Skip to main content

Advertisement

SpringerLink
Log in

Motion of the vaginal apex during strain and defecation

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction and hypothesis

Although the main function of the suspensory ligaments of the vaginal apex is to prevent its descent toward the vaginal introitus, there remains limited information regarding its normal physiological motion. This study was aimed at quantifying the motion of the non-prolapsed vaginal apex during strain and defecation maneuvers.

Methods

This study represents a sub-analysis of a parent study that was aimed at evaluating rectal mobility with regard to obstructed defecation symptoms. Patients with normal apical vaginal support who had undergone MR defecography were entered into the study. For each patient, midsagittal images at rest, maximum strain, and maximum evacuation were utilized. The location of the cervicovaginal junction, S4–S5 intervertebral disc, sacral promontory, and hymen were identified. Vectors were calculated from each of these landmarks to the vaginal apex to compare vector angles and magnitudes across subjects.

Results

Twelve patients were included in this study. At rest, the vagina extends from the hymen, which is inferior and posterior to the inferior symphysis pubis, to the vaginal apex at an angle of 45.2° ± 14.5° relative to the pubococcygeal line. This angle became more acute with strain and even more so during maximum evacuation (14.1° ± 9.0°, p < 0.001). Differences in the vector magnitude, although not statistically significant, showed a trend indicating shorter lengths with maximum evacuation.

Conclusions

The vaginal apex is a highly mobile structure demonstrating significantly more mobility during defecation compared with strain. The data obtained contradict the general perception that the vaginal apex is relatively fixed within the pelvis of normally supported women.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Blaisdell FE Sr. The anatomy of the sacro-uterine ligaments. Anat Rec. 1917;12(1):1–42.

    Article  Google Scholar 

  2. Range RL, Woodburne RT. The gross and microscopic anatomy of the transverse cervical ligament. Am J Obstet Gynecol. 1964;90(4):460–7.

    Article  CAS  Google Scholar 

  3. Chen L, Ramanah R, Hsu Y, Ashton-Miller JA, DeLancey JO. Cardinal and deep uterosacral ligament lines of action: MRI based 3D technique development and preliminary findings in normal women. Int Urogynecol J. 2013;24(1):37–45.

    Article  Google Scholar 

  4. DeLancey JO. Surgery for cystocele III: do all cystoceles involve apical descent? Int Urogynecol J. 2012;23(6):665–7.

    Article  Google Scholar 

  5. Kantartzis KL, Turner LC, Shepherd JP, Wang L, Winger DG, Lowder JL. Apical support at the time of hysterectomy for uterovaginal prolapse. Int Urogynecol J. 2015;26(2):207–12.

    Article  Google Scholar 

  6. Swenson CW, Luo J, Chen L, Ashton-Miller JA, DeLancey JO. Traction force needed to reproduce physiologically observed uterine movement: technique development, feasibility assessment, and preliminary findings. Int Urogynecol J. 2016;27(8):1227–34.

    Article  Google Scholar 

  7. Schreyer AG, Paetzel C, Fürst A, Dendl LM, Hutzel E, Müller-Wille R, et al. Dynamic magnetic resonance defecography in 10 asymptomatic volunteers. World J Gastroenterol. 2012;18(46):6836.

    Article  Google Scholar 

  8. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol. 2004;104(4):805–23.

    Article  Google Scholar 

  9. Halaska M, Maxova K, Sottner O, Svabik K, Mlcoch M, Kolarik D, et al. A multicenter, randomized, prospective, controlled study comparing sacrospinous fixation and transvaginal mesh in the treatment of posthysterectomy vaginal vault prolapse. Am J Obstet Gynecol. 2012;207(4):301.e1–7.

    Article  Google Scholar 

  10. Barone WR, Moalli PA, Abramowitch SD. Textile properties of synthetic prolapse mesh in response to uniaxial loading. Am J Obstet Gynecol. 2016;215(3):326.e1–9.

    Article  Google Scholar 

  11. Broekhuis SR, Fütterer JJ, Barentsz JO, Vierhout ME, Kluivers KB. A systematic review of clinical studies on dynamic magnetic resonance imaging of pelvic organ prolapse: the use of reference lines and anatomical landmarks. Int Urogynecol J. 2009;20(6):721–9.

    Article  Google Scholar 

  12. Cates J, Fletcher T, Whitaker R. A hypothesis testing framework for high-dimensional shape models. In: 2nd MICCAI workshop on mathematical foundations of computational anatomy; 2008. p. 170–81.

  13. Baessler K, Schuessler B. Abdominal sacrocolpopexy and anatomy and function of the posterior compartment. Obstet Gynecol. 2001;97(5):678–84.

    CAS  PubMed  Google Scholar 

  14. Maher CF, Qatawneh AM, Dwyer PL, Carey MP, Cornish A, Schluter PJ. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol. 2004;190(1):20–6.

    Article  Google Scholar 

  15. Pilsgaard K, Mouritsen L. Follow-up after repair of vaginal vault prolapse with abdominal colposacropexy. Acta Obstet Gynecol Scand. 1999;78(1):66–70.

    Article  CAS  Google Scholar 

  16. Virtanen H, Hirvonen T, Mäkinen J, Kiilholma P. Outcome of thirty patients who underwent repair of posthysterectomy prolapse of the vaginal vault with abdominal sacral colpopexy. J Am Coll Surg. 1994;178(3):283–7.

    CAS  PubMed  Google Scholar 

  17. Geomini PM, Brölmann HA, van Binsbergen NJ, Mol BW. Vaginal vault suspension by abdominal sacral colpopexy for prolapse: a follow up study of 40 patients. Eur J Obstet Gynecol Reprod Biol. 2001;94(2):234–8.

    Article  CAS  Google Scholar 

  18. Sung VW, Rogers RG, Schaffer JI, Balk EM, Uhlig K, Lau J, et al. Graft use in transvaginal pelvic organ prolapse repair: a systematic review. Obstet Gynecol. 2008;112(5):1131–42.

    Article  Google Scholar 

  19. Stanford E, Cassidenti A, Moen M. Traditional native tissue versus mesh-augmented pelvic organ prolapse repairs: providing an accurate interpretation of current literature. Int Urogynecol J. 2012;23(1):19–28.

    Article  CAS  Google Scholar 

  20. Ow LL, Lim YN, Dwyer PL, Karmakar D, Murray C, Thomas E, et al. Native tissue repair or transvaginal mesh for recurrent vaginal prolapse: what are the long-term outcomes? Int Urogynecol J. 2016;27(9):1313–20.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Female Pelvic Medicine and Reconstructive Surgery (FPMRS), Division of Urogynecology, University of Chicago Pritzker School of Medicine, NorthShore University HealthSystem, 9650 Gross Point Road, Suite 3900, Skokie, IL, 60076, USA

    Ghazaleh Rostaminia & Roger P. Goldberg

  2. Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA

    Megan Routzong & Steven Abramowitch

  3. NorthShore University HealthSystem Research Institute, Evanston, IL, USA

    Cecilia Chang

Authors
  1. Ghazaleh Rostaminia
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Megan Routzong
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Cecilia Chang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Roger P. Goldberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Steven Abramowitch
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ghazaleh Rostaminia.

Ethics declarations

Conflicts of interest

None.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rostaminia, G., Routzong, M., Chang, C. et al. Motion of the vaginal apex during strain and defecation. Int Urogynecol J 31, 391–400 (2020). https://doi.org/10.1007/s00192-019-03981-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-019-03981-2

Keywords

Search

Navigation