Title Page Shifting and Shaping Perceptions: Towards the Characterization and Literacy of Female Pelvic Organ Support by Deanna Christine Easley Sinex B.S. Mechanical Engineering, University of Maryland Baltimore County 2012 Submitted to the Graduate Faculty of the Swanson School of Engineering in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2021 Committee Page UNIVERSITY OF PITTSBURGH SWANSON SCHOOL OF ENGINEERING This dissertation was presented by Deanna Christine Easley Sinex It was defended on February 25, 2021 and approved by Harvey S. Borovetz, PhD Distinguished Professor, Bioengineering Renee Clark, PhD Assistant Professor, Industrial Engineering Christiane Hakim, MD, Professor, Radiology Prahlad Menon, PhD, Assistant Professor, Bioengineering Pamela Moalli, MD, PhD Professor, Obstetrics, Gynecology & Reproductive Sciences Yongjie Jessica Zhang, PhD, Professor, Mechanical Engineering Dissertation Director: Steven Abramowitch, PhD, Associate Professor, Bioengineering ii Copyright © by Deanna Christine Easley Sinex 2021 iii Abstract Shifting and Shaping Perceptions: Towards the Characterization and Literacy of Female Pelvic Organ Support Deanna Christine Easley Sinex, PhD University of Pittsburgh, 2019 Pelvic Organ Prolapse (POP) is a pelvic floor condition characterized by the unnatural descent of pelvic organs into the vagina. It occurs as the result of compromised connective tissues and musculature following vaginal delivery and/or changes in tissue composition due to aging. Approximately 50% of women in the United States experience some degree of POP during their lifetime, with symptoms that include altered urination and defecation, physical discomfort, depression, and anxiety. Over the last decade, POP treatments have gained public notoriety due to surgical complications and recurrence of prolapse after surgical repair. Both outcomes stem, in part, from gaps in knowledge regarding the complex interactions of pelvic viscera, tissues, and musculature, and is exacerbated by the significant time span between events surrounding vaginal birth injuries and symptomatic prolapse. Over the last century, fields such as cardiovascular medicine and orthopedics have made significant strides to improve the human condition through the application of biomechanics, diagnostic imaging techniques, and modeling. Such methods have been used to reliably differentiate normal and diseased anatomy with respect to orientation, location, and other geometric attributes. In contrast, urogynecology remains decades behind as a result of a failure to adopt new interdisciplinary methods, limiting our ability to effectively treat POP. Thus, iv approximately 80% of women with symptomatic POP choose to suffer in silence. This is troubling, given that POP and related disorders will become increasingly prevalent due to the advancing age of the global population. This dissertation explores the assessment and development of diagnostic tools that improve our ability to quantify the position of the vagina with respect to physiologic changes that may occur over the lifespan within the normal range. These tools provide valuable information regarding the physical changes that occur over time and the differences between populations while serving as a potential standard by which pelvic anatomy can be quantified. Furthermore, this work explores our knowledge, perceptions, and attitudes regarding female pelvic health to challenge misconceptions surrounding normal and abnormal physiological functions, foster attitudes of empathy and acceptance for disorders, and improve health literacy by illustrating the impact that it has on lives worldwide. v Table of Contents Preface ........................................................................................................................................... iv 1.0 Introduction ............................................................................................................................. 1 1.1 Maturation and Anatomical Development of Female Pelvic Anatomy: From Gestation to Adolescence .......................................................................................... 7 1.2 Adult Female Pelvic Anatomy ....................................................................................... 9 1.2.1 Bony Pelvis ........................................................................................................... 9 1.2.2 Musculature ....................................................................................................... 12 1.2.3 Female Pelvic Viscera ....................................................................................... 14 1.2.4 Connective Tissues and Ligaments .................................................................. 16 1.2.5 Impact of Gestation and Delivery on Female Pelvic Anatomy ..................... 18 1.2.6 Impact of Aging on Female Pelvic Anatomy .................................................. 20 1.3 Pelvic Floor Disorders (PFDs) ..................................................................................... 21 1.3.1 Pelvic Organ Prolapse (POP) ........................................................................... 22 1.3.2 Risk Factors for POP ........................................................................................ 25 1.3.3 Clinical characterization of prolapse: POP-Q Exam ..................................... 28 1.3.4 Treatments for POP .......................................................................................... 31 1.3.5 Application of Diagnostic Imaging Towards the Characterization of POP 35 1.4 Ethical and Practical Limitations Associated with Conducting Urogynecology Research ................................................................................................................... 40 1.5 Motivations and Specific Aims .................................................................................... 43 vi 2.0 The Evolution, Development and Applications of Patient Databases Towards the Characterization of Vaginal Position ............................................................................ 49 2.1 Overview ........................................................................................................................ 49 2.2 Towards the Development of a Female Pelvic Anatomical Reference Database .... 50 2.2.1 Introduction ....................................................................................................... 50 2.2.2 Methods .............................................................................................................. 53 2.2.3 Results ................................................................................................................ 56 2.2.4 Discussion ........................................................................................................... 58 2.2.5 Challenges .......................................................................................................... 62 2.3 Characterization of Hymenal Ring Position with Respect to Age and Parity ........ 63 2.3.1 Introduction ....................................................................................................... 63 2.3.2 Methodology ...................................................................................................... 66 2.3.2.1 Scan Selection and Subject Demographics ....................................... 66 2.3.2.2 Scan Alignment ................................................................................... 67 2.3.2.3 Hymenal Ring Measurement Quantification ................................... 68 2.3.3 Statistics ............................................................................................................. 69 2.3.4 Results ................................................................................................................ 70 2.3.4.1 Distance from Pubic Symphysis to Anterior Hymenal Ring........... 72 2.3.4.2 Distance from Pubic Symphysis to Posterior Hymenal Ring .......... 76 2.4 Discussion ...................................................................................................................... 80 2.5 Conclusion ..................................................................................................................... 86 3.0 Determining Vaginal Axis and Spatial Position Using a 3D Anatomical Coordinate System .............................................................................................................................. 87 vii 3.1 Introduction .................................................................................................................. 87 3.2 Relevance of Vaginal Axis Measurements ................................................................. 88 3.3 Existing Pelvic Reference Systems .............................................................................. 90 3.4 3D Anatomical Patient Coordinate Systems .............................................................. 93 3.5 Motivation ..................................................................................................................... 95 3.6 Methods ......................................................................................................................... 96 3.6.1 Defining the 3D Anatomical Coordinate System ........................................... 96 3.6.2 Derivation of Vaginal Axis and Position ....................................................... 101 3.6.3 Vaginal Angle Measurements with