| Objective: To observe the anatomical changes in postpartum patients with different types of anterior pelvic organ prolapse(POP)using translabial ultrasound,to analyze the differences of ultrasonic appearances between the supportive structures of urethra and bladder,to determine the anatomical basis of the differences in urethra rotation angle and retrovesical angle(RVA)among patients with different types of anterior compartment prolapse,and to promote further comprehension of the features of anterior compartment prolapse,providing objective morphological evidences for clinical therapeutic planning.Methods: We enrolled 152 primiparas who were referred for pelvic floor ultrasound examination between October 2016 and March 2017 in Shenzhen No.2 People's Hospital.All participants were able to perform maximal Valsalva maneuver.A translabial ultrasound examination was performed and three relevant images were obtained including: the two dimensional and three-dimensional ultrasonic images of midsagittal plane of pelvic floor at resting state and the two-dimensional image on maximal Valsalva maneuver image.Based on the results of the examination,all participants were divided into the prolapsed group and the non-prolapsed group.The prolapsed group were further stratified into the following arms according to the clinical classification of anterior compartment prolapse proposed by Green: Green type I group,Green type II group and Green type III group.From the two-dimensional ultrasonic images obtained in the state of resting and maximal Valsalva maneuver,several parameters were measured including: the perpendicular distance from the lowest point of posterior bladder wall and the internal urethral orifice to the reference line passing through the inferior margin of pubic symphysis,the perpendicular distance from the internal urethral orifice to the Y axis reference line,the angle between the body axis and the line passing through the internal urethral orifice and the inferior margin of pubic symphysis.The plane of minimal hiatal dimension was obtained on three-dimensional images and data of levator hiatal area,the vaginal cross-sectional thickness of anterior and posterior wall,vaginal cross-sectional area were retrieved and statistically analyzed.Correlations between the parameters and the retrovesical angle or urethral rotation were analyzed.Results:(1)A total of 152 participants were enrolled and all were able to perform maximal Valsalva maneuver: 30 non-prolapsed controls and 122 with prolapse.Of the prolapsed patients,44 patients were classified into Green type I,37 for Green type II and 41 for Green type III.(2)Comparisons on bladder neck descent and urethral descent among different groups:(1)Both in the state of resting and maximal Valsalva maneuver,t the perpendicular distances from the lowest point of posterior bladder wall and the internal urethral orifice to the reference line passing through the inferior margin of pubic symphysis were larger in non-prolapsed group.The difference was statistically significant.(2)At resting state,there were no aberrations in the perpendicular distance from the lowest point of posterior bladder wall and the internal urethral orifice to the reference line passing through the inferior margin of pubic symphysis among different Green type groups.(3)Comparisons on the perpendicular distance from the lowest point of posterior bladder wall and the internal urethral orifice to the reference line passing through the inferior margin of pubic symphysis among different Green type on maximal Valsalva maneuver : Green type I group < Green type II group / Green type III group;the intergroup differences were statistically significant except for the difference between Green type II group and Green type III group.(3)Comparisons on ultrasonic appearance of the supportive structures of urethra and bladder among different groups:(1)The perpendicular distance from the internal urethral orifice to the Y axis reference line,the angle between the body axis and the line passing through the internal urethral orifice and the inferior margin of pubic symphysis in the non-prolapsed group were significantly smaller than those in the prolapsed group.(2)Comparisons on the perpendicular distance from the internal urethral orifice to the Y axis reference line among different Green types at the state of resting and maximal Valsalva maneuver: Green type I group < Green type II group / Green type III group,the intergroup differences were statistically significant except for the difference between Green type II group and Green type III group.(3)Comparisons on the angle between the body axis and the line passing through the internal urethral orifice and the inferior margin of pubic symphysis among different Green types at the state of resting and maximal Valsalva maneuver: Green type I group < Green type II group < Green type III group,all intergroup differences were of statistically significance.(4)Comparisons on the three-dimensional ultrasonic features of the supportive structures of urethra and bladder among different groups:(1)There was no difference in the vaginal cross-sectional thickness of anterior and posterior wall between the prolapsed and non-prolapsed group.(2)The vaginal cross-sectional area of the prolapsed group was significantly larger than that of the non-prolapsed group.(3)The vaginal cross-sectional area in Green type III was significantly smaller than that in other Green types.The intergroup difference between Green type I and Green type II was of no statistically significance.(4)Levator hiatus area was significant smaller in the non-prolapsed group than that of the prolapsed group.(5)Comparisons on levator hiatus area among different Green type: Green type I group / Green type II group > Green type III group.The intergroup differences were statistically significant except for the difference between Green type I group and Green type II group.(5)Correlation analysis between the retrovesical angle,urethral rotation and the parameters of intergroup significant difference:(1)Retrovesical angle on maximal Valsalva maneuver was positive correlated with the perpendicular distance from the internal urethral orifice to the Y axis reference line at state of resting or maximal Valsalva maneuver,the angle between the body axis and the line passing through the internal urethral orifice and the inferior margin of pubic symphysis and vaginal cross-sectional area.However,it was negative correlated with the levator hiatal area at rest.(2)The extent of urethral rotation was positive correlated with the perpendicular distance from the internal urethral orifice to the Y axis reference line at state of resting or maximal Valsalva maneuver,the angle between the body axis and the line passing through the internal urethral orifice and the inferior margin of pubic symphysis and vaginal cross-sectional area at state of resting and maximal Valsalva maneuver.Conclusions:(1)Translabial ultrasound can be used to observe several direct or indirect features of urethrovesical supportive structures injuries with excellent reproducibility.(2)The ventral urethral support was impaired in all Green types.(3)The function of levator ani muscle was impaired in patients with anterior compartment prolapse,especially serious with Green type III.(4)There was no significant difference of the vaginal cross-sectional thickness of anterior and posterior wall on the plane of minimal hiatal dimension between the non-prolapsed group and the prolapsed group.The area of urethrovesical supporting surface of anterior vaginal wall was narrower in Green type III.(5)On maximal Valsalva maneuver,the alteration in retrovesical angle and urethral rotation angle were the results of the joint actions of multiple urethrovesical supportive structures. |
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