Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse

doi:10.1067/mob.2002.125733

American Journal of Obstetrics and Gynecology

Volume 187, Issue 1, July 2002, Pages 93-98

Presented at the Twenty-Second Annual Meeting of the American Urogynecologic Society, Chicago, Ill, October 25-28, 2001.

https://doi.org/10.1067/mob.2002.125733 Get rights and content

Abstract

Objective: Our purpose was to assess the structural integrity of individual elements of the urethral and anterior vaginal wall support system. Study Design: Notes were made during retropubic operations for cystourethrocele and stress incontinence in 71 women aged 52 ± 12.4 (SD) years. Vaginal support was assessed with the Baden-Walker system with the following average findings: urethra 1.9 ± 0.6, bladder 1.9 ± 1.0, apex 0.8 ± 1.1, upper posterior wall 0.3 ± 0.8, and rectocele 1.1 ± 0.7. The presence of the following features was noted: paravaginal defect, integrity of the pubic and ischial attachments of the arcus tendineus fascia pelvis (ATFP), appearance of the ATFP on the sidewall, and abnormalities in the pubococcygeal muscle. Results: Paravaginal defects were present in 87.3% on the left and in 88.7% on the right. Detachment of the ATFP from the pubic bone was present in 1.4% (left) and 2.8% (right). The ATFP was detached from the ischial spine in 97.6% (left) and 95.1% (right). Remnants of the ATFP were present on the sidewall in 62% (left) and 63% (right). Of these, 9% extended one fourth the distance to the spine, 21% one half the distance, 3% three fourths the distance, and 17% all the way to the spine. The pubococcygeal muscle was visibly normal in 45% (left) and 39% (right). It showed localized atrophy in 22% (left) and 30% (right) and generalized atrophy in 22.5% (left) 30.0% (right). Conclusion: The ATFP usually detaches from the ischial spine, but not from the pubis; slightly less than half of these women have visibly abnormal levator ani muscles. (Am J Obstet Gynecol 2002;187:93-8.)

Section snippets

Study population

Between June 1, 1996, and February 1, 2001, notes were made during retropubic operations in 68 women operated on for cystourethrocele and stress urinary incontinence. In addition, there were 3 women with cystourethrocele in whom paravaginal defect repair was planned in conjunction with abdominal sacral colpopexy with urethral hypermobility to support the anterior vaginal wall in women without stress incontinence, making a total study population of 71. Women with prior surgery that could distort

Presence and absence of paravaginal defect

Most of these women had a paravaginal defect (Table III).

. Presence of paravaginal defect

Paravaginal defect	Left		Right
Paravaginal defect	No.	%	No.	%
Present	62	87.3	63	88.7
Absent	5	7.0	4	5.6
Atypical	2	2.8	2	2.8
Not evaluable	2	2.8	2	2.8
Total	71	100	71	100

Of the 71 women, 62 had bilateral defects, with 2 having unilateral right defects and 1 a left defect. In 3 women the anatomy was atypical or could not be adequately assessed.

Three women with urethral hypermobility and stress incontinence did not have a paravaginal defect on either side. A

Comment

The ATFP is a band of dense regular connective tissue stretched between the pubic bone and the ischial spine. The pubocervical fascia forms a trapezoidal layer spanning the area between the two arcus tendineae. We have found that dorsal detachment of the arcus from the spine is associated with anterior vaginal wall descent. The mechanical concept relating this detachment to descent of the urethra and anterior vaginal wall can be seen in Fig 3.

The finding that the arcus is detached from the

Acknowledgements

Submitted in memory of A. Cullen Richardson, MD.

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^☆: Supported by grants No. DK 47516 and DK 51405 from the National Institutes of Health.

^☆☆: Reprint requests: John O. L. DeLancey, MD, Women's Hospital L4100, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0276. E-mail: [email protected]

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General Obstetrics and Gynecology: GynecologyFascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse☆,☆☆

Abstract

Section snippets

Study population

Presence and absence of paravaginal defect

Comment

Acknowledgements

Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Treatment of stress urinary incontinence due to paravaginal fascial defect

Obstet Gynecol

Structural aspects of the extrinsic continence mechanism

Obstet Gynecol

Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis

Am J Obstet Gynecol

Surgical repair of vaginal defects

General Obstetrics and Gynecology: Gynecology
Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse☆,☆☆