Abstract
Introduction and hypothesis
The objective was to identify structural failure sites in rectocele by comparing women with and those without posterior vaginal wall prolapse and accessing their relative contribution to rectocele size based on stress MRI-based measurements.
Methods
We studied three-dimensional stress MRI at maximal Valsalva of 25 women with (cases) and 25 without (controls) posterior vaginal prolapse of similar age and parity. Vaginal wall factors (posterior wall length and width); attachment factors (paravaginal posterior wall location, posterior fornix height, and perineal height); and hiatal factors (hiatal size and levator ani defects) were measured using Slicer 4.3.0® and a custom Python program. Stepwise linear regression was used to assess the relative contribution of all factors to the posterior prolapse size.
Results
We identified three primary factors with large effect sizes of 2 or greater: two attachment factors—posterior paravaginal descent and perineal height; and one hiatal factor—genital hiatus size. These were the strongest predictors of the presence and size of rectocele, the most common failure sites, found in 60–76% of cases; and highly correlated with one another (r = 0.72–0.84, p < .001). Longer vaginal length, wider distal vagina, lower posterior fornix, and larger levator ani hiatus had smaller effect sizes and were less likely to fall outside the norm (20–24%) than the three primary factors. When considering all the supporting factors, the combination of perineal height, posterior fornix height, and vaginal length explained 73% of the variation in rectocele size.
Conclusions
Lower perineal and lateral posterior vaginal location and enlarged genital hiatus size were strong predictors of rectocele occurrence and size and correlated highly.
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Acknowledgements
The authors thank Sarah Block for assistance with manuscript preparation.
Funding
Supported by the National Institutes of Health, grants P50 HD044406 and R01 HD094954.
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L. Chen: Project development, Data collection, Data analysis, Manuscript writing; B. Xie: Data collection, Manuscript writing; D. Fenner: Project development, Manuscript writing; D. Thibault: Manuscript writing; J.A. Ashton-Miller: Project development, Data analysis; J.O.L. DeLancey: Project development, Data collection, Data analysis, Manuscript writing.
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Appendices
Appendix 1
Posterior compartment anatomy and measurement strategy. a Conceptual framework of posterior wall support showing normal posterior wall support anatomy: vaginal wall, posterior fornix support, distal support for the perineal body, and the levator ani muscle. b The length and width of a normally supported posterior vaginal wall. c Illustration on how the paravaginal location in normal women changes in women with posterior vaginal prolapse. Arrowheads posterior arcus
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Chen, L., Xie, B., Fenner, D.E. et al. Structural failure sites in posterior vaginal wall prolapse: stress 3D MRI-based analysis. Int Urogynecol J 32, 1399–1407 (2021). https://doi.org/10.1007/s00192-021-04685-2
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DOI: https://doi.org/10.1007/s00192-021-04685-2