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Fascial and Muscular Abnormalities in Women with Urethral Hypermobility and Anterior Vaginal Wall Prolapse

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Fascial and Muscular Abnormalities in Women with Urethral Hypermobility and Anterior Vaginal Wall Prolapse Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse John O. L. DeLancey, MD Ann Arbor, Mich OBJECTIVE: Our purpose was to assess the structural integrity of individual elements of the urethral and anterior vaginal wall support system. STUDY DESIGN: Notes were made during retropubic operations for cystourethrocele and stress inconti- nence in 71 women aged 52 ± 12.4 (SD) years. Vaginal support was assessed with the Baden-Walker sys- tem with the following average findings: urethra 1.9 ± 0.6, bladder 1.9 ± 1.0, apex 0.8 ± 1.1, upper posterior wall 0.3 ± 0.8, and rectocele 1.1 ± 0.7. The presence of the following features was noted: paravaginal defect, integrity of the pubic and ischial attachments of the arcus tendineus fascia pelvis (ATFP), appearance of the ATFP on the sidewall, and abnormalities in the pubococcygeal muscle. RESULTS: Paravaginal defects were present in 87.3% on the left and in 88.7% on the right. Detachment of the ATFP from the pubic bone was present in 1.4% (left) and 2.8% (right). The ATFP was detached from the ischial spine in 97.6% (left) and 95.1% (right). Remnants of the ATFP were present on the sidewall in 62% (left) and 63% (right). Of these, 9% extended one fourth the distance to the spine, 21% one half the distance, 3% three fourths the distance, and 17% all the way to the spine. The pubococcygeal muscle was visibly nor- mal in 45% (left) and 39% (right). It showed localized atrophy in 22% (left) and 30% (right) and generalized atrophy in 22.5% (left) 30.0% (right). CONCLUSION: The ATFP usually detaches from the ischial spine, but not from the pubis; slightly less than half of these women have visibly abnormal levator ani muscles. (Am J Obstet Gynecol 2002;187:93-8.) Key words: Urethral hypermobility, vaginal wall prolapse, fascial abnormalities, muscular abnor- malities, paravaginal defect Structural failure of the urethral support system is one of could separate from an intact ATFP. Alternatively, the lev- the important factors involved in the cause of stress urinary ator ani muscles that contract during cough could be incontinence. Richardson et al1 have observed that loss of damaged and their impulse lost. At present, the fre- anterior wall descent occurred because of lateral detach- quency with which any of these defects occurs in women ment rather than midline stretching in women with stress with stress incontinence is not known. incontinence and urethral hypermobility. They observed a The following study was undertaken to determine the paravaginal defect where the edge of the pubocervical fas- occurrence of these anatomic abnormalities visible in cia is displaced medially from the pelvic sidewall. urethral support system anatomy among women with ure- The urethral support system has several compo- thral hypermobility. nents.2,3 Damage to either the connective tissue elements or the muscles of this apparatus could result in increased Material and methods urethral mobility. For example, the arcus tendineus fascia Study population. Between June 1, 1996, and February pelvis (ATFP) could become detached from either the 1, 2001, notes were made during retropubic operations in pubis or the ischial spine and the pubocervical fascia 68 women operated on for cystourethrocele and stress urinary incontinence. In addition, there were 3 women with cystourethrocele in whom paravaginal defect repair From the Department of Obstetrics and Gynecology, University of Michi- was planned in conjunction with abdominal sacral gan Medical Center. Supported by grants No. DK 47516 and DK 51405 from the National colpopexy with urethral hypermobility to support the an- Institutes of Health. terior vaginal wall in women without stress incontinence, Presented at the Twenty-Second Annual Meeting of the American Urogy- making a total study population of 71. Women with prior necologic Society, Chicago, Ill, October 25-28, 2001. Reprint requests: John O. L. DeLancey, MD, Women’s Hospital L4100, surgery that could distort the anatomy in this area and 1500 E Medical Center Dr, Ann Arbor, MI 48109-0276. E-mail: De- women with genitourinary anomalies were excluded. [email protected] Stress incontinence was considered to be present in © 2002, Mosby, Inc. All rights reserved. 0002-9378/2002 $35.00 + 0 6/6/125733 women with a primary complaint of urinary incontinence doi:10.1067/mob.2002.125733 when symptoms were associated with activity that in- 93 94 DeLancey July 2002 Am J Obstet Gynecol Table II. Findings on Baden Walker assessment of vagi- nal support Lower Upper Cx/ Upper Lower Grade anterior anterior apex posterior posterior 002395511 I142415637 II 46 25 5 5 18 III 8 12 7 0 2 IV 0 5 2 2 0 Not recorded 3 3 3 3 3 Total 71 71 71 71 71 Cx, Cervix. Table III. Presence of paravaginal defect Left Right Paravaginal defect No. % No. % Fig 1. Space of Retzius showing the left pelvic sidewall. ATLA, Present 62 87.3 63 88.7 Absent 5 7.0 4 5.6 Arcus tendineus levator ani; CL, Cooper’s ligament; IS, ischial Atypical 2 2.8 2 2.8 spine (not seen directly, put position indicated); PCM, pubococ- Not evaluable 2 2.8 2 2.8 cygeus muscle; PBA, pubic bone attachment of the ATFP; Total 71 100 71 100 PS, pubic symphysis (unusually prominent). © DeLancey. Table I. Patient characteristics and test results Five women had previously had an abdominal hysterec- tomy and 3 had a vaginal hysterectomy (not performed for Straining cotton prolapse). At the time of the study operation, 35 women swab had 42 operations performed in addition to retropubic Age Parity MUCP angle surgery for stress incontinence. These included abdominal Average 52 3 48 67.7 hysterectomy, 19; posterior colporrhaphy, 9; abdominal SD 12.4 1.38 15.8 16.8 sacral colpopexy, 4; vaginal hysterectomy, 3; anterior-poste- Minimum 28 0 21 30 rior colporrhaphy, 3; anal sphincteroplasty, 2; sacrospinous Maximum 78 8 89 100 ligament suspension, 1; and tubal ligation, 1. MUCP, Maximal ureteral closure pressure. Once the space of Retzius was fully opened for par- avaginal defect repair, the status of the fascial and muscu- lar elements of the urethral support system were creases abdominal pressure. Each woman confirmed that observed and noted. the physical finding of stress urinary incontinence Presence or absence of paravaginal defect. For the pur- demonstrated during a full bladder cough test was the poses of this study, we define paravaginal defect as the type of incontinence for which she sought treatment. A medial displacement of the vaginal wall and pubocervical cotton swab test and urethral pressure study with a later- fascia from its normal line of attachment to the pelvic ally oriented 8F dual microtip catheter was obtained. sidewall at the ATFP. The attachment between the pubo- A cystometrogram was also performed. cervical fascia and pelvic wall normally lies along a line Patient characteristics and test results are seen in Table I. from a point 1 cm above the inferior border of the pubic Pelvic support was assessed with the Baden Walker sys- bone to the ischial spine.1 The lateral margin of the pub- tem4 in all patients because the pelvic organ support sys- ocervical fascia was identified by three anatomic land- tem had not been introduced at study initiation (Table marks: (1) the longitudinal blood vessels that run along II). A score of 1 indicated descent of the relevant portion the superior lateral sulcus of the vagina, (2) the edge of of the vaginal wall half way to the hymen; 2, to the hymen; the bladder and perivesical fat, and (3) the palpable lat- 3, <4 cm below the hymen; and 4, ≥4 cm below the eral edge of the pubocervical fascia at the lateral margin hymen. Points evaluated are the lower anterior vaginal of the bladder. Decisions on what constitutes normal wall (urethrovesical junction), upper half of the anterior anatomy were based on my experience with normal con- vaginal wall, cervix or vaginal apex, upper posterior vagi- tinence support anatomy.2,3,5 nal wall, and lower posterior vaginal wall. In three indi- Status of the ATFP. The ATFP is a fibrous band viduals scores were not recorded. stretched between attachments at the pubic bone and the Volume 187, Number 1 DeLancey 95 Am J Obstet Gynecol Fig 2. Examples of defects seen during surgery showing the ven- Fig 3. Conceptual diagram showing the mechanical effect of de- tral half of the arcus. A, Normal anatomy. B, Paravaginal defect tachment of the ATFP from the ischial spine. Top, The trape- without any remnant of the ATFP left on the pelvic wall. C, Rem- zoidal plane of the pubocervical fascia. Left, The attachments to nant that extends one fourth the way to the ischial spine (not the pubis and the ischial spines are intact. Right, The connection shown). D, Split insertion to the pubic bone and remnant that to the spine has been lost, allowing the fascial plane to swing goes at least three fourths the way to the spine. © DeLancey. downward. Bottom, The anterior vaginal wall as they would be seen with a weighted speculum in place. Left, Normal anterior vaginal wall support; right, the effect of dorsal detachment of the ischial spine (Fig 1). The anatomic characteristics evalu- arcus from the ischial spine. © DeLancey. ated were (1) the anterior attachment of the ATFP to the pubis, (2) the posterior attachment of the ATFP to the is- chium near the spine, and (3) presence of arcus rem- for the normal connection between this structure and the nants on the pelvic sidewall. The details of each periosteum of the ischium just cephalad to the ischial assessment follow.
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