This work was supported by the Ministry of Economy and Competitiveness, ISCIII (AES), grants no PI13/01237 and the Seneca Foundation, Murcia Regional Agency of Science and Technology, grant no 19443/PI/14. Funding to pay the Open Access publication charges for this article was provided by the Ministry of Economy and Competitiveness, ISCIII (AES), grant no PI13/01237.

This study was approved by the Ethics Research Committee of the University of Murcia. Written informed consent was obtained from all participants.
1. Perineum Measurements
NOTE: Before taking the measurements, two observers have to be trained to minimize inter-observer variability.
<ol>
	<li>Patient Preparation
	<ol>
		<li>Place the patient in a lithotomy position, with thighs at an angle of 45&#176; to the examination table.</li>
		<li>Use a digital caliper with a resolution length of 0.000500 inches (Figure 2A).</li>
		<li>To begin measuring, close the device and check that &#34;0&#34; appears on the display and press the calibration button.</li>
		<li>Select millimeters as the unit of measurement. 
		NOTE: Other measurement units, such as inches, may be selected.</li>
	</ol>
	</li>
	<li>AGD Measurements
	<ol>
		<li>Perform the two AGD measurements in each woman using the digital caliper.</li>
		<li>Measure AGDAC from the anterior clitoral surface to the upper verge of the anus (Figure 1, point 1 to point 3).</li>
		<li>Measure AGDAF from the posterior fourchette or posterior margin of the hymen to the upper verge of the anus (Figure 1, point 2 to point 3).</li>
		<li>To improve accuracy, have two examiners perform each of these measurements three times, taking a total of six measures for AGDAF and AGDAC, respectively.</li>
		<li>Use the averaged values of the six measurements as the true estimate of the AGD in subsequent analyses.</li>
		<li>Blind each examiner to the other examiner&#180;s results. 
		NOTE: The caliper does not need to be sterilized after each use, but has to be cleaned up with soap and water and disinfectant, such as 2% alcoholic chlorhexidine solution.</li>
	</ol>
	</li>
	<li>POP-Q Measurements
	<ol>
		<li>Take GH and PB measurements according to the parameters of the POP-Q classification20,21, using a centimeter ruler or tape (Figure 2). Use a kit containing a centimeter ruler and a skin marker in this report (Figure 2B). Measurements of the GH and PB are shown in Figure 1.</li>
		<li>Measure GH from the middle of the external urethral meatus to the posterior margin of the hymen (Figure 1).</li>
		<li>Measure PB from the posterior margin of the hymen to the mid-anal opening. 
		NOTE: Bump et al.20 recommend expressing all measurements in centimeters. Measurements may be taken to the nearest 0.5 cm, and the authors consider that further precision is unlikely. All reports should clearly specify how measurements were taken and the accuracy of the instrument used as no specific instruments are recommended in the POP-Q system.</li>
		<li>Have two examiners collect each measurement 3 times. Take the average of the six measurements as the true value.</li>
		<li>Blind each examiner to the other examiner&#180;s results.</li>
	</ol>
	</li>
</ol>

<ol>
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L., Moya-Jim&#233;nez, L. C., Mendiola, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+the+anogenital+distance+and+anthropometry+of+the+perineum+in+patients+with+and+without+pelvic+organ+prolapse.">Comparison of the anogenital distance and anthropometry of the perineum in patients with and without pelvic organ prolapse.</a> Actas urologicas espanolas. 40 (10), 628-634 (2016).</li><li>Gallavan, R. H., Holson, J. F., Stump, D. G., Knapp, J. F., Reynolds, V. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interpreting+the+toxicologic+significance+of+alterations+in+anogenital+distance:+Potential+for+confounding+effects+of+progeny+body+weights.">Interpreting the toxicologic significance of alterations in anogenital distance: Potential for confounding effects of progeny body weights.</a> Reproductive Toxicology. 13 (5), 383-390 (1999).</li><li>Bump, R. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+standardization+of+terminology+of+female+pelvic+organ+prolapse+and+pelvic+floor+dysfunction.">The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction.</a> American journal of obstetrics and gynecology. 175 (1), 10-17 (1996).</li><li>Haylen, B. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+International+Urogynecological+Association+(IUGA)+/+International+Continence+Society+(ICS)+Joint+Report+on+the+Terminology+for+Female+Pelvic+Organ+Prolapse+(POP).">An International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP).</a> Neurourology and Urodynamics. 35 (2), 137-168 (2016).</li><li>Lince, S. L., van Kempen, L. C., Vierhout, M. E., Kluivers, K. 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The authors have nothing to disclose.

The article shows the procedure to carry out the perineal measurements according to both the AGD concept and the POP-Q system. Both procedures are described with different measurement systems: the AGD measurement with calipers in millimeters, and the POP-Q measurement with a ruler in centimeters. It would be desirable to unify the measuring instruments and the accuracy of the methods, and not just the landmarks. This is of great importance, since the more reproducible a measure is, the more reliable it will be. That will also guarantee the comparison of measures between different working groups and minimize the risk of bias among different observers. Nowadays, only PB and GH measures are standardized within the POP-Q prolapse classification system. However, AGD landmarks could replace the POP-Q landmarks if they were easier to measure and had less intra and interobserver variability (higher reproducibility).
This study shows that there are some significant differences in perineal anthropometric measurements among patients affected with POP and patients without this condition (controls). Regarding medical and surgical variables (Table 1), we found differences in the number of deliveries and fetal weight, which are both well known risk factors for POP. No other differences were found between controls and POP patients regarding risk factors for POP. We found differences between the AGDAF (which is shorter in cases of prolapse), AGDAC and GH length (which were longer in women with POP). This is an observational study that shows an association between pelvic floor disease and perineal measures but cannot determine whether differences in these distances are a cause or a consequence of POP. Therefore, it may be interesting to point out that there were statistically significant differences between AGDAF in both groups; meanwhile, there were no differences in the PB measurements, which would be its analogue measurement in the POP-Q system.
The landmarks of AGD measurement are more objective and concise than the ones of the POP-Q system. Therefore, as AGD&#180;s landmarks may be easier to identify anatomically, they may be easier to measure and reproduce. Our group has previously reported low intra- and inter-examiner coefficients of variation for AGD (5% and 10% for AGDAF and AGDAC, respectively). Even more, intra-class correlation coefficients were above 0.95 for both AGD measurements16. Regarding the POP-Q system, in 1996, Hall et al. reported good Spearman&#39;s Correlation coefficients for GH and for PB in both inter and intra-observer studies, reporting good reproducibility of the system26. Later, Persu et al. confirmed good reliability of the POP-Q system27.
However, data and differences reported in this study are important. To our knowledge, PB and GH measurements have not been previously reported in women without pelvic floor disease, since these measurements are only used in the POP-Q system designed to evaluate women with POP. Moreover, we included AGD measurements in the perineal exploration of women with POP. AGD measurements have only been explored in women in relation to antral follicular count and serum testosterone levels, polycystic ovary syndrome and endometriosis, but POP-Q measurements were not included in these studies. When compared with controls, we have seen that AGD measurements are significantly different between patients with POP and patients without POP, which might suggest that AGD measurements may be useful to evaluate POP in women.
Future investigation is needed to evaluate comparability of AGD and POP-Q measurements, and to achieve a standardization of AGD measurements. It is important to point out that PB and GH measurements are not useful per se to quantify the grade of prolapse. GH measurements have been proposed as a prolapse risk factor28 and a risk factor for recurrence after repair29. Shorter PB measurement has also been described as a risk factor for medical treatment failure with pessary30. Apical prolapse has to be evaluated by other measures of the POP-Q system (Point C and Point D). Whether the equivalent measures of AGD could have similar clinical uses to GH and PB remains to be explored. Further studies are necessary to confirm our results and before suggesting modifications in the pelvic floor measurements procedure. The previously published results suggest the idea that the GH enlargement is a consequence of POP28. Our suggestion is that the anthropometric characteristics of the perineum, such as shorter AGDAF (which is determined prenatally) may be an independent etiological factor for pelvic floor dysfunction. In that case, AGD could be a cheaper and more accessible than others methods, like 3D ultrasound which is currently being used to calculate the volume of the genital area hiatus in women with POP31,32. Even more, a risk score prolapse could be established for women early in life that considers all risk factors and AGD. Patients might then be encouraged to perform activities to strengthen the pelvic floor during pregnancy and childbirth and to practice postpartum rehabilitation as soon as possible.

Anogenital distance (AGD) is an easily accessible and noninvasive anthropometric measurement (Figure 1). AGD is a sexual dimorphism in placental mammals, being almost twice longer in males than in females. It is considered a marker of intra uterus hormonal environment1,2. AGD has been related to prenatal exposure to endocrine disruptors3,4,5 and androgens during critical periods of genital development6,7. In prenatal consultations, AGD may be useful to determine fetus gender with great accuracy in the first trimester (scan at 11-13 &#177; 6 weeks of gestation)8,9. In adult women, AGD length is associated with the female reproductive function10,11,12,13. Longer AGD distances in adult women have been associated in cross-sectional studies to a higher number of ovarian follicles10 and to higher testosterone levels11. Young women with longer AGD were several times more likely to have had mothers with irregular menstrual cycles, suggesting that the potentially hyperandrogenic intrauterine environment of the mother was sufficient to modify the female offspring&#39;s reproductive tract12. Recently, Wu et al.14 have shown that the presence of polycystic ovarian syndrome (PCOS) is associated with longer AGD measurements in Chinese women, and Barrett et al.15 have also reported longer AGD in newborn daughters of women with PCOS15. Our research group have also confirmed this finding in adult Mediterranean women16. On the other hand, AGD is negatively and strongly associated with the presence and severity of endometriosis17, suggesting the potential of AGD as a biomarker of developmental antiandrogen/estrogen exposure. There is still controversy about the definitions and measurements of the female perineal and genital area. Previous human studies have applied a variety of measurements when referring to AGD. In women, some modification has been observed in the anatomical references for AGD measures. When AGD was firstly described and measured in women, the lower reference for the anatomical landmark was the &#34;middle&#34; anus. Nowadays, the lower reference is established as the top margin of the anus as it is a more accurate reference, making AGD a more reproducible measure18. AGD measurements must be corrected by weight or BMI as they are anthropometric measurements associated with body size19.
A similar set of measurements are the Pelvic Organ Prolapse Quantification System (POP-Q)20 that includes two perineal measurements: the perineal body (PB) length and genital hiatus (GH) length (Figure 1). These measurements have been standardized according to the International Continence Society and are commonly used in clinical practice and biomedical studies, especially in women with pelvic organ prolapse (POP)21. PB is the measurement taken from the posterior margin of the genital hiatus to the midanal opening and is equivalent to AGDAF (ano-fourchette). GH does not correlate exactly with DAGAC (anoclitoral), although it would be its analog measurement. Women with POP have a strong familial association22, and parity is also considered a risk factor for POP23. However, there is no data to presume that they have been subjected to abnormal hormonal environments and may associated to other reproductive problems. Because of the similarities of the measurements, however, we hypothesize that women with shorter PB would have shorter AGDAF as well.
In this paper, we present both procedures and assess their similarities to ensure uniformity of these measurements in research and clinical practice. To our knowledge, there is no video publication showing how to perform these measurements. The main objective of this study was to show how to perform both AGD measurements: ano-clitoral (AGDAC) and ano-fourchette (AGD AF), and how to measure GH and PB lengths. A secondary objective was to compare both sets of anthropometric measures in women with POP (cases) and asymptomatic women without pelvic floor dysfunction (control women).
A case-control study was conducted from August 2014 to June 2015 at the Department of Obstetrics and Gynecology of the University Clinical Hospital &#39;Virgen de la Arrixaca&#39; in the Murcia Region (southeastern Spain). Cases were women over 40 years of age seeking care for genital lumps. If POP was confirmed in the gynecological examination and classified as stage II or more by the POP-Q classification20, women were invited to participate, regardless of the affected compartment (anterior, middle or posterior). Women with stress urinary incontinence that requires surgical treatment were excluded. Controls were women of similar age seeking routine gynecological exams with neither pelvic floor disease nor other gynecological conditions such as adnexal disease or uterine fibroids. The exclusion criteria for both cases and controls were the following: previous corrective surgery for pelvic floor disease or urinary incontinence; an active tumor that alters the mechanics and biometry of the pelvic floor; an active infection of external anogenital tract; and external hemorrhoids. Women having locomotor impairment preventing the physicians from taking the measurements were also excluded. A complete gynecological and obstetrical history was performed including menstrual and obstetric formulae (parity, vaginal and instrumented deliveries and birthweight) as well as medical and surgical history, and BMI. Women were questioned about symptoms of POP and/or urinary incontinence using the ICIQ-F questionnaires24 and Sandvik severity index25.
The pelvic status was assessed using the POP-Q classification system. A test of stress urinary incontinence was performed by emptying the bladder and introducing 300 mL of saline with a disposable urinary catheter. The patients performed Valsalva maneuvers with prolapse, and after reducing the prolapse, occult stress urinary incontinence was diagnosed. A 2D-transvaginal ultrasound was performed to rule out uterine or adnexal disease.

<table><tbody><tr><td>Digital Caliper. Stainless Steel Digital Caliper</td><td>VWR International, LLC, West Chester, PA, USA</td><td>76181-562&amp;nbsp; OS ABS DIGTL CALIPER 500-171-30 STAIN</td><td>Absolute Digimatic Calipers, Stainless Steel, SPC, Accuracy +/-0.001in, Batt. Life 3.5 Years (20,000 hours), Display Type Digital LCD, Measurement Type ABS, Range 6in, Resolution (Length) 0.000500 in, Tip</td></tr><tr><td>Voluson E8</td><td>General Electric Healthcare</td><td></td><td></td></tr><tr><td>Sterile Utility Skin Marker and Ruler</td><td>Medline</td><td>DYNJSM06</td><td></td></tr></tbody></table>

anogenital distance and perineal measurements of the pelvic organ prolapse (pop) quantification system

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. Interest in AGD measurements is increasing due to mounting evidence on their potential clinical implications. A parallel set of perineal measurements, the Pelvic Organ Prolapse Quantification System (POP-Q), include similar, but not exactly the same, landmarks: the perineal body (PB) and the genital hiatus (GH) lengths. However, clinical reproducibility of both perineal measurements and their usefulness to describe perineal anthropometry needs to be elucidated. To our knowledge, there is no publication in video format showing the methodology of these measurements. The main objective of this work is to show how to properly perform perineal anthropometry, including measurements of the AGD in its two variants [anoclitoral (AGDAC) and anofourchette (AGDAF)], genital hiatus (GH) and perineal body (PB). Moreover, we explored if there were differences in these measurements in women with and without Pelvic Organ Prolapse (POP). We research whether the anthropometric characteristics of the perineum, such as AGD (which is determined prenatally), may be altered in these women and be an independent etiological factor for pelvic floor dysfunction. We show two different ways of measuring perineal lengths, as they might be quite comparable. Our suggestion is that unifying perineal measurements could be useful for clinical and biomedical investigation. More studies are needed in order to compare GH and PB measurements and its AGD counterparts to analyze which procedures are more reproducible with less intra and interobserver variability.

Fifty-eight patients were included. Previous studies in women have reported that the minimum AGD distances was 24 mm12 with a standard deviation of about 10 mm12. The minimum sample size to detect a significant difference between the groups with respect to AGDAC (type I error &#945;=0.05 and type II error &#946; = 0.1) was estimated to be 25 individuals in each group (50 in total), based on a difference of at least 12 mm in AGDAC between the two groups. Eight more participants were added to mitigate potential losses. For a study power of 80%, the number of individuals per group would drop to 17. Patients that fulfilled the inclusion criteria were included in the study. Finally, 22 cases of prolapse and 36 controls were enrolled in the study.
Statistics were derived from the raw data. Continuous variables were summarized by arithmetic mean and standard deviation (SD), and categorical variables given as number of cases and percentages (%). Normal distribution of the data was confirmed with the Kolmogorov-Smirnov test. To study the differences between groups, unpaired Student&#39;s t-tests were used for quantitative variables and Chi-square for dichotomous variables. All tests were two-tailed at a 0.05 significance level.
The general characteristics of women participating in the study were evaluated, including the obstetrical history and other medical and surgical variables (Table 1). We found significant differences in age between the two groups of patients (mean value of 65.1 years in the patients with POP, compared to an average of 50 years in the controls (p = 0.0001)). Regarding the number of pregnancies, there was an average of 4.1 in POP patients compared to 2.3 in control women (p = 0.001). We also found differences in the number of vaginal deliveries (3.7 births in the group of POP patients, compared to the controls with 1.6 births (p = 0.0001)). Mean birthweight was also different in both groups (3,831 g in the population of patients with POP vs. 3,160 g in the control group (p = 0.0001)). However, there were no significant differences in the number of instrumented deliveries (18.1% in POP cases vs. 30.5% in the controls; p = 0.58) or in the number of cesarean sections (9% vs. 16.7% p = 0.5). Other personal, medical and surgical variables considered risk factors for POP were also evaluated, but there were no differences in any of them between the two groups. Figure 3 shows the box-plots of the four perineal measurements in both groups. There were significant differences between POP patients and the controls for AGDAC (88.1 &#177; 19.7 mm vs. 70.1 &#177; 11.7 mm, p=0.0001) (Figure 3A) and AGDAF (18 &#177; 5.4 mm in POP vs. 23 &#177; 5 mm in controls, p = 0.001) (Figure 3B). The length of the genital hiatus (GH) that was also longer in the POP cases than in the controls (53.7 &#177; 19.1 mm vs. 44.3 &#177; 10.3 mm) (p = 0.02) (Figure 3C). No significant differences were found in PB measurements between the two groups (Figure 3D).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57912/57912fig1.jpg" /> 
Figure 1. Benchmarks of perineal measurements. AGDAC, from the surface of the anterior clitoris to the upper edge of the anus (point 1 to point 3), and AGDAF, from the posterior fourchette to the upper edge of the anus (point 2 to point 3). Measurement of genital hiatus length (GH) is shown with a red line according to POP-Q: from the center of the urethral meatus to the posterior midline of the hymen or the leading edge of the nucleus of the perineum (identified by palpation of the levator ani and not by skin fold of the fourchette). Perineal body length (PB) according to POP-Q is shown with a green line: from the posterior margin of the urogenital hiatus or from the central node of the perineum to the center of the anus. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57912/57912fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57912/57912fig2.jpg" /> 
Figure 2. Measuring instruments. A) Digital caliper. B) Sterile utility skin marker and ruler. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57912/57912fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57912/57912fig3.jpg" /> 
Figure 3. Box plots that represent differences in anthropometric measures of the region of the perineum between patients and controls. A) AGDAC, B) AGDAF, C) genital hiatus, D) perineal body. Error bars correspond to standard deviation (SD). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57912/57912fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td rowspan="2"></td>
			<td colspan="3">CASES</td>
			<td colspan="3">CONTROLS</td>
			<td rowspan="2"></td>
		</tr>
		<tr>
			<td colspan="3">(n = 22)</td>
			<td colspan="3">(n = 36)</td>
		</tr>
		<tr>
			<td>Characteristics</td>
			<td>Mean</td>
			<td>SD</td>
			<td>Median</td>
			<td>Mean</td>
			<td>SD</td>
			<td>Median</td>
			<td>P</td>
		</tr>
		<tr>
			<td>Age (years)</td>
			<td>65.1</td>
			<td>9</td>
			<td>67.5</td>
			<td>50</td>
			<td>7.7</td>
			<td>49</td>
			<td>0.0001</td>
		</tr>
		<tr>
			<td>Body mass index (BMI) (kg/m2)</td>
			<td>27.6</td>
			<td>3.8</td>
			<td>26.8</td>
			<td>26.1</td>
			<td>3.8</td>
			<td>25.3</td>
			<td>0.146</td>
		</tr>
		<tr>
			<td>Mean number of deliveries</td>
			<td>3.7</td>
			<td>1.8</td>
			<td>3</td>
			<td>1.6</td>
			<td>1.5</td>
			<td>2</td>
			<td>0.0001</td>
		</tr>
		<tr>
			<td>Birth weight (g)</td>
			<td>3831</td>
			<td>404.5</td>
			<td>4000</td>
			<td>3160</td>
			<td>414.5</td>
			<td>3075</td>
			<td>0.0001</td>
		</tr>
		<tr>
			<td>External genital injury (%)</td>
			<td>9.1</td>
			<td></td>
			<td></td>
			<td>2.8</td>
			<td></td>
			<td></td>
			<td>0.29</td>
		</tr>
		<tr>
			<td>Perianal lesions (%)</td>
			<td>4.5</td>
			<td></td>
			<td></td>
			<td>2.8</td>
			<td></td>
			<td></td>
			<td>0.72</td>
		</tr>
		<tr>
			<td>&#160;Chronic cough (%)</td>
			<td>4.5</td>
			<td></td>
			<td></td>
			<td>2.9</td>
			<td></td>
			<td></td>
			<td>0.73</td>
		</tr>
		<tr>
			<td>COPD (%)</td>
			<td>4.5</td>
			<td></td>
			<td></td>
			<td>2.9</td>
			<td></td>
			<td></td>
			<td>0.76</td>
		</tr>
		<tr>
			<td>Inguinal Repair %</td>
			<td>0</td>
			<td></td>
			<td></td>
			<td>11.1</td>
			<td></td>
			<td></td>
			<td>0.1</td>
		</tr>
	</tbody>
</table>
Table 1: General descriptive characteristics, obstetric and medical-surgical history of patients and controls.

Watch this Scientific Journal Video about Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse POP Quantification System at JoVE.com

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse POP Quantification System

This manuscript describes the procedures to perform anogenital distance (AGD) and perineal measurements standardized by the Pelvic Organ Prolapse Quantification System (POP-Q): perineal body (PB) and genital hiatus (GH). These measurements are compared in women with and without pelvic organ prolapse.

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. ...

anogenital-distance-perineal-measurements-pelvic-organ-prolapse-pop

Nanyang Technological University

Research

JoVE Journal

Medicine

18.8K Views.  "Virgen de la Arrixaca", University Clinical Hospital. Deze methode kan helpen bij het beantwoorden van belangrijke vragen in de epidemiologische en urogynecologic velden over de klinische reproduceerbaarheid van perineale metingen en hun nut bij het beschrijven van perineale antropometrie. Het belangrijkste voordeel van deze techniek is dat de metingen gemakkelijk te leren zijn van visuele demonstraties. Begin met het helpen van de patiënt in de lithotomiepositie met de dijen in een hoek van 45 graden naar de onderzoekstafel.Selecteer ee...

Video: Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse POP Quantification System

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.

Loss of peritoneal integrity provides a new paradigm to understand and treat chronic pelvic pain in women with mild forms of endometriosis and can be easily detected using intraoperative instillation of dye at the time of laparoscopy.

Endometriosis is a  common disease affecting 40 to 70% of reproductive-aged women with chronic  pelvic pain (CPP) and/or infertility. The purpose of this ...

Technique of Subnormothermic Ex Vivo Liver Perfusion for the Storage, Assessment, and Repair of Marginal Liver Grafts

The success of liver transplantation has resulted in a dramatic organ shortage. In most transplant regions 20-30% of patients on the waiting list for liver transplantation die without receiving an organ transplant or are delisted for disease progression. One strategy to increase the donor pool is the utilization of marginal grafts, such as fatty livers, grafts from older donors, or donation after cardiac death (DCD). The current preservation technique of cold static storage is only poorly tolerated by marginal livers resulting in significant organ damage. In addition, cold static organ storage does not allow graft assessment or repair prior to transplantation.
These shortcomings of cold static preservation have triggered an interest in warm perfused organ preservation to reduce cold ischemic injury, assess liver grafts during preservation, and explore the opportunity to repair marginal livers prior to transplantation. The optimal pressure and flow conditions, perfusion temperature, composition of the perfusion solution and the need for an oxygen carrier has been controversial in the past.
In spite of promising results in several animal studies, the complexity and the costs have prevented a broader clinical application so far. Recently, with enhanced technology and a better understanding of liver physiology during ex vivo perfusion the outcome of warm liver perfusion has improved and consistently good results can be achieved.
This paper will provide information about liver retrieval, storage techniques, and isolated liver perfusion in pigs. We will illustrate a) the requirements to ensure sufficient oxygen supply to the organ, b) technical considerations about the perfusion machine and the perfusion solution, and c) biochemical aspects of isolated organs.

Technique of Subnormothermic Ex Vivo Liver Perfusion for the Storage, Assessment, and Repair of Marginal Liver Grafts

Marginal grafts, such as fatty livers, grafts from older donors, or livers retrieved after cardiac death (DCD) tolerate conventional, cold static storage only poorly. We developed a novel model of subnormothermic ex vivo liver perfusion for preservation, assessment, and repair of marginal liver grafts prior to transplantation.

The success of liver transplantation has resulted in a dramatic organ shortage. In most transplant regions 20-30% of patients on the waiting list for ...

Quantification of Levator Ani Hiatus Enlargement by Magnetic Resonance Imaging in Males and Females with Pelvic Organ Prolapse

Here we present a protocol to examine the levator ani hiatus in males and females with pelvic organ prolapse, during the Valsalva maneuver and while evacuating acoustic gel, using a horizontally oriented 1.5 T magnetic resonance (MR) scanner. On midsagittal images, the vertical distance of pelvic organs is measured in millimeters relative to the hymen plane (female) and to the lower border of the symphysis pubis (male), preceded by - (above) or + ( below) signs. On axial images, the levator ani area is calculated in square centimeters with a free-hand tracing method from three key images, passing through the midsymphysis (level I), tangential to the lower border of the symphysis (level II), and at the maximal anterior rectal wall bulging (level III). Areas at rest and strained are compared to find evidence of a percentage of increase. The purpose is to provide objective evidence of the maximal extent of pelvic organs descent and hiatus enlargement without the interference of foreign objects or the examiner&#39;s proximity, so as to overcome the limitations of pelvic examination and transperineal sonography (i.e., subjectivity and sex-related limitations [female only]).

Here we present a protocol to standardize the measurement of the levator ani hiatus size&#160;by magnetic resonance imaging. The purpose is to extract biomechanical inferences from image analysis by comparing resting and straining values in patients of both sexes with pelvic prolapse, using consistent anatomical bony landmarks.

Here we present a protocol to examine the levator ani hiatus in males and females with pelvic organ prolapse, during the Valsalva maneuver and while ...

Posterior Approach for Debridement of the Psoas Abscess

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior approach to the spine was performed to ensure that the anterior longitudinal ligament and the psoas muscle could be visualized. All the abdominal organs were removed. Subsequently, a posterior approach was performed to remove the paraspinal muscles from L1&#8211;L5. The transverse processes, pars interarticularis and lamina of L1&#8211;L5 were identified. The exiting nerve root was identified between the transverse processes and followed into the substance of the psoas muscle. Using the anterior and posterior approach, the lumbar plexus was isolated from the substance of the psoas muscle. Before and after various steps of dissection, digital photographs were obtained. These images were uploaded into ImageJ and multiple measurements, including the distance between the lateral superior and inferior tip of each TP to the most lateral region of the plexus, the distance between the lateral superior and inferior tip of the TP to the lateral edge of the psoas, and the width of the lumbar plexus were recorded. The safe zone for entering the substance of the psoas muscle was defined between the lateral edge of the psoas muscle and the lateral edge of the lumbar plexus. The relationship of this interval to the tip of the transverse process at each level was measured and reported.

This is a cadaveric study investigating the landmarks for the posterior approach for irrigation and debridement of the psoas abscess. The interval between the transverse processes (TP) was used to access the substance of the psoas muscle.

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

Development of a Uterosacral Ligament Suspension Rat Model

Pelvic organ prolapse (POP) is a common pelvic floor disorder (PFD) with the potential to significantly impact a woman's quality of life. Approximately 10%-20% of women undergo pelvic floor repair surgery to treat prolapse in the United States. PFD cases result in an overall $26.3 billion annual cost in the United States alone. This multifactorial condition has a negative impact on the quality of life and yet the treatment options have only dwindled in the recent past. One common surgical option is uterosacral ligament suspension (USLS), which is typically performed by affixing the vaginal vault to the uterosacral ligament in the pelvis. This repair has a lower incidence of complications compared to those with mesh augmentation, but is notable for a relatively high failure rate of up to 40%. Considering the lack of standard animal models to study pelvic floor dysfunction, there is an urgent clinical need for innovation in this field with a focus on developing cost-effective and accessible animal models. In this manuscript, we describe a rat model of USLS involving a complete hysterectomy followed by fixation of the remaining vaginal vault to the uterosacral ligament. The goal of this model is to mimic the procedure performed on women to be able to use the model to then investigate reparative strategies that improve the mechanical integrity of the ligament attachment. Importantly, we also describe the development of an in situ tensile testing procedure to characterize interface integrity at chosen time points following surgical intervention. Overall, this model will be a useful tool for future studies that investigate treatment options for POP repair via USLS.

Pelvic organ prolapse affects millions of women worldwide and yet some common surgical interventions have failure rates as high as 40%. The lack of standard animal models to investigate this condition impedes progress. We propose the following protocol as a model for uterosacral ligament suspension and in vivo tensile testing.

Pelvic organ prolapse (POP) is a common pelvic floor disorder (PFD) with the potential to significantly impact a woman's quality of life. Approximately ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Uterine-Preserving Laparoscopic Cerclage Pectopexy 

Laparoscopic Non-Mesh Cerclage Pectopexy with Uterine Preservation for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for treating POP. Recent research has increasingly validated the efficacy and safety of laparoscopic pectopexy (LP) for addressing apical POP. However, the cost of synthetic mesh and associated complications restrict the widespread use of this technique. Our team previously published a study describing a novel, non-mesh procedure called laparoscopic non-mesh cerclage pectopexy (LNMCP), demonstrating successful outcomes with satisfactory objective and subjective success rates. Many patients express a preference for retaining their uterus during prolapse surgery due to considerations related to sexuality, partnership, and body image. 
The present research introduces a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation (LNMCPUP) for POP, wherein the uterus is suspended to the iliopectineal ligament through the round ligament using permanent cerclage sutures. We successfully performed this procedure in 14 cases at our hospital, six of whom still had menstruation, and the remaining eight were postmenopausal, with a mean operation time of 54.43 min (&plusmn; 10.18 min) and an average bleeding volume of 53.57 mL (&plusmn; 48.77 mL). The mean follow-up duration was 19.71 &plusmn; 15.87 months. The objective success rate of LNMCPUP was 100%, with a subjective success rate of 92.86%. No significant complications were observed during or after surgery. LNMCPUP integrates cervical cerclage and shortening of the round ligament, as well as LP without using mesh, thereby eliminating the risk of mesh erosion and lowering healthcare costs. Moreover, this novel technique is relatively easy to master, making it accessible even in rural and underdeveloped areas where synthetic mesh is unavailable. Therefore, it is worthwhile to adopt LNMCPUP in POP patients who desire the preservation of their uterus.

Author Spotlight: Advancing Pelvic Prolapse Treatment with a Non-Mesh Approach using Laparoscopic Pectopexy

Here we introduce a novel approach known as laparoscopic non-mesh cerclage pectopexy with uterine preservation for pelvic organ prolapse (LNMCPUP) for patients who wish to preserve their uterus. Permanent cerclage sutures are used to suspend the uterus to the iliopectineal ligament through the round ligament.

Pelvic organ prolapse (POP) affects millions of women globally and carries a significant socioeconomic burden. Adequate apical support is essential for ...

Isolation and Characterization of the Murine Uterosacral Ligaments and Pelvic Floor Organs

Pelvic organ prolapse (POP) is a condition that affects the integrity, structure, and mechanical support of the pelvic floor. The organs in the pelvic floor are supported by different anatomical structures, including muscles, ligaments, and pelvic fascia. The uterosacral ligament (USL) is a critical load-bearing structure, and injury to the USL results in a higher risk of developing POP. The present protocol describes the dissection of murine USLs and the pelvic floor organs alongside the acquisition of unique data on the USL biochemical composition and function using Raman spectroscopy and the evaluation of mechanical behavior. Mice are an invaluable model for preclinical research, but dissecting the murine USL is a difficult and intricate process. This procedure presents an approach to guide the dissection of murine pelvic floor tissues, including the USL, to enable multiple assessments and characterization. This work aims to aid the dissection of pelvic floor tissues by basic scientists and engineers, thus expanding the accessibility of research on the USL and pelvic floor conditions and the preclinical study of women's health using mouse models.

This article presents a detailed protocol for dissecting uterosacral ligaments and other pelvic floor tissues, including the cervix, rectum, and bladder in mice, to expand the study of female reproductive tissues.

Pelvic organ prolapse (POP) is a condition that affects the integrity, structure, and mechanical support of the pelvic floor. The organs in the pelvic ...

Biology

Pelvic Exam I: Assessment of the External Genitalia

Source: 
Alexandra Duncan, GTA, Praxis Clinical, New Haven, CT 
Tiffany Cook, GTA, Praxis Clinical, New Haven, CT 
<a href="https://www-jove-com.remotexs.ntu.edu.sg/author/Jaideep+S._Talwalkar">Jaideep S. Talwalkar</a>, MD, Internal Medicine and Pediatrics, Yale School of Medicine, New Haven, CT
The pelvic exam can feel invasive to patients, so it is important to do everything possible to make patients feel comfortable and empowered, rather than vulnerable. Clinicians should be aware of how they are communicating, both verbally and nonverbally, and should give their patients control whenever possible. There are many ways to do this, from how the exam table is positioned to how the patient is engaged throughout the exam. As many as 1 in 5 patients may have experienced sexual trauma; therefore, it is important to avoid triggering those patients, but it&#39;s not always possible to know who they are. The exam in this video demonstrates neutral language and techniques that can be employed with all patients to create the best experience possible.
It&#39;s important to keep the patient covered wherever possible and to minimize extraneous contact. A clinician should be careful to tuck fingers that aren&#39;t being used to examine the patient to avoid accidental contact with the clitoris or anus.
Before performing the pelvic examination, examiners should find out how knowledgeable the patients are about the exam and their own bodies, and establish the expectation that the patients can communicate questions or concerns throughout the exam. While it is always important to avoid extremely clinical language, certain colloquial words can cross the line from caring to overly intimate during this exam. It is helpful to avoid the words &#34;touch&#34; and &#34;feel,&#34; which can feel sexualized in this context; instead, the words &#34;assess,&#34; &#34;check,&#34; &#34;inspect,&#34; or &#34;examine&#34; should be used. The words &#34;bed&#34; and &#34;sheet&#34; should be avoided, and &#34;table&#34; and &#34;drape&#34; should be used instead. Also, a clinician should use the word &#34;footrests&#34; rather than &#34;stirrups&#34; to avoid connoting horses. It&#39;s a good idea to avoid telling patients to &#34;relax,&#34; because it&#39;s a hard order for a patient to follow when anxious. Asking patients to &#34;soften&#34; or &#34;release&#34; specific muscles can be more useful, and having a patient do a Kegel exercise or Valsalva maneuver can serve as a specific relaxation technique.
Best practice dictates avoiding assumptions about patients&#39; gender, as patients with female anatomy may identify as another gender (e.g., transgender or genderqueer). This video depicts the approach to a patient whose history has revealed no specific complaints or risk factors related to gynecological health.
The pelvic exam consists of three parts: the visual and manual exam of the external genitalia, a speculum exam, and a bimanual exam. This video covers the introduction to the pelvic exam and the external genitalia exam. To avoid missing potential findings, the external pelvic exam should be performed in a systematic approach consisting of two main components: a visual inspection of the vulva (Figure 1), and internal palpation and assessment of glands and tone.
<img alt="Figure 1" src="/files/ftp_upload/10144/10144fig1.jpg" /> 
Figure 1. Diagram of the vulva. A diagram showing external genitals with the structures labelled.

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System

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