anorectal
abscesses and fistulas. Br J Surg. 1967;54(12):977–83.
8. Seow-Choen F, Ho JM.  Histoanatomy of anal glands. Dis Colon
4. Parks’ classification includes all fistulae of different etiol- Rectum. 1994;37(12):1215–8.
ogy, e.g. inflammatory bowel diseases, trauma and intra-­ 9. Rojanasakul A, Pattanaarun J, Sahakitrungruang C, Tantiphlachiva
abdominal infection. K.  Total anal sphincter saving technique for fistula-in-ano;
the ligation of intersphincteric fistula tract. J Med Assoc Thai.
5. Parks’ classification may not be applicable in some cir- 2007;90(3):581–6.
cumstances. Garcia-Aguilar reported that the number of 10. Malakorn S, Sammour T, Khomvilai S, Chowchankit I, Gunarasa
unclassified fistulae was as high as 20% [19]. S, Kanjanasilp P, et al. Ligation of intersphincteric fistula tract for
Another classification that needs mentioning is the St. fistula in Ano: lessons learned from a decade of experience. Dis
Colon Rectum. 2017;60(10):1065–70.
James University Hospital MRI classification [20]. This 11. Eisenhammer S. The final evaluation and classification of the surgi-
classification is widely used by radiologists, but not sur- cal treatment of the primary anorectal cryptoglandular intermus-
geons. This MRI classification is the radiological extrapo- cular (intersphincteric) fistulous abscess and fistula. Dis Colon
lation of Parks’ classification (Table  80.3) and hence Rectum. 1978;21(4):237–54.
12. Shafik A. A new concept of the anatomy of the anal sphincter mech-
should have similar limitations. anism and the physiology of defecation. The external anal sphinc-
ter: a triple-loop system. Invest Urol. 1975;12(5):412–9.
13. Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-­
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operated patients: Is it time for a new classification? A Retrospective
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RD.  Anal fistula surgery. Factors associated with recurrence and
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patterns.
• A new “Anal Fistula Map” has been introduced to
be a better communication language between per-
sonnel who involve in the anal abscess/fistula
management.
• This classification is awaiting international consen-
sus to be achieved.
 Ultrasonographic Assessment
of Anorectal Fistulae
Giulio Aniello Santoro, Christian Raymond S. Magbojos,
Giovanni Maconi, and Iwona Sudoł-Szopińska
Learning Objectives
• To understand the technical aspects and imaging
interpretations of ultrasonography in the evaluation
of anorectal abscesses and fistulae.
• To understand the role of endoanal ultrasound in the
treatment algorithm for anorectal fistulae.
81.1 Introduction
The pathogenesis of anorectal abscesses and fistulae is gener-
ally attributed to an infection of the anal glands, usually located
in the subepithelial position, the intersphincteric space, or the
external sphincter, which ducts enter at the base of the anal
crypts of Morgagni at the dentate line level [1]. Infection of the
glands can result in an abscess that can spread in a number of
directions, usually along the path of least resistance, and can
lead to the subsequent development of anal fistula. Five presen-
tations of anorectal abscess have been described (Fig. 81.1) [1]:
(a) Perianal abscess is the most common type of anorectal
abscess, occurring in 40–45% of cases. It is identified as
a superficial, tender mass outside the anal verge. Physical
examination reveals an area of erythema, induration, or
G. A. Santoro (*) · C. R. S. Magbojos
Tertiary Referral Pelvic Floor and Incontinence Center,
IV°Division of General Surgery, Regional Hospital, Treviso,
University of Padua, Padua, Italy
e-mail: giulioasantoro@yahoo.com
G. Maconi
Diagnostic and Gastroenterologic Pathophysiology Unit,”Luigi
Sacco” Hospital, Milan, Italy
I. Sudoł-Szopińska
Department of Radiology, National Institute of Geriatrics,
Rheumatology and Rehabilitation, Warsaw and Imaging Diagnostic
Department, Warsaw Medical University, Warsaw, Poland
e-mail: sudolszopinska@gmail.com
© Springer Nature Switzerland AG 2021
G. A. Santoro et al. (eds.), Pelvic Floor Disorders, https://doi.org/10.1007/978-3-030-40862-6_81
81
D
C
E
B
A
Fig. 81.1  Types of anorectal abscesses: (a) perianal; (b) ischioanal; (c)
submucosal/intramural; (d) supralevator; (e) intersphincteric.
Reproduced with permission from: Santoro GA, Wieczorek AP, Bartram
CI, editors. Pelvic floor disorders. Springer Verlag Italia 2010
fluctuance, and anoscopic examination can demonstrate
pus exuding at the base of a crypt (Fig. 81.2).
(b) Submucosal abscess, arises from an infected crypt in
the anal canal and is located under the mucosa. Rectal
examination may reveal a tender submucosal mass,
which may not be readily apparent by anoscopy.
(c) Intersphincteric abscess, represents between 2% and
5% of anorectal abscesses. In this condition, the infec-
tion dissects in the intersphincteric plane and can spread
cephalad (high type) or caudal (low type).
(d) Ischioanal abscess, is seen in 20–25% of patients and
may present a large, erythematous, indurated, tender mass
of the buttock or may be virtually inapparent, the patient
complaining only of severe pain or fever (Fig. 81.3).
(e) Supralevator or pelvirectal abscesses, are relatively
rare, comprising less than 2.5% of anorectal abscesses.
They usually lack local classic symptomas, instead gen-
eral conditions are present: fever, weakness, or symp-
toms related to another disease (Crohn’s disease). They
1003
1004 G. A. Santoro et al.

D D

C C
B B

A A
Fig. 81.2  Perianal abscess appears as an area of erythema, induration,
or fluctuance

Fig. 81.4  Schematic representation of horseshoe extension of anal

sepsis in the different perianal spaces: (a) perianal; (b) ischioanal; (c)
intersphincteric; (d) supralevator. Reproduced with permission from:
Santoro GA, Wieczorek AP, Bartram CI, editors. Pelvic floor disorders.
Springer Verlag Italia 2010

(Fig. 81.5). Occasionally the primary tract can present a sec-

ondary extension/s (Fig.  81.5), or a fistula is without an
external opening (defined blind fistula). Parks et al. [1] clas-
sified the main tract of the fistula in relation to the sphincters
into four types (Fig. 81.6):

(a) Intersphincteric tract (incidence between 55% and

Fig. 81.3  Ischioanal abscess may present as a large, erythematous,
indurated, or fluctuating tender mass of the buttock
may occur as a cephalad extension of an intersphincteric
or ischioanal abscess (defined “complex abscess” for
involving more than one anal space), or may be associ-
ated with a pelvic inflammatory condition (non-crypto-
glandular fistula). These include fistula associated with
inflammatory bowel disease (Crohn’s disease), divertic-
ulitis, salpingitis, tuberculosis, actinomycosis, human
immunodeficiency virus, anal carcinoma and pelvic sur-
gery [2]. Sepsis can spread through the different perianal
spaces and become a horseshoe infection (Fig. 81.4).
Anorectal fistula represents a communication between
two epithelial surfaces: the perianal skin and the anal canal
or rectal mucosa [1]. Any fistula is characterized by an inter-
nal opening, a primary tract, and an external opening
70%). An intersphincteric fistula passes through the
internal sphincter and through the intersphincteric plane
to the skin. Secondary extension may proceed cephalad
in the intersphincteric plane (high blind tract) and reach
the suprasphincteric space.
(b) Transsphincteric tract (incidence between 55% and
70%). A transsphincteric fistula passes through both the
internal and external sphincters, into the ischioanal fossa
and to the skin. The external opening usually is more dis-
tant from the anal margin compared to the intersphincteric
fistula. The level of the tract determines two types of trans-
sphincteric fistula: high (traversing the upper two-thirds of
the external sphincter), or low (traversing the lower third of
the external sphincter). The height of the internal opening,
however, does not always reflect the level at which a trans-
sphincteric fistula crosses the external anal sphincter [3].
(c) Suprasphincteric tract (incidence between 1% and
3%). A suprasphincteric fistula courses through the
puborectalis muscle after initially passing cephalad as
an intersphincteric fistula. It then transverses downward
through the ischioanal fossa to the skin.
(d) Extrasphincteric tract (incidence between 2% and 3%).
An extrasphincteric fistula is described by a direct com-
munication between the perineum and rectum with no anal
canal involvement. The origin is not cryptoglandular, but
may be due to rectal diseases or as a consequence of pelvic
surgery or pelvic inflammation/trauma/foreign body.
81  Ultrasonographic Assessment of Anorectal Fistulae
a b
Fig. 81.5  Perianal fistulas with one external orifice at 2 o’clock position (a), two external orifices at 9 and 11 o’clock positions (b), and multiple
external openings (c) (clock-wise, 12 o’clock is anterior, 3 o’clock is left lateral, 6 o’clock is posterior, 9 o’clock is right lateral)
Submucosal fistulae are those in which the tract is sub-
sphincteric and does not involve or pass the sphincter com-
plex. Anovaginal fistulae have an extension toward the
vaginal introitus and most develop along with obstetric
sphincter tears. Ano-perineal fistulae are sometimes
described, however they represent transsphincteric fistulas
with external orifice in the skin of perineum. Some may
develop a fistula secondary to Bartholin cysts inflammation.
Secondary tracks may develop in any part of the anal canal
or may extend circumferentially in the intersphincteric,
ischioanal, or supralevator spaces (horseshoe extensions).
The term “complex” describes fistulae which treatment
poses a higher risk for recurrence and impairment of conti-
nence. According to the American Society of Colon and
Rectal Surgeons (ASCRS) classification [4], an anal fistula
may be termed “complex” when one or more of the follow-
ing findings are present: the tract crosses more than 30% of
the external anal sphincter (high transsphincteric, supra-
sphincteric, and extrasphincteric), horseshoe configuration,
anterior location in a female, multiple tracts, recurrent fistu-
las, Crohn’s disease, rectovaginal fistula, prior radiotherapy,
or baseline incontinence.
81.2 Assessment of Anorectal Fistulae
The configuration of perianal sepsis and the relationship
of abscesses or fistulae with internal and external sphinc-
ters are the most important factors influencing the results
of surgical management [4]. Preoperative identification of
all loculate purulent areas and definition of the anatomy
of the primary fistulous tract, secondary extensions, and
internal opening play an important role in adequately
planning the operative approach in order to ensure com-
plete drainage of abscesses, to prevent early recurrence
after surgical treatment, and to minimize iatrogenic dam-
age of sphincters and the risk of minor or major degrees of
incontinence.
1005
c
81.2.1 Physical Examination
Useful information can be obtained by clinical assessment
including digital examination [4]. Physical examination
may reveal the fistulous tract proceeding into the anal canal,
and anoscopic examination may demonstrate purulent
material exuding from the base of the crypt. Intersphincteric
tracts usually open externally very close to the anal verge,
and transsphincteric and other more complicated tracts
open far away, as they will have to traverse the external anal
sphincter first. According to Goodsall’s rule [5], when the
external opening lies anterior to the transverse plane, the
internal opening tends to be located radially and in the
same position as the external opening. Conversely, when
the external opening lies posterior to this plane, the internal
opening is usually located in the posterior midline, irre-
spective of the site of the external opening (Fig. 81.7). An
exception to the rule are anterior fistulae lying more than
3 cm from the anus, which may open in the posterior mid-
line of the anal canal (Fig. 81.7).
The use of Goodsall’s rule alone in decision making
before surgical intervention is, however, not recom-
mended because the positive predictive value is 59% for
primary fistulae (anterior fistulae: 72%, posterior fistulae:
41%) and 41% for recurrent fistulae (anterior fistulae:
67%, posterior fistulae: 12.5%) [6]. Passage of a probe
from both the external and the internal openings may con-
firm the course of the tract; however, a stenotic or sharply
angulated tract may preclude complete passage from
either end. Furthermore, this method is potentially dan-
gerous, because a false tract can be made. Methylene blue
or hydrogen peroxide injection (Fig.  81.8) through the
external opening may confirm the patency of the tract and
its communication with an internal opening. The problem
with methylene blue is that the material stains the entire
mucosa. Staining of the tissue does not occur with hydro-
gen peroxide, and bubbles may be seen through the inter-
nal opening [4].
1006 G. A. Santoro et al.

a b

c d

Fig. 81.6  Schematic drawings of different types of anorectal fistulae tula. Reproduced with permission from: Santoro GA, Wieczorek AP,
according to Parks’ classification. (a) Intersphincteric fistula, (b) trans- Bartram CI, editors. Pelvic floor disorders. Springer Verlag Italia 2010
sphincteric fistula, (c) suprasphincteric fistula, (d) extrasphincteric fis-

Physical examination reaches a very good accuracy in iden-
tifying superficial (100%) and transsphincteric (100%) tracts,
but it appears inadequate for both suprasphincteric (63.6%) and
intersphincteric (33.3%) tracts. In addition, physical examina-
tion may not differentiate external fistula opening from hidrad-
enitis suppurativa or in some cases assess the relation of a
pilonidal cyst with anal sphincters. Deen et al. [7] were able to
identify only 50% of the internal openings and 27.3% of the
horseshoe tracts by physical examination, and Poen et al. [8]
reported a correct diagnosis of primary tracts in 38% of patients,
with 62% of patients unclassified. Ratto et  al. [9] also con-
firmed a low overall accuracy (65.4%) of physical examination
81  Ultrasonographic Assessment of Anorectal Fistulae
Fig. 81.7  Schematic representation of typical courses of fistula tracts
according to Goodsall’s rule. Reproduced with permission from:
Santoro GA, Wieczorek AP, Bartram CI, editors. Pelvic floor disorders.
Springer Verlag Italia 2010
Fig. 81.8  Hydrogen peroxide injection through the external orifice
helps to identify the internal orifice. Reproduced with permission from:
Santoro GA, Wieczorek AP, Bartram CI, editors. Pelvic floor disorders.
Springer Verlag Italia 2010
for preoperative identification of primary fistulous tracts, and
no suprasphincteric or extrasphincteric extensions were cor-
rectly described. Moreover, physical examination did not help
in the identification of any of the ischioanal, pelvirectal/supra-
sphincteric/supralevator, and horseshoeing secondary tracts
and most of the internal openings.
81.2.2 Fistulography
Fistulography has a very limited role in the assessment of
cryptogenic anorectal sepsis, and it is currently used very
rarely in clinical practice [4]. It can be helpful in a chronic
fistula with an external opening distant from the anus; how-
ever, it can offer only indirect and not very reliable informa-
1007
tion on the involvement of anal sphincters. While the primary
tract is demonstrated by fistulography, secondary extensions
may not fill and the complexity of the fistula may be under-
estimated. Furthermore, it is not possible on fistulography to
determine the relationship between the tract and the anorec-
tal junction. Thus, it is not possible to distinguish between
sepsis above or below the levator plate. Kuijpers and
Schulpen [10] found that fistulograms were correct in only
16% of anal fistulae, with a false-positive rate of 10% and the
internal orifice identified in only 24% of patients. They con-
sidered fistulography an inaccurate and unreliable procedure
and did not recommend it in the diagnosis of fistula-in-ano.
81.2.3 Endoanal Ultrasonography
Endoanal ultrasonography (EAUS) has been demonstrated to be
a very helpful diagnostic tool in accurately assessing all fistula
or abscess characteristics [4, 6–9, 11, 12]. Preoperative ultra-
sound imaging can prevent difficulties or unexpected findings
during surgery due to the following scenarios: (1) internal open-
ing cannot be identified; (2) the fistulous track cannot be probed;
(3) unexpected fistula anatomy; (4) fistulae without an external
opening; (5) synchronous fistula; (6) compromised anal canal
[13]. EAUS can be easily repeated while following patients with
perianal sepsis to choose the optimal timing and modality of
surgical treatment, to evaluate the integrity of or damage to
sphincters after operation, and to identify recurrence of fistula.
It also gives information about the state of the anal sphincters,
which is valuable in performing successful fistula surgery. The
sensitivity of EAUS exceeds 90% in detecting occult anal
sphincter defects [14]. A fistula tract affecting less than 30% of
the anal canal muscle length can be safely excised (fistulec-
tomy) or laid open (fistulotomy), but where the bulk of external
sphincter muscle is affected, it is best treated by sphincter saving
procedures like seton drainage, mucosal advancement flap, or
ligation of intersphincteric fistula tract [14].
Ultrasound examination is generally started using
10–16 MHz, changing to 7 or 5 MHz to optimize visualiza-
tion of the deeper structures external to the anal sphincters.
The puborectalis and longitudinal muscles and the external
and internal sphincters should always be identified and used
as reference structures for the spatial orientation of the fistula
or abscess [15]. An anal abscess appears as an anechoic fluid
collection or an hypoechoic inhomogeneous area, sometimes
with hyperechoic spots within it due to debris or gas, possi-
bly in connection with a fistulous tract directed through the
anal canal lumen. Abscesses are classified as superficial/peri-
anal (Fig.  81.9) intersphincteric (Fig.  81.10), ischioanal
(Fig. 81.11), supralevator/pelvirectal (Fig. 81.12), and intra-
mural (Fig. 81.13). Intersphincteric, ischioanal and suprale-
vator collections may extend through the midline (horseshoe
configuration) (Fig. 81.14).
An anal fistula appears as a hypoechoic tract, which is
followed along its crossing of the subepithelium, internal or
1008 G. A. Santoro et al.

a b

Fig. 81.9  Three-dimensional endoanal ultrasound with rotating probe (a) Axial plane. (b) Coronal plane. Reproduced with permission from:
at 13 MHz frequency (type 2052 BK Medical). Acute abscess in the left Santoro GA, Wieczorek AP, Bartram CI, editors. Pelvic floor disorders.
anterior perianal space presenting as an area of low reflectivity. Springer Verlag Italia 2010

a b

Fig. 81.10 Three-dimensional endoanal ultrasound with rotating teric space, deep to the hyperechoic ring of the external anal sphincter
probe at 13 MHz frequency (type 2052 BK Medical). (a) Acute abscess (EAS) (IAS internal anal sphincter). (b) Longitudinal plane
(A) presenting as an area of low reflectivity in the posterior intersphinc-

external sphincters, according to the fistula type, and through
the perianal spaces. With regard to the anal sphincters,
according to Parks’ classification [1], the fistulous primary
tract can be classified into four types:
(a) Intersphincteric tract, which appears as a band of poor
reflectivity within the longitudinal muscle layer, causing
widening and distortion of an otherwise narrow inter-
sphincteric plane (Figs.  81.15, 81.16 and 81.17). The
tract goes through the intersphincteric space without tra-
versing the external sphincter fibers. Intersphincteric fis-
tulae are divided into high and low, corresponding to the
ultrasound levels of the anal canal [16]. Low inter-
sphincteric tract occupies up to 1/3 of the anal canal
81  Ultrasonographic Assessment of Anorectal Fistulae 1009

a b c

Fig. 81.11 Three-dimensional endoanal ultrasound with rotating in the axial plane. The abscess (A) presents as an area of low reflectivity
probe at 13  MHz frequency (type 2052 BK Medical). (a) Acute, left in the left ischioanal space. (c) Reconstruction in the coronal plane.
lateral, ischioanal abscess at physical examination. (b) Reconstruction EAS external anal sphincter, IAS internal anal sphincter

a b c

Fig. 81.12 Three-dimensional endoanal ultrasound with rotating axial plane. (b and c) Multiplanar reconstruction. The supralevator
probe at 13 MHz frequency (type 2052 BK Medical). (a) Acute, right abscess (Asp) is traversing the puborectalis muscle and becomes ischio-
lateral, ischioanal-supralevator abscess (A) presents as an area of low anal abscess (Aia)
reflectivity above the puborectalis muscle (PR). Reconstruction in the

Fig. 81.13  Three-dimensional endoanal ultrasound with rotating

probe at 13 MHz frequency (type 2052 BK Medical). Acute, left
lateral, intramural abscess (A) presenting as an area of low
reflectivity at the level of the prostate gland (P)
1010
a b
Fig. 81.14 Three-dimensional endoanal ultrasound with rotating
probe at 13 MHz frequency (type 2052 BK Medical). Posterior horse-
shoe suppurative collection. (a) Schematic representation; (b)  Ultra­
a b
Fig. 81.15 Three-dimensional endoanal ultrasound with rotating
probe at 13 MHz frequency (type 2052 BK Medical). (a) In the axial
plane, a hypoechoic tract is visualized in the left intersphincteric space
(3 o’clock). (b) In the coronal plane, the intersphincteric high fistula
appears as a band of poor reflectivity (arrows). The tract extends
length, whereas high exceeds that height (Figs.
81.15–81.20).
(b) Transsphincteric tract, appearing as a poorly reflec-
tive tract running out through the external sphincter
and disrupting its normal architecture. The point at
which the main tract of the fistula traverses the sphinc-
ters defines the fistula level. Transsphincteric fistulae
are divided into high, and low, corresponding to the
ultrasound level of the anal canal [16]. Low trans-
sphincteric tract traverses the lower one third of the
external sphincter. High transsphincteric tract tra-
verses both sphincters in the middle (Fig. 81.20) or in
G. A. Santoro et al.
c
sonographic reconstruction in the axial plane; (c) Ultrasonographic
multiplanar reconstruction
through the intersphincteric space without traversing the external anal
sphincter (EAS). IAS internal anal sphincter. Reproduced with permis-
sion from: Santoro GA, Wieczorek AP, Bartram CI, editors. Pelvic floor
disorders. Springer Verlag Italia 2010
the higher part of the anal canal, in the space below
the puborectalis (Fig. 81.21) [16];
(c) Suprasphincteric tract goes through the puborectalis
level (Fig.  81.23). It can be sometimes difficult to
determine a suprasphincteric fistula because EAUS is
not able to visualize the precise position of the levator
plate that lies in the same plane as the ultrasound
beam;
(d) Extrasphincteric tract may be seen close to but more
laterally placed around the external sphincter. The visu-
alization of these fistulae may however be difficult if
they run far away from the anal canal, sometimes beyond
81  Ultrasonographic Assessment of Anorectal Fistulae
a b
Fig. 81.16 Three-dimensional endoanal ultrasound with rotating
probe at 13 MHz frequency (type 2052 BK Medical). (a) In the axial
plane, a hypoechoic tract is visualized in the posterior intersphincteric
a b
Fig. 81.17 Three-dimensional endoanal ultrasound with rotating
probe at 13 MHz frequency (type 2052 BK Medical). (a) In the axial
plane, a hypoechoic tract is visualized in the anterior-right intersphinc-
the field of view of the ultrasound probe. To identify the
internal opening into the rectum, it may be necessary to
use a water-filled balloon for transrectal ultrasound.
Differentiation between granulated tracts and scars is some-
times difficult because of a similar echogenicity. Straight tracts
are easily identified, but smaller and oblique tracts are more
difficult to image. Secondary tracts, when present, are related
1011
space (6 o’clock). (b) In the longitudinal plane, the intersphincteric
high fistula (FIS) appears as a band of poor reflectivity
teric space (12 o’clock). (b) In the longitudinal plane, the intersphinc-
teric high fistula (FIS) appears as a band of poor reflectivity
to the main one and are classified as intersphincteric, trans-
sphincteric, suprasphincteric, or extrasphincteric (Fig. 81.24).
Similarly, horseshoe tracts are categorized as intersphincteric,
ischioanal, suprasphincteric, or extrasphincteric (Fig. 81.25).
The exact location (radial site and anal canal level) of the
internal opening can be difficult to be defined, as the dentate
line cannot be identified as a discrete anatomical entity on
EAUS. It is assumed to lie at approximately mid-anal canal
1012
a b
Fig. 81.18 Three-dimensional endoanal ultrasound with rotating
probe at 13 MHz frequency (type 2052 BK Medical). (a) Axial plane.
Low right lateral high intersphincteric fistula traversing only the subcu-
a b
Fig. 81.19 Three-dimensional endoanal ultrasound with rotating
probe at 13 MHz frequency (type 2052 BK Medical). (a) Axial plane.
Posterior high intersphincteric fistula traversing the middle part of the
level, which is midway between the superior border of the
puborectalis muscle and the most caudal extent of the subcu-
taneous external sphincter. According to this, the site of the
internal opening is categorized as being above, at, or below
the dentate line, or in the rectal ampulla. In addition, the site
can also be characterized by the clock position, being classi-
fied from 1 o’clock to 12 o’clock. The internal opening can
G. A. Santoro et al.
taneous external sphincter. (b) Coronal plane. The length of the fistula
(2) is lesser than one third of the length of the anal canal (4)
external sphincter. (b) Longitudinal plane. The length of the fistula (4)
(arrows) is half the length of the anal canal (2)
be identified as hypoechoic when acute inflammation is
present.
EAUS showed better accuracy than digital examination in
anal fistula assessment (95.1% vs. 55.6%, P < 0.01) [17]. Law
et al. [11] reported good accuracy of EAUS for the selective
identification of fistula (91.7%) and abscess (75%) configura-
tions. However, a significant number of the internal openings
81  Ultrasonographic Assessment of Anorectal Fistulae 1013

a b

Fig. 81.20 Three-dimensional endoanal ultrasound with rotating nal sphincter. (b) Coronal plane. The length of the fistula is half the
probe at 13 MHz frequency (type 2052 BK Medical). (a) Axial plane. length of the anal canal (2)
Left lateral high transsphincteric fistula traversing the superficial exter-

a b

Fig. 81.21 Three-dimensional endoanal ultrasound with rotating puborectalis muscle level. (b) Longitudinal plane. The length of the
probe at 13 MHz frequency (type 2052 BK Medical). (a) Axial plane. fistula (4) is more than two-thirds of the anal canal length (2)
High posterior intersphincteric fistula, blindly ended just below the

(33.3%) were not detected. Worse results in the identification
of the internal opening were reported by Poen et al. [8] (5.3%
accuracy), and Deen et  al. [7] (11% accuracy). The most
probable reason for the poor results in the identification of
internal openings by EAUS are the ultrasonographic criteria
used. Seow-Choen et  al. [6] described the ultrasonographic
criteria for identifying an internal opening, which included
one or more of the following features: a hypoechoic breach of
the subepithelial layer of the anorectum, a defect in the circu-
lar muscles of the internal anal sphincter, and a hypoechoic
1014 G. A. Santoro et al.

a b

Fig. 81.22  Three-dimensional endoanal ultrasound with rotating probe at 13 MHz frequency (type 2052 BK Medical). (a) Axial plane. High right
lateral transsphincteric fistula. (b) Coronal plane. The length of the fistula (2) is more than two-thirds of the anal canal length

a b

Fig. 81.23 Three-dimensional endoanal ultrasound with rotating Reproduced with permission from: Santoro GA, Wieczorek AP,
probe at 13 MHz frequency (type 2052 BK Medical). Suprasphincteric Bartram CI, editors. Pelvic floor disorders. Springer Verlag Italia
tract (arrows) extending through the puborectalis muscle (PR). (a) 2010
Axial plane. (b) Coronal plane. EAS: external anal sphincter.
81  Ultrasonographic Assessment of Anorectal Fistulae
a b
Fig. 81.24 Three-dimensional endoanal ultrasound with rotating
probe at 13 MHz frequency (type 2052 BK Medical). (a) Axial plane.
Posterior transsphincteric fistula (PT, primary tract) with two secondary
transsphincteric tracts (ST, secondary tracts) extending through the
lesion of the normally hyperechoic longitudinal muscle abut-
ting on the normally hypoechoic circular smooth muscle. In
spite of the improvement in accuracy (73%) in identifying the
internal openings, they found no significant difference
between EAUS and digital examination. Cho [15] proposed
the following endosonographic criteria to define the site of
the internal opening (Fig. 81.26): Criterion 1. an appearance
of a root-like budding formed by the intersphincteric tract,
which contacts the internal sphincter; Criterion 2. an appear-
ance of a root-like budding with an internal sphincter defect;
Criterion 3. a subepithelial breach connected to the inter-
sphincteric tract through an internal sphincter defect. Using a
combination of these three criteria, Cho reported 94% sensi-
tivity, 87% specificity, and 81% and 96% positive and nega-
tive predictive values.
The majority of problems while investigating anal fistulae
with EAUS occur because of limited tissue differentiation. If
the primary or secondary tracts are not dilated and filled with
fluid or echogenic content, they present the same echo-
genicity of the surrounding tissues and may be misdiag-
nosed. It is also difficult to differentiate a chronic recurrent
fistula from a scar. Emile et al. [14] showed that although the
accuracy and sensitivity of EAUS in assessing recurrent fis-
tula were lower, the difference between primary and recur-
rent fistulas was not statistically significant, denoting the
ultimate utility of EAUS even in the presence of fibrosis and
scarring. Karanikas et al. [18] reported that acute inflamma-
tory processes do not affect the accuracy of EAUS.
The disappointing results of EAUS in diagnosing the
extrasphincteric fistulae could be due to the echogenicity of
1015
ischioanal space. (b) Multiplanar reconstruction. Reproduced with per-
mission from: Santoro GA, Wieczorek AP, Bartram CI, editors. Pelvic
floor disorders. Springer Verlag Italia 2010
the fistulae, especially those with a narrow lumen, which is
practically identical to the fat tissue in the ischioanal fossa,
and to the short focal length of the transducer, which pre-
vents imaging of fistulae that are located at a large distance
from the anal canal. For this reason, performing ultrasonog-
raphy after injecting 1.0–2.0 mL of 3% hydrogen peroxide
(HPUS) through the external opening of the fistula appears
to be particularly useful. This technique allows identifica-
tion of tracts whose presence has not been definitively
established, or distinction of an active fistulous tract from
postsurgical or posttrauma scar tissue [9]. Gas is a strong
ultrasound reflector, and after injection, fistula tracts become
hyperechoic and the internal opening is identified as an
echogenic breach at the submucosa (Fig.  81.27). Because
the injected HP often results in bubbling into the anal canal,
which then acts as a barrier to the ultrasound wave, injection
should be performed in two phases: an initial injection of a
small amount of HP, and a further injection at a greater pres-
sure [12]. A disadvantage inherent to HP injection is the
very strong reflection that occurs at a gas/tissue interface,
which blanks out any detail deep to this interface. The bub-
bles produced by HP induce acoustic shadowing deep to the
tract, so all information deep to the inner surface of the tract
are lost. The reported diagnostic accuracy of HPUS ranges
from 71% to 95% for primary tracts and from 63% to 96.1%
for secondary tracts, while that of standard EAUS ranges
from 50% to 91.7% for the primary tract and from 60% to
68% for secondary tracts [8, 9, 19, 20]. The highest concor-
dance is usually reported for primary transsphincteric fistu-
lae, while the major diagnostic difficulty is still the adequate
1016 G. A. Santoro et al.

a b

c d

Fig. 81.25  Three-dimensional endoanal ultrasound with rotating probe at 13 MHz frequency (type 2052 BK Medical). (a) Axial plane. Anterior
horseshoe transsphincteric fistula. (b, c, d) Multiplanar reconstructions

identification of primary supra- and extrasphincteric fistu-
lae. Injection can also contribute to a more accurate identifi-
cation of the internal opening (HPUS accuracy ranging from
48% to 96.6% vs. EAUS accuracy ranging from 5.3% to
93.5%) [19–21].
The availability of a three-dimensional (3D) imaging sys-
tem has further improved the accuracy of EAUS. With this
technique, the operator can follow the pathway of the fistu-
lous tract along all the desired planes (axial, coronal, sagittal,
oblique). It enables the operator to identify with certainty all
the components of the fistula, such as position and type of
primary and secondary tract(s), internal opening(s), as well
as extent of operative sphincter division and association with
healing rates and functional compromise [22]. In addition,
volume render mode can facilitate depiction of a tortuous
fistula tract after hydrogen peroxide injection, due to the
81  Ultrasonographic Assessment of Anorectal Fistulae
a b
c d
e f
Fig. 81.26  Cho criteria for the identification of the internal opening.
Criterion 1: an appearance of a root-like budding formed by the inter-
sphincteric tract, which contacts the internal sphincter. (a) Schematic
illustration; (b) Endoanal ultrasound with rotating probe at 13  MHz
frequency (type 2052 BK Medical). Criterion 2: an appearance of a
root-­like budding with an internal sphincter defect. (c) Schematic illus-
1017
tration; (d) Endoanal ultrasound with linear probe at 13 MHz frequency
(type 8838 BK Medical). Criterion 3: a subepithelial breach connected
to the intersphincteric tract through an internal sphincter defect. (e)
Schematic illustration; (f) Endoanal ultrasound with rotating probe at
13 MHz frequency (type 2052 BK Medical)
1018
a b
Fig. 81.27 Three-dimensional endoanal ultrasound with rotating
probe at 13 MHz frequency (type 2052 BK Medical). After hydrogen
peroxide injection through an external orifice, an anterior transsphinc-
transparency and depth information (Fig.  81.28) [23, 24].
Sudol-Szopinska et al. [24] reported that in the classification
of the primary tract, the agreement between surgery and
3D-EAUS with volume render mode was much higher than
that with conventional 3D-EAUS (marginal homogeneity
test P  >  0.1, κ  =  0.96, and marginal homogeneity test
P = 0.0048, κ = 0.28, respectively) (Fig. 81.29). Buchanan
et al. [25] reported a good accuracy of 3D-EAUS in detecting
primary tracts (81%), secondary tracts (68%), and internal
openings (90%) in 19 patients with recurrent or complex fis-
tulae. The addition of hydrogen peroxide (3D-HPUS) did not
improve these features (accuracies of 71%, 63% and 86%,
respectively). Using 3D imaging, Ratto et al. [20] reported
an accuracy of 98.5% for primary tracts, 98.5% for second-
ary tracts, and 96.4% for internal openings, compared with
G. A. Santoro et al.
teric fistula becomes evident as a hyperechoic tract (arrows) extending
through the external sphincter (a) Axial plane. (b) Longitudinal plane.
(c) Multiplanar reconstruction
89.4%, 83.3%, and 87.9%, respectively, when the 2D system
was used. Our experience [21, 23] on 57 patients with peri-
anal fistulae confirmed that 3D reconstructions improved the
accuracy of EAUS in the identification of internal opening
compared to 2D-EAUS (89.5% vs. 66.7%; P  =  0.0033).
Primary tracts, secondary tracts, and abscesses were simi-
larly evaluated by both procedures. According to Xue et al.
[26], both 2D-EAUS and 3D-EAUS showed good concor-
dance with intraoperative findings for the internal opening
(k: 0.776 vs. 0.636). 3D-EAUS had better concordance with
intraoperative findings in the diagnosis of intersphincteric,
high transsphincteric and suprasphincteric fistulas as com-
pared to 2D-EAUS (k: 0.810 vs. 0.592, k: 0.863 vs. 0.548, k:
1.000 vs. 0.672). 3D-EAUS showed better concordance with
intraoperative findings for secondary tract compared to
81  Ultrasonographic Assessment of Anorectal Fistulae
a b
Fig. 81.28 Three-dimensional endoanal ultrasound with rotating
probe at 13  MHz frequency (type 2052 BK Medical). (a) B-mode.
Strong reflectivity of the fistulous tract after hydrogen peroxide injec-
2D-EAUS (k: 0.659 vs. 0.535). Both 2D-EAUS and
3D-EAUS had good concordance with intraoperative find-
ings for complicated abscesses (k: 0.881 vs. 0.816).
Identification of secondary tracts by preoperative 3D-EAUS
examination is the strongest independent risk factor for
recurrence (hazard ratio 2.4 (95% CI 1.2–51), P = 0.016) [2].
This stresses the importance of preoperative 3D-EAUS in
mapping the pathological anatomy of the fistula and a thor-
ough search for secondary tract formation during surgery
[2]. Overall sensitivity and specificity of 3D-EAUS in the
diagnosis of sepsis with anorectal source were reported as
98.3% and 91.3%, respectively [27]. The outcome of ­surgical
treatment of anal fistula between patients with and those
without 3D-EAUS were compared by Ding et al. [28]. Global
1019
tion through the external orifice. (b, c) Rendering of the images facili-
tates the visualization of a intersphincteric tortuous fistula due to
transparency and depth information
recurrence rate tended to be lower (8.8% vs. 13.8%) when
compared to those examined only under anesthesia.
Recurrence rates were lower as well for complex fistulas
(12.8% vs. 22.5%). The 3D-EAUS group had shorter opera-
tive time that can be attributed to the facilitated identification
of the internal opening, primary and secondary tracts. Anal
sphincter injuries were minimal as evidenced by postopera-
tive anal manometry showing both maximum resting pres-
sure and maximum squeeze pressure being significantly
higher in the 3D-EAUS group [28].
3D-EAUS is more accurate than 2D-EAUS in defining
fistula configuration due to higher panoramicity and the
ability to view coronal and sagittal planes with multiplanar
reconstruction [16, 23]. It provides precise measurements of
1020 G. A. Santoro et al.

a b

Fig. 81.29 Three-dimensional endoanal ultrasound with rotating facilitates the visualization of the internal opening (IO) as a hyper-
probe at 16  MHz frequency (type 2052 BK Medical). (a) Recurrent echoic spot due to transparency and depth information (b. Axial plane.
anterior fistula not clearly visible in B-mode. Rendering of the image c. Longitudinal plane)
81  Ultrasonographic Assessment of Anorectal Fistulae
the length of IAS or EAS involved (Figs.  81.19, 81.20,
81.21, and 81.22) and quantifies how much sphincter can be
safely divided or transected [16, 22, 29], reducing the inci-
dence of postoperative fecal incontinence in patients with
high fistulas [16, 22, 30]. Kolodziejczak et  al. [16] found
91% overall accuracy of 3D-EAUS for definition of fistula
type and 92% overall accuracy for definition of fistula
height, with good inter-observer agreement. Gárces-Albir
et al. [31] reported good correlation between 3D-EAUS and
surgical findings for transsphincteric fistulas, whereas
2D-EAUS overestimated the amount of anal sphincter
involved.
3D-EAUS has been used [22] in the postoperative follow-
­up to confirm healing and delayed healing without recur-
rence or to identify recurrences needing further surgical
procedure. In a study by Murad-Regadas et  al. [22], 25
patients with high fistulas underwent ligation of intersphinc-
teric fistula tract (LIFT) procedure. 3D-EAUS confirmed
complete healing in 20/25 (80%) cases demonstrating the
presence of fibrosis in the area previously occupied by the
fistula tract and external opening. Two of them, with a small
persistent cavity without evidence of recurrence, were treated
conservatively. 3D-EAUS identified five failures in patients
treated with another surgical procedure.
81.2.3.1 E  ndoanal Ultrasonography in Crohn’s
Disease
Thirty percent of patients with perianal Crohn’s disease
(PACD) may develop a perianal fistula [32], and in 10–20% of
cases, a fistula of apparent cryptogenic origin (no history or
suspicion of inflammatory bowel disease) can be the first man-
ifestation of CD [33]. A prompt diagnosis of CD can direct
appropriate specific treatment, and avoid surgical misadven-
tures. In another clinical setting, a patient with an established
diagnosis of CD may present with new-onset perianal fistulas
that might be cryptoglandular. In both situations, 3D-EAUS
becomes an invaluable imaging tool to differentiate crypto-
glandular from CD fistula [33]. There are several 3D acoustic
characteristics described as pathognomonic of CD fistula or
abscess. First, it is the so-called Crohn’s Ultrasound Fistula
Signs (CUFS) consisting of a hypoechoic rim around an
abscess collection or fistula and a hyperechoic margin along-
side, indicative of a chronic inflammatory process (Figs. 81.30
and 81.31) [34, 35]. The biological and histological bases of
this sign are not fully understood, probably being related to the
fact that CD fistulas are more likely to create a deep and cavi-
tating inflammatory process, with some debris inside [33].
Zbar et al. [36] reported that CUFS were only moderately sen-
sitive but highly specific for the diagnosis of PACD. Second,
the presence of debris (hyperechoic secretions) in the fistulous
tract or abscess is a sign peculiar to perianal CD [33, 37].
Third, the presence of a fistulous tract bifurcation or a double
tract was found to be a specific sign for PACD, being very rare
1021
in cryptoglandular fistulas. Fourth, a wider fistula tract
(≥4 mm) has been correlated with PACD [33, 37]. The pres-
ence of two ultrasonographic features increases the probabil-
ity of having perianal CD by >80% [22]. In a retrospective
study of 21 cases with PACD and anal fistula (with or without
abscesses), where patients were treated strictly based on
3D-EAUS data, (e.g. drainage with or without probe inser-
tion), none developed new abscesses during follow-up with
more than half showing improvement in fistula activity [34].
Lahat et al. [38] reported that EAUS influenced patient man-
agement in 86% of patients with CD perianal fistulas.
EAUS can be used to evaluate the efficacy of infliximab
treatment in fistulizing Crohn’s disease [39]. Schwartz et al.
[40] found that the use of EAUS to guide therapy for PACD
was associated with a high short- and long-term fistula
response rate. EAUS identified a subset of patients who could
discontinue infliximab without recurrence of fistula drainage.
Similar results were reported by Spradlin et al. [41] in a ran-
domized controlled trial. Guidi et  al. [42] treated complex
perianal fistulas in CD with infliximab and setons, which
were removed after ultrasonographic evidence of healing of
fistulous tracts. However, van Bodegraven et  al. [43] found
endosonographic evidence of persistence of CD fistulas after
infliximab, irrespective of clinical response. Ardizzone et al.
[44] reported that patients with fistula closure after inflix-
imab, but with endosonographic persistence of fistula tract,
were at higher risk of recurrence. MRI seems to predict deep
remission in patients with fistulizing CD on long-term main-
tenance anti-tumor necrosis factor (TNF)-α [45].
81.2.3.2 EAUS Vs. MRI
In recent years, magnetic resonance imaging (MRI) has
emerged as a highly accurate technique in diagnosing peri-
anal fistulae (see Chap. 82) [19, 46]. Differences in detecting
the fistulous tract have been described in relation to the tech-
nique used [47, 48]. The best spatial resolution is achieved
by using dedicated endoluminal anal coils. Limitations of
endoanal coils are higher cost than phased-array, relatively
restricted availability, and limited field of view (2–3 cm from
the coil) [48], so fistulous extensions beyond this range can
be missed. When extensive sepsis or supralevator sepsis is
suspected, a pelvic phased array coil is more accurate.
The most valuable use of MRI is in the assessment of recur-
rent sepsis not visualized on EAUS where differentiation
between a scar and an active tract requires i.v. contrast injec-
tions [46–48]. A variety of investigators have directly com-
pared EAUS with MRI, both with and without an endoanal
coil, and these comparisons have found EAUS variously supe-
rior [49], equivalent [50], or inferior [25]. West et  al. [19]
reported that 3D-HPUS and endoanal MRI were equally ade-
quate for the evaluation of perianal fistulae. The methods
agreed in 88% of cases for the primary fistula tract, in 90% for
the location of the internal opening, in 78% for secondary
1022 G. A. Santoro et al.

a b

Fig. 81.30  Three-dimensional endoanal ultrasound with a linear endoprobe at 16 MHz frequency (type 8838 BK Medical). Bilateral ischioanal
abscess in Crohn’s disease (a. Axial plane. b. Coronal plane. c. Multiplanar reconstruction)

tracts, and in 88% for fluid collections. In most studies compar-
ing EAUS and MRI, surgical findings have been used as the
gold standard. This, however, may be discussed and ques-
tioned, especially for those patients who did not heal after sur-
gery. The difficulty of defining a true reference standard for
fistula-in-ano is related to the following potential source of
bias: the operators who perform the assessments can have dif-
fering levels of experience with EAUS or with MRI, and, simi-
larly, the surgeons who perform the operations have different
levels of experience. Buchanan et al. [25] classified 108 pri-
mary tracts using clinical examination, EAUS, and MRI, and
compared the findings to a reference standard that was based
on ultimate clinical outcome. Digital evaluation correctly clas-
sified 61% of primary tracts in comparison to 81% for EAUS
and 90% for MRI. While MRI was superior in every compari-
son made by the authors, EAUS was particularly helpful at cor-
rectly predicting the site of the internal opening, achieving this
in 91% compared to 97% for MRI. Barker et al. [51] showed
that 9% of all fistulae do not heal, because fistulous tracts that
were identified by endoanal MRI were not recognized during
surgery. Therefore, using clinical outcome as the final arbiter
can minimize potential biases. Because it is well established
that the most common cause of fistula recurrence is infection
that has been missed at surgical examination, patients should
be followed-up to determine clinical outcome and to identify
patients who require further unplanned surgery because of a
failure to heal or further recurrence. Fistula healing is, other-
wise, the only definitive assurance that all infections have been
81  Ultrasonographic Assessment of Anorectal Fistulae 1023

a b

Fig. 81.31  Three-dimensional endoanal ultrasound with rotating probe at 13 MHz frequency (type 2052 BK Medical). Bilateral intersphincteric
fistula in Crohn’s disease (arrows) (a. Axial plane. b. Coronal plane)

identified and treated. Thus, if there is disagreement between and well tolerated by patients, it is an office or an intraopera-
findings at EAUS, MRI, and surgical examination, the findings tive procedure, and it visualizes the internal sphincter better
ass