DSpace Repository :: Browsing by Author "Shek, Ka Lai"

Browsing by Author "Shek, Ka Lai"

Now showing 1 - 13 of 13

Anal sphincter trauma and anal incontinence in urogynecological patients
(2015) Guzmán Rojas, Rodrigo; Kamisan, Ixora; Shek, Ka Lai; Dietz, Hans
OBJECTIVES: 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.
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, Hans
BACKGROUND: 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.
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, Hans
Introduction: 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.
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, Hans
BACKGROUND: 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.
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, Hans
INTRODUCTION 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.
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, Rodrigo
INTRODUCTION: 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.
Impact of levator trauma on pelvic floor muscle function.
(Springer, 2014) Rojas, Rodrigo; Wong, Vivien; Shek, Ka Lai; Dietz, Hans
INTRODUCTION 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.
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 Lai
AIMS: 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.
Predicting levator avulsion from ICS POP-Q findings
(Springer, 2016) Pattillo Garnham, Alejandro; Guzmán Rojas, Rodrigo; Shek, Ka Lai; Dietz, Hans Peter
Levator avulsion is a common consequence of vaginal childbirth. It is associated with symptomatic female pelvic organ prolapse and is also a predictor of recurrence after surgical correction. Skills and hardware necessary for diagnosis by imaging are, however, not universally available. Diagnosis of avulsion may benefit from an elevated index of suspicion. The aim of this study was to examine the predictive value of the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) for the diagnosis of levator avulsion by tomographic 4D translabial ultrasound. This is a retrospective analysis of data obtained in a tertiary urogynaecological unit. Subjects underwent a standardised interview, POP-Q examination and 4D translabial pelvic floor ultrasound. Avulsion of the puborectalis muscle was diagnosed by tomographic ultrasound imaging. We tested components of the ICS POP-Q associated with symptomatic prolapse and other known predictors of avulsion, including previous prolapse repair and forceps delivery with uni- and multivariate logistic regression. A risk score was constructed for clinical use. The ICS POP-Q components Ba, C, gh and pb were all significantly associated with avulsion on multivariate analysis, along with previous prolapse repair and forceps delivery. A score was assigned for each of these variables and patients were classified as low, moderate or high risk according to total score. The odds of finding an avulsion on ultrasound in patients in the “high risk” group were 12.8 times higher than in the “low risk” group. Levator avulsion is associated with ICS POP-Q measures. Together with simple clinical data, it is possible to predict the risk of avulsion using a scoring system. This may be useful in clinical practice by modifying the index of suspicion for the condition.
The evolution of transperineal ultrasound findings of the external anal sphincter during the first years after childbirth
(Springer, 2016) Shek, Ka Lai; Della Zazzera, Vincent; Atan, Ixora Kamisan; Guzmán Rojas, Rodrigo; Langer, Susanne; Dietz, Hans Peter
INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries (OASI) are a major form of maternal birth trauma. Ultrasound imaging is commonly used to evaluate the condition. We undertook a study to compare the sonographic appearance of the external anal sphincter (EAS) 3 to 6 months and 2 to 3 years after a first birth. METHODS: A retrospective analysis of data of primiparous women obtained in a prospective perinatal imaging study. Women were invited for postnatal assessment 3 - 6 months and 2 - 3 years after a first delivery. All had completed a standardized questionnaire, and had undergone clinical examination and translabial 4D ultrasound imaging. A "significant" EAS defect was diagnosed if four out of six slices on tomographic ultrasound imaging showed a defect of ≥30° circumference. RESULTS: Datasets of 76 women with complete data and no intervening birth were assessed. Their mean age was 30.0 years (range 19.5 - 45.3 years) at the time of antenatal assessment. They were delivered at a mean gestation of 40 weeks (range 37 - 42 weeks), by caesarean section in 19, normal vaginal delivery in 42, vacuum delivery in 14 and forceps delivery in 1. A significant EAS defect on transperineal ultrasound imaging was found in 13 of 57 women (23 %) at an average of 4.7 months and in 12 of 57 (21 %) at a mean 26.4 months after a first vaginal delivery. CONCLUSIONS: In this cohort of primiparous women after a term singleton delivery, we found only minor improvement in sonographic appearance of the EAS between 4.7 months and 26.4 months on transperineal ultrasound imaging, arguing against any significant degree of structural recovery during this time period.
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, Hans
INTRODUCTION 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.
The repeatability of sonographic measures of functional pelvic floor anatomy.
(IUGA with Springer International Publishing AG, 2015) Tan, Li; Shek, Ka Lai; Kamisan, Ixora; Guzmán Rojas, Rodrigo
Translabial 3D/4D ultrasound is increasingly being used in the diagnostic evaluation of pelvic floor dysfunction. The result of the assessment is influenced by a number of confounders that are generally unrecognised. The aim of this study was to determine the short- to medium-term repeatability of translabial ultrasound measures of female pelvic organ support and pelvic floor anatomy. METHODS: This is a retrospective study analyzing archived ultrasound volume datasets of 106 patients with pelvic floor dysfunction. Every subject was assessed twice at an average interval of 73 days. Outcome measures including hiatal area on Valsalva, descent of the bladder neck, bladder, uterus and rectal ampulla, rectocele depth, diagnosis of true rectocele, and levator integrity (avulsion) were compared at the first and second appointments. RESULTS: All parameters of organ descent demonstrated good to excellent reliability (ICC 0.73-0.93) except for rectocele descent, which showed moderate reliability (ICC 0.44, CI 0.26-0.58). The most highly repeatable measure was hiatal area on Valsalva or "ballooning" (ICC 0.93, CI 0.90-0.95). For the diagnosis of levator avulsion and true rectocele, agreement was very high (kappa 0.91 for avulsion (CI 0.77-0.94) and kappa 0.73 (CI 0.56-0.84) for true rectocele). CONCLUSIONS: The short- to medium-term repeatability of translabial ultrasound measures of functional pelvic floor anatomy seems to be high. Hiatal area on Valsalva (ballooning) and diagnosis of levator avulsion were the most repeatable measures. The least repeatable measures related to the posterior compartment.
Warping of the levator hiatus: how significant is it?
(John Wiley & Sons, 2016) Dietz, Hans; Severino, I; Atan, Kamisan; Shek, Ka Lai; Guzman, Rodrigo
OBJECTIVES: 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.

Browsing by Author "Shek, Ka Lai"

Results Per Page

Sort Options