The relationship between anterior and apical compartment support

doi:10.1016/j.ajog.2006.01.057

American Journal of Obstetrics and Gynecology

Volume 194, Issue 5, May 2006, Pages 1438-1443

https://doi.org/10.1016/j.ajog.2006.01.057 Get rights and content

Objective

The purpose of this study was to determine whether the degree of anterior compartment (bladder) and apical compartment (cervix) prolapse are correlated, and whether 2 anterior compartment elements (urethra and bladder) are related at maximal Valsalva.

Study design

Women with a complete spectrum of pelvic support were recruited for a pelvic support study. Dynamic magnetic resonance scans were taken during Valsalva. A convenience sample of 153 women with a mean age of 53.3 ± 12.5 (SD) years with a uterus in situ was studied. Anterior compartment status was assessed by the most caudal bladder point and the internal urinary meatus. The external cervical os was used to assess the apical compartment. The position of the bladder, urethra, and uterus were determined in 20 nulliparous women to determine their reference locations. The distances of each structure below the reference positions were calculated at maximum Valsalva.

Results

Average distances of the bladder base, urethra, and uterus from the reference positions at maximal Valsalva were 4.1 ± 2.4 cm, 3.1 ± 1.3 cm, and 4.3 ± 2.4 cm, respectively. The Pearson correlation coefficient of the relationship between the bladder base and uterine distances was r = 0.73 (r² = 0.53). The Pearson correlation coefficient of the bladder distance and urethral distance was r = 0.82 (r² = 0.67).

Conclusion

Half of the observed variation in anterior compartment support may be explained by apical support.

Section snippets

Material and methods

We recruited women representing both normal support, as well as varying degrees of pelvic organ prolapse as part of an ongoing case control study of pelvic organ support at the University of Michigan. Women with prolapse were recruited from the Urogynecology clinic and those with normal support, by advertisement. Women who had previously been operated on for pelvic organ prolapse or urinary incontinence were excluded. A convenience sample was selected from this pool to include women in whom the

Results

Figure 2 shows examples of variation in cervix, bladder, and urethra descent demonstrating different combinations of support with some women having descent of only the uterus, while others have anterior compartment descent despite a well-supported uterus, and others having descent in both compartments.

The locations of the bladder and the cervix at rest and during maximal Valsalva are shown in Figure 3. The “normal” locations of the bladder and cervix calculated from the nulliparous women are

Comment

This study quantifies the relationship between the anterior compartment and the apical compartment revealing an r² value of 0.53 indicating that half the size of the anterior compartment prolapse is explained by the size of the apical compartment and vice versa. A substantial number of women had descent of either anterior or apical compartment alone. Therefore, multi-compartment prolapse needs to be considered on an individual basis. A relationship (r² = 0.67) also exists between descent of the

References (13)

S.H. Boyles et al.
Procedures for pelvic organ prolapse in the United States, 1979-1997
Am J Obstet Gynecol
(2003)
J.O. DeLancey
Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse
Am J Obstet Gynecol
(2002)
J.L. Whiteside et al.
Clinical evaluation of anterior vaginal wall support defects: interexaminer and intraexaminer reliability
Am J Obstet Gynecol
(2004)
M.D. Barber et al.
Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse
Am J Obstet Gynecol
(1999)
J.O. DeLancey
Anatomic aspects of vaginal eversion after hysterectomy
Am J Obstet Gynecol
(1992 Jun)
N.F. Miller et al.
Human parturition: normal and abnormal labor
(1958)

There are more references available in the full text version of this article.

Cited by (198)

Comparison of in vivo visco-hyperelastic properties of uterine suspensory tissue in women with and without pelvic organ prolapse
2023, Journal of the Mechanical Behavior of Biomedical Materials
The uterine suspensory tissue (UST) complex includes the cardinal (CL) and uterosacral “ligaments” (USL), which are mesentery-like structures that play a role in resisting pelvic organ prolapse (POP). Since there is no information on the time-dependent material properties of the whole structure in situ and in vivo, we developed and tested an intraoperative technique to quantify in vivo whether there is a significant difference in visco-hyperelastic behavior of the CL and USL between women with and without POP. Thirteen women with POP (cases) and four controls scheduled for surgery were selected from an ongoing POP study. Immediately prior to surgery, a computer-controlled linear servo-actuator with a series force transducer applied a continuous, caudally directed traction force while simultaneously recording the resulting cervical displacement in the same direction. After applying an initial 1.1 N preload, a ramp rate of 4 mm/s was used to apply a maximum force of 17.8 N in three “ramp-and-hold” test trials. A simplified bilateral four-cable biomechanical model was used to identify the material behavior of each ligament. For this, the initial cross-section areas of the CL and USL were measured on 3-T magnetic resonance image-based 3D models from each subject. The time-dependent strain energy function of CL/USL was defined with a three-parameter hyperelastic Mooney–Rivlin material model and a two-term Prony series in relaxation form. When cases were compared with controls, the estimated time-dependent material constants of CL and USL did not differ significantly. These are the first measurements that compare the in vivo and in situ visco-hyperelastic response of the tissues comprising the CL and USL to loading in women with and without prolapse. Larger sample sizes would help improve the precision of intergroup differences.
Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension
2023, American Journal of Obstetrics and Gynecology
Citation Excerpt :
Loss of apical support is usually present in women with prolapse that extends beyond the hymen, when prolapse symptoms tend to occur.1,2 At least half of the observed variation in anterior compartment support may be explained by apical support.3 Adequate support for the vaginal apex is thought to be an essential component of a durable surgical repair for women with advanced prolapse.4,5
Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery in the Vaginal hysterectomy with Native Tissue Vault Suspension vs Sacrospinous Hysteropexy with Graft Suspension (Study for Uterine Prolapse Procedures Randomized Trial) trial, sacrospinous hysteropexy with graft (hysteropexy) resulted in a lower composite surgical failure rate than vaginal hysterectomy with uterosacral suspension over 5 years.
This study aimed to identify factors associated with the rate of surgical failure over 5 years among women undergoing sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral suspension for uterovaginal prolapse.
This planned secondary analysis of a comparative effectiveness trial of 2 transvaginal apical suspensions (NCT01802281) defined surgical failure as either retreatment of prolapse, recurrence of prolapse beyond the hymen, or bothersome prolapse symptoms. Baseline clinical and sociodemographic factors for eligible participants receiving the randomized surgery (N=173) were compared across categories of failure (≤1 year, >1 year, and no failure) with rank-based tests. Factors with adequate prevalence and clinical relevance were assessed for minimally adjusted bivariate associations using piecewise exponential survival models adjusting for randomized apical repair and clinical site. The multivariable model included factors with bivariate P<.2, additional clinically important variables, apical repair, and clinical site. Backward selection determined final retained risk factors (P<.1) with statistical significance evaluated by Bonferroni correction (P<.005). Final factors were assessed for interaction with type of apical repair at P<.1. Association is presented by adjusted hazard ratios and further illustrated by categorization of risk factors.
In the final multivariable model, body mass index (increase of 5 kg/m²: adjusted hazard ratio, 1.7; 95% confidence interval, 1.3–2.2; P<.001) and duration of prolapse symptoms (increase of 1 year: adjusted hazard ratio, 1.1; 95% confidence interval, 1.0–1.1; P<.005) were associated with composite surgical failure, where rates of failure were 2.9 and 1.8 times higher in women with obesity and women who are overweight than women who have normal weight and women who are underweight (95% confidence intervals, 1.5–5.8 and 0.9–3.5) and 3.0 times higher in women experiencing >5 years prolapse symptoms than women experiencing ≤5 years prolapse symptoms (95% confidence interval, 1.8–5.0). Sacrospinous hysteropexy with graft had a lower rate of failure than hysterectomy with uterosacral suspension (adjusted hazard ratio, 0.6; 95% confidence interval, 0.4–1.0; P=.05). The interaction between symptom duration and apical repair (P=.07) indicated that failure was less likely after hysteropexy than hysterectomy for those with ≤5 years symptom duration (adjusted hazard ratio, 0.5; 95% confidence interval, 0.2–0.9), but not for those with >5 years symptom duration (adjusted hazard ratio, 1.0; 95% confidence interval 0.5–2.1).
Obesity and duration of prolapse symptoms have been determined as risk factors associated with surgical failure over 5 years from transvaginal prolapse repair, regardless of approach. Providers and patients should consider these modifiable risk factors when discussing treatment plans for bothersome prolapse.
Levator ani muscle avulsion in patients with pelvic floor dysfunction – Does it help in understanding pelvic organ prolapse?
2022, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
However, other studies confirmed that loss of apical support is involved in the occurrence of anterior compartment POP by other mechanisms. This suggests that the anterior vaginal wall forms a roughly trapezoidal layer on which the bladder is supported, with the narrow ventral portion attached to the pubis at the insertion of the tendinous arch of the pelvic fascia and the wide dorsal part attached to the ischial spine [28]. The broad dorsal margin of the trapezoid is held upward by the suspending action of the cardinal/uterosacral ligament complex [29].
Levator ani muscle (LAM) lesions are an important factor in the development of female pelvic organ prolapse (POP).
To determine the prevalence of LAM avulsion by transperineal ultrasound. The second outcome is to evaluate the association between complete avulsion and the type, degree, and number of POP compartments involved.
This was a retrospective cohort study performed in a tertiary hospital that included patients with pelvic floor dysfunction evaluated from January 2016 to March 2020. The presence of LAM avulsion was diagnosed by 3D/4D pelvic floor transperineal ultrasound. We identified women with POP, and they were classified according to the POP-Q system. The association between complete avulsion and the type, degree and number of compartments were calculated using generalized logit models.
848 women were included in the analysis. A complete LAM avulsion was found in 195 patients (23 %). Patients with complete avulsion were 4.7 (CI: 1.98–11.5) times more likely to have POP than patients with partial avulsion. The anterior compartment was the most frequently affected (n = 605, 25.8 %). Women with severe stage POP were 3.13 times (CI: 1.90–5.16) more likely to have bilateral complete LAM avulsion than women with mild prolapse. Patients with three-compartment POP were 2.75 times (CI: 1.53–4.94) more likely to have unilateral complete LAM avulsion than women with POP in one compartment.
The prevalence of LAM avulsion is high in patients with urogynecological symptoms. Patients with complete LAM avulsion are at greater risk of developing POP and have a more advanced stage of prolapse and involvement of multiple compartments.
Effect of two different surgical modalities for pelvic organ prolapse on postoperative wound infection in patients: A meta-analysis
2024, International Wound Journal
Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse?
2024, Journal of Ultrasound in Medicine
Anterior–apical Transvaginal Mesh (Calistar-S) for Treatment of Advanced Urogenital Prolapse: Surgical and Functional Outcomes at 1 Year
2024, International Urogynecology Journal

View all citing articles on Scopus

Funded by National Institute of Child and Human Development: R01 HD 038665 and P50 HD 44406.

Presented at the Twenty-Sixth Annual Meeting of the American Urogynecologic Society, Atlanta, GA, September 15-17, 2005.

View full text

Transactions from the Twenty-Sixth Annual Meeting of the American Urogynecologic SocietyThe relationship between anterior and apical compartment support

Objective

Study design

Results

Conclusion

Section snippets

Material and methods

Results

Comment

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Anatomic aspects of vaginal eversion after hysterectomy

Am J Obstet Gynecol

Human parturition: normal and abnormal labor

Transactions from the Twenty-Sixth Annual Meeting of the American Urogynecologic Society
The relationship between anterior and apical compartment support