Pelvic Floor Ultrasound: A Review Dietz, Hans Peter
Clinical obstetrics and gynecology,
2017-March, Letnik:
60, Številka:
1
Journal Article
Recenzirano
Female pelvic floor dysfunction encompasses a number of prevalent conditions and includes pelvic organ prolapse, urinary and fecal incontinence, obstructed defecation, and sexual dysfunction. In most ...cases neither etiology nor pathophysiology are well understood. Imaging has great potential to enhance both research and clinical management capabilities, and to date this potential is underutilized. Of the available techniques such as x-ray, computed tomography, magnetic resonance imaging, and ultrasound, the latter is generally superior for pelvic floor imaging, especially in the form of perineal or translabial imaging. The technique is safe, simple, cheap, easily accessible and provides high spatial and temporal resolutions.
Since its introduction in the early 1990s, endoanal sonography has become the mainstay of morphologic assessment of the anal canal and sphincter, especially for obstetric anal sphincter trauma. Lack ...of availability of suitable systems and the invasive nature of the method have limited uptake and clinical utility. More recently, exoanal or transperineal/translabial tomographic imaging has been developed as a noninvasive alternative. This pictorial overview aims to introduce the reader to this new diagnostic modality and to demonstrate common findings in asymptomatic and symptomatic women.
Pelvic floor trauma in childbirth Dietz, Hans Peter
Australian & New Zealand journal of obstetrics & gynaecology,
06/2013, Letnik:
53, Številka:
3
Journal Article
Recenzirano
Odprti dostop
The investigation of female pelvic floor function and anatomy is moving from the fringes to the mainstream of urogynaecology and female urology, and it is becoming increasingly relevant for ...obstetrics. We are coming to realise that pelvic floor trauma in labour is common, usually overlooked, and a major factor in the causation of pelvic organ prolapse. Modern imaging methods such as magnetic resonance and 3D/4D ultrasound have enabled us to diagnose such trauma reliably and accurately, most commonly in the form of an avulsion of the puborectalis muscle; that is, a disconnection of the muscle from its insertion on the os pubis. Such damage to the levator muscle is macroscopically evident and can also be palpated, a skill that is available to every clinician, requiring neither investment nor specialised equipment. In this review, I will describe pelvic floor assessment by palpation and ultrasound and illustrate the commonest abnormalities and their clinical consequences. This paper will not focus on magnetic resonance imaging due to technical restrictions, cost and access issues in most jurisdictions, and because several papers have recently shown that ultrasound is at least as effective in diagnosing such trauma. Anal sphincter trauma is generally well covered in the literature and hence not subject of this review.
Pelvic floor ultrasound: a review Dietz, Hans Peter, MD, PhD
American journal of obstetrics and gynecology,
04/2010, Letnik:
202, Številka:
4
Journal Article
Recenzirano
Imaging currently plays a limited role in the investigation of pelvic floor disorders. It is obvious that magnetic resonance imaging has limitations in urogynecology and female urology at present due ...to cost and access limitations and due to the fact that it is generally a static, not a dynamic, method. However, none of those limitations apply to sonography, a diagnostic method that is very much part of general practice in obstetrics and gynecology. Translabial or transperineal ultrasound is helpful in determining residual urine; detrusor wall thickness; bladder neck mobility; urethral integrity; anterior, central, and posterior compartment prolapse; and levator anatomy and function. It is at least equivalent to other imaging methods in visualizing such diverse conditions as urethral diverticula, rectal intussusception, mesh dislodgment, and avulsion of the puborectalis muscle. Ultrasound is the only imaging method able to visualize modern mesh slings and implants and may predict who actually needs such implants. Delivery-related levator trauma is the most important known etiologic factor for pelvic organ prolapse and not difficult to diagnose on 3-/4-dimensional and even on 2-dimensional pelvic floor ultrasound. It is likely that this will be an important driver behind the universal use of this technology. This review gives an overview of the method and its main current uses in clinical assessment and research.
Toward normal birth–but at what cost? Dietz, Hans Peter, PhD; Campbell, Stuart, DSc (Med)
American journal of obstetrics and gynecology,
10/2016, Letnik:
215, Številka:
4
Journal Article
Recenzirano
The rate of cesarean delivery has become an important health care issue, and has attracted the attention of governments, professional organizations, health care administrators, clinicians, and ...patients. This has resulted in the generation of guidelines, clinical recommendations, and other documents aimed at increasing the likelihood of vaginal delivery. Sometimes, these recommendations are formulated with limited input from clinicians. In some countries, such as the United Kingdom, external pressure exerted on clinicians to reduce the rate of cesarean delivery has been the subject of public debate, and has led to unintended consequences, including an increase in medicolegal tensions. In the United States and Australia, recent recommendations generated by professional bodies have advocated that clinicians should change practice to reduce the rate of cesarean delivery. We do not summarize the risks and benefits of cesarean birth in different clinical situations, which have been the subject of numerous reviews. Rather, we try to examine the potential implications of such policies in light of recent observations made in maternity units, judicial decisions, and clinical research. The emphasis is on maternal morbidity and patient autonomy. This may include the negative consequences of increasingly risky attempts at vaginal birth after cesarean delivery such as uterine rupture, higher rates of pelvic floor and anal sphincter trauma due to rising forceps rates, and a bias against elective cesarean delivery on maternal request.
The methodological developments of in vivo and in vitro protein labeling and subsequent detection enable sensitive and specific detection of redox modifications. Such methods are presently applied to ...diverse cells and tissues, subproteomes and developmental as well as environmental conditions. The chloroplast proteome is particularly suitable for such kind of studies, because redox regulation of chloroplast proteins is well established, many plastid proteins are abundant, redox network components have been inventoried in great depth, and functional consequences explored. Thus the repertoire of redox-related posttranslational modifications on the one hand side and their abundance on the other pose a challenge for the near future to understand their contribution to physiological regulation. The various posttranslational redox modifications are introduced, followed by a description of the available proteomics methods. The significance of the redox-related posttranslational modification is exemplarily worked out using established examples from photosynthesis. This article is part of a Special Issue entitled: Plant Proteomics — a bridge between fundamental processes and crop production, edited by Dr. Hans-Peter Mock.
•The plant proteome is subjected to multiple redox-related posttranslational modifications, some of which are reversible.•Redox regulation is a central feature in the control of chloroplast metabolism.•The protein components involved in redox regulation of chloroplasts are meanwhile well established.•Redox proteomics has advanced and is providing a toolbox of tailor-made approaches to study processes in detail.•The detailed physiological context of candidates identified by proteomic studies has to be established in follow-up studies.
Unimolecular triple incretins, combining the activity of glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and glucagon (GCG), have demonstrated reduction in body ...weight and improved glucose control in rodent models. We developed SAR441255, a synthetic peptide agonist of the GLP-1, GCG, and GIP receptors, structurally based on the exendin-4 sequence. SAR441255 displays high potency with balanced activation of all three target receptors. In animal models, metabolic outcomes were superior to results with a dual GLP-1/GCG receptor agonist. Preclinical in vivo positron emission tomography imaging demonstrated SAR441255 binding to GLP-1 and GCG receptors. In healthy subjects, SAR441255 improved glycemic control during a mixed-meal tolerance test and impacted biomarkers for GCG and GIP receptor activation. Single doses of SAR441255 were well tolerated. The results demonstrate that integrating GIP activity into dual GLP-1 and GCG receptor agonism provides improved effects on weight loss and glycemic control while buffering the diabetogenic risk of chronic GCG receptor agonism.
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•SAR441255 showed substantial body weight loss in diabetic obese monkeys•SAR441255 also improved glucose control in diabetic obese monkeys•PET imaging in monkeys confirmed high receptor occupancy with SAR441255•In healthy subjects, biomarkers confirmed engagement of the three receptors by SAR441255
Bossart et al. designed a unimolecular triple GLP-1R/GCGR/GIPR agonist with substantial metabolic activity in preclinical animal models. In a single-dose study in human subjects, SAR441255 lowered plasma glucose during a mixed-meal tolerance test with a decrease in plasma biomarker levels supportive of engagement at all three targeted receptors.
Our objective was to identify non-obstetric risk factors for pelvic organ prolapse in women attending a urogynecology clinic.
A retrospective study of 662 women referred for pelvic floor dysfunction ...between January 2017 and August 2018. Participants underwent a standardized interview, clinical exam including Pelvic Organ Prolapse Qualification (POP-Q) assessment, and four-dimensional transperineal ultrasound. They were questioned about smoking, asthma, heavy lifting and family history of pelvic organ prolapse, as well as prolapse symptoms. Significant clinical prolapse was defined as POP-Q stage ≥2 for anterior and posterior compartments and stage ≥1 for apical prolapse. Offline analysis of volume data was performed blinded against all other data. Statistical analysis included logistic regression with multivariable models adjusted for age, body mass index, vaginal parity, levator hiatal area and levator avulsion.
Participating women were assessed at a mean age of 58 (SD 13.3) years with a mean body mass index of 28.93 kg/m2 (standard deviation 5.98). The vast majority were vaginally parous (88.2 %) with a median of two vaginal deliveries (range 0−7). Previous hysterectomy was reported by 29.3 % of women (n = 194) and previous prolapse repair by 17.2 % (n = 114). Past or current smoking was reported by 300 (45.6 %) women, 113 (17.2 %) reported asthma, 246 (37.6 %) heavy lifting and 186 (28.6 %) a family history of pelvic organ prolapse. Heavy lifting was associated with sonographic prolapse (odds ratio 1.71, 95 % confidence interval 1.2−2.4), confirmed on multivariable analysis (P = 0.046). Heavy lifting was positively associated with symptoms (P = 0.053) and clinical signs of pelvic organ prolapse (P = 0.056) on univariate analysis; however, this became non-significant on multivariable analysis. No associations were found for individual compartments except for a trend towards more posterior compartment prolapse with heavy lifting.
Smoking, asthma and family history of prolapse were not found to be a significant risk factor for prolapse in our study population. Heavy lifting may be a potential risk factor, in particular for posterior compartment prolapse.
Imaging is increasingly being used in urogynaecology. Because of low cost and universal availability, ultrasound (US) is the most commonly used diagnostic modality, which allows the observation of ...manoeuvres such as Valsalva and pelvic floor muscle contraction in real time. The ability to see beyond surface anatomy is particularly important in the posterior compartment and in obstructed defecation where this method may replace defecation proctography. Imaging is especially useful in the form of 3D/4D multiplanar and tomographic translabial US, as these modalities give access to the axial plane and the levator ani. This allows assessment of both avulsion, i.e. major maternal birth trauma, and hiatal overdistension, i.e. ballooning. Both are major risk factors for both prolapse and prolapse recurrence. This review will outline current clinical utility, introduce recent research in the respective field and provide an overview of likely future utility of imaging in the investigation of pelvic organ prolapse.
•Surface anatomy is often insufficient for the assessment of pelvic organ prolapse (POP).•Posterior compartment descent may occur due to several different conditions.•Levator avulsion is the traumatic disconnection of the puborectalis component of the levator ani from the os pubis.•Ballooning is defined as excessive distensibility of the levator hiatus ≥25 cm2 on Valsalva.•Avulsion and ballooning are risk factors for prolapse and prolapse recurrence.
While normal pelvic organ support has been defined for women with intact uterus, this is not the case for post- hysterectomy vault descent. A recent systematic review found that definitions of apical ...prolapse are highly variable.
To investigate the relationship between prolapse symptoms and apical POP-Q measurements and establish cutoffs for 'significant apical descent using receiver-operator characteristics (ROC) statistics.
Retrospective analysis of patients seen at a tertiary urogynecological unit. Evaluation included a standardized interview and clinical assessment using the Pelvic Organ Prolapse Quantification (POP-Q) system. ROC curves were prepared for the relationship between prolapse symptoms and POP-Q measure "C".
The records of 3010 women were available for analysis. Prolapse symptoms were reported by 52.3% (n = 1573), with a mean bother of 5.9 (SD 3.0, range 0-10). POP-Q point "C" was associated with symptoms of prolapse (p <0.0001) and prolapse bother (p <0.0001) on both univariate and multivariate analysis. ROC curves for women with and without uterus were similar, although the relationship between apical descent and symptoms of prolapse was stronger for women with uterus (AUC 0.728 versus 0.678). After controlling for multi-compartment prolapse, the models improved, resulting in AUCs of 0.782 and 0.720. For prediction of prolapse symptoms, cutoffs were set at C = -5 (sensitivity 0.73, specificity 0.67 with uterus in situ, sensitivity 0.59, specificity, 0.73 after hysterectomy).
A cut- off for 'significant central compartment descent' of 5 cm above the hymen on Valsalva seems valid regardless of previous hysterectomy.
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