Browsing by Author "Dietz, Hans"
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Item Anal sphincter trauma and anal incontinence in urogynecological patients(2015) Guzmán Rojas, Rodrigo; Kamisan, Ixora; Shek, Ka Lai; Dietz, HansOBJECTIVES: To determine the prevalence of evidence of residual obstetric anal sphincter injury, to evaluate its association with anal incontinence (AI) and to establish minimal diagnostic criteria for significant (residual) external anal sphincter (EAS) trauma. METHODS: This was a retrospective analysis of ultrasound volume datasets of 501 patients attending a tertiary urogynecological unit. All patients underwent a standardized interview including determination of St Mark's score for those presenting with AI. Tomographic ultrasound imaging (TUI) was used to evaluate the EAS and the internal anal sphincter (IAS). RESULTS: Among a total of 501 women, significant EAS and IAS defects were found in 88 and 59, respectively, and AI was reported by 69 (14%). Optimal prediction of AI was achieved using a model that included four abnormal slices of the EAS on TUI. IAS defects were found to be less likely to be associated with AI. In a multivariable model controlling for age and IAS trauma, the presence of at least four abnormal slices gave an 18-fold (95% CI, 9-36; P < 0.0001) increase in the likelihood of AI, compared with those with fewer than four abnormal slices. Using receiver-operating characteristics curve statistics, this model yielded an area under the curve of 0.86 (95% CI, 0.80-0.92). CONCLUSIONS: Both AI and significant EAS trauma are common in patients attending urogynecological units, and are strongly associated with each other. Abnormalities of the IAS seem to be less important in predicting AI. Our data support the practice of using, as a minimal criterion, defects present in four of the six slices on TUI for the diagnosis of significant EAS trauma.Item Atraumatic normal vaginal delivery: how many women get what they want?(Elsevier Inc., 2018) Caudwell-Hall, Jessica; Kamisan Atan, Ixora; Guzmán Rojas, Rodrigo; Langer, Susanne; Shek, Ka Lai; Dietz, HansBACKGROUND: Trauma to the perineum, levator ani complex, and anal sphincter is common during vaginal childbirth, but often clinically underdiagnosed, and many women are unaware of the potential for long-term damage. OBJECTIVE: In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery. STUDY DESIGN: This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma. RESULTS: A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035). CONCLUSION: The prevalence of significant pelvic floor trauma after vaginal child birth is much higher than generally assumed. Rates of obstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33-40%) of primiparous women achieved an atraumatic normal vaginal delivery.Item Can pelvic floor trauma be predicted antenatally?(Nordic Federation of Societies of Obstetrics and Gynecology/ Wiley, 2018) Caudwell‐Hall, Jessica; Kamisan Atan, Ixora; Brown, Chris; Guzmán Rojas, Rodrigo; Langer, Susanne; Shek, Ka Lai; Dietz, HansIntroduction: Levator trauma is a risk factor for the development of pelvic organ prolapse. We aimed to identify antenatal predictors for significant damage to the levator ani muscle during a first vaginal delivery. Material and Methods: A retrospective observational study utilizing data from two studies with identical inclusion criteria and assessment protocols between 2005 and 2014. A total of 1148 primiparae with an uncomplicated singleton pregnancy were recruited and assessed with translabial ultrasound at 36 weeks antepartum and 871 (76%) returned for reassessment 3-6 months postpartum. The ultrasound data of vaginally parous women were analyzed for levator avulsion and microtrauma. The former was diagnosed if the muscle insertion at the inferior pubic ramus in the plane of minimal hiatal dimensions and within 5 mm above were abnormal on tomographic ultrasound imaging. Microtrauma was diagnosed in women with an intact levator and if there was a postpartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2 Results: The complete datasets of 844 women were analyzed. Among them, 609 delivered vaginally: by normal vaginal delivery in 452 (54%), a vacuum birth in 102 (12%) and a forceps delivery in 55 (6%). Levator avulsion was diagnosed in 98 and microtrauma in 97. On multivariate analysis, increasing maternal age, lower body mass index and lower bladder neck descent were associated with avulsion. Increased bladder neck descent and a family history of cesarean section (CS) were associcated with microtrauma. Conclusions: Maternal age, body mass index, bladder neck descent and family history of CS are antenatal predictors for levator traum.Item Defect-specific rectocele repair: medium-term anatomical, functional and subjective outcomes.(The Royal Australian and New Zealand College of Obstetricians and Gynaecologists by Wiley, 2015) Guzmán Rojas, Rodrigo; Kamisan, Ixora; Shek, Ka Lai; Dietz, HansBACKGROUND: Rectocele is a herniation of the anterior wall of the rectal ampulla through a defect in the rectovaginal septum causing protrusion of the posterior vaginal wall. Common symptoms include symptoms of prolapse and obstructed defecation. AIMS: To describe subjective, anatomical and functional results of defect-specific rectocele repair. MATERIALS AND METHODS: This is an internal audit of 137 women who underwent defect-specific rectocele repair. Pre- and post-operative assessment included a standardised interview, clinical examination and 3D/4D transperineal ultrasound. Outcome measures were symptoms of obstructed defecation, recurrent prolapse symptoms, clinical posterior compartment recurrence and rectocele recurrence on ultrasound. RESULTS: At a mean follow-up of 1.4 years, 117 (85%) of women considered themselves cured or improved. Thirty-four (25%) complained of recurrent prolapse symptoms and 47 (34%) symptoms of obstructed defecation, a significant reduction (P < 0.0001). Clinical recurrence (Bp ≥ -1) was seen in 19 women (14%) and recurrence on ultrasound in 27 (20%). The mean depth of recurrence was 16.6 mm (10.3-25.1). We tested multiple potential predictors of recurrence, including age, BMI, vaginal parity, previous hysterectomy and/or prolapse surgery, follow-up time, pre-operative clinical and ultrasound findings. Only hiatal area on Valsalva (OR 0.95 for sonographic recurrence, P = 0.01) and enterocele (for clinical and sonographic recurrence, OR 4.03, P = 0.01 and OR 2.72, P = 0.02, respectively) reached significance. CONCLUSION: Defect-specific rectocele repair is effective both in restitution of normal anatomy and in resolving prolapse and obstructed defecation symptoms at a mean follow-up of 1.4 years.Item Digitation associated with defecation: what does it mean in urogynaecological patients?(IUGA with Springer International Publishing AG, 2016) Hai-Ying, Cao; Guzmán Rojas, Rodrigo; Caudwell, Jessica; Kamisan, Ixora; Dietz, HansINTRODUCTION AND HYPOTHESIS: Obstructed defecation is a common symptom complex in urogynaecological patients, and perineal, vaginal and/or anal digitation may required for defecation. Translabial ultrasound can be used to assess anorectal anatomy, similar to defecation proctography. The aim of the present study was to determine the association between different forms of digitation (vaginal, perineal and anal) and abnormal posterior compartment anatomy. METHODS: A total of 271 patients were analysed in a retrospective study utilising archived ultrasound volume datasets. Symptoms of obstructed defecation (straining at stool, incomplete bowel emptying, perineal, vaginal and anal digitation) were ascertained on interview. Postprocessing of stored 3D/4D translabial ultrasound datasets obtained on maximal Valsalva was used to diagnose descent of the rectal ampulla, rectocoele, enterocoele and rectal intussusception at a later date, blinded to all clinical data. RESULTS: Digitation was reported by 39 % of our population. The position of the rectal ampulla on Valsalva was associated with perineal (p = 0.02) and vaginal (p = 0.02) digitation. The presence of a true rectocoele was significantly associated with perineal (p = 0.04) and anal (p = 0.03) digitation. Rectocoele depth was associated with all three forms of digitation (P = 0.005-0.02). The bother of symptoms of obstructed defecation was strongly associated with digitation (all P < = 0.001), with no appreciable difference in bother among the three forms. CONCLUSION: Digitation is common, and all forms of digitation are associated with abnormal posterior compartment anatomy. It may not be necessary to distinguish between different forms of digitation in clinical practice.Item Does childbirth play a role in the etiology of rectocele?(IUGA with Springer International Publishing AG, 2015) Guzmán Rojas, Rodrigo; Quintero, Cristián; Shek, Ka Lai; Dietz, HansINTRODUCTION AND HYPOTHESIS: Rectoceles are common among parous women and they are believed to be due to disruption or distension of the rectovaginal septum as a result of childbirth. However, the etiology of rectocele is likely to be more complex since posterior compartment prolapse does occur in nulliparous women. This study was designed to determine the role of childbearing as an etiological factor in true radiological rectocele. METHODS: This was a secondary analysis of the data from 657 primiparous women recruited as part of a previously reported study and another ongoing prospective study. Women were invited for antenatal and postnatal appointments comprising an interview, clinical examination and translabial ultrasonography. The presence and depth of any rectocele were determined on maximum Valsalva maneuver, as was descent of the rectal ampulla. Potential demographic and obstetric factors as predictors of rectocele development were evaluated using either multiple regression or logistic regression analysis as appropriate. RESULTS: A true rectocele was identified in 4% of women antenatally and in 16% after childbirth (P < 0.001). Mean rectocele depth was 13.5 mm (10 - 23.2 mm). The mean antepartum position of the rectal ampulla on Valsalva maneuver was 4.39 mm above and it was 1.64 mm below the symphysis pubis postpartum (P < 0.0001). De novo appearance of true rectocele was significantly associated with a history of previous <20 weeks pregnancy and fetal birth weight. Body mass index and length of the second stage were associated with rectocele depth increase. CONCLUSIONS: Childbirth seems to play a distinct role in the pathogenesis of rectocele. Both maternal and fetal factors seem to contribute.Item How large does a rectocele have to be to cause symptoms? A 3D/4D ultrasound study.(IUGA with Springer International Publishing AG, 2015) Dietz, Hans; Zhang, Xue; Shek, Ka Lai; Guzmán Rojas, RodrigoINTRODUCTION: Rectocele is a common condition, which on imaging is defined by a pocket identified on Valsalva or defecation. Cut-offs of 10 and 20 mm for pocket depth have been described. This study analyses the correlation between rectocele depth and symptoms of bowel dysfunction to define a cut-off for the diagnosis of "significant rectocele" on ultrasound. METHODS: A retrospective study using 564 archived data sets of patients seen at tertiary urogynaecological clinics. Patients underwent a standardised interview including a set of questions regarding bowel function, and translabial 3D/4D ultrasound. Assessments were undertaken supine and after voiding. Rectocele depth was measured on Valsalva. RESULTS: Out of 564, data on symptoms was missing in 18 and ultrasound volumes in 25, leaving 521. Mean age was 56 years (range 18-86), mean BMI 29 (17-56). Presenting symptoms were prolapse (51 %), constipation (21 %), vaginal digitation (17 %), straining at stool (46 %), incomplete bowel emptying (41 %) and faecal incontinence (10 %). A clinically significant rectocele (ICS POPQ stage ≥2) was found in 48 % (n=250). In 261 women a rectal diverticulum was identified, of an average depth of 17 (SD, 7) mm. On ROC statistics a cut- off of 15 mm in depth provided optimal sensitivities of 66 % for vaginal digitation and 63 % for incomplete emptying, and specificities of 52 and 57 % respectively. CONCLUSIONS: Rectocele depth is associated with symptoms of obstructed defecation. A "clinically significant" rectocele may be defined as a diverticulum of the rectal ampulla of ≥15 mm in depth, although poor test characteristics limit clinical utility of this cut-off.Item Impact of levator trauma on pelvic floor muscle function.(Springer, 2014) Rojas, Rodrigo; Wong, Vivien; Shek, Ka Lai; Dietz, HansINTRODUCTION AND HYPOTHESIS: Levator trauma is common after vaginal delivery, either as macrotrauma, i.e., levator avulsion, or microtrauma, i.e., irreversible overdistension of the levator hiatus. The effect of microtrauma on muscle function is unknown. We tested the hypothesis that levator trauma is associated with reduced contractile function of the levator ani. METHODS: Pregnant nulliparous women were recruited and seen before and after childbirth. All underwent an interview, a clinical examination including pelvic floor muscle (PFM) assessment using the Modified Oxford scale (MOS) [as an optional component] and translabial ultrasound. Sonographic and clinical parameters of PFM function were assessed before and after childbirth. RESULTS: Out of 560 women, 446 returned at a median of 5 months after childbirth and 433 were suitable for analysis. There was a significant reduction in all measures of PFM function except for MOS. Change in MOS was associated with delivery mode [analysis of variance (ANOVA) P = 0.006). Forty-seven (15 %) vaginally parous women were diagnosed with levator avulsion, which was associated with a reduction in PFM contractility on sonographic parameters and MOS. However, only clinical assessment reached statistical significance. Sixty-five of 312 (21 %) women were diagnosed with microtrauma. We found no evidence of impairment in PFM contractility on ultrasound, but there was a statistically significant reduction in MOS. CONCLUSIONS: Both levator avulsion (macrotrauma) and irreversible overdistension (microtrauma) are associated with reduced contractile function. This effect is more easily detected by palpation than by sonographic indices of levator function.Item Is the levator-urethra gap helpful for diagnosing avulsion?(Springer, 2016) Dietz, Hans; Garnham, Alejandro; Rojas, RodrigoINTRODUCTION AND HYPOTHESIS: Levator avulsion is a risk factor for female pelvic organ prolapse (POP) and recurrence after POP surgery. Imaging diagnosis requires the observation of an abnormal muscle insertion on tomographic ultrasound imaging (TUI). This study was designed to compare the diagnostic performance of the qualitative diagnosis (visual qualitative assessment) to measurement of the distance between muscle insertion and urethra [levator-urethra gap; (LUG)]. METHODS: This was a retrospective analysis of data obtained in a tertiary urogynecological unit. All patients presented with symptoms of pelvic floor dysfunction and underwent 4D translabial pelvic floor ultrasound (US), supine, and after voiding. Avulsion was defined qualitatively as abnormal muscle insertion and quantitatively as LUG ≥25 mm on at least three consecutive central axial plane slices, with one examiner using both methods. We examined the correlation between both methods and validated them against clinical prolapse, significant organ descent on US, and hiatal ballooning. RESULTS: Between January and July 2013, 233 patients were seen, of whom 202 had complete volume data sets. The qualitative method diagnosed avulsion in 22 % and the quantitative method in 24.3 %. Agreement was good, with a kappa of 0.79 (0.70-0.87). Avulsion diagnosed by either method was associated with clinical and sonographic prolapse and hiatal ballooning, with odds ratios nonsignificantly higher for the quantitative method. CONCLUSION: Qualitative analysis of slices on TUI and a method using LUG measurement show good agreement for the diagnosis of avulsion. The LUG method is at least equally as valid in its capacity to predict significant prolapse on clinical examination and US, as well as ballooning of the levator hiatus.Item Negative urodynamic testing in women with stress incontinence.(The Royal Australian and New Zealand College of Obstetricians and Gynaecologists by Wiley, 2015) Liversidge, Kylie; Guzmán Rojas, Rodrigo; Kamisan, Ixora; Dietz, HansINTRODUCTION: A minority of women with a subjective complaint of stress urinary incontinence will have negative urodynamic stress incontinence (USI) findings. AIM: To test clinical and ultrasound measures as predictors of an unexpected absence of USI. We hypothesised that unexpectedly negative USI would be more common in young women with good pelvic floor and urethral function. METHODS: A retrospective study analysing 398 data sets from women attending a urogynaecology clinic for evaluation of lower urinary tract and pelvic floor dysfunction. Clinical, urodynamic and translabial ultrasound data were tested as possible predictors of negative USI findings. RESULTS: Women with unexpectedly negative USI findings were younger, had less anterior compartment prolapse and had a higher maximum urethral pressure. Measures of pelvic floor muscle function were not predictive. CONCLUSIONS: Women with unexpectedly negative USI are younger and have better urethral function, but voluntary pelvic floor muscle function seems unrelated to this phenomenon.Item Obesity: how much does it matter for female pelvic organ prolapse?(Springer, 2017) Young, Natharnia; Atan, Ixora; Guzman, Rodrigo; Dietz, HansINTRODUCTION AND HYPOTHESIS: The objective was to determine the association between body mass index (BMI) and symptoms and signs of female pelvic organ prolapse (POP). METHODS: An observational cross-sectional study of 964 archived datasets of women seen for symptoms and signs of lower urinary tract and pelvic organ dysfunction between September 2011 and February 2014 at a tertiary urogynaecology centre in Australia was carried out. An in-house standardised interview, the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) and 4-D translabial ultrasound, followed by analysis of ultrasound volumes for pelvic organ descent and hiatal area on Valsalva, were performed, blinded against other data. RESULTS: There is a positive association between BMI and posterior compartment prolapse on clinical examination and ultrasound imaging, but not for the anterior and central compartments. There was no association with prolapse symptom bother and a negative association with symptoms of prolapse. CONCLUSIONS: In this observational study, we found a strong association between all tested measures of posterior compartment descent and BMI, both clinical and on imaging.Item Postprocessing of pelvic floor ultrasound data: how repeatable is it?(Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2014) Dietz, Hans; Guzman, Rodrigo; Shek, Ka LaiAIMS: Translabial 3D/4D pelvic floor ultrasound (PFUS) is increasingly used in the evaluation of pelvic floor disorders. Commonly, this involves the analysis of stored volume data sets by postprocessing. In this study, we aimed to assess the time requirement to reaching acceptable repeatability for commonly employed outcome measures in PFUS. METHODS: Between 2010 and 2013, 20 individuals from 11 countries underwent training in postprocessing of PFUS volume data sets. They undertook test-retest series (n ≥ 20) between day 2 and day 15 of training. Outcome measures tested included levator hiatal area on Valsalva, descent of the bladder neck, bladder, uterus and rectal ampulla, and rectocele depth. After an initial training session of 10-20 cases, test-retest series were undertaken between the trainee and measurements obtained by the author or senior trainees. RESULTS: Trainees were obstetricians/gynaecologists in training (n = 4), obstetricians/gynaecologists or subspecialty trainees (n = 13), medical students (n = 1) and physiotherapists (n = 2). A total of 58 repeatability series were analysed, obtained between days 2 and 15 of training. When second or third retest series were necessary, there always was improvement in repeatability except for one series in one individual. Satisfactory repeatability (ICC > 0.7) was achieved by all trainees for all parameters required by them. Training lasted from 3 to 15 days, with means between 4 and 5.8 days. CONCLUSIONS: Postprocessing analysis of commonly used PFUS parameters can be taught to an acceptable standard within 1 week. Most commonly used ultrasound parameters obtained by postprocessing for prolapse assessment can be taught to an acceptable standard of repeatability within one week.Item The prevalence of abnormal posterior compartment anatomy and its association with obstructed defecation symptoms in urogynecological patients(Springer, 2016) Guzmán Rojas, Rodrigo; Kamisan, Ixora; Shek, Ka Lai; Dietz, HansINTRODUCTION AND HYPOTHESIS: Symptoms of obstructive defecation (OD) are common in women. Transperineal ultrasound (TPUS) has been used for the evaluation of defecatory disorders. The aim of our study was to determine the overall prevalence of anatomical abnormalities of the posterior compartment and their correlations with OD in women seen in a tertiary urogynecology clinic. METHODS: This is a retrospective study on 750 women seen at a tertiary urogynecological unit who had undergone a standardized interview, clinical examination, and 4D TPUS. Univariate and multivariate logistic regression analyses were undertaken to study the association between examination findings and symptoms of OD. This study was approved by the local human research ethics committee (Nepean Blue Mountains Local Health District Human Research Ethics Committee, IRB approval no. 13-16). RESULTS: The datasets of 719 women were analyzed. Mean age was 56.1 (18.4-87.6) years. Ninety-seven patients (13 %) reported fecal incontinence, 190 (26 %) constipation, and 461 (64 %) symptoms of OD. On examination, 405 women (56 %) were diagnosed with significant posterior compartment prolapse (POP-Q ≥ stage 2), which was associated with symptoms of OD (p < 0.0001). On ultrasound, 103 (14 %) patients had an enterocele, 382 (53 %) a true rectocele and 31 (4.3 %) had rectal intussusception. On multivariate analysis true rectocele (p = 0.003) and rectal intussusception (p = 0.004) remained significantly associated with symptoms of OD. CONCLUSION: Both symptoms of OD and anatomical abnormalities of the posterior compartment are highly prevalent in urogynecological patients. Ultrasound findings of a true rectocele and rectal intussusception are significantly associated with obstructed defecation.Item The ‘bother’ of obstructed defecation(John Wiley & Sons, 2017) Alam, Pakeeza; Guzman, Rodrigo; Kamisan, Ixora; Robledo, Kristy; Dietz, HansOBJECTIVE: To examine the relationship of visual analog scale (VAS) 'bother' scores for obstructed defecation (OD) with demographic data, physical examination and sonographic findings of the posterior compartment. METHODS: All patients seen at a urogynecology clinic between January and October 2013 were included. Patients were diagnosed with OD if they had any of the following: incomplete bowel emptying, straining with bowel movement or need for digitation. Patients used a VAS to rate OD bother on a scale of 0-10 (0, no bother; 10, worst imaginable bother). For each patient, a comprehensive history was obtained, the International Continence Society Pelvic Organ Prolapse Quantification was performed and four-dimensional translabial ultrasound volumes were recorded on maximal Valsalva maneuver. Linear and multiple regression models were used to correlate bother VAS scores with demographic, clinical and sonographic findings. RESULTS: Among 265 patients included in the analysis, 61% had OD symptoms with a mean VAS bother score of 5.6. OD bother scores were associated with a history of previous prolapse surgery (P = 0.0001), previous hysterectomy (P = 0.0006), descent of the posterior compartment (Bp; P = 0.004) and hiatal dimensions (Pb and Gh + Pb; P = 0.006 and P = 0.004). OD bother was associated with the following sonographic findings: true rectocele (P = 0.01), depth of rectocele (P = 0.04), descent of rectal ampulla (P = 0.02), enterocele (P = 0.03) and rectal intussusception (P < 0.0001). CONCLUSIONS: VAS bother scores are associated with both clinical and sonographic measures of posterior compartment descent. Rectal intussusception was most likely to result in highly bothersome symptoms of OD. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.Item Warping of the levator hiatus: how significant is it?(John Wiley & Sons, 2016) Dietz, Hans; Severino, I; Atan, Kamisan; Shek, Ka Lai; Guzman, RodrigoOBJECTIVES: The levator hiatus is the largest potential hernial portal in the human body. Excessive distensibility is associated with female pelvic organ prolapse (POP). Distension occurs not just laterally but also caudally, resulting in perineal descent and hiatal deformation or 'warping'. The aim of this study was to quantify the warping effect in symptomatic women, to validate the depth of the rendered volume used for the 'simplified method' of measuring hiatal dimensions and to determine predictors for the degree of warping. METHODS: This was a retrospective study utilizing records of patients referred to a tertiary urogynecological service between November 2012 and March 2013. Patients underwent a standardized interview, clinical assessment using the POP quantification system of the International Continence Society and four-dimensional translabial ultrasound. The craniocaudal difference in the location of minimal distances in mid-sagittal and coronal planes was determined by offline analysis of ultrasound volumes, and provided a numerical measure of warping. We tested potential predictors, such as demographic factors, signs and symptoms of prolapse, levator avulsion and levator distensibility, for an association with warping. RESULTS: Full datasets were available for 190 women. The mean craniocaudal difference in location of minimal distances in mid-sagittal and coronal planes was -1.26 mm (range, -6.7 to 4.6 mm; P < 0.001). This measure of warping was associated with hiatal area on Valsalva maneuver (r = - 0.284; P < 0.0001) and signs of significant prolapse on clinical and ultrasound examination (both P < 0.0001). CONCLUSIONS: The plane of minimal dimensions of the levator ani hiatus is non-Euclidean, i.e. warped, and the degree of warping is associated with hiatal distension, or 'ballooning', and with POP. However, the degree of warping is minor, the largest difference we found in the location of the plane of minimal dimensions being 6.7 mm. Hence, our results support the determination of hiatal area in a rendered volume of 1-2 cm in depth.