Validity Of Trans-Perineum Pelvic Ultrasound For The Diagnosis Of Pelvic Organ Prolapse

Pelvic organ prolapse(POP)is associated with virginal delivery and obesity.Its’prevalence has increased steadily as human longevity increases.This condition compromises the life quality of women worldwide.Early identification of POP during pregnancy or after vaginal delivery is crucial because only timely intervention can achieve satisfactory results.Transperinal ultrasound can identify early stage development of POP by visualizing the morphological and functional changes.Up to now there are a limited number of studies on transperineal ultrasound diagnosis of POP,mostly measuring a single ultrasound parameter with a low diagnostic sensitivity,and the cut-off value varies widely.Efforts are greatly needed to study ultrasound diagnosis of POP using more than one sonographic parameters with a high sensitivity.Objective:This study aims to study the validity of Levator ani hiatal antro posterior diameter(LHap),levator ani hiatal area and pelvic organ mobility on the diagnosis of POP,and especially to find a highly sensitive ultrasound method by combining these two kinds of ultrasound parameters.Methods:Three hundred and forty-three women consecutively visiting the POP clinic at the fourth hospital of Hebei Medical University from Jan 12017 through June.30 2018 for consultation of symptoms of pelvic floor disorders,without a history of hysterectomy or POP correctional surgery were recruited.All women were subjected to history taking,gynecological examination for prolapse according to POP-Q(the International Urogynecological Association/International Continence Society POP quantification system),transperineal ultrasound examination for dynamically measuring the percentage decrease in the LHap from rest to maximum contraction(PDC%)and percentage increase from rest to Valsalva(PIV%,the two parameters studied in the first part of paper),mobility of bladder neck(BNM),cervix(CM),and rectum ampulla(RMA)from rest to Valsalva,and Levator ani hiatal area at rest(rHA),on Valsalva(vHA),and at maximum contraction(cHA,the latter six parameters studied in the second and the third parts of paper).All ultrasound examinations involved a Mindray Resona 8Elite system(Shenzhen,P.R.China.)with a RAB 4–8 MHz curved array volume transducer.As classified by the golden criterion of POP-Q,women with4 grade POP were excluded.The remaining two hundred and forty-seven women with stage 2-3 POP in the anterior/posterior compartments or stage 1-3in the apical compartment and 96 women with stage 0,1 POP in the anterior/posterior compartments or with stage 0 POP in the apical compartment were included as the patient and control group.Statistics analysis was performed to examine the difference in ultrasound parameters between POP and control group,and Receiver Operating Characteristic Curve Analysis(ROC)was employed to calculate the cut-off value,sensitivity,specificity,area under the curve(AUC)of the diagnostic test for those significant different parameters.Results:1.The mean LHap of the patients at rest,maximum contraction and on Valsalva were all significantly larger than the control group.The PIV%was significantly larger but the PDC%significantly smaller in patients than the control.The optimum cut-off value,sensitivity,specificity and AUC of PIV%to predict POP was≥12.64%,58.70%,87.50%and 0.73 respectively,likewise,that of PDC%was<23.23%,71.70%,87.50%and 0.76.2.If POP were diagnosed by the combination of PIV≥12.64%or PDC%<23.23%,the sensitivity,specificity and AUC was 81.40%,83.30%,0.82.3.The mean value of rHA,vHA,and cHA in patients were all significantly larger than the control.The optimum cut-off value,sensitivity,specificity and AUC of rHA to predict POP was≥14.64 cm~2,62.8%,91.7%and 0.78 respectively;similarly,that of vHA was≥20.26 cm~2,70.4%,88.5%and 0.80;and that of cHA was≥8.62 cm~2,78.5%,88.5%and 0.86respectively.4.The mean value of BNM,CM,and RAM were all significantly larger with prolapse cases than the controls.The optimum cut-off value,sensitivity,specificity and AUC of BNM to predict POP was≥19.65 mm,81.0%,85.4%,and 0.89 respectively,likewise,that of CM was≥18.45 mm,72.9%,86.5%and 0.80,and of RAM was≥15.5 mm,85.0%,91.7%and 0.86.5.The largest BNM,CM,and RAM,were observed for patients with anterior-,apical-,and posterior compartment predominant POP cases,respectively.Therefore BNM,CM,and RAM were used as the optimal parameter for discriminating between anterior,apical,or posterior predominant prolapse cases and controls.The optimum cut-off values for BNM,CM,and RAM,to predict anterior-,apical-,and posterior-predominant POP were≥20.50 mm,≥18.45 mm,and≥15.77 mm,and the sensitivity,specificity,AUC were 85.6%,87.5%,0.92;78.1%,85.9%,0.85;and 88.6%,91.2%,0.91 respectively.6.The sensitivity of a combined test was 92.6%when predicting anterior predominant prolapse by rHA≥13.38,vHA≥18.01 and cHA≥8.42 cm~2;was92.8%when predicting apical predominant prolapse by rHA≥14.65,vHA≥18.12 and cHA≥8.62 cm~2;and was 88.9%when predicting posterior predominant prolapse by rHA≥14.79,vHA≥20.38 and cHA≥8.42 cm~2.7.The sensitivity improved from 92.6%to 94.9%when predicting anterior predominant prolapse by rHA≥13.38,vHA≥18.01,cHA≥8.42 cm~2and BNM≥20.50 mm;The sensitivity improved from 92.8%to 97.1%when predicting apical predominant prolapse by rHA≥14.65,vHA≥18.12,cHA≥8.62 cm~2and CM≥18.45 mm;the sensitivity improved from 88.9%to95.6%when predicting posterior predominant prolapse by rHA≥14.97,vHA≥2 0.38,cHA≥8.42 cm~2and RAM≥15.77 mm.Conclusions:PDC%and PIV%are specific ultrasound parameters for the diagnosis of POP.Measuring BNM,CM,RAM,rHA,vHA,or cHA helps to identify patients with POP,but the sensitivity is low.The combined measurement of levator ani hiatal area and pelvic organ mobility significantly improves the sensitivity of transperineal ultrasound for the diagnosis of POP.This method deserves to be used routinely to assist the diagnosis of POP or as a front-line test to facilitate POP-Q grading.