Urinary and colorectal-anal distress in women - prevalence, risk factors and effect of pelvic floor muscle exercise in women with pelvic organ prolapse

ISBN 978-82-326-6872-4 (printed ver.) ISBN 978-82-326-5085-9 (electronic ver.) ISSN 1503-8181 (printed ver.) ISSN 2703-8084 (online ver.)

Doctoral theses at NTNU, 2021:199

Seema Mathew

Urinary and colorectal-anal distress in women

- prevalence, risk factors and effect of pelvic floor muscle exercise in women with pelvic organ prolapse

Doctor al thesis

Doctoral theses at NTNU, 2021:199Seema Mathew NTNU Norwegian University of Science and Technology Thesis for the Degree of Philosophiae Doctor Faculty of Medicine and Health Sciences Department of Clinical and Molecular Medicine

Thesis for the Degree of Philosophiae Doctor Trondheim, June 2021

Norwegian University of Science and Technology Faculty of Medicine and Health Sciences

Department of Clinical and Molecular Medicine

Seema Mathew

Urinary and colorectal-anal distress in women

- prevalence, risk factors and

effect of pelvic floor muscle

exercise in women with pelvic

organ prolapse

NTNU

Norwegian University of Science and Technology Thesis for the Degree of Philosophiae Doctor Faculty of Medicine and Health Sciences Department of Clinical and Molecular Medicine

© Seema Mathew

ISBN 978-82-326-6872-4 (printed ver.) ISBN 978-82-326-5085-9 (electronic ver.) ISSN 1503-8181 (printed ver.)

ISSN 2703-8084 (online ver.) Doctoral theses at NTNU, 2021:199 Printed by NTNU Grafisk senter

“Two roads diverged in a yellow wood, And sorry I could not travel both And be one traveller, long I stood And looked down one as far as I could

To where it bent in the undergrowth;”

Robert Frost: ‘The road not taken’ (1961)

Š‹•’ƒ‰‡ƒ†Žƒ•–’ƒ‰‡ƒ”–„›”‡–Š‡›‹•‡

SUMMARY

Background:Š‡…‘–‹‡…‡‡…Šƒ‹•‹•…‘’Ž‡šǤŠ‡‹ˆŽ—‡…‡‘ˆŽ‡˜ƒ–‘”ƒ‹—•…Ž‡

ȋȌ‹Œ—”›ƒ†‘–Š‡”’‡Ž˜‹…ˆŽ‘‘”…Šƒ‰‡•‹–Š‡Ž‘‰Ǧ–‡”†‡˜‡Ž‘’‡–‘ˆ—”‹ƒ”›

ƒ†…‘Ž‘”‡…–ƒŽǦƒƒŽ†‹•–”‡••‹•‘–…Ž‡ƒ”Ǥ‘‡™‹–Š’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡ȋȌŠƒ˜‡

…‘…‘‹–ƒ–•›’–‘•‘ˆ‹…‘–‹‡…‡ǤŠ‡’”‡˜ƒŽ‡…‡‘ˆƒƒŽ•’Š‹…–‡”†‡ˆ‡…–•ƒ†

ƒ••‘…‹ƒ–‡†ƒƒŽ‹…‘–‹‡…‡ȋȌ‹™‘‡™‹–Š‡‡†•ˆ—”–Š‡”‡˜ƒŽ—ƒ–‹‘Ǥ‡Ž˜‹…

ˆŽ‘‘”—•…Ž‡–”ƒ‹‹‰ȋ Ȍ‹•–Š‡ˆ‹”•–Ž‹‡–”‡ƒ–‡–ˆ‘”‹Ž†ƒ†—”‹ƒ”›

‹…‘–‹‡…‡ȋȌǤŠ‡–Š‡”‹–‡•‹˜‡’‡Ž˜‹…ˆŽ‘‘”‡š‡”…‹•‡‹’”‘˜‡—”‹ƒ”›ƒ†

…‘Ž‘”‡…–ƒŽǦƒƒŽ†‹•–”‡••ƒ†“—ƒŽ‹–›‘ˆŽ‹ˆ‡‹™‘‡™‹–Šƒ†˜ƒ…‡†‡‡†•ˆ—”–Š‡”

‹˜‡•–‹‰ƒ–‹‘Ǥ Aims

ͳǤ–—†›’‘••‹„Ž‡ƒ••‘…‹ƒ–‹‘•„‡–™‡‡–”ƒ—ƒƒ†—”‹ƒ”›ƒ†…‘Ž‘”‡…–ƒŽǦ

ƒƒŽ†‹•–”‡••ǡ‹…Ž—†‹‰ƒ†ˆ‡…ƒŽ‹…‘–‹‡…‡ȋ ȌǤ–—†›ƒ••‘…‹ƒ–‹‘•„‡–™‡‡

•–”—…–—”ƒŽ…Šƒ‰‡•‹–Š‡„Žƒ††‡”‡…ƒ†ƒ‘‰’ƒ”‘—•™‘‡Ǥ ʹǤ••‡••–Š‡’”‡˜ƒŽ‡…‡‘ˆƒƒŽ•’Š‹…–‡”†‡ˆ‡…–•ƒ†ƒ••‘…‹ƒ–‹‘™‹–Š‹

™‘‡™‹–Š•›’–‘ƒ–‹…—†‡”‰‘‹‰•—”‰‡”›Ǥ

3.Explore the effect of preoperative PFMT on urinary and colorectal-anal distress and related quality of life in women scheduled for POP surgery.

Methodsǣƒ–ƒ™‡”‡…‘ŽŽ‡…–‡†ˆ”‘–™‘•–—†›’‘’—Žƒ–‹‘•Ǣƒ…”‘••Ǧ•‡…–‹‘ƒŽ•–—†›‘ˆ

͸Ͳͺ™‘‡‡šƒ‹‡†ͳͷǦʹͳ›‡ƒ”•ƒˆ–‡”ˆ‹”•–†‡Ž‹˜‡”›ȋƒ’‡”ͳȌƒ†ƒ”ƒ†‘‹œ‡†

…‘–”‘ŽŽ‡†–”‹ƒŽ‘ˆ™‘‡™‹–Š•›’–‘ƒ–‹…—†‡”‰‘‹‰•—”‰‡”›ȋƒ’‡”ʹƒ†

͵ȌǤŽŽ’ƒ”–‹…‹’ƒ–•™‡”‡ƒ••‡••‡†—•‹‰’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡“—ƒ–‹ˆ‹…ƒ–‹‘•›•–‡ǡ

͵ȀͶ–”ƒ•’‡”‹‡ƒŽ—Ž–”ƒ•‘—†ǡ˜‹•—ƒŽƒƒŽ‘‰—‡•…ƒŽ‡ƒ†˜ƒŽ‹†ƒ–‡†“—‡•–‹‘ƒ‹”‡•Ǥ

–Š‡”ƒ†‘‹œ‡†…‘–”‘ŽŽ‡†–”‹ƒŽǡ–Š‡‹–‡”˜‡–‹‘‰”‘—’™ƒ•‰‹˜‡‹†‹˜‹†—ƒŽ

’Š›•‹‘–Š‡”ƒ’‹•–‰—‹†‡† ˆ”‘‹…Ž—•‹‘–‘–Š‡†ƒ›‘ˆ•—”‰‡”›Ǥ—Ž–‹˜ƒ”‹ƒ„Ž‡

”‡‰”‡••‹‘ƒƒŽ›•‹•ǡƒǦŠ‹–‡›–‡•–ƒ†‹š‡†‘†‡Ž•ƒƒŽ›•‹•™‡”‡—•‡†Ǥ Main results

ͳǣ‡ˆ‘—†‘ƒ••‘…‹ƒ–‹‘•„‡–™‡‡‹Œ—”›ƒ†•›’–‘•‘ˆƒ† ͳͷǦ ʹͶ›‡ƒ”•ƒˆ–‡”ˆ‹”•–†‡Ž‹˜‡”›ǡ„—–—”‡–Š”ƒŽˆ—‡Ž‹‰™ƒ•ƒ••‘…‹ƒ–‡†™‹–Š•–”‡••Ǥ ʹǣʹͷΨ‘ˆ™‘‡•…Š‡†—Ž‡†ˆ‘”•—”‰‡”›Šƒ†ƒƒŽ•’Š‹…–‡”†‡ˆ‡…–•Ǥƒ†

†‡ˆ‡…–•™‡”‡•–”‘‰Ž›ƒ••‘…‹ƒ–‡†™‹–Š ƒ†ˆŽƒ–ƒŽ‹…‘–‹‡…‡ǡ”‡•’‡…–‹˜‡Ž›Ǥ

͵ǣ›’–‘•ƒ†“—ƒŽ‹–›‘ˆŽ‹ˆ‡”‡Žƒ–‡†–‘—”‹ƒ”›ƒ†…‘Ž‘”‡…–ƒŽǦƒƒŽ†‹•–”‡••

‹’”‘˜‡†ˆ‘”ƒŽŽ™‘‡ƒˆ–‡”•—”‰‡”›ǡ”‡‰ƒ”†Ž‡••‘ˆ Ǥ

Conclusion:Š‡‡–‹‘Ž‘‰›—”‹ƒ”›ƒ†…‘Ž‘”‡…–ƒŽǦƒƒŽ†‹•–”‡••‹•—Ž–‹ˆƒ…–‘”‹ƒŽƒ†‘–

”‡Žƒ–‡†–‘–”ƒ—ƒǤŽƒ††‡”‡…ˆ—‡Ž‹‰™ƒ•‹†‹…ƒ–‹˜‡‘ˆ•–”‡••Ǥ‘‡™‹–Š

•‡˜‡”‡Šƒ˜‡Š‹‰Š’”‡˜ƒŽ‡…‡‘ˆƒƒŽ•’Š‹…–‡”†‡ˆ‡…–•ƒ†•’Š‹…–‡”†‡ˆ‡…–•™‡”‡

ƒ••‘…‹ƒ–‡†™‹–ŠǤ‡ˆ‘—†‘‡˜‹†‡…‡‘ˆƒ††‹–‹‘ƒŽƒ†˜ƒ–ƒ‰‡•‘ˆ’”‡‘’‡”ƒ–‹˜‡

ˆ‘”‹’”‘˜‹‰—”‹ƒ”›ƒ†…‘Ž‘”‡…–ƒŽǦƒƒŽ†‹•–”‡••‹™‘‡™‹–Š•‡˜‡”‡ǡ

„‡›‘†•—”‰‡”›Ǥ

SAMMENDRAG

Bakgrunn:‘–‹‡•‡ƒ‹•‡‡”‘’Ž‡•Ǥƒ‡Š‡‰‡‡ŽŽ‘•ƒ†‡’¤

„‡‡„—•—•Žƒ–—”ȋŽ‡˜ƒ–‘”—•‡ŽȌ‘‰—–˜‹Ž‹‰‡ƒ˜’Žƒ‰‡””‡Žƒ–‡”––‹Ž—”‹˜‡‹‡”

‡ŽŽ‡”ƒƒŽƒƒŽ‡‡”—Žƒ”Ǥ˜‹‡”‡†—†‡”Ž‹˜•ˆ”‡ˆƒŽŽ‡”‘ˆ–‡’Žƒ‰‡–‡†

‹‘–‹‡•Ǥƒ‡Š‡‰‡‡ŽŽ‘•ƒ†‡”’¤‡†‡–ƒ”•—•Žƒ–—”‡‘‰

ƒƒŽ‹‘–‹‡•„Žƒ–˜‹‡”‡†ˆ”‡ˆƒŽŽ„Þ”ƒ”–Ž‡‰‰‡•§”‡”‡Ǥ

‡‡„—•–”‡‹‰‡”ˆÞ”•–‡˜ƒŽ‰˜‡†‹Ž†‡ˆ”‡ˆƒŽŽ‡ŽŽ‡”—”‹Ž‡ƒ•Œ‡Ǥ‡––”‡‰•„‡†”‡

—•ƒ’‡”‘„‡‡„—•–”‡‹‰„Žƒ–˜‹‡”‡†„‡Šƒ†Ž‹‰•–”‡‰‡†‡ˆ”‡ˆƒŽŽ

ƒ”‡†—•‡”‡’Žƒ‰‡”ˆ”ƒ—”‹˜‡‹‡”‘‰ƒƒŽƒƒŽ‡‘‰ˆÞ”‡–‹Ž„‡†”‡Ž‹˜•˜ƒŽ‹–‡–Ǥ Mål:

ͳǣ†‡”•Þ‡ƒ••‘•‹ƒ•Œ‘‡‡ŽŽ‘Ž‡˜ƒ–‘”•ƒ†‡‘‰’Žƒ‰‡”ˆ”ƒ—”‹˜‡‹‡”‘‰

ƒƒŽƒƒŽ‡ǡ‹Ž—†‡”–—”‹Ǧ‘‰ƒ˜ˆÞ”‹‰•Ž‡ƒ•Œ‡„Žƒ–˜‹‡”‹‡‘”ƒŽ

„‡ˆ‘Ž‹‰Ǥ–—†‡”‡ƒ••‘•‹ƒ•Œ‘‡ŽŽ‘„Ž§”‡ŠƒŽ•ƒƒ–‘‹‘‰‹•ƒ‡

’‘’—Žƒ•Œ‘Ǥ

ʹǣ†‡”•Þ‡ˆ‘”‡‘•–ƒ˜•ƒ†‡”’¤‡†‡–ƒ”•—•Žƒ–—”‘‰ƒƒŽ‹‘–‹‡•

Š‘•˜‹‡”•‘‘’‡”‡”‡•ˆ‘”—†‡”Ž‹˜•ˆ”‡ˆƒŽŽ‘‰ƒ••‘•‹ƒ•Œ‘‡ŽŽ‘

—•‡Ž•ƒ†‡‘‰‹‘–‹‡•Ǥ

͵ǣ–—†‡”‡‡ˆˆ‡–ƒ˜’”‡‘’‡”ƒ–‹˜„‡‡„—•–”‡‹‰’¤’Žƒ‰‡”ˆ”ƒ—”‹˜‡‹‡”‡ŽŽ‡”

ƒƒŽƒƒŽ‡‘‰Ž‹˜•˜ƒŽ‹–‡–„Žƒ–˜‹‡”•‘‰Œ‡‘‰¤”‹”—”‰‹ˆ‘”

—†‡”Ž‹˜•ˆ”‡ˆƒŽŽǤ

Metoder:ƒ–ƒ‹•ƒŽ‹‰ˆ”ƒ–‘•–—†‹‡’‘’—Žƒ•Œ‘‡”Ǣ–˜‡””•‹––•–—†‹‡ƒ˜͸Ͳͺ˜‹‡”

—†‡”•Þ–ͳͷǦʹͳ¤”‡––‡”ˆÞ”•–‡ˆÞ†•‡Žȋ”–‹‡ŽͳȌ‘‰‡”ƒ†‘‹•‡”–‘–”‘ŽŽ‡”–•–—†‹‡

ƒ˜˜‹‡”•‘‰Œ‡‘‰‹ˆ”‡ˆƒŽŽ•‹”—”‰‹Ǥȋ”–‹‡Žʹ‘‰͵ȌǤ‡Ž–ƒ‡”‡‰Œ‡‘‰‹

‰›‡‘Ž‘‰‹•—†‡”•Þ‡Ž•‡‡†–”ƒ•’‡”‹‡ƒŽ—Ž–”ƒŽ›†ƒ˜„‡‡„—‡‘‰„‡•˜ƒ”–‡

˜‹•—‡ŽŽƒƒŽ‘‰•ƒŽƒ•ƒ–˜ƒŽ‹†‡”–‡•’Þ””‡•Œ‡ƒǤ†‡”ƒ†‘‹•‡”–‡‘–”‘ŽŽ‡”–‡

•–—†‹‡ȋ”–‹‡Ž͵Ȍ‰Œ‡‘ˆÞ”–‡‹–‡”˜‡•Œ‘•‰”—’’‡„‡‡„—•–”‡‹‰ˆ”ƒ

‹Ž—•Œ‘–‹Ž†ƒ‰‡ˆ‘”ˆ”‡ˆƒŽŽ•‹”—”‰‹Ǥ—Ž–‹˜ƒ”‹ƒ„‡Ž”‡‰”‡•Œ‘•ƒƒŽ›•‡ǡƒǦŠ‹–‡›

–‡•–‘‰Ǽ‹š‡†‘†‡Ž•ǽƒƒŽ›•‡„Ž‡„”—–Ǥ Resultater:

ͳǣ‹ˆƒ–‹‰‡ƒ••‘•‹ƒ•Œ‘‡ŽŽ‘Ž‡˜ƒ–‘”•ƒ†‡‘‰•›’–‘‡”’¤—”‹Ǧ‡ŽŽ‡”

ƒ˜ˆÞ”‹‰•‹‘–‹‡•ͳͷǦʹͶ¤”‡––‡”ˆÞ†•‡Žǡ‡ˆƒ–ƒ–—–˜‹†‡Ž•‡ƒ˜’”‘•‹ƒŽ‡

—”‡–”ƒ˜ƒ”ƒ••‘•‹‡”–‡†•–”‡••—”‹Ž‡ƒ•Œ‡Ǥ

ʹǣʹͷΨƒ˜˜‹‡”‡†„‡Šƒ†Ž‹‰•–”‡‰‡†‡—†‡”Ž‹˜•ˆ”‡ˆƒŽŽŠƒ††‡•ƒ†‡’¤

‡†‡–ƒ”•—•Žƒ–—”‡Ǥƒ†‡‡Šƒ††‡Žƒ”•ƒ‡Š‡‰‡†Ž—ˆ–Ǧ‘‰

ƒ˜ˆÞ”‹‰•‹‘–‹‡•Ǥ

͵ǣ‹ˆƒ–‹‰‡Þ–‰‡˜‹•–ƒ˜’”‡‘’‡”ƒ–‹˜„‡‡„—•–”‡‹‰’¤Ž‹˜•˜ƒŽ‹–‡–

‡ŽŽ‡”—†‡”Ž‹˜•’Žƒ‰‡””‡Žƒ–‡”––‹Ž—”‹˜‡‹‡”‡ŽŽ‡”ƒƒŽƒƒŽ‡Ǥ

Konklusjon:%”•ƒ‡‡–‹Ž—”‹˜‡‹•Ǧ‘‰ƒƒŽ‡’Žƒ‰‡”‡”•ƒ‡•ƒ––‡‘‰‹‡”‡Žƒ–‡”––‹Ž

Ž‡˜ƒ–‘”•ƒ†‡Ǥ–˜‹†‡Ž•‡ƒ˜„Ž§”‡ŠƒŽ•‡‹†‹‡”‡”•–”‡••—”‹Ž‡ƒ•Œ‡Ǥ˜‹‡”‡†

„‡Šƒ†Ž‹‰•–”‡‰‡†‡—†‡”Ž‹˜•ˆ”‡ˆƒŽŽŠƒ”ŠÞ›ˆ‘”‡‘•–ƒ˜•ƒ†‡”’¤

‡†‡–ƒ”•—•Žƒ–—”‡‘‰•Ž‹‡•ƒ†‡”‡”ƒ••‘•‹‡”–‡†ƒƒŽ‹‘–‹‡•Ǥ‡ˆŽ‡•–‡

˜‹‡‡‘’’Ž‡˜†‡„‡†”‹‰ƒ˜Ž‹˜•˜ƒŽ‹–‡–‘‰—†‡”Ž‹˜•’Žƒ‰‡””‡Žƒ–‡”––‹Ž—”‹˜‡‹‡”‡ŽŽ‡”

ƒƒŽƒƒŽ‡‡––‡”ˆ”‡ˆƒŽŽ•‹”—”‰‹ǡ—ƒ˜Š‡‰‹‰ƒ˜’”‡‘’‡”ƒ–‹˜„‡‡„—•–”‡‹‰Ǥ

ƒ†‹†ƒ– ‡‡ƒƒ–Š‡™

‘˜‡†˜‡‹Ž‡†‡” ‰”‹†‘ŽŽÞ›Šƒ—‰

‹˜‡‹Ž‡†‡” Œ‡ŽŽ%•—†ƒŽ˜‡•‡

•–‹–—–– Ž‹‹•‘‰‘Ž‡›Ž§”‡†‹•‹

‹ƒ•‹‡”‹‰ ‡Ž•‡‹†–Ǧ‘”‰‡ǡƒƒ”„‡‹†•‘”‰ƒ‡–Ǥ

TABLE OF CONTENTS

TABLE OF CONTENTS ... 1

ACKNOWLEDGEMENTS ... 3

1.0 INTRODUCTION ... 7

2.0 BACKGROUND ... 9

ʹǤͳŠ‡ˆ‡ƒŽ‡’‡Ž˜‹…ˆŽ‘‘”ǣƒƒ–‘›ƒ†ˆ—…–‹‘ ... 9

ʹǤʹŠ‡”‘Ž‡‘ˆŽ‡˜ƒ–‘”ƒ‹—•…Ž‡‹ƒ‹–ƒ‹‹‰…‘–‹‡…‡ ... 13

ʹǤ͵‡Ž˜‹…ˆŽ‘‘”†›•ˆ—…–‹‘... 14

ʹǤͶšƒ‹ƒ–‹‘ƒ††‹ƒ‰‘•‹•‘ˆ’‡Ž˜‹…ˆŽ‘‘”ƒƒ–‘›ǡˆ—…–‹‘ƒ†•›’–‘• ... 22

ʹǤͷƒƒ‰‡‡–‘ˆ‡Ž˜‹… Ž‘‘”›•ˆ—…–‹‘ ... 36

3.0 KNOWLEDGE GAP AND RATIONALE FOR THESIS ... 41

4.0 AIMS AND RESEARCH QUESTIONS ... 43

5.0 MATERIALS AND METHODS ... 45

ͷǤͳ–—†›†‡•‹‰ ... 45

ͷǤʹǤƒ”–‹…‹’ƒ–•ƒ†”‡…”—‹–‡– ... 45

ͷǤ͵ƒ†‘‹œƒ–‹‘ȋƒ’‡”͵Ȍ ... 47

ͷǤͶƒ–ƒ•‘—”…‡• ... 48

ͷǤͷƒ’Ž‡•‹œ‡…ƒŽ…—Žƒ–‹‘ ... 53

ͷǤ͸ƒ–ƒƒƒŽ›•‹•ƒ†•–ƒ–‹•–‹…• ... 53

ͷǤ͹ƒ–ƒŠƒ†Ž‹‰ƒ†”‡‰‹•–”ƒ–‹‘ ... 56

ͷǤͺ–Š‹…• ... 57

ͷǤͻ ‹ƒ…‹ƒŽ•—’’‘”– ... 57

6.0 SUMMARY OF RESULTS ... 59

͸Ǥͳ–—†›’‘’—Žƒ–‹‘ƒ††‡‘‰”ƒ’Š‹…• ... 59

͸Ǥʹƒ‹”‡•—Ž–• ... 66

7.0 DISCUSSION ... 77

͹Ǥͳ‘’ƒ”‹•‘™‹–Š‡š‹•–‹‰‘™Ž‡†‰‡ ... 77

͹Ǥʹ–”‡‰–Š•ƒ†Ž‹‹–ƒ–‹‘• ... 81

͹Ǥ͵‘••‹„Ž‡‡š’Žƒƒ–‹‘•–‘–Š‡”‡•—Ž–• ... 87

͹ǤͶŽ‹‹…ƒŽ‹’Ž‹…ƒ–‹‘•ˆ‘”—†‡”•–ƒ†‹‰ƒ†ƒƒ‰‹‰‹…‘–‹‡…‡‹™‘‡ ... 90

8.0 CONCLUSION ... 91

9.0 FUTURE RESEARCH ... 93

10.0 REFERENCES... 95

11.0 PAPERS ...105

12.0 APPENDICES ...113

ACKNOWLEDGEMENTS

Š‡™‘”’”‡•‡–‡†‹–Š‹•–Š‡•‹•™ƒ•…ƒ””‹‡†‘—–‹–Š‡’‡”‹‘†ʹͲͳ͹ǦʹͲͳͻƒ––Š‡

‡’ƒ”–‡–‘ˆ„•–‡–”‹…•ƒ†›ƒ‡…‘Ž‘‰›ǡ–ǤŽƒ˜•‹˜‡”•‹–›‘•’‹–ƒŽƒ†–Š‡

‡’ƒ”–‡–‘ˆŽ‹‹…ƒŽƒ†‘Ž‡…—Žƒ”‡†‹…‹‡ǡ ƒ…—Ž–›‘ˆ‡†‹…‹‡ƒ†‡ƒŽ–Š…‹‡…‡

ƒ––Š‡‘”™‡‰‹ƒ‹˜‡”•‹–›ˆ‘”…‹‡…‡ƒ†‡…Š‘Ž‘‰›Ǥ

Š‹••–—†›™ƒ•ˆ—†‡†„›–Š‡‘”™‡‰‹ƒ‘‡ǯ•—„Ž‹…‡ƒŽ–Š••‘…‹ƒ–‹‘Ȁ–Š‡

‘”™‡‰‹ƒš–”ƒ ‘—†ƒ–‹‘ȋƒ’‡”ͳȌƒ†Š‡‹ƒ•‹‘‘‹––‡‡ˆ‘”†—…ƒ–‹‘ǡ

‡•‡ƒ”…Šƒ†‘˜ƒ–‹‘‹‡–”ƒŽ‘”™ƒ›ȋƒƒ”„‡‹†•‘”‰ƒ‡–‡Ž•‡Ǧ‹†–Ȍȋƒ’‡”ͳǦ

͵ȌǤ

…ƒ‡—’‘–Š‹•„›…Šƒ…‡ƒ•›•—’‡”˜‹•‘”ƒ†…‘ŽŽ‡ƒ‰—‡ƒ•‡†‹ˆ™‘—Ž†„‡

‹–‡”‡•–‡†‹Œ‘‹‹‰ƒ•–—†›‘’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡ǤŠ‡‘”‡‰‘–‹˜‘Ž˜‡†‹–Š‡

•—„Œ‡…–ǡ–Š‡‘”‡‹–‡”‡•–‡†ƒ†…—”‹‘—•„‡…ƒ‡ƒ†›™‘”‹–Š‹•ˆ‹‡Ž†ˆ‡Ž–

‡ƒ‹‰ˆ—ŽǤ

‹”•–Ž›ǡ™‘—Ž†Ž‹‡–‘–Šƒ›•—’‡”˜‹•‘”•ǡ‰”‹†‘ŽŽÞ›Šƒ—‰ƒ†Œ‡ŽŽ%•—†

ƒŽ˜‡•‡ǤŠ‹•™‘—Ž†‡˜‡”Šƒ˜‡„‡‡’‘••‹„Ž‡™‹–Š‘—–›‘—”‰—‹†ƒ…‡ǡ’ƒ–‹‡…‡ƒ†

…‘’Ž‡–‡•—’’‘”–Ǥ‰”‹†ǡ›‘—ƒ”‡–”—Ž›Šƒ†•Ǧ‘ƒ†™‘—Ž†‘–†”‡ƒ‘ˆŠƒ˜‹‰

ƒ›‘‡‡Ž•‡ƒ•›•—’‡”˜‹•‘”Ǥ–ǯ•ƒƒœ‹‰Š‘™—…Š„‡––‡”ƒ›–Š‹‰„‡…‘‡•ƒˆ–‡”›‘—

Šƒ˜‡„‡‡–Š”‘—‰Š‹–ǤŠƒ˜‡Ž‡ƒ”–•‘—…Šƒ†‘™–Š‡”‡‹•‘”‡–‘…‘‡Ǥ‡’‡ǡ›‘—

ƒ”‡•—’‡”ˆƒ•–™Š‡‰‘‹‰–Š”‘—‰Š’ƒ’‡”•ƒ†›‘—”ˆ‡‡†„ƒ…‹•ƒŽ™ƒ›•–‘–Š‡’‘‹–Ǥ

ƒ”‹ƒ]›ƒ•§–‡”›Š—•ǡŠƒ˜‡•‘‡Œ‘›‡†™‘”‹‰™‹–Š›‘—ƒ†ˆ‘—†•‘—…Š

‹•’‹”ƒ–‹‘ˆ”‘›‘—Ǥ‘—Ž‹˜‡ƒ†„”‡ƒ–Š‡ˆ‘”–Š‡’‡Ž˜‹…ˆŽ‘‘”ƒ†Ž‘‘•‘—…Š—’–‘

›‘—Ǩƒ•‘‰”ƒ–‡ˆ—Ž–Šƒ–›‘—’ƒ˜‡†–Š‡™ƒ›ǤŠƒ•ˆ‘”„‡‹‰›’ƒ”–‡”‹…”‹‡Ǩǯ

•‹…‡”‡Ž›‰”ƒ–‡ˆ—Ž–‘‘†”‹‰‘—œƒ‘Œƒ•ǡˆ‘”‰‘‹‰–Š”‘—‰ŠƒŽŽ–Š‡—Ž–”ƒ•‘—†

˜‘Ž—‡•ƒ†’ƒ–‹‡–Ž›—†‰‹‰‡–‘‰‡–‡˜‡„‡––‡”‹—Ž–”ƒ•‘—†ƒƒŽ›•‹•ǤŠƒ›‘—

]›˜‹†ƒŽ˜‡•‡ǡˆ‘”–Š‡Š‡Ž’™‹–Š•–ƒ–‹•–‹…ƒŽƒƒŽ›•‹•‡š’Žƒ‹‹‰–Š‹‰•–Šƒ–™ƒ•™ƒ›

‘˜‡”›Š‡ƒ†ǤŠƒ•–‘‹‰‡‹Ž•‡–ƒˆ‡™Š‘Šƒ•†‡˜‡Ž‘’‡†–Š‡–”ƒ‹‹‰’”‘‰”ƒ‡

ƒ†–‘Žƒ”ƒƒ”‘Ž‹—••‡ˆ‘”‰—‹†‹‰ƒ†ˆ‘ŽŽ‘™Ǧ—’‘ˆ‘—”’ƒ–‹‡–•Ǥ

Šƒ›‘—ǡ‹ƒ•‹†ƒŽƒ†—”‹‘Ž„‡”‰ˆ‘”…‘‘”†‹ƒ–‹‘‘ˆ…Ž‹‹…ƒŽ‡šƒ‹ƒ–‹‘•Ǥ

ƒŽ•‘™ƒ––‘–Šƒ‘Šƒ‘”–‡”‡‹‡”ˆ‘”–‡…Š‹…ƒŽ•—’’‘”–™‹–Š–Š‡‹ƒ‰‹‰•‘ˆ–™ƒ”‡ǡ

‡”‹–ƒ”‹ƒ‡Œ‡Žƒƒ•‡ˆ‘”•—’’‘”–™‹–Š“—‡•–‹‘ƒ‹”‡•ǡ—˜ƒƒŽŽ‡ǡŠ”‹•–‹‡

]•–‡”Ž‹ƒ†‘—”…‘ŽŽ‡ƒ‰—‡•ƒ–”‘†Š‡‹‹˜‡”•‹–›Š‘•’‹–ƒŽˆ‘”Š‡Ž’‹‹†‡–‹ˆ›‹‰

’‘–‡–‹ƒŽ•–—†›’ƒ”–‹…‹’ƒ–•Ǥ…‘—Ž†‘–†‘–Š‹•™‹–Š‘—––Š‡•—’’‘”–‘ˆ›…‘ŽŽ‡ƒ‰—‡•

‡”‡–‡ǡ‹ŽŒ‡ǡ”‹ǡ‰”‹†ǡ—˜‘”ǡ‡…‹Ž‹‡ƒ†‹•ƒƒ––Š‡‡’ƒ”–‡–‘ˆ›‡…‘Ž‘‰›™Š‘

Šƒ˜‡™‘”‡†Šƒ”†•‘–Šƒ–…‘—Ž†‹‡”•‡›•‡Žˆ‹–Š‹•’”‘Œ‡…–ǤŠƒ›‘—ˆ‘”–Š‡

…‘–‹—‘—•‹–‡”‡•–‹–Š‡•—„Œ‡…–Ǥ™‘—Ž†Ž‹‡–‘–Šƒ–Š‡—”•‡•ƒ†•–ƒˆˆƒ––Š‡

’‘Ž‹…Ž‹‹…ˆ‘”ƒŽ™ƒ›•ƒ‹‰•—”‡Šƒ˜‡ƒ’Žƒ…‡–‘†‘›‡šƒ‹ƒ–‹‘•ƒ†Š‡Ž’‹‰™‹–Š

ˆ‹†‹‰‹•–”—‡–•‡‡†‡†Ǥ

ƒ‰”ƒ–‡ˆ—Ž–‘ƒŽŽ–Š‡™‘‡™Š‘’ƒ”–‹…‹’ƒ–‡†‹–Š‡•–—†›Ǥ‹–Š‘—–›‘—ǡ–Š‡”‡™‘—Ž†

„‡‘’”‘Œ‡…–Ǩ

™ƒ”–Šƒ•–‘›„‘›•ǡ‹Žƒƒ†‡‘ƒ†›Š—•„ƒ†ǡ‹––‘ǡ™Š‘Šƒ˜‡–‘Ž‡”ƒ–‡†ƒŽŽ

›—’•ƒ††‘™•ǡ‡…‘—”ƒ‰‹‰ƒ†Ž‹•–‡‡†–‘›’”‡•‡–ƒ–‹‘•–Šƒ–’”‘„ƒ„Ž›ƒ†‡

‘•‡•‡–‘–Š‡Ǥ›•‹…‡”‡‰”ƒ–‹–—†‡–‘›•‹•–‡”ǡ‡‡’ƒˆ‘”–Š‡„‡ƒ—–‹ˆ—Ž†”ƒ™‹‰•

–Šƒ–…‘’Ž‡‡––Š‡™‘”ƒ†–‘›„”‘–Š‡”‹ǦŽƒ™ǡƒ”Žˆ‘”–Š‡•—’’‘”–Ǥ›‹ǦŽƒ™•ǡ

Ž‡›ƒƒƒ††‹…—Žƒǡ–Šƒ•ˆ‘”›‘—”‹–‡”‡•–‹›™‘”Ǥ ‹ƒŽŽ›ǡ–Šƒ•–‘›

LIST OF PAPERS

ƒ’‡”ͳ

Levator ani muscle injury and risk for urinary and fecal incontinence in parous women from a normal population, a cross-sectional study.

ƒ–Š‡™ǡ—œž‘Œƒ•ǡƒŽ˜‡•‡ǡ‘ŽŽÞ›Šƒ—‰Ǥ

‡—”‘—”‘Ž”‘†›ǤʹͲͳͻǢ͵ͺȋͺȌǣʹʹͻ͸Ǧʹ͵ͲʹǤ

†‘‹ǣͳͲǤͳͲͲʹȀƒ—ǤʹͶͳ͵ͺǤ’—„ʹͲͳͻ—‰ʹͲǤǣ͵ͳͶ͵ʹͷͷͺǤ

ƒ’‡”ʹ

Prevalence of anal sphincter defects and association with anal incontinence in women scheduled for pelvic organ prolapse surgery.

ƒ–Š‡™ǡ—œƒ‘Œƒ•ǡ›Š—•ǡƒŽ˜‡•‡ǡ‘ŽŽÞ›Šƒ—‰ǡǤ

‡—”‘—”‘Ž”‘†›ǤʹͲʹͲǢ͵ͻȋͺȌǣʹͶͲͻǦʹͶͳ͸Ǥ

†‘‹ǣͳͲǤͳͲͲʹȀƒ—ǤʹͶͷͲͶǤ’—„ʹͲʹͲ‡’͹Ǥǣ͵ʹͺͻͶ͸ͶͷǤ

ƒ’‡”͵

The effect of preoperative pelvic floor muscle training on urinary and colorectal- anal distress in women undergoing pelvic organ prolapse surgery-a randomized controlled trial.

ƒ–Š‡™ǡ›Š—•]ǡƒŽ˜‡•‡]ǡƒŽ˜‡•‡%ǡ–ƒˆ‡ǡ‘ŽŽÞ›Šƒ—‰Ǥ

–”‘‰›‡…‘ŽǤʹͲʹͳ ‡„ͳ͵Ǥ

†‘‹ǣͳͲǤͳͲͲ͹Ȁ•ͲͲͳͻʹǦͲʹͳǦͲͶ͸ͺͶǦ͵Ǥ’—„ƒŠ‡ƒ†‘ˆ’”‹–Ǥǣ

͵͵ͷͺͲͺͲͻǤ

ABBREVIATIONS

ʹ ʹǦ†‹‡•‹‘ƒŽ –‘‘‰”ƒ’Š‹…—Ž–”ƒ•‘—†‹ƒ‰‹‰

͵ȀͶ ͵Ǧ†‹‡•‹‘ƒŽȀͶǦ†‹‡•‹‘ƒŽ Ǧ͸ —”‹ƒ”›†‹•–”‡••‹˜‡–‘”›

ƒ ƒ†Œ—•–‡†‘††•”ƒ–‹‘ —”‹ƒ”›‹…‘–‹‡…‡

ƒƒŽ‹…‘–‹‡…‡ —”‰‡—”‹ƒ”›‹…‘–‹‡…‡

„‘†›ƒ••‹†‡š —”‹ƒ”›‹’ƒ…–“—‡•–‹‘ƒ‹”‡

„Žƒ††‡”‡…†‡•…‡–

…‘ˆ‹†‡…‡‹–‡”˜ƒŽ

Ǧͺ …‘Ž‘”‡…–ƒŽǦƒƒŽ†‹•–”‡••‹˜‡–‘”›

…‘Ž‘”‡…–ƒŽǦƒƒŽ‹’ƒ…–“—‡•–‹‘ƒ‹”‡

‡š–‡”ƒŽƒƒŽ•’Š‹…–‡”

ˆ‡…ƒŽ‹…‘–‹‡…‡ ‹–‡”ƒŽƒƒŽ•’Š‹…–‡”

‹–‡”ƒ–‹‘ƒŽ…‘–‹‡…‡•‘…‹‡–›

Ž‡˜ƒ–‘”ƒ‹—•…Ž‡

ƒ‰‡–‹…”‡•‘ƒ…‡‹ƒ‰‹‰

‘”ƒŽ˜ƒ‰‹ƒŽ†‡Ž‹˜‡”›

‘„•–‡–”‹…ƒƒŽ•’Š‹…–‡”‹Œ—”›

‘††•”ƒ–‹‘

’‡Ž˜‹…ˆŽ‘‘”†›•ˆ—…–‹‘

ǦʹͲ ’‡Ž˜‹…ˆŽ‘‘”†‹•–”‡••‹˜‡–‘”›

’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡–”ƒ‹‹‰

Ǧ͹ ’‡Ž˜‹…ˆŽ‘‘”‹’ƒ…–“—‡•–‹‘ƒ‹”‡

Ǧ͸ ’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡†‹•–”‡••‹˜‡–‘”›

’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡‹’ƒ…–“—‡•–‹‘ƒ‹”‡

’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡

Ǧ ’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡“—ƒ–‹ˆ‹…ƒ–‹‘

‘ “—ƒŽ‹–›‘ˆŽ‹ˆ‡

”ƒ†‘‹•‡†…‘–”‘ŽŽ‡†–”‹ƒŽ

”‡‰‹‘ƒŽ‡–Š‹…ƒŽ…‘‹––‡‡

•–ƒ†ƒ”††‡˜‹ƒ–‹‘

•–ƒ–‹•–‹…ƒŽ’ƒ…ƒ‰‡ˆ‘”–Š‡•‘…‹ƒŽ•…‹‡…‡•

•–”‡••—”‹ƒ”›‹…‘–‹‡…‡

1.0 INTRODUCTION

Šƒ˜‡ƒŽ™ƒ›•„‡‡ˆƒ•…‹ƒ–‡†„›™‘‡ǯ•Š‡ƒŽ–Šƒ†‹‹ƒŽ‹˜ƒ•‹˜‡•—”‰‡”›ǡ•‘

ƒ–—”ƒŽŽ›„‡Ž‹‡˜‡†–Šƒ–‹ˆ™‡”‡–‘‹‡”•‡›•‡Žˆ‹•‘‡”‡•‡ƒ”…Š‹–™‘—Ž†„‡‹–Š‹•

•—„Œ‡…–ǤŠ‹•ƒ›•‘—†Ž‹‡ƒ…Ž‹…Š±ǡ„—–•–ƒ”–‡†™‘”‹‰‘–Š‹•’”‘Œ‡…–„›…Šƒ…‡ƒ•

Ž‡ƒ”‡†‘ˆƒ…Ž‹‹…ƒŽ–”‹ƒŽ†‡•‹‰‡†„›‹•’‹”‹‰ƒ†•‹ŽŽ‡†…‘ŽŽ‡ƒ‰—‡•Ž‘‘—’–‘Ǥ …‘’Ž‡–‡‘˜‹…‡ƒ–”‡•‡ƒ”…ŠǡŠƒ˜‡”‡ƒŽŽ›—†‡”•–‘‘†–Š‡•ƒ›‹‰„›—‹ǣ̵ƒ•›‘—•–ƒ”–

–‘™ƒŽ‘–Š‡™ƒ›ǡ–Š‡™ƒ›ƒ’’‡ƒ”•ǯǤ

•™‡–†‡‡’‡”‹–‘–Š‡ˆ‹‡Ž†‘ˆ—”‘‰›‡…‘Ž‘‰›–Š‡‘”‡‹–‡”‡•–‹‰ƒ†‡ƒ‹‰ˆ—Ž

›™‘”ˆ‡Ž–ǤŠ‡•‡ƒ”‡™‘‡™Š‘Š‡•‹–ƒ–‡–‘•‡‡‡†‹…ƒŽƒ†˜‹…‡ˆ‘”›‡ƒ”•ǤŠ‡

Šƒ’’‹‡••‘–Š‡‹”ˆƒ…‡•ƒˆ–‡”ƒ•—……‡••ˆ—Ž–”‡ƒ–‡–™‹ŽŽƒŽ™ƒ›••–ƒ›™‹–Š‡Ǥ‡‘™

•‘—…Šƒ„‘—––Š‡ˆ—…–‹‘ƒ†ƒƒ–‘›ǡ„—––Š‡”‡‹••–‹ŽŽ‘”‡–‘—†‡”•–ƒ†ƒ„‘—––Š‡

‹–”‹…ƒ–‡‹–‡”ƒ…–‹‘„‡–™‡‡–Š‡’‡Ž˜‹…ˆŽ‘‘”ƒ†‹…‘–‹‡…‡ǤŠ‡†ƒƒ‰‡•†‘‡

†—”‹‰…Š‹Ž†„‹”–Š‹•…‘•‹†‡”‡†–Š‡ƒ‹…—Ž’”‹–‘ˆ‡‡”‰‹‰’‡Ž˜‹…ˆŽ‘‘”†›•ˆ—…–‹‘ǡ„—–

‹ˆ•‘ǡ™Š›†‘•›’–‘•ƒ’’‡ƒ”ƒˆ–‡”ƒ››‡ƒ”•ǫŽ–Š‘—‰Š†ƒƒ‰‡–‘–Š‡’‡Ž˜‹…ˆŽ‘‘”‹•

ƒ••‘…‹ƒ–‡†™‹–Š’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡ǡ–Š‡”‡Žƒ–‹‘•Š‹’™‹–Š‹…‘–‹‡…‡‹•”ƒ–Š‡”

—…Ž‡ƒ”Ǥ

‘”‰›‡…‘Ž‘‰‹•–•ǡƒ—Ž–”ƒ•‘—†ƒ…Š‹‡ǡ‹•ƒ–‘—”ˆ‹‰‡”–‹’•ǤŽ–”ƒ•‘—†–‡…Š‘Ž‘‰›

ƒ†‹ƒ‰‡“—ƒŽ‹–›Šƒ•ƒ†‡…‘•‹†‡”ƒ„Ž‡ƒ†˜ƒ…‡•‹”‡…‡–›‡ƒ”•ǤŠ‡

—”‘‰›‡…‘Ž‘‰‹…ƒŽ’ƒ–‹‡–‘ˆ–‡Šƒ•…‘’Ž‡šƒ†‹–‡”Žƒ…‹‰•›’–‘•‘ˆ‘”‡–Šƒ‘‡

’‡Ž˜‹…ˆŽ‘‘”†›•ˆ—…–‹‘Ǥ”ƒ•’‡”‹‡ƒŽ—Ž–”ƒ•‘—†‹•‡ƒ•›–‘Ž‡ƒ”ƒ†”‡’”‘†—…‹„Ž‡ǡ

—•‡ˆ—Ž‹†‹ƒ‰‘•‹‰‘–Š‡”‹Œ—”‹‡•‘”™Šƒ–Ž‹‡•„‡Š‹†–Š‡’”‘Žƒ’•‡ǡ’”‘˜‹†‹‰˜ƒŽ—ƒ„Ž‡

‹ˆ‘”ƒ–‹‘–‘–Š‡•—”‰‡‘ǤŽ•‘ǡ™‘‡Šƒ˜‡„‡‡‘˜‡”™Š‡Ž‹‰Ž›’‘•‹–‹˜‡–‘–Š‡

‹–‡”ƒ…–‹˜‡—Ž–”ƒ•‘—†Ǧ‰—‹†‡†•—ƒ”›‘ˆ–Š‡’‡Ž˜‹…ˆŽ‘‘”ƒƒ–‘›ƒ†…‘””‡…–—•…Ž‡

…‘–”ƒ…–‹‘–‡…Š‹“—‡Ǥ

—•…Ž‡‹Œ—”‹‡•ƒ”‡–”‡ƒ–‡†™‹–Š’”‘‰”‡••‹˜‡”‡•‹•–ƒ…‡–”ƒ‹‹‰ˆ‘”‹…”‡ƒ•‹‰•–”‡‰–Š

ƒ†–‘ƒ˜‘‹†ƒ–”‘’Š›Ǥ‡‘™–Šƒ–‹–‹•’‘••‹„Ž‡–‘‡š‡”…‹•‡–Š‡’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡•

‡˜‡‹ˆ–Š‡•‡ƒ”‡‹Œ—”‡†Ǥ†‡ˆ‡…–ƒƒŽ•’Š‹…–‡”ƒ›„‡‘”‡†‹ˆˆ‹…—Ž–ǡƒ†™‡‡‡†

‘”‡‹ˆ‘”ƒ–‹‘‘–Š‡‡ˆˆ‡…–‘ˆ‡”˜‡‹Œ—”›‘–Š‡†‡˜‡Ž‘’‡–‘ˆ’‡Ž˜‹…†›•ˆ—…–‹‘Ǥ

‡Ž˜‹…ˆŽ‘‘”—•…Ž‡‡š‡”…‹•‡‹•–Š‡ƒ‹•–ƒ›‹ƒ›…‘†‹–‹‘•‹’”‘˜‹‰—”‹‡Ž‡ƒƒ‰‡ǡ

•‡š—ƒŽˆ—…–‹‘ƒ†‹Ž†’”‘Žƒ’•‡Ǥ…”‡ƒ•‡†—•…Ž‡•–”‡‰–Š•Š‘—Ž†ǡ‹–Š‡‘”›ǡ‹’”‘˜‡

•›’–‘•”‡Žƒ–‡†–‘—”‹ƒ”›ƒ†ƒƒŽ…ƒƒŽ‹…Ž—†‹‰Ž‡ƒƒ‰‡ǡƒ†‹–‹•‡ˆˆ‡…–‹˜‡ˆ‘”

’‡”•‹•–‘”‡‡”‰‡’‘•–‘’‡”ƒ–‹˜‡Ž›Ǥƒ–ƒ”‰‡–‡†‡š‡”…‹•‡†‡Žƒ›‘”ŠƒŽ– •›’–‘•ǫ

ƒ›•–—†‹‡•Šƒ˜‡Ž‘‘‡†ƒ–‡š‡”…‹•‡ƒˆ–‡”•—”‰‡”›ǡ„—–ˆ‡™Šƒ˜‡•–—†‹‡†–Š‡‡ˆˆ‡…–•‘ˆ

‡ƒ”Ž›‹–‡”˜‡–‹‘Ǥ

Š‹•’”‘Œ‡…–™ƒ•†‡˜‡Ž‘’‡†ƒ”‘—†–Š‡ˆ‘ŽŽ‘™‹‰”‡•‡ƒ”…Š“—‡•–‹‘•–Šƒ–Š‘’‡–‘

ƒ•™‡”‹–Š‡…‘—”•‡‘ˆ–Š‹•–Š‡•‹•ǣ

ͳǤ ‡Ž˜‹…ˆŽ‘‘”—•…Ž‡•ƒ†‹…‘–‹‡…‡‹’ƒ”‘—•™‘‡

o Šƒ–‹•–Š‡‹’‘”–ƒ…‡‘ˆŽ‡˜ƒ–‘”ƒ‹—•…Ž‡‹Œ—”‹‡•ƒ†Žƒ–‡‘•‡–

—”‹ƒ”›ƒ†…‘Ž‘”‡…–ƒŽǦƒƒŽ•›’–‘•‹…Ž—†‹‰‹…‘–‹‡…‡‹ƒ‘”ƒŽ

’‘’—Žƒ–‹‘ǫ

o ‘™†‘‡•—Ž–”ƒ•‘—††‹ƒ‰‘•‡†’ƒ”ƒ‡–‡”•‘ˆ„Žƒ††‡”‡…ƒƒ–‘›

”‡Žƒ–‡–‘—”‹ƒ”›‹…‘–‹‡…‡ǫ

ʹǤ ƒŽ•’Š‹…–‡”†‡ˆ‡…–•ƒ†ƒƒŽ‹…‘–‹‡…‡‹ƒ—”‘‰›‡…‘Ž‘‰‹…ƒŽ’‘’—Žƒ–‹‘

o Šƒ–‹•–Š‡’”‡˜ƒŽ‡…‡‘ˆƒƒŽ•’Š‹…–‡”†‡ˆ‡…–•ƒ†ƒƒŽ‹…‘–‹‡…‡‹

™‘‡™‹–Šƒ†˜ƒ…‡†’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡ǫ

o Šƒ–‹•–Š‡”‡Žƒ–‹‘•Š‹’„‡–™‡‡—Ž–”ƒ•‘—††‹ƒ‰‘•‡†ƒƒŽ•’Š‹…–‡”

†‡ˆ‡…–•ƒ†ƒƒŽ‹…‘–‹‡…‡‹™‘‡ƒ™ƒ‹–‹‰’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡

•—”‰‡”›ǫ

͵Ǥ ‡Ž˜‹…ˆŽ‘‘”—•…Ž‡–”ƒ‹‹‰

o ƒ’”‡‘’‡”ƒ–‹˜‡’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡‡š‡”…‹•‡Ž‡ƒ†–‘„‡––‡”•ƒ–‹•ˆƒ…–‹‘

ƒ†‹’”‘˜‡‡–‘ˆ’‡Ž˜‹…ˆŽ‘‘”†›•ˆ—…–‹‘‹™‘‡—†‡”‰‘‹‰

’”‘Žƒ’•‡•—”‰‡”›ǫ

2.0 BACKGROUND

2.1 The female pelvic floor: anatomy and function

Š‡ˆ‡ƒŽ‡’‡Ž˜‹…ˆŽ‘‘”…‘•‹•–•‘ˆ„‘›•–”—…–—”‡•ǡ—•…Ž‡•ǡ…‘‡…–‹˜‡–‹••—‡ǡ‡”˜‡•

ƒ†˜ƒ•…—Žƒ–—”‡–Šƒ–…‘‘’‡”ƒ–‡–‘’‡”ˆ‘”…‘’Ž‡šˆ—…–‹‘•Ǥ Bones

Š‡’‡Ž˜‹…„‘‡…‘•‹•–•‘ˆ–Š”‡‡ˆ—•‡†„‘‡•ǣ–Š‡‹Ž‹—ǡ‹•…Š‹—ƒ†–Š‡’—„‹…„‘‡•ǡ …‘‡…–‡†’‘•–‡”‹‘”Ž›„›–Š‡•ƒ…”—ƒ†ƒ–‡”‹‘”Ž›–‘–Š‡’—„‹…•›’Š›•‹•ˆ‘”‹‰ƒ

‘˜ƒŽ’”‘–‡…–‹˜‡…ƒ•‡ˆ‘”–Š‡’‡Ž˜‹…‘”‰ƒ•Ǥ^ͳŠ‡ƒ„†‘‹ƒŽ‘”‰ƒ•ƒ”‡…‘–ƒ‹‡†‹–Š‡

‰”‡ƒ–‡”’‡Ž˜‹•ǤŠ‡Ž‡••‡”’‡Ž˜‹•‹•ƒ‹ˆ‡”‹‘”…‘–‹—ƒ–‹‘™Š‡”‡–Š‡„Žƒ††‡”ǡ‰‡‹–ƒŽ‹ƒ

ƒ†”‡…–—ƒ”‡Ž‘…ƒ–‡†. Š‡ˆ‡ƒŽ‡’‡Ž˜‹•Šƒ•ƒ™‹†‡”†‹ƒ‡–‡”ƒ†ƒ‘”‡…‹”…—Žƒ”

•Šƒ’‡–Šƒ–Š‡ƒŽ‡’‡Ž˜‹•ǡ‡ƒ„Ž‹‰…Š‹Ž†„‹”–Š„—–’”‡†‹•’‘•‡•–‘•—„•‡“—‡–

™‡ƒ‡••Ǥ^ͳǡʹŠ‡ƒ–‡”‹‘”–‹Ž–Š‡Ž’•ƒ‰ƒ‹•–ƒ†‹”‡…–‰”ƒ˜‹–ƒ–‹‘ƒŽˆ‘”…‡…ƒ—†ƒŽŽ›Ǥ^ʹ

Figure 1 The muscles of the pelvic floor. Illustrated by Deepa Mathew.

Muscles

—•…—Žƒ”„ƒ•‡…‘˜‡”•–Š‡‹•‹†‡‘ˆ–Š‡’‡Ž˜‹•ȋ ‹‰—”‡ͳȌǤŠ‡Ž‡˜ƒ–‘”ƒ‹—•…Ž‡ȋȌ

‹•ƒ„”‘ƒ†—•…Ž‡ƒ––ƒ…Š‡†–‘–Š‡‹‡”„”‹‘ˆ–Š‡’‡Ž˜‹•–Š”‘—‰Š–Š‡ƒ”…—•–‡†‹ƒ‡

Žƒ–‡”ƒŽŽ›ǡ…‘•‹•–‹‰‘ˆ–Š”‡‡ƒ‹…‘’‘‡–•ǣ‹Ž‹‘…‘……›‰‡—•ǡ’—„‘…‘……›‰‡—•ƒ†

’—„‘”‡…–ƒŽ‹•—•…Ž‡Ǥ^ͳ‘‡†‹•ƒ‰”‡‡‡–”‡‰ƒ”†‹‰–Š‡–‡”‹‘Ž‘‰›‘ˆ–Š‡…‘’‘‡–•

‘ˆ–Š‡‡š‹•–•Ǥ^ͳ–Š‹•–Š‡•‹•ǡ–Š‡–‡”’—„‘”‡…–ƒŽ‹•‹•—•‡†ǤŠ‡–‘‰‡–Š‡”™‹–Š

–Š‡…‘……›‰‡—•—•…Ž‡ˆ‘”–Š‡’‡Ž˜‹…ˆŽ‘‘”ǡƒ—•…—Ž‘–‡†‹‘—•†‹ƒ’Š”ƒ‰–Šƒ–Ž‹‡•‘˜‡”

–Š‡’‡Ž˜‹…‘—–Ž‡–ǤŠ‡’—„‘”‡…–ƒŽ‹••Ž‹‰‹•–Š‡‹‡”‘•–’‘”–‹‘‘ˆ–Š‡–Šƒ–†‡ˆ‹‡•

–Š‡Ž‡˜ƒ–‘”Š‹ƒ–—•ƒŽŽ‘™‹‰’ƒ••ƒ‰‡ˆ‘”–Š‡—”‡–Š”ƒǡ˜ƒ‰‹ƒƒ†ƒ—•Ǥƒ‹–ƒ‹•ƒ

…Ž‘•‡†—”‘‰‡‹–ƒŽŠ‹ƒ–—•†—‡–‘‰”ƒ˜‹–›ƒ†•Ž‹‰Š–ƒ„†‘‹ƒŽ’”‡••—”‡Ǥ^ͳǡʹ

Š‡‡š–‡”ƒŽ—”‡–Š”ƒŽ•’Š‹…–‡”‹•ƒ…‹”…—Žƒ”•–”‹ƒ–‡†—•…Ž‡Ž‘…ƒ–‡†‹–Š‡‹††Ž‡

’‘”–‹‘‘ˆ–Š‡—”‡–Š”ƒƒ†ƒ…–•„›‹…”‡ƒ•‹‰–Š‡‹–”ƒ—”‡–Š”ƒŽ’”‡••—”‡ǤŠ‡—”‡–Š”ƒŽ

•‘‘–Š—•…Ž‡Šƒ•–™‘’ƒ”–•ǣƒ‹‡”Ž‘‰‹–—†‹ƒŽƒ†‘—–‡”…‹”…—Žƒ”Ǥ”‡–Š”ƒŽ

…‘–”ƒ…–‹‘‹•ƒ‹–ƒ‹‡†„›–Š‡…‹”…—Žƒ”ˆ‹„‡”•Ǥ^ʹǡ͵Š‡…‘„‹‡†‡ˆˆ‡…–‘ˆ–Š‡—”‡–Š”ƒŽ

•’Š‹…–‡”•ƒ†–Š‡•—„—…‘•ƒŽ˜ƒ•…—Žƒ”’Ž‡š—•ȋ™‹–Š‹–Š‡„Žƒ††‡”‡…Ȍ‡‡’–Š‡

Ž—‡…Ž‘•‡†ƒ†–Š‡—”‡–Š”ƒŽ…Ž‘•—”‡’”‡••—”‡Š‹‰Š‡”–Šƒ–Š‡„Žƒ††‡”’”‡••—”‡Ǥ^ʹǡͶ

Š‡ƒƒŽ…ƒƒŽ‹••—””‘—†‡†„›–Š‡ƒƒŽ•’Š‹…–‡”…‘’Ž‡šȋ ‹‰—”‡ʹȌǤ^ͷǡ͸Š‡‹–‡”ƒŽ

ƒƒŽ•’Š‹…–‡”ȋȌ—•…Ž‡‹•ƒ…‘–‹—ƒ–‹‘‘ˆ–Š‡‹‡”…‹”…—Žƒ”•‘‘–Š—•…Ž‡‘ˆ–Š‡

”‡…–—ǤŠ‡‡š–‡”ƒŽƒƒŽ•’Š‹…–‡”ȋȌ‹•ƒ•–”‹ƒ–‡†˜‘Ž—–ƒ”›—•…Ž‡–Šƒ–‡š–‡†–‘

Œ‘‹–Š‡’—„‘”‡…–ƒŽ‹••—’‡”‹‘”Ž›Ǥ–…ƒ…‘–”ƒ…–˜‘Ž—–ƒ”‹Ž›‹”‡•’‘•‡–‘

‹–”ƒƒ„†‘‹ƒŽ’”‡••—”‡ƒ†ƒ‹†•‹”‡–ƒ‹‹‰•‘Ž‹†•ƒ†ˆŽ—‹†•Ǥ^ͷǡ͸Š‡‹•ƒ‹–ƒ‹‡†

‹ƒ•–‡ƒ†›•–ƒ–‡‘ˆ…‘–”ƒ…–‹‘„›‡š…‹–ƒ–‘”›•›’ƒ–Š‡–‹…ˆ‹„‡”•ƒ†‹Š‹„‹–‘”›

’ƒ”ƒ•›’ƒ–Š‡–‹…ˆ‹„‡”•Ǥ^͹Š‡‹˜‘Ž—–ƒ”›•‘‘–Š—•…Ž‡•‘ˆ–Š‡ƒŽ‘‰™‹–Š–Š‡

’—„‘”‡…–ƒŽ‹••Ž‹‰ƒ†˜ƒ•…—Žƒ”’Ž‡š—•’”‡•‡”˜‡„ƒ•ƒŽ…‘–‹‡…‡ˆ‘”•‘Ž‹†•ǡŽ‹“—‹†•ƒ†

ˆŽƒ–—•Ǥ^ͷǡ͹ǡͺŠ‡‹•”‡•’‘•‹„Ž‡ˆ‘”ƒ–Ž‡ƒ•–ͷͷΨ‘ˆ–Š‡”‡•–‹‰–‘‡‹–Š‡ƒƒŽ…ƒƒŽ

™Š‹Ž‡ƒ†–Š‡ƒƒŽ—…‘•ƒƒŽ‘‰™‹–Š–Š‡˜ƒ•…—Žƒ”…—•Š‹‘•…‘–”‹„—–‡ƒ„‘—–͵ͲΨ

ƒ†ͳͷΨ”‡•’‡…–‹˜‡Ž›Ǥ^ͷǡͺ

Figure 2 The anal canal. Illustration by Deepa Mathew.

Connective tissue

Š‡…‘‡…–‹˜‡–‹••—‡•—””‘—†‹‰–Š‡—•…—Ž‘•‡Ž‡–ƒŽ•–”—…–—”‡•…‘•‹•–•‘ˆŽ‹‰ƒ‡–•ǡ

ˆƒ•…‹ƒƒ†ˆƒ––›–‹••—‡ǤŠ‡”‡ƒ”‡–Š”‡‡Ž‡˜‡Ž•‘ˆ…‘‡…–‹˜‡–‹••—‡•—’’‘”––‘–Š‡—–‡”—•

ƒ†˜ƒ‰‹ƒƒ•…Žƒ••‹ˆ‹‡†„›‡ƒ…‡›ȋ ‹‰—”‡͵Ȍ^ͶǤ

‡˜‡Žͳȋ•—•’‡•‹‘Ȍǣ…‘’”‹•‡•‘ˆ–Š‡…ƒ”†‹ƒŽƒ†—–‡”‘•ƒ…”ƒŽŽ‹‰ƒ‡–••—’’‘”–‹‰–Š‡

—–‡”—•ƒ†–Š‡’”‘š‹ƒŽ˜ƒ‰‹ƒǤ

‡˜‡Žʹȋƒ––ƒ…Š‡–ȌǣŠ‡„”‘ƒ†‡†‘’‡Ž˜‹‡ˆƒ•…‹ƒƒ…Š‘”•–Š‡…‡”˜‹šƒ†˜ƒ‰‹ƒ–‘–Š‡

’—„‹…„‘‡ƒ†–Š‡‹•…Š‹ƒŽ•’‹‡˜‹ƒ–Š‡ƒ”…—•–‡†‹‘—•ˆƒ•…‹ƒ’‡Ž˜‹•ƒ†…‘–ƒ‹•–Š‡

‡—”‘˜ƒ•…—Žƒ”•—’’Ž›–‘–Š‡’‡Ž˜‹…‘”‰ƒ•ƒ†–Š‡•—’’‘”–‹‰•ƒ…”‘—–‡”‹‡Ǧ…ƒ”†‹ƒŽ

Ž‹‰ƒ‡–…‘’Ž‡šƒ†–Š‡’—„‘—”‡–Š”ƒŽŽ‹‰ƒ‡–•Ǥ^ʹǡ͵Š‡ƒ’‘‡—”‘•‹•‘ˆ–Š‡Ž‡˜ƒ–‘”ƒ‹

ƒ†–Š‡”‡…–‘˜ƒ‰‹ƒŽˆƒ•…‹ƒ•—’’‘”––Š‡‹†˜ƒ‰‹ƒǤ

‡˜‡Ž͵ȋˆ—•‹‘ȌǣŠ‡—”‘‰‡‹–ƒŽ†‹ƒ’Š”ƒ‰ˆ‘”•ƒ†‡•‡–”‹ƒ‰—Žƒ”…‘‡…–‹˜‡–‹••—‡

‡„”ƒ‡ƒ––Š‡Ž‡˜‡Ž‘ˆ–Š‡Š›‡‡‡’‹‰–Š‡†‹•–ƒŽ—”‡–Š”ƒƒ†˜ƒ‰‹ƒ‹’Žƒ…‡ǡ

‹•…Š‹‘…ƒ˜‡”‘•—•ƒ†–Š‡•—’‡”ˆ‹…‹ƒŽ–”ƒ˜‡”•‡’‡”‹‡‹—•…Ž‡‹•‡”–‹‰ƒ––Š‡’‡”‹‡ƒŽ

„‘†›‹–Š‡’‡”‹‡—Ǥ^͵Š‡’‡”‹‡ƒŽ„‘†›ƒŽ‘‰™‹–Š–Š‡‡š–‡”ƒŽƒƒŽ•’Š‹…–‡”

’”‘˜‹†‡•–Š‡’‘•–‡”‹‘”•—’’‘”–ƒ––Š‹•Ž‡˜‡ŽǤ

Innervation

Š‡’—†‡†ƒŽ‡”˜‡ƒ”‹•‡•ˆ”‘–Š‡•ƒ…”ƒŽ’Ž‡š—•ȋ•’‹ƒŽ‡”˜‡•ʹǦͶȌǤ–•—’’Ž‹‡•

•‡•ƒ–‹‘ǡ‘–‘”ˆ—…–‹‘ƒ†…ƒ””‹‡••›’ƒ–Š‡–‹…ˆ‹„‡”•–‘–Š‡‡š–‡”ƒŽ‰‡‹–ƒŽ‹ƒǡ

—”‡–Š”ƒǡƒƒŽ…ƒƒŽƒ†–Š‡˜‘Ž—–ƒ”›ƒ†‡š–‡”ƒŽ—”‡–Š”ƒŽ•’Š‹…–‡”Ǥ^͹Š‡

’—†‡†ƒŽ‡”˜‡‹•ƒƒ……‡••‘”›•—’’Ž‹‡”–‘–Š‡ǡƒ•–Š‡Ž‡˜ƒ–‘”ƒ‹‡”˜‡’”‘˜‹†‡•

–Š‡ƒ‹‹‡”˜ƒ–‹‘ȋ͵ǦͶȌǤ^͹‡Ž˜‹…•’Žƒ…Š‹…‡”˜‡•ƒ”‹•‹‰ˆ”‘–Š‡‹ˆ‡”‹‘”

Š›’‘‰ƒ•–”‹…’Ž‡š—•ƒ‡—’–Š‡’ƒ”ƒ•›’ƒ–Š‡–‹…‹‡”˜ƒ–‹‘Ǥ^͵

Figure 3 A sagittal view of the levels of support according to DeLancey with a cross-section of each level.

Illustration by Deepa Mathew.

2.2 The role of levator ani muscle in maintaining continence

Š‡’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡•ƒ”‡‡’–‹ƒ•–‡ƒ†›•–ƒ–‡‘ˆ…‘–”ƒ…–‹‘„›ƒ…‘„‹‡†

ƒ…–‹˜ƒ–‹‘‘ˆ„‘–Š„”ƒ‹•–‡ƒ†”‡ˆŽ‡š’ƒ–Š™ƒ›•Ǥ^͹‘Ž—–ƒ”›‹…–—”‹–‹‘•–ƒ”–•™‹–Šƒ

”‡Žƒšƒ–‹‘‘ˆ–Š‡ƒ†•’Š‹…–‡”•Ǥ^ʹŠ‡•—’’‘”–‹˜‡ǮŠƒ‘…ǯˆ—…–‹‘‘ˆ–Š‡

–‡•‡•–Š‡•—„—”‡–Š”ƒŽˆƒ•…‹ƒǡ”‡†—…‹‰„Žƒ††‡”‡…†‡•…‡–ƒ†…‘’”‡••‡•–Š‡

—”‡–Š”ƒ†—”‹‰•—††‡‹…”‡ƒ•‡•‹‹–”ƒƒ„†‘‹ƒŽ’”‡••—”‡Ǥ^ͻŠ‹•ƒ‡—˜‡”…ƒŽŽ‡†–Š‡

Ǯƒ…ǯǡ‹•—•‡†–‘–”ƒ‹…‘‘”†‹ƒ–‹‘‹’”‡’ƒ”ƒ–‹‘ˆ‘”’‘••‹„Ž‡‹…”‡ƒ•‡‹ƒ„†‘‹ƒŽ

’”‡••—”‡†—”‹‰…‘—‰Šƒ†’Š›•‹…ƒŽƒ…–‹˜‹–›Ǥ^ͳͲ–ƒ…–…‘–”ƒ…–‹‘‡‡’•–Š‡

ƒ‘”‡…–ƒŽƒ‰Ž‡ƒ–ͻͲ†‡‰”‡‡•ǡ–Š—•Š‡Ž’‹‰‹ƒ‹–ƒ‹‹‰ƒƒŽ…‘–‹‡…‡Ǥ^͸ǡͺ‡…–ƒŽ

†‹•–‡–‹‘’”‘’–•ƒ”‡Žƒšƒ–‹‘ƒ†ˆ—”–Š‡”‡š’—Ž•‹‘‹•ƒŽŽ‘™‡†ƒˆ–‡”’—„‘”‡…–ƒŽ‹•

ƒ†”‡Žƒšƒ–‹‘‘……—”•Ǥ^ͺ

‘”ƒŽ…‘–‹‡…‡‡…Šƒ‹•†‡’‡†•‘–Š‡•›‡”‰‹•–‹…ƒ…–‹‘‘ˆƒ‹–ƒ…–

—•…—Ž‘ˆƒ•…‹ƒŽ•—’’‘”–•›•–‡•ǡ•’Š‹…–‡”•ǡ•–‘”ƒ‰‡ˆ—…–‹‘ƒ†Ž‹ˆ‡•–›Ž‡Šƒ„‹–•Ǥ^ͳǦ͵‹…‡

–Š‡•Ž‹‰ˆ—…–‹‘‘ˆ–Š‡’”‡˜‡–•Ž‡ƒƒ‰‡‘ˆ—”‹‡ƒ†ˆ‡…ƒŽƒ––‡”ǡ‘‡™‘—Ž†

‡š’‡…–‹Œ—”›–‘„‡ƒ••‘…‹ƒ–‡†™‹–Š‹…‘–‹‡…‡Ǥ^ͳͳ‘™‡˜‡”ǡ–Š‡‡–‹‘Ž‘‰›‘ˆ—”‹ƒ”›ƒ†

…‘Ž‘”‡…–ƒŽǦƒƒŽ•›’–‘•‹…Ž—†‹‰‹…‘–‹‡…‡‹•…‘’Ž‡šƒ†–Š‡‹’ƒ…–‘ˆ

‹Œ—”›‹•‘–ˆ—ŽŽ›—†‡”•–‘‘†Ǥ

2.3 Pelvic floor dysfunction

2.3.1 Prevalence and impact on quality of life

‡Ž˜‹…ˆŽ‘‘”†›•ˆ—…–‹‘ȋ Ȍ‹•ƒ™‹†‡–‡”–Šƒ–‹…Ž—†‡•’”‘Žƒ’•‡ǡ•‡•‘”›ƒ†

‡’–›‹‰‹””‡‰—Žƒ”‹–‹‡•‘ˆ–Š‡—”‹ƒ”›‘”†‹•–ƒŽ‰ƒ•–”‘‹–‡•–‹ƒŽ–”ƒ…–ǡ’‡Ž˜‹…’ƒ‹ƒ†

•‡š—ƒŽ†›•ˆ—…–‹‘ȋ ‹‰—”‡ͶȌǤ^ͳʹ–Š‹”†‘ˆ™‘‡”‡’‘”–ƒ–Ž‡ƒ•–‘‡ •›’–‘ƒ†

ʹͲΨ—†‡”‰‘•—”‰‡”›ˆ‘”’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡ȋȌ‘”—”‹ƒ”›‹…‘–‹‡…‡ȋȌ„›

–Š‡ƒ‰‡‘ˆͺͲǤ^ͳ͵Ǧͳ͸›’–‘•‘ˆ–‡‘˜‡”Žƒ’ǡƒ•‹ŽŽ—•–”ƒ–‡†‹ ‹‰—”‡ͶǤ^ͳͷǡͳ͹—•…Ž‡ƒ†

‡”˜‡–”ƒ—ƒ•—•–ƒ‹‡†–‘–Š‡’‡Ž˜‹…ˆŽ‘‘”†—”‹‰…Š‹Ž†„‹”–ŠŽ‡ƒ†–‘…‘Ǧ‡š‹•–‡…‡‘ˆ

†‹ˆˆ‡”‡– •ƒ†–Š‡’”‡˜ƒŽ‡…‡‹…”‡ƒ•‡•™‹–Šƒ‰‡Ǥ^{ͳͷǡͳ͹Ǧͳͻ}

Figure 4 Illustration of the interrelated conditions for the umbrella term ‘Pelvic floor dysfunction’.

Image by S. Mathew.

Urinary distress

”‹ƒ”›†‹•–”‡••‹˜‘Ž˜‡•‹…‘–‹‡…‡ǡ˜‘‹†‹‰†‹ˆˆ‹…—Ž–‹‡•ǡ’ƒ‹†—”‹‰‹…–—”‹–‹‘ƒ†

—”‰‡…›ǤŠ‡‘•–…‘‘—”‹ƒ”›…‘’Žƒ‹–‹•ƒ†–Š‡’”‡˜ƒŽ‡…‡˜ƒ”‹‡•ˆ”‘ͳ͹Ǧ

͸ͻΨ†‡’‡†‹‰‘†‡ˆ‹‹–‹‘•ƒ†’‘’—Žƒ–‹‘•–—†‹‡†Ǥ^{ͳͶǡͳͷǡʹͲ}‹•–Š‡‹˜‘Ž—–ƒ”›Ž‘••‘ˆ

—”‹‡ƒ†‹•ˆ—”–Š‡”†‹˜‹†‡†‹–‘^ͳʹǣ

o –”‡••—”‹ƒ”›‹…‘–‹‡…‡ȋȌƒ••‘…‹ƒ–‡†™‹–Š’Š›•‹…ƒŽ‡š‡”–‹‘‘”

•‡‡œ‹‰Ȁ…‘—‰Š‹‰Ǥ

o ”‰‡—”‹ƒ”›‹…‘–‹‡…‡ȋȌǡŽ‡ƒƒ‰‡ƒ••‘…‹ƒ–‡†™‹–Š•—††‡…‘’‡ŽŽ‹‰

†‡•‹”‡–‘˜‘‹†Ǥ

o ‹š‡†—”‹ƒ”›‹…‘–‹‡…‡ǡ…‘„‹ƒ–‹‘‘ˆ–Š‡ƒ„‘˜‡–™‘Ǥ

o Š”‘‹…†‹•‘”†‡”•‹…Ž—†‹‰‡—”‘Ž‘‰‹…ƒŽ†‹•‡ƒ•‡•ƒ†‹Œ—”‹‡•…‘–”‹„—–‡–‘‘–Š‡”

–›’‡•‘ˆ—”‹ƒ”›‹…‘–‹‡…‡Ǥ

‹•–Š‡‘•–ˆ”‡“—‡–„‘–Š‡”ƒˆˆ‡…–‹‰ͳͶǦͶ͵ΨǤ^ͳ͸ǡʹͲ‹•”‡’‘”–‡†‹ͳͶΨƒ†–Š‡

’”‡˜ƒŽ‡…‡‘ˆ—”‰‡ƒ†‹š‡†‹…”‡ƒ•‡•™‹–Šƒ‰‡ǡ™‹–Š–Š‡Žƒ––‡”„‡…‘‹‰–Š‡‘•–

’”‡˜ƒŽ‡––›’‡‘ˆƒ‘‰™‘‡‘˜‡”͸Ͳ›‡ƒ”•‘ˆƒ‰‡Ǥ^ʹͲ Colorectal-anal distress

Š‹•‹•ƒ—„”‡ŽŽƒ–‡”ˆ‘”ƒŽŽ•›’–‘•”‡Žƒ–‡†–‘–Š‡‰ƒ•–”‘‹–‡•–‹ƒŽ–”ƒ…–‹…Ž—†‹‰

Ž‡ƒƒ‰‡‘ˆ•–‘‘Ž‘”ˆŽƒ–—•ǡ‡’–›‹‰†‹ˆˆ‹…—Ž–‹‡•ǡ’ƒ‹†—”‹‰†‡ˆ‡…ƒ–‹‘ƒ†”‡…–ƒŽ

’”‘Žƒ’•‡ǤƒŽ‹…‘–‹‡…‡ȋȌ‹•†‡ˆ‹‡†ƒ•ƒ…‘’Žƒ‹–‘ˆ‹˜‘Ž—–ƒ”›Ž‘••‘ˆˆŽƒ–—•‘”

ˆ‡…‡•Ǥ^ʹͳ ‡…ƒŽ‹…‘–‹‡…‡ȋ Ȍ‹•†‡ˆ‹‡†ƒ•ƒ…‘’Žƒ‹–‘ˆ‹˜‘Ž—–ƒ”›Ž‘••‘ˆˆ‡…‡•ǡ

™Š‡ˆ‡…‡•‹••‘Ž‹†ƒ†Ȁ‘”™Š‡ˆ‡…‡•‹•Ž‹“—‹†Ǥ˜‘Ž—–ƒ”›Ž‘••‘ˆˆŽƒ–—•ȋ‰ƒ•Ȍ‹•–‡”‡†

ˆŽƒ–ƒŽ‹…‘–‹‡…‡Ǥ^ͳʹ‘……—”•‹͸ǦͳͻΨ†‡’‡†‹‰‘†‡ˆ‹‹–‹‘•‹†‹ˆˆ‡”‡–

•–—†‹‡•Ǥ^ͳͷǡʹͳ•ˆ‘”‘–Š‡” •–Š‡”‡ƒŽ’”‡˜ƒŽ‡…‡ƒ›„‡Š‹‰Š‡”Ǥ^ʹʹǡʹ͵

Pelvic organ prolapse

‹•†‡ˆ‹‡†ƒ•–Š‡†‘™™ƒ”††‡•…‡–‘ˆ–Š‡’‡Ž˜‹…‘”‰ƒ•ȋ„Žƒ††‡”ǡ—–‡”—•ǡŽ‘™‡”

‰ƒ•–”‘‹–‡•–‹ƒŽ–”ƒ…–Ȍ…ƒ—•‹‰ƒ‘—–™ƒ”†•„—Ž‰‹‰‘ˆ–Š‡˜ƒ‰‹ƒŽ™ƒŽŽ•‘”—–‡”—•‹–Š‡

…ƒ—†ƒŽ†‹”‡…–‹‘Ǥ^ʹͶŠ‡’”‡˜ƒŽ‡…‡‘ˆ‹•ƒ”‘—†͵Ǧ͸ΨǤ‘™‡˜‡”ǡ‹…‹†‡–ƒŽˆ‹†‹‰•

‹ƒ•ƒ›ƒ•ͷͲΨ™‘‡•—‰‰‡•––Šƒ–‘•–ƒ”‡ƒ•›’–‘ƒ–‹…Ǥ^ͳ͹›’–‘•‹…Ž—†‡

„—Ž‰‹‰ǡ’”‡••—”‡ǡ’ƒ‹ǡ„Žƒ††‡”‘”„‘™‡Ž‡’–›‹‰Ȁ•–‘”ƒ‰‡†‹•–—”„ƒ…‡•ƒ†

‹…‘–‹‡…‡Ǥ›’‡‘ˆ’”‘Žƒ’•‡‹•†‹˜‹†‡†‹–‘ƒ–‡”‹‘”ǡ’‘•–‡”‹‘”ƒ†‹††Ž‡

…‘’ƒ”–‡–‘”ƒ…‘„‹ƒ–‹‘‘ˆ…‘’ƒ”–‡–•„ƒ•‡†‘ƒƒ–‘‹…ƒŽˆ‹†‹‰•ȋ ‹‰—”‡

ͷȌǤ^ʹͶǡʹͷ

Figure 5 Different types of prolapse. Illustration by Deepa Mathew

Pelvic pain

Š‡’”‡˜ƒŽ‡…‡‘ˆ’‡Ž˜‹…’ƒ‹˜ƒ”‹‡•ˆ”‘ͶǦʹͶΨƒ†ƒ›„‡—†‡”‡•–‹ƒ–‡†Ǥ^ʹ͸‘Ǧ …›…Ž‹…’ƒ‹Žƒ•–‹‰‘”‡–Šƒ͸‘–Š•‹•†‡ˆ‹‡†ƒ•…Š”‘‹…’‡Ž˜‹…’ƒ‹ǡƒ†ƒ›„‡

‘…‹…‡’–‹˜‡ǡ‡—”‘’ƒ–Š‹…‘”’•›…Š‘‰‡‹…Ǥ^ʹ͹‡Ž˜‹…’ƒ‹ƒ›ƒŽ•‘„‡–Š‡”‡•—Ž–‘ˆ•—”‰‹…ƒŽ

–”‡ƒ–‡–Ǥ^ʹͺ

Sexual dysfunction

‡ƒŽ‡•‡š—ƒŽ†›•ˆ—…–‹‘‹•ƒŠ‡–‡”‘‰‡‘—•‰”‘—’‘ˆ•›’–‘•”‡Žƒ–‡†–‘•‡š—ƒŽ

ˆ—…–‹‘ƒ†ƒ”‘—•ƒŽƒˆˆ‡…–‹‰—’–‘ͶͲΨ‘ˆ™‘‡Ǥ^ʹ͵ƒŒ‘”‹–›‘ˆ™‘‡™‹–Šƒ›

‡š’‡”‹‡…‡•‡š—ƒŽ†›•ˆ—…–‹‘Ǥ^ʹͺŠ‡”‡ƒŽ’”‡˜ƒŽ‡…‡ƒ›„‡Š‹‰Š‡”ƒ•ƒ›

™‘‡†‘‘–•‡‡ƒ†˜‹…‡ˆ‘”–Š‹•…‘’Žƒ‹–Ǥ^ʹ͵

Quality of life

•Šƒ˜‡ƒŒ‘”…‘•‡“—‡…‡•‘“—ƒŽ‹–›‘ˆŽ‹ˆ‡ȋ‘Ȍ™‹–Š‹’ƒ…–‘†ƒ‹Ž›…Š‘”‡•ǡ

•‡š—ƒŽˆ—…–‹‘ƒ†’Š›•‹…ƒŽƒ…–‹˜‹–›Ǥ^{ͳͶǡʹͻǡ͵Ͳ}ƒ‹ƒ†•‡š—ƒŽ†›•ˆ—…–‹‘Šƒ’‡”•

’Š›•‹…ƒŽ™‡ŽŽǦ„‡‹‰Ǥ^ʹ͵‘‡™‹–Š‘”ƒ›™‘””›ƒ„‘—–ƒ……‹†‡–ƒŽ•‘‹Ž‹‰ƒ†ƒ”‡

…‘•–ƒ–Ž›…‘…‡”‡†ƒ„‘—––‘‹Ž‡–ƒ……‡••Ǥ^ʹͺŠ‹•…—”„•–”ƒ˜‡ŽǡŠ‘„„‹‡•ƒ†‘—–†‘‘”

ƒ…–‹˜‹–‹‡•ǤŠ‡†‹ˆˆ‡”‡– •‹ˆŽ—‡…‡‡ƒ…Š‘–Š‡”Ǣ‹…‘–‹‡…‡ƒ›ƒŽ•‘Ž‡ƒ†–‘‘–Š‡”

•Ž‹‡•‡š—ƒŽ†›•ˆ—…–‹‘Ǥ^ʹͺ•›…Š‘Ž‘‰‹…ƒŽ’”‘„Ž‡•†—‡–‘ƒš‹‡–›ǡ’ƒ‹‘”ˆ‡‡Ž‹‰‘ˆ

—ƒ––”ƒ…–‹˜‡‡••ƒ†„‘†›‹ƒ‰‡‹••—‡•†‡ƒ†‹…”‡ƒ•‡†Š‡ƒŽ–Š”‡•‘—”…‡•Ǥ^ʹͺ…”‡ƒ•‡†

’‡”•‘ƒŽ‡š’‡•‡•†—‡–‘Žƒ—†”›ƒ†‡™…Ž‘–Š‡•Ž‹‹–•‡…‘‘‹…ˆ”‡‡†‘‹ƒˆˆ‡…–‡†

‹†‹˜‹†—ƒŽ•Ǥƒ††‹–‹‘ǡ–Š‡—•‡‘ˆŠ‡ƒŽ–Š…ƒ”‡ƒ†•—”‰‹…ƒŽ‹–‡”˜‡–‹‘•Šƒ˜‡ƒŒ‘”

‡…‘‘‹……‘•‡“—‡…‡•ˆ‘”–Š‡•‘…‹‡–›ǤŽ–Š‘—‰Š›‘—‰‡”ƒ†‹††Ž‡Ǧƒ‰‡†™‘‡

•‡‡–‘…‘•–‹–—–‡–Š‡„—Ž‘ˆ™‘‡ƒ……‡••‹‰‡†‹…ƒŽŠ‡Ž’ǡ–Š‹•—„‡”‹••–‹’—Žƒ–‡†

–‘‹…”‡ƒ•‡‹–Š‡…‘‹‰†‡…ƒ†‡•Ǥ^ʹʹ ‹‰—”‡͸•Š‘™•–Š‡—„‡”‘ˆ™‘‡•‡‡‹‰Š‡Ž’

ƒ……‘”†‹‰–‘ƒ‰‡Ǧ‰”‘—’•Ǥ^ʹʹ

0 50 100 150 200 250 300 350 400 450

30-39 40-49 50-59 60-69 70-79 80-89

Number of consults in 2010 Predicted number of consults in 2030 Figure 6 Annual number of women (per 1000) seeking medical care due to pelvic floor

dysfunction according to age in United States and predicted number in 2030. Adapted from Kirby AC et al. An update on the current and future demand for care of pelvic floor disorders in the United States. Am J Obstet Gynecol.2013. By S. Mathew

2.3.2 Risk factors for pelvic floor disorders

Š‡‡–‹‘Ž‘‰›†‡’‡†•‘ƒ‹–‡”ƒ…–‹‘„‡–™‡‡•‡˜‡”ƒŽˆƒ…–‘”•–Šƒ–Ž‡ƒ†–‘ƒŽ‘••‘ˆ

•—’’‘”–ˆ‘”’‡Ž˜‹…‘”‰ƒ•ƒ†•’Š‹…–‡”†›•ˆ—…–‹‘Ǥ‡”–ƒ‹”‹•ˆƒ…–‘”•ƒ”‡•‹‰‹ˆ‹…ƒ–

‹†‹ˆˆ‡”‡–’Šƒ•‡•‘ˆŽ‹ˆ‡ ƒ••—ƒ”‹œ‡†‹ ‹‰—”‡͹Ǥ^{ͳ͵ǡ͵ͳǡ͵ʹ}

†‹•…—••‹‘‘ˆƒŽŽ–Š‡…‘’‘‡–•‘ˆ •‹•„‡›‘†–Š‡•…‘’‡‘ˆ–Š‹•–Š‡•‹•Ǥ ‘”–Š‡

’—”’‘•‡‘ˆ–Š‹•™‘”ǡ™‹ŽŽˆ—”–Š‡”ƒ††”‡••”‹•ˆƒ…–‘”•ǡ†‹ƒ‰‘•‹•ƒ†ƒƒ‰‡‡–‘ˆ

ǡƒ†Ǥ

Figure 7 Risk factors summarized into five categories divided into three phases of life. Illustration by S. Mathew adapted from Bump and DeLancey.

Pregnancy and parturition

”‡‰ƒ…›‹†—…‡•Š‘”‘ƒŽƒ†‡…Šƒ‹…ƒŽ…Šƒ‰‡•‘–Š‡’‡Ž˜‹…ˆŽ‘‘”ǡ„—––Š‡ƒ‹

”‹•…‘‡•ˆ”‘–Š‡‘†‡‘ˆ†‡Ž‹˜‡”›Ǥ^ͳͻŠ‡•–”‡–…Š‡•–‘ͳǤͷǦ͵–‹‡•‹–••‹œ‡†—”‹‰

†‡Ž‹˜‡”›ƒ†•–”‹ƒ–‡†—•…Ž‡•ƒ”‡’”‘‡–‘‹Œ—”›™Š‡ˆ‘”…‹„Ž›•–”‡–…Š‡†ƒ•‹ƒ

‘’‡”ƒ–‹˜‡˜ƒ‰‹ƒŽ†‡Ž‹˜‡”›Ǥ^͵͵‹”–Š™‡‹‰Š–ǡƒƒŽ•’Š‹…–‡”‹Œ—”›ƒ†‹…”‡ƒ•‡††—”ƒ–‹‘

‘ˆ•‡…‘†•–ƒ‰‡‘ˆŽƒ„‘”ƒ”‡ƒŽ•‘”‹•ˆƒ…–‘”•ˆ‘”‹Œ—”›Ǥ^ͳͻǡ͵ͶŠ‡‡…Šƒ‹•‘ˆ‹Œ—”›

‹•‡‹–Š‡”‘˜‡”•–”‡–…Š‹‰…ƒ—•‹‰ƒ’‡”ƒ‡–‹…”‡ƒ•‡‹Š‹ƒ–ƒŽƒ”‡ƒȋ‹…”‘–”ƒ—ƒȌ‘”ƒ

—‹Ǧ‘”„‹Žƒ–‡”ƒŽ”—’–—”‡‘ˆ–Š‡ˆ”‘‹–•‹•‡”–‹‘’‘‹–•ȋƒ…”‘–”ƒ—ƒȌǤ^͵Ͷ

˜ƒ‰‹ƒŽŽ›’ƒ”‘—•™‘‡–Š‡’”‡˜ƒŽ‡…‡‘ˆ–”ƒ—ƒ˜ƒ”‹‡•ˆ”‘ͳ͵Ǧ͵͸Ψƒ†ƒŽ‘•–

‘‡–Š‹”†Šƒ˜‡‘˜‡”†‹•–‡•‹‘‘ˆ–Š‡Ž‡˜ƒ–‘”Š‹ƒ–—•ǡ†‡–‡…–ƒ„Ž‡ƒˆ–‡”†‡Ž‹˜‡”›^͵ͷǦ͵ͺ›

‹Œ—”›–‘–Š‡—•…—Ž‘ˆƒ•…‹ƒŽ’‡Ž˜‹…ˆŽ‘‘”™‹ŽŽŽ‡ƒ†–‘”‡†—…‡†•—’’‘”––‘–Š‡’‡Ž˜‹…‘”‰ƒ•

™‹–Š•—„•‡“—‡–”‹•ˆ‘”’”‘Žƒ’•‡Ǥ^{ͳͳǡͳͻǡ͵ͳ}‹Œ—”›‹•ƒ”‹•ˆƒ…–‘”ˆ‘”ƒ–‡”‹‘”ƒ†‹†Ǧ …‘’ƒ”–‡–ǡ„—––Š‡”‡‹•Ž‡••…‘…Ž—•‹˜‡‡˜‹†‡…‡‘–Š‡ƒ••‘…‹ƒ–‹‘„‡–™‡‡

‹Œ—”‹‡•ƒ†’‘•–‡”‹‘”…‘’ƒ”–‡–ǡƒ†Ǥ^{ͳͳǡ͵ͻǦͶͳ}

„•–‡–”‹…ƒƒŽ•’Š‹…–‡”‹Œ—”›ȋȌ•Šƒ”‡••‘‡…‘‘”‹•ˆƒ…–‘”•™‹–Š‹Œ—”›

†—‡–‘–Š‡•‹‹Žƒ”…ƒ—•ƒ–‹˜‡‡…Šƒ‹••Ǥ^ͳͻǡͶʹŠ‡”‹•ˆ‘”•’Š‹…–‡”‹Œ—”›‹•Š‹‰Š‡•–ˆ‘”

—ŽŽ‹’ƒ”ƒƒ†’”‡˜ƒŽ‡…‡‘ˆ˜ƒ”‹‡•ˆ”‘ͶǦʹͷΨ†‡’‡†‹‰—’‘–Š‡†‹ƒ‰‘•–‹…

‡–Š‘†—•‡†Ǥ^Ͷ͵ǦͶͷŽ–”ƒ•‘—††‹ƒ‰‘•‡†”‡•‹†—ƒŽ†‡ˆ‡…–•™‡”‡’”‡•‡–‹ͶͲǦͺͷΨƒˆ–‡”

’”‹ƒ”›”‡’ƒ‹”‘ˆǤ^Ͷ͸•–—†›„›ƒ—†™‡ŽŽǦƒŽŽ•Š‘™‡†–Šƒ–‘Ž›ƒ–Š‹”†‘ˆ

—ŽŽ‹’ƒ”‘—•™‘‡”‡ƒŽŽ›Šƒ˜‡ƒ‘”ƒŽ˜ƒ‰‹ƒŽ†‡Ž‹˜‡”›™‹–Š‘—–•—•–ƒ‹‹‰‡‹–Š‡”

‘”•’Š‹…–‡”‹Œ—”‹‡•Ǥ^Ͷͷ™‘‡™‹–Šǡ…‘…‘‹–ƒ–‹Œ—”›™ƒ•ˆ‘—†‹

ƒŽ‘•–ƒ–Š‹”†Ǥ^Ͷʹ–‡”‡•–‹‰Ž›ǡ•—„•‡“—‡–’”‡‰ƒ…‹‡•ƒ††‡Ž‹˜‡”‹‡•†‘‘–•‡‡–‘

…‘–”‹„—–‡—…Š–‘™ƒ”†•‘”•’Š‹…–‡”‹Œ—”›Ǥ^{Ͷ͵ǡͶ͹ǡͶͺ}ˆ–‡”’”‹ƒ”›”‡’ƒ‹”‘ˆǡ Ͷ͵Ψ†‡˜‡Ž‘’‹–Š‡‹‡†‹ƒ–‡’‘•–’ƒ”–—’‡”‹‘†ǤŽ–Š‘—‰Š‘•–•›’–‘•”‡•‘Ž˜‡

‘˜‡”–‹‡ǡͳͳΨ†‡˜‡Ž‘’…Š”‘‹…•›’–‘•ƒ†ƒŒ‘”†‡ˆ‡…–•ƒ›„‡’”‡†‹…–‹˜‡‘ˆ

’‡”•‹•–‡–„‘–Š‡”Ǥ^Ͷͻ

””‡˜‡”•‹„Ž‡’—†‡†ƒŽ‡”˜‡†ƒƒ‰‡†—‡–‘ƒŽ‘•–͵ͷΨ‘˜‡”•–”‡–…Š‹‰Ž‡ƒ†•–‘Ž‘••‘ˆ

…‘–”ƒ…–‹Ž‹–›ƒ†•–”‡‰–Šǡƒ††‹‰–‘–Š‡†‡…‘’‡•ƒ–‹‰ˆƒ…–‘”ˆ‘” •Ǥ^ͷͲ

•–—†›•Š‘™‡†’ƒ”–‹ƒŽ†‡‡”˜ƒ–‹‘ƒ†–‡”‹ƒŽ‘–‘”‡—”‘Žƒ–‡…›‹ˆ‘—”‘ˆˆ‹˜‡

˜ƒ‰‹ƒŽŽ›’ƒ”‘—•™‘‡ƒ†ƒ•—„‘’–‹ƒŽ”‡…‘˜‡”›’‘•–’ƒ”–—Ǥ^ͷͳ

Other risk factors

‰‡Ǧ”‡Žƒ–‡††‡–‡”‹‘”ƒ–‹‘‘ˆ•–”‹ƒ–‡†—•…Ž‡ƒ†‡—”‘Ž‘‰‹…ƒŽ‹Œ—”›ƒˆˆ‡…–•’Š‹…–‡”

…Ž‘•—”‡’”‡••—”‡ƒ†–Š‡Ǥ^ͷʹ‡…—””‡–—”‹ƒ”›‹ˆ‡…–‹‘•ǡ‹…‘””‡…–„Žƒ††‡”

‡’–›‹‰Šƒ„‹–•ǡ†‹‡–ƒ†™ƒ–‡”‹–ƒ‡‹ˆŽ—‡…‡†‡˜‡Ž‘’‡–‘ˆǤ^͹„‡•‹–›‹•

ƒ••‘…‹ƒ–‡†™‹–Š„‘–Š‹…”‡ƒ•‡†’”‡˜ƒŽ‡…‡ƒ†•‡˜‡”‹–›‘ˆƒŽŽ •ǡ‡•’‡…‹ƒŽŽ›

‹…‘–‹‡…‡ƒ†”‡Žƒ–‡†‘ǡ™‹–Šƒ”‡†‹’”‘˜‡‡–ƒˆ–‡”™‡‹‰Š–Ž‘••Ǥ^ͷ͵ǡͷͶǤ

‘…‹‘‡…‘‘‹…ˆƒ…–‘”•ƒ†•‘‹‰’Žƒ›ƒ”‘Ž‡‹‹…‘–‹‡…‡Ǥ^ͷͷǡͷ͸‹•…‘‘‹

™‘‡™‹–Š…Š”‘‹……‘†‹–‹‘•™Š‡”‡–Š‡‹–”ƒƒ„†‘‹ƒŽ’”‡••—”‡‹•…‘•–ƒ–Ž›

Š‹‰ŠǤ^ͳͶǡͷ͸—–‘‹—‡„‘™‡Ž†‹•‡ƒ•‡ǡ…Š”‘‹…‘„•–‹’ƒ–‹‘ƒ††‹ƒ””Š‡ƒƒ›’”‘’–Ǥ

ͷ͹Ž…‡”ƒ–‹˜‡†‹•‡ƒ•‡•‘ˆ–Š‡…‘Ž‘ƒˆˆ‡…–…‘–‹‡…‡„‘–Š†—‡–‘–Š‡—…‘—•†‹ƒ””Š‡ƒ

ƒ••‘…‹ƒ–‡†™‹–Š–Š‡ƒ—–‘‹—‡†‹•‡ƒ•‡ƒ†•—”‰‹…ƒŽ’”‘…‡†—”‡•ˆ‘”ˆ‹•–—Žƒ–Šƒ–ƒ›

‹ˆŽ—‡…‡•’Š‹…–‡”ˆ—…–‹‘Ǥ•—”‰‡”›‹–•‡Žˆ…ƒŽ‡ƒ†–‘”‡…—””‡…‡‘”ˆƒ‹Ž‡†

’‘•–‘’‡”ƒ–‹˜‡”‡•—Ž–•ǡƒ†–Š‘•‡™‹–ŠƒŠ‹‰Š‡”’”‡‘’‡”ƒ–‹˜‡•–ƒ‰‡‘ˆ’”‘Žƒ’•‡Šƒ˜‡–Š‡

Š‹‰Š‡•–”‹•Ǥ^ͷͺ

2.4 Examination and diagnosis of pelvic floor anatomy, function and symptoms

2.4.1 Assessment of symptoms

†‡–ƒ‹Ž‡†Š‹•–‘”›‹•’ƒ”ƒ‘—–ƒ•‹–†‡–‡”‹‡•ˆ—”–Š‡”‹˜‡•–‹‰ƒ–‹‘ƒ†–”‡ƒ–‡–

‘’–‹‘•Ǥƒ–‹‡–”‡’‘”–‡†•›’–‘•—•‹‰˜ƒŽ‹†ƒ–‡†“—‡•–‹‘ƒ‹”‡•ƒ”‡™‹†‡Ž›—•‡†‹

”‡•‡ƒ”…Š•‡––‹‰•ƒ††‡‘•–”ƒ–‡‰‘‘†…‘””‡Žƒ–‹‘™‹–Š‘„Œ‡…–‹˜‡…Ž‹‹…ƒŽˆ‹†‹‰•Ǥ^ͷͻǦ͸ͳ

‹•—ƒŽƒƒŽ‘‰—‡•…ƒŽ‡•ȋȌƒ”‡ˆ”‡“—‡–Ž›‹’Ž‡‡–‡†‹„—•›…Ž‹‹…ƒŽ•‡––‹‰•ˆ‘”

“—‹…‡˜ƒŽ—ƒ–‹‘‘ˆƒ›…‘†‹–‹‘•Ǥƒ–‹‡–”‡’‘”–‡†ˆ‘”“—ƒ–‹ˆ‹…ƒ–‹‘‘ˆ •‹•

•Š‘™–‘„‡˜ƒŽ‹†ƒ†”‡’‡ƒ–ƒ„Ž‡‹—”‘‰›‡…‘Ž‘‰‹…ƒŽ’‘’—Žƒ–‹‘•Ǥ^͸ʹ‘‘Ž›—•‡†

˜ƒŽ‹†ƒ–‡†“—‡•–‹‘ƒ‹”‡•ˆ‘”‰”ƒ†‹‰•›’–‘•‘ˆ •‹…Ž—†‡ǣ

x Š‡‡Ž˜‹… Ž‘‘”‹•–”‡••˜‡–‘”›ȋ ǦʹͲȌƒ†‹–••—„•…ƒŽ‡•‡šƒ‹‡ƒ›

„‘–Š‡””‡Žƒ–‡†–‘ǡ—”‹ƒ”›ƒ†…‘Ž‘”‡…–ƒŽǦƒƒŽ–”ƒ…–ǡ‹…Ž—†‹‰Ž‡ƒƒ‰‡ƒ†

’ƒ‹Ǥ ǦʹͲ•…‘”‡‹•ƒ…‘’‘•‹–‡•…‘”‡ȋ”ƒ‰‡ͲǦ͵ͲͲȌ‘ˆ‹–•–Š”‡‡•—„•…ƒŽ‡•Ǥ

ƒ…Š•—„•…ƒŽ‡•…‘”‡•”ƒ‰‡ˆ”‘ͲǦͳͲͲǤ

o ‡Ž˜‹…”‰ƒ”‘Žƒ’•‡‹•–”‡••˜‡–‘”›ȋǦ͸Ȍ o ”‹ƒ”›‹•–”‡••˜‡–‘”›ȋǦ͸Ȍ

o ‘Ž‘”‡…–ƒŽǦƒŽ‹•–”‡••˜‡–‘”›ȋǦͺȌ

x ‡Ž˜‹… Ž‘‘”’ƒ…–—‡•–‹‘ƒ‹”‡ȋ Ǧ͹Ȍƒ†‹–••—„•…ƒŽ‡•ƒ••‡••–Š‡‘

”‡Žƒ–‡†–‘ǡ„‘™‡Ž‘”—”‹ƒ”›•›’–‘•Ǥƒ…Š•—„•…ƒŽ‡’‘•‡•͹“—‡•–‹‘•

ˆ”‘†ƒ‹Ž›Ž‹ˆ‡ǡ’•›…Š‘Ž‘‰‹…ƒŽ‡ˆˆ‡…–•ǡ•‘…‹ƒŽƒ†’Š›•‹…ƒŽƒ…–‹˜‹–›–‘•…‘”‡‘

”‡Žƒ–‡†–‘†‹•–”‡••†—‡–‘ǡ—”‹ƒ”›‘”‰ƒ•–”‘‹–‡•–‹ƒŽ–”ƒ…–Ǥ o ‡Ž˜‹…”‰ƒ”‘Žƒ’•‡’ƒ…–—‡•–‹‘ƒ‹”‡ȋȌ o ”‹ƒ”›’ƒ…–—‡•–‹‘ƒ‹”‡ȋȌ

o ‘Ž‘”‡…–ƒŽǦƒƒŽ’ƒ…–—‡•–‹‘ƒ‹”‡ȋȌȌ

‹‰Š‡”•…‘”‡•‡“—ƒ–‡–‘‘”‡„‘–Š‡”‘”™‘”•‡‘Ǥ‘–Š–Š‡ ǦʹͲƒ† Ǧ͹™‹–Š

–Š‡‹”•—„•…ƒŽ‡••Š‘™ƒ„‹Ž‹–›–‘ƒ••‡••…Šƒ‰‡•‹ •›’–‘•ƒˆ–‡”–”‡ƒ–‡–ƒ†ƒ”‡

—•‡ˆ—Ž‹‡˜ƒŽ—ƒ–‹‰…Ž‹‹…ƒŽŽ›•‹‰‹ˆ‹…ƒ–…Šƒ‰‡•Ǥ^ͷͻ

Š‡–‡”ƒ–‹‘ƒŽ‘•—Ž–ƒ–‹‘‘ˆ…‘–‹‡…‡—‡•–‹‘ƒ‹”‡‘ƒ‰‹ƒŽ›’–‘•

ȋǦȌ‡˜ƒŽ—ƒ–‡•ƒ†•‡š—ƒŽ†›•ˆ—…–‹‘™Š‹Ž‡–Š‡Ǧƒ†Ǧ‘™‡Ž

‡šƒ‹‡••›’–‘•ƒ†‘”‡Žƒ–‡†–‘ƒ†„‘™‡Ž•›’–‘•Ǥ^͸͵Ǧ͸ͷ

ƒ†˜‹•‡˜‡”‹–›‹†‡š‹•—•‡†–‘“—ƒ–‹ˆ›Ǥ^͸ͳ‘”™ƒ›ǡ–Š‡˜ƒŽ‹†ƒ–‡†‘”™‡‰‹ƒ

‡ƒŽ‡…‘–‹‡…‡‡‰‹•–”›ȋȌ‹•™‹†‡Ž›—•‡†‹…Ž‹‹…•–‘”‡’‘”–’”‡Ǧƒ†

’‘•–‘’‡”ƒ–‹˜‡•›’–‘•ƒ†‘Ǥ^͸͸–ƒŽ•‘…‘’”‹•‡•‘ˆƒ•‡…–‹‘–‘”‡…‘”†‘„Œ‡…–‹˜‡

ˆ‹†‹‰•‘ˆ–Š‡•–”‡••–‡•–ǡ’ƒ–‹‡–Š‹•–‘”›ƒ††‡–ƒ‹Ž•‘ˆ•—”‰‹…ƒŽ’”‘…‡†—”‡•Ǥ

–Ǥƒ”•ǡ‡š‡”ǡ‡”‹…ƒ‡†‹…ƒŽ›•–‡•ƒ†‡•…ƒ–‘”‹•…‘”‡•ƒ”‡•Š‘”–ƒ†

”‡Ž‹ƒ„Ž‡–‘‘Ž•–‘‰”ƒ†‡„‘–Š‡”Ǥ^͸Ͳ

2.4.2 Prolapse quantification

Š‡–‡”ƒ–‹‘ƒŽ‘–‹‡…‡‘…‹‡–›ȋȌ”‡…‘‡†•ƒ•–ƒ†ƒ”†‹œƒ–‹‘‘ˆ–Š‡‰”ƒ†‡

‘ˆ’‡Ž˜‹…‘”‰ƒ’”‘Žƒ’•‡—•‹‰–Š‡‡Ž˜‹…”‰ƒ”‘Žƒ’•‡—ƒ–‹ˆ‹…ƒ–‹‘•…‘”‡ȋǦȌǤ^ʹͶ

Š‡‰‡‹–ƒŽŠ‹ƒ–—•ǡ’‡”‹‡ƒŽ„‘†›ƒ†–Š‡†‹•–ƒ…‡ȋ‹…•Ȍˆ”‘–Š‡Š›‡–‘ˆ‹š‡†

’‘‹–•‹–Š‡˜ƒ‰‹ƒŽ™ƒŽŽǡ…‡”˜‹šƒ”‡‡ƒ•—”‡†—†‡”ƒŽ•ƒŽ˜ƒǤŠ‡–‘–ƒŽ˜ƒ‰‹ƒŽŽ‡‰–Š‹•

“—ƒ–‹ˆ‹‡†ƒ–”‡•–Ǥ‡ƒ•—”‹‰’‘‹–•–Šƒ–ƒ”‡’Žƒ…‡†’”‘š‹ƒŽ–‘–Š‡Š›‡Šƒ˜‡‡‰ƒ–‹˜‡

˜ƒŽ—‡•ƒ†–Š‘•‡†‹•–ƒŽ–‘–Š‡Š›‡Šƒ˜‡’‘•‹–‹˜‡˜ƒŽ—‡•ȋ ‹‰—”‡ͺȌǤ^ʹͶ

ƒ•‡†‘–Š‡‡ƒ•—”‡‡–•‹•†‹˜‹†‡†‹–‘–Š‡ˆ‘ŽŽ‘™‹‰•–ƒ‰‡•ǣ

–ƒ‰‡Ͳǣ‘’”‘Žƒ’•‡‹••‡‡Ǥ‘‹–•ƒ”‡ƒ„‘˜‡Ȃ͵…ǡ™‹–Š‡‹–Š‡”’‘‹–•ƒ†„‡–™‡‡

ƒ†Ǧʹ…

–ƒ‰‡ͳǣ›’‘‹–‹•εͳ…’”‘š‹ƒŽ–‘–Š‡Š›‡

–ƒ‰‡ʹǣ›’‘‹–‹•ƒ–‘”ΪȀǦͳ…’”‘š‹ƒŽ‘”†‹•–ƒŽ–‘–Š‡Š›‡

–ƒ‰‡͵ǣ›’‘‹–’”‘–”—†‹‰εͳ…†‹•–ƒŽ–‘–Š‡Š›‡

–ƒ‰‡Ͷǣ‘’Ž‡–‡‡˜‡”•‹‘‘ˆ–Š‡–‘–ƒŽŽ‡‰–Š‘ˆ–Š‡Ž‘™‡”‰‡‹–ƒŽ–”ƒ…–Ǥ

Figure 8 Pelvic Organ Prolapse Quantification (POP-Q) System is recommended to grade POP in women. Six vaginal sites (Aa, Ba, Ap, Bp, C and D), genital hiatus (gh), perineal body (pb) and total vagina length (tvl) utilized for quantification with the 3x3 grid. From Bump RC et al. The

standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175, with permission from Elsevier.

2.4.3 Muscle integrity and strength

—•…Ž‡‹–‡‰”‹–›ƒ†•–”‡‰–Š‹•†‡–‡”‹‡†„›•‡˜‡”ƒŽ†‹”‡…–ƒ†‹†‹”‡…–‡–Š‘†•

ƒŽ–Š‘—‰Š–Š‡”‡‹•‘‰‘Ž†•–ƒ†ƒ”†Ǥ Palpation

ƒŽ’ƒ–‹‘‹•™‹†‡Ž›—•‡††—”‹‰–Š‡‰›‡…‘Ž‘‰‹…‡šƒ–‘ƒ••‡••”‡•–‹‰–‘‡ǡ …‘–”ƒ…–‹Ž‹–›ǡ’ƒ‹ƒ†—•…Ž‡‹–‡‰”‹–›Ǥ†‹‰‹–ƒŽ‡šƒ‹•’‡”ˆ‘”‡†™‹–Šʹˆ‹‰‡”•

‹•‡”–‡†͵ǦͶ…‹–‘–Š‡˜ƒ‰‹ƒǡƒ––Š‡Ž‡˜‡Ž‘ˆ–Š‡ǤŠ‡”‡•–‹‰–‘‡ƒ†—•…—Žƒ”

’ƒ‹‹•‰”ƒ†‡†—•‹‰ƒ͸Ǧ’‘‹–•…ƒŽ‡Ǥ^͸͹›…‘’Ž‡–‡‘”’ƒ”–‹ƒŽ—•…Ž‡–‡ƒ”•ƒ”‡–Š‡

‹†‡–‹ˆ‹‡†Ǥ‘†‹ˆ‹‡†šˆ‘”†…ƒŽ‡ȋȌǡ”‹•…ƒŽ‡ƒ†–Š‡ •…Š‡‡ƒ”‡

˜ƒ”‹‘—•ƒ••‡••‡––‘‘Ž•—•‡†ˆ‘”‡˜ƒŽ—ƒ–‹‘’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡ˆ—…–‹‘ƒ†•–”‡‰–ŠǤ^͸ͺ Perineometry

˜ƒ‰‹ƒŽƒ‘‡–‡”‹•ƒ’”‡••—”‡•‡•‹–‹˜‡‹–”ƒ˜ƒ‰‹ƒŽ„ƒŽŽ‘‘‹•‡”–‡†‹–‘–Š‡

˜ƒ‰‹ƒƒ––Š‡Ž‡˜‡Ž‘ˆ–Š‡ǤŠ‡Š‹‰Š‡•–•“—‡‡œ‡’”‡••—”‡‹•‡ƒ•—”‡†‹ʹǡƒ•ƒ

†‹”‡…–‡ƒ•—”‡‡–‘ˆ…‘–”ƒ…–‹‘ƒ†—•…Ž‡•–ƒ‹ƒǤ^͸ͻ Electromyography (EMG)

Ž‡…–”‹…ƒŽƒ…–‹˜‹–›‹–Š‡’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡•‹•—•‡†ƒ•ƒ‹†‹”‡…–‡ƒ•—”‡‘ˆ

…‘–”ƒ…–‹Ž‹–›Ǥ˜ƒ‰‹ƒŽ•‡•‘”‹•’Žƒ…‡†ƒ––Š‡’Žƒ‡‘ˆ–Š‡ƒ††‡–‡…–•–Š‡‡Ž‡…–”‹…

’‘–‡–‹ƒŽ‰‡‡”ƒ–‡†„›–Š‡—•…Ž‡…‘–”ƒ…–‹‘Ǥ^͹Ͳ

2.4.4 Urodynamic testing

—…–‹‘‘ˆ–Š‡Ž‘™‡”—”‹ƒ”›–”ƒ…–‹•‡˜ƒŽ—ƒ–‡†„›†‹ˆˆ‡”‡–‹˜ƒ•‹˜‡ƒ†‘Ǧ‹˜ƒ•‹˜‡

–‡•–•‹Ž‹‡™‹–Š”‡…‘‡†ƒ–‹‘•ˆ”‘–Š‡Ǥ^͹ͳŠ‡•‡ƒ›‹…Ž—†‡ƒ„‘–Š‡”•…‘”‡ǡ …Ž‹‹…ƒŽ‡šƒ‹ƒ–‹‘ǡ˜‘‹†‹‰†‹ƒ”›ǡ—”‘ˆŽ‘™‡–”›ǡ…›•–‘‡–”›ƒ†‡ƒ•—”‡‡–‘ˆ

”‡•‹†—ƒŽ—”‹‡Ǥ^͹ʹ”‘†›ƒ‹…–‡•–‹‰†‡Ž‹˜‡”•ƒ•›•–‡ƒ–‹…ƒ’’”‘ƒ…Š–Šƒ–”‡’”‘†—…‡–Š‡

„‘–Š‡”ǡ’”‘˜‹†‹‰„‡––‡”—†‡”•–ƒ†‹‰‘ˆ–Š‡•’‡…‹ˆ‹…’”‘„Ž‡ƒ†ƒ’’”‘’”‹ƒ–‡

‡ƒ•—”‡•–‘„‡…‘•‹†‡”‡†Ǥ^͹ʹ

2.4.5 Ultrasound diagnosis

Ž–”ƒ•‘—†ƒƒŽ›•‹•‘ˆ’‡Ž˜‹…ˆŽ‘‘”ƒƒ–‘›‹•ƒ‘Ǧ‹˜ƒ•‹˜‡ǡ™‡ŽŽǦ–‘Ž‡”ƒ–‡†–‡…Š‹“—‡

–Šƒ–’”‘˜‹†‡•„‘–Š‘„Œ‡…–‹˜‡‡ƒ•—”‡‡–•ƒ††›ƒ‹…‹–‡”ƒ…–‹‘„‡–™‡‡–Š‡

•–”—…–—”‡•‘ˆ–Š‡’‡Ž˜‹…ˆŽ‘‘”Ǥ^͹͵ǡ͹Ͷ Levator ani muscle

Ž–”ƒ•‘—†‹•ƒ”‡Ž‹ƒ„Ž‡ƒ†”‡’”‘†—…‹„Ž‡‡–Š‘†ˆ‘”ƒ••‡••‡–‘ˆ’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡

ƒƒ–‘›ƒ†•–”‡‰–Š‡šŠ‹„‹–‹‰‘†‡”ƒ–‡…‘””‡Žƒ–‹‘–‘‘–Š‡”–‡…Š‹“—‡•Ǥ^͹ͷǦ͹͹

††‹–‹‘ƒŽƒ†˜ƒ–ƒ‰‡•‹•–Šƒ––Š‡†›ƒ‹…˜‹•—ƒŽ‹œƒ–‹‘’”‘˜‹†‡•„‹‘ˆ‡‡†„ƒ…™Š‡

‹•–”—…–‹‰™‘‡‹…‘””‡…–’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡…‘–”ƒ…–‹‘ƒ†ƒ“—‹…‘˜‡”˜‹‡™‘ˆ–Š‡

’‡Ž˜‹…‘”‰ƒ•Ǥ^͹ͺ

…—”˜‡†ƒ””ƒ›–”ƒ•†—…‡”…‘˜‡”‡†™‹–Š—Ž–”ƒ•‘—†‰‡Ž‹•‹•‡”–‡†‹–‘ƒ‰Ž‘˜‡ǤŠ‡

’”‘„‡‹•’Žƒ…‡†‹–Š‡•ƒ‰‹––ƒŽ’Žƒ‡‘–Š‡’‡”‹‡—‘”„‡–™‡‡–Š‡Žƒ„‹ƒƒŒ‘”‡•™‹–Š

–Š‡’ƒ–‹‡–‹–Š‡†‘”•ƒŽŽ‹–Š‘–‘›’‘•‹–‹‘Ǥ’–›„‘™‡Žƒ†„Žƒ††‡”‹•’”‡ˆ‡””‡†ˆ‘”

‘’–‹ƒŽ‹ƒ‰‹‰Ǥ™‹†‡ƒ…“—‹•‹–‹‘ƒ‰Ž‡ȋ‘˜‡”͹Ͳ†‡‰”‡‡•ǡ’”‡ˆ‡”ƒ„Ž›ͺͷǦͻͲ†‡‰”‡‡•Ȍ

‡ƒ„Ž‡•ˆ—ŽŽ˜‹•—ƒŽ‹œƒ–‹‘”‡“—‹”‡†ˆ‘”ƒƒŽ›•‹•Ǥ^͹͵ǡ͹Ͷ

™‘†‹‡•‹‘ƒŽȋʹȌ‹ƒ‰‡•†‡’‹…––Š‡’‡Ž˜‹…ˆŽ‘‘”ƒƒ–‘›‹–Š‡‹†Ǧ•ƒ‰‹––ƒŽ’Žƒ‡

†—”‹‰”‡•–ǡ’‡Ž˜‹…ˆŽ‘‘”—•…Ž‡…‘–”ƒ…–‹‘‘”ƒŽ•ƒŽ˜ƒǡ•Š‘™‹‰ƒ›†‹•’Žƒ…‡‡–‘ˆ

•–”—…–—”‡•Ǥ ‹‰—”‡ͻ•Š‘™•ƒ•…Š‡ƒ–‹…ˆ‹‰—”‡‘ˆ–Š‡—Ž–”ƒ•‘—†‹ƒ‰‡”‡†‡”‡†‹–Š‡

‹†Ǧ•ƒ‰‹––ƒŽ’Žƒ‡ǤŠ‡͵ȀͶ‹ƒ‰‹‰‹•—•‡†ˆ‘”–Š‡˜‹•—ƒŽ‹œƒ–‹‘‘ˆ–Š‡’‡Ž˜‹…ˆŽ‘‘”‹

†‹ˆˆ‡”‡–ƒƒ–‘‹…ƒŽ’Žƒ‡•ǡ‡˜ƒŽ—ƒ–‹‰…Šƒ‰‡‹”‡ƒŽǦ–‹‡ǤŠ‡”‡…‘”†‹‰‘ˆ†›ƒ‹…

…‘–”ƒ…–‹‘‘”ƒŽ•ƒŽ˜ƒƒ‡—˜‡”•ƒ‹†‹‡˜ƒŽ—ƒ–‹‰ˆ—…–‹‘ƒŽƒƒ–‘›—•‹‰

–‘‘‰”ƒ’Š‹…—Ž–”ƒ•‘—†‹ƒ‰‹‰ȋȌǤ^͹ͺǡ͹ͻ‘‘†‹–”ƒǦƒ†‹–‡””ƒ–‡”…‘””‡Žƒ–‹‘‘ˆ–Š‡

—Ž–”ƒ•‘—†‡ƒ•—”‡‡–•Šƒ•„‡‡†‡‘•–”ƒ–‡†Ǥ^͹ͷǡ͹͹

‡˜ƒ–‘”—•…Ž‡‘”’Š‘Ž‘‰›‹••–—†‹‡†‹–Š‡’Žƒ‡‘ˆ‹‹ƒŽŠ‹ƒ–ƒŽ†‹‡•‹‘•ǡ–Š‡

•Š‘”–‡•–†‹•–ƒ…‡„‡–™‡‡–Š‡’‘•–‡”‹‘”ƒ•’‡…–‘ˆ–Š‡•›’Š›•‹•’—„‹•ƒ†–Š‡ƒ–‡”‹‘”

’‘”–‹‘‘ˆ–Š‡’—„‘”‡…–ƒŽ‹•—•…Ž‡Ǥ^͹ͻǦͺͳ —…–‹‘ƒŽ„‹‘‡–”›‹•‡˜ƒŽ—ƒ–‡†‹†‹ˆˆ‡”‡–

™ƒ›•ȋ ‹‰—”‡ͳͲȌǣ

o —•…Ž‡–Š‹…‡••ƒ†—•…Ž‡ƒ”‡ƒ

o ʹƒ–‡”‘Ǧ’‘•–‡”‹‘”†‹‡•‹‘ƒ–”‡•–ǡ…‘–”ƒ…–‹‘ƒ†ƒŽ•ƒŽ˜ƒ

o ʹ–”ƒ•˜‡”•‡†‹ƒ‡–‡”

o ͵Š‹ƒ–ƒŽƒ”‡ƒƒ–”‡•–ǡ…‘–”ƒ…–‹‘ƒ†ƒŽ•ƒŽ˜ƒ

o ”‘’‘”–‹‘ƒŽ…Šƒ‰‡‹ʹƒ†͵†‹ƒ‡–‡”•ƒ†ƒ”‡ƒ

‘–”ƒ…–‹Ž‹–›‹•—•—ƒŽŽ›‡ƒ•—”‡†ƒ•ƒ’”‘’‘”–‹‘ƒŽ…Šƒ‰‡ƒ•‡ƒ•—”‡‡–•…ƒ

†‹ˆˆ‡”‹˜ƒ”‹‘—•‡–Š‹…‹–‹‡•Ǥ^͵ͷǡ͹͸

Figure 9 A: schematic illustration of 2D transperinal ultrasound in mid-sagittal plane. B: 2D transperineal ultrasound image. S=symphysis pubis, B=bladder, U=uterus, V=Vagina, R=rectum and PR=puborectalis muscle. Illustration by S Mathew.