Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Published online 28 July 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.14711
Correspondence to: Dr C. M. Durnea, 5th floor, INFANT Research Centre, Department of Obstetrics and Gynaecology, Cork University
Maternity Hospital, Cork, Ireland (e-mail: costea.durnea@gmail.com)
Accepted: 21 October 2014
Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. ORIGINAL PAPER
Pelvic floor status in young primiparae 357
Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
358 Durnea et al.
a better correlation between the presence of symptoms diseases, induction of labor, mode of delivery, oxytocin
and the grade of ultrasound prolapse16 . We used an augmentation, duration of labor, fetal head circumference
ultrasound POP classification, categorizing prolapse into and birth weight.
clinically significant or non-significant17 . A cut-off level
of 10 mm below the symphysis pubis was proposed
to define significant cystocele and 15 mm below the RESULTS
symphysis pubis to define significant rectocele. We used Clinical follow-up was attended by 202 primiparous
the reference line (cut-off of 0 mm) as the definition of women (30.3% of all 666 women eligible for follow-up,
significant uterine prolapse based on unpublished data after excluding 206 with a second ongoing pregnancy
provided by H.P.D., as there is currently no published from the cohort of 872 invited for follow-up). Among
cut-off for central compartment descent. the participants, 99.5% were Caucasian, with a mean
LAM integrity was assessed using 3D-TPS in tomo- age of 31.2 years, mean body mass index of 25.1 kg/m2
graphic ultrasound imaging mode, and the image acquired and mean weight of 68.0 kg. Demographic characteristics
on maximum pelvic floor muscle contraction. The plane of the women who participated in the 4P Study clinical
of minimal hiatal dimensions was selected as the reference follow-up and SCOPE Ireland were similar (Table 1).
plane. To cover the whole width of the LAM, five tomo- The SCOPE cohort has been shown previously to be
graphic slices cephalad to the reference plane, with a slice representative of the entire population11 .
thickness of 2.5 mm, were included in the analysis. LAM In order to avoid transitory postnatal pelvic floor
avulsion was diagnosed if the distance between the center changes, participants were invited for clinical follow-up
of the urethra and the LAM insertion (levatorurethra at least 1 year after delivery. The average interval between
gap) was 25 mm18 . Complete LAM avulsion was delivery and clinical assessment was 1 year and 9 months
diagnosed if a distance of more than 25 mm was observed (range, 1.14.1 years). Of all participants who answered
in the reference slice and in the two slices cephalad to it. the question concerned, 158 (80.2%) were asymptomatic,
Any other combination of abnormal slices was considered 19 (9.6%) complained of symptoms of a vaginal lump
as partial LAM avulsion19 . We also assessed ballooning or bulge, 30 (15.2%) of vaginal pressure or heaviness,
of the levator hiatus, which was defined as distension of four (2.2%) of prolapse reduction to void, 10 (5.6%) of
the hiatal area of > 25 cm2 , which has been shown to be prolapse reduction to defecate and 10 (5.6%) reported
associated with LAM trauma and symptoms and signs associated bother due to prolapse symptoms.
of prolapse20 . The subpubic arch angle was measured On clinical examination, the mean POP-Q values for
in the axial plane close to the plane of minimal hiatal various points on maximal Valsalva maneuver were
dimensions, where the pubic rami join. The image was as follows: Ba, 1.21 0.84 cm; Bp, 1.92 0.75 cm;
manipulated to obtain maximal pubic rami length8 . C, 5.23 1.03 cm. On 2D-TPS, maximal descent of
We measured the level of blood serum procollagen
Type III N-terminal propeptide (PIIINP) in 96 partici-
Table 1 Demographic characteristics of study population and
pants, using commercial enzyme-linked immunosorbent overall population of SCOPE Ireland study
assay (ELISA) tests (USCN Life Science Inc., Wuhan,
China). Participants with the highest and lowest values Present study SCOPE Ireland
for point C (leading edge of the cervix on POP-Q Characteristic (n = 202) (n = 1774)
assessment) were selected from the cohort for subsequent
Caucasian 201 (99.5) 1450 (81.7)
PIIINP quantification. The methodology used has been Age (years) 31.2 4.7 29.9 4.5
described in detail previously16 . Aged 1724 years 19 (9.4) 207 (11.7)
Aged 2529 years 49 (24.3) 545 (30.7)
Aged 3034 years 89 (44.1) 787 (44.4)
Statistical analysis Aged 3545 years 45 (22.3) 235 (13.2)
Weight (kg) 68.0 11.3 67.5 12.2
Statistical analysis was performed using IBM SPSS 19 Body mass index (kg/m2 ) 25.1 4.1 24.9 4.2
(IBM Corp., Armonk, NY, USA) and Stata Software 10.0 Underweight 4 (2.0) 22 (1.2)
(StataCorp, College Station, TX, USA). All statistical tests Normal weight 103 (51.0) 1036 (58.4)
were two-sided and P < 0.05 was considered statistically Overweight 70 (34.7) 495 (27.9)
significant. To investigate the effect of potential risk Obese 25 (12.4) 221 (12.5)
Education
factors on PFD, stepwise ordinal logistic regression
12 years 28 (13.9) 230 (13.0)
analysis was used to calculate the odds ratio (OR) and > 12 years 174 (86.1) 1544 (87.0)
95% CIs. In ordinal logistic regression, the outcome Smoking
measure is ordinal with more than two categories. Risk Non-smoker 148 (73.3) 1285 (72.4)
factors with borderline statistical significance (P < 0.1) Smoker 54 (26.7) 489 (27.6)
were used for multivariable logistic regression analysis. Alcohol consumption
No 39 (19.3) 339 (19.1)
Main outcome measures were rectocele, uterine prolapse,
Yes 163 (80.7) 1435 (80.9)
LAM trauma and LAM hiatal ballooning. The examined
risk factors were subpubic arch angle, collagen Type Data given as n (%) or mean SD. SCOPE, Screening for
III levels, personal or family history of collagen-related Pregnancy Endpoints.
Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
Pelvic floor status in young primiparae 359
Table 2 Prevalence of various types of pelvic organ prolapse on Pelvic Organ Prolapse Quantification (POP-Q) and three-dimensional
transperineal sonography (3D-TPS) assessment in 202 primiparous women at least 1 year after delivery
Data given as n (%). *Prolapse present if POP-Q Stage 2. Prolapse present if significant prolapse according to Dietz et al.17 . Prolapse
present if Grade 12 according to POP-Q according to Dietz et al.14 .
the bladder on Valsalva was 0.45 1.16 cm below the Table 3 Association between presence of prolapse symptoms and
symphyseal reference line. Maximal descent of the rectal various risk factors in 202 primiparous women examined at least
1 year after delivery by Pelvic Organ Prolapse Quantification and
ampulla was to 0.46 1.17 cm above the reference line. transperineal ultrasound on univariable logistic regression analysis
The prevalence of various types of POP assessed by
POP-Q and 3D-TPS is presented in Table 2. Clinically Outcome/risk factor OR (95% CI) P
significant uterine prolapse (Stage 1) on POP-Q mea-
Vaginal pressure or heaviness
surement (described in Methods section) was present in
Prepregnancy vaginal 4.4 (0.7724.8) 0.096
62.9% of participants. The prevalence of clinically sig- pressure/heaviness
nificant cystocele on POP-Q examination (Stage 2) was Prepregnancy total prolapse 4.4 (2.308.30) < 0.0001
three-fold higher compared with the finding of a signifi- score
cant cystocele on ultrasound (bladder 10 mm below the Forceps delivery 1.7 (0.962.94) 0.071
Emergency CS 0.4 (0.180.86) 0.019
symphysis pubis), with a prevalence of 41.6% vs 13.9%.
Elective CS 0.2 (0.090.52) 0.001
Significant posterior compartment descent (ICS-POP-Q Partial LAM avulsion 1.1 (0.353.70) 0.820
Stage 2, or descent of the ampulla 15 mm below the Complete LAM avulsion 5.3 (2.1413.3) < 0.0001
symphysis pubis) was similar for both diagnostic methods, Ballooning of LAM hiatus 3.9 (1.738.58) 0.001
with a prevalence of around 24%. Prolapse sensation
Examination by 3D-TPS revealed that nearly one-third Prepregnancy vaginal 3.5 (1.1310.66) 0.029
pressure/heaviness
(29.2%) of participants had some form of abnormal
Prepregnancy prolapse score 2.7 (1.106.85) 0.03
LAM morphology. Partial LAM avulsion was detected in Forceps delivery 0.3 (0.120.99) 0.048
15% of participants and complete avulsion in 14%, with Partial LAM avulsion 3.2 (0.8411.92) 0.089
right-sided avulsion being more common than left-sided Complete LAM avulsion 9.5 (3.0829.26) < 0.0001
(10.9% vs 2.5%), and bilateral avulsion being common Ballooning of LAM hiatus 3.2 (1.218.28) 0.019
at 15.8%. One-third (n = 67; 33.2%) of participants had Presence of multiple prolapse
symptoms
ballooning of the LAM hiatus, of whom 38 (56.7%) had
Prepregnancy vaginal 7.2 (1.1944.33) 0.032
associated LAM avulsion. pressure/heaviness
When analyzing factors associated with the presence Prepregnancy total prolapse 4.8 (2.379.55) < 0.0001
of prolapse symptoms (Table 3), we found statistically score
significant correlations with a prepregnancy presence Forceps delivery 1.8 (0.963.25) 0.069
Emergency CS 0.3 (0.120.83) 0.019
of prolapse symptoms (OR, 2.77.2), complete LAM
Elective CS 0.2 (0.090.63) 0.004
avulsion (OR, 4.89.5), LAM hiatal ballooning (OR, Partial LAM avulsion 1.6 (0.614.12) 0.340
2.55.2) and there was borderline significance for forceps Complete LAM avulsion 4.8 (1.9911.34) < 0.0001
delivery (OR, 1.8). Delivery by Cesarean section was Ballooning of LAM hiatus 2.5 (1.245.15) 0.011
found to be protective (OR, 0.20.4). Bother due to prolapse symptoms
Additionally, we analyzed the association of various Prepregnancy total prolapse 4.2 (1.5211.51) 0.006
score
antepartum and intrapartum factors with LAM trauma
Partial LAM avulsion 1.7 (0.329.40) 0.519
(Table 4) and ballooning of the LAM hiatus (Table 5). Complete LAM avulsion 7.4 (2.0726.21) 0.002
On univariable analysis we found statistically significant Ballooning of LAM hiatus 5.2 (1.5317.54) 0.008
or borderline significant correlation between any LAM
trauma and the use of oxytocin in labor (OR, 1.8), CS, Cesarean section; LAM, levator ani muscle; OR, odds ratio.
duration of the second stage of labor (OR, 1.01),
forceps delivery (OR, 4.5), episiotomy (OR, 4.2) and On multivariable analysis, LAM avulsion was found
postnatal presence of cystocele (OR, 4.2). Ballooning of to be statistically significantly associated with duration
the LAM hiatus was associated with forceps delivery of the second stage of labor (OR, 1.01), forceps delivery
(OR, 4.8), episiotomy (OR, 1.9), birth weight (OR, (OR, 4.9) and postnatal presence of cystocele (OR, 11.7)
1.01), postnatal presence of cystocele, rectocele or (Table 4). Multivariable analysis of risk factors for bal-
uterine prolapse (OR, 7.5, 2.6 and 7.6, respectively) and looning of the LAM hiatus found significant associations
partial or complete LAM avulsion (OR, 2.8 and 17.4, with uterine prolapse (OR, 6.8) and partial (OR, 3.2)
respectively). and complete (OR, 12.2) LAM avulsion. Forceps delivery
Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
360 Durnea et al.
Table 4 Association between diagnosis of levator ani muscle avulsion on transperineal sonography at least 1 year after childbirth and
various antenatal, intrapartum and postpartum factors in 202 primiparous women on univariable and multivariable ordinal logistic
regression analyses
Table 5 Association between diagnosis of ballooning of the levator ani muscle (LAM) hiatus on transperineal sonography at least 1 year
after childbirth and various antenatal, intrapartum and postpartum factors in 202 primiparous women on univariable and multivariable
logistic regression analyses
Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
Pelvic floor status in young primiparae 361
showed only borderline significance for ballooning of the an association between LAM trauma and duration of the
LAM hiatus (OR, 4.0; P = 0.074) (Table 5). second stage of labor, mode of delivery and episiotomy,
We did not find any association between LAM in which the use of forceps was most predictive of
abnormality and head circumference, total duration of trauma5,24,25 . In contrast to other reports, we did not find
labor, subpubic arch angle, collagen levels or history a significant association with fetal head circumference5 .
of collagen disease. In addition, the time interval from This could reflect different obstetric practices, or it could
delivery to 3D-TPS examination did not significantly be due to power issues. In addition, definitions of avulsion
influence the presence of LAM pathology. Delivery by vary in the published literature, which may explain some
Cesarean section appeared to be protective, but this was of the differences in results.
not statistically significant. The logistic regression analysis did not demonstrate
an association between congenital non-modifiable fac-
tors, such as subpubic arch angle, collagen levels or
DISCUSSION
collagen-related disease, with LAM pathology, which
In the present study, we investigated the postnatal most probably occurs because of the mechanical impact of
prevalence of pelvic floor trauma in primiparous women vaginal delivery, rather than because of pelvic weakness.
using 3D-TPS. Unlike previous studies, we intended to This conclusion confirms the results from previous studies
describe the ultrasound appearance of the pelvic floor that used 3D-TPS intrapartum and in the early postnatal
in primiparous women at least 1 year after childbirth period, which have shown that crowning of the head is
and to investigate associations between these findings the immediate cause of avulsion of the LAM27 . Addi-
and potential prepregnancy and intrapartum contributing tionally, other research groups have shown that hiatal
factors21 . We intentionally used a cut-off of 1 year to avoid dimensions, bladder neck descent, subpubic arch angle
inclusion of transitory changes in the pelvic floor in our and other anthropometric parameters are not associated
study, which can persist for up to 6 months postnatally with avulsion. Our results are in keeping with these data,
or even longer22 . and suggest that antenatal prediction of LAM trauma may
We found that POP is very common in primiparous not be possible28 .
women, with clinically significant cystocele being more The main strength of our study is the fact that it
prevalent on POP-Q assessment, and rectocele having was nested within the SCOPE study, gaining access
similar detection rates on POP-Q and 3D-TPS investi- to a detailed database containing information about
gation. Around half of the participants had clinically intrapartum risk factors and nulliparous women whose
significant cystocele or uterine prolapse, and one quarter phenotype has been well established. The present study is
had clinically significant posterior compartment descent, likely to be representative of the entire study population,
although none had any form of prolapse greater than which is homogeneous and has been shown to be repre-
Stage 2 (Table 2). It is known that the correlation sentative of the Irish population overall. All participants
between POP findings on POP-Q assessment and TPS is were relatively young women who delivered in the
fair-to-good15 . However, it has also been shown that TPS same hospital following similar obstetric management
is more likely to avoid the potential confounding effect of principles and protocols. A potential congenital predictor
important factors such as levator coactivation, or a full of pelvic organ support, procollagen III, was included
bladder or rectum (which can be visualized directly on in the study design to investigate naturally occurring
the screen and dealt with accordingly), whereas clinical confounders. All participants were assessed both clin-
examination is able to displace one compartment to allow ically by ICS-POP-Q and by TPS in order to describe
other compartments to descend23 . comprehensively the state of pelvic organ support.
Prolapse symptoms were not uncommon (even though The lack of baseline assessments remains a major
80% of participants with objective prolapse were limitation, especially when interpreting clinical symp-
asymptomatic) and were associated with LAM trauma toms. Another drawback is the limited number of
and forceps delivery, whereas delivery by Cesarean section observations performed owing to attrition, which may
had a protective effect16 . At 14.4%, the prevalence of limit the conclusions that can be drawn from our results,
complete LAM avulsion diagnosed by ultrasound in although the participants demographic characteristics in
this study is well within the range of values reported the present study were reasonably similar to those of the
previously, being similar to those reported recently in Cork SCOPE population. The study had limited statistical
studies using the same methodology24,25 . Our rate of power owing to a small sample size, and this is reflected
partial LAM avulsion is higher than rates found in in the wide 95% CIs for some ORs. For example, a
previous studies, however, similarly to previous reports, family history of collagen diseases, induction of labor
we found that right-sided trauma is more common than and oxytocin use during labor were not statistically
left-sided26 . This is probably owing to the fact that, in significant in the univariable models for LAM avulsion or
Ireland, active management of labor is advocated, with a ballooning, despite the elevated OR. Further investigation
high rate of forceps delivery. Slightly more than half the of these risk factors in larger cohorts is warranted.
cases with ballooning of the LAM hiatus were associated In conclusion, more than half of relatively young
with LAM trauma. The results of our univariable analysis premenopausal primiparous women were shown to have
correspond well with those of previous studies, showing some form of clinically significant POP at 14 years
Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
362 Durnea et al.
after their first delivery. This is likely to contribute to 6. Zhuang RR, Song YF, Chen ZQ, Ma M, Huang HJ, Chen JH, Li YM. Levator
avulsion using a tomographic ultrasound and magnetic resonance-based model. Am
the development of PFD later in life. One-third showed J Obstet Gynecol 2011; 205: 232.e18.
some degree of LAM trauma, which is associated with the 7. Dietz HP. Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynaecol 2013; 53:
220230.
presence of POP and symptoms related to it in later life. 8. Choi S, Chan SS, Sahota DS, Leung TY. Measuring the angle of the subpubic arch
Congenital factors seem to play little role in the etiology of using three-dimensional transperineal ultrasound scan: intraoperator repeatability
and interoperator reproducibility. Am J Perinatol 2013; 30: 191196.
LAM trauma, and the main risk factor seems to be forceps 9. Dietz HP, Clarke B, Herbison P. Bladder neck mobility and urethral closure pressure
delivery. Cesarean section was shown to be protective as predictors of genuine stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct
2002; 13: 289293.
against the presence of some symptoms. Avoidance of 10. Weinstein MM, Pretorius DH, Jung SA, Nager CW, Mittal RK. Transperineal
difficult vaginal deliveries may prevent severe pelvic floor three-dimensional ultrasound imaging for detection of anatomic defects in the anal
sphincter complex muscles. Clin Gastroenterol Hepatol 2009; 7: 205211.
trauma and associated symptoms. 11. Durnea CM, Khashan AS, Kenny LC, Tabirca SS, OReilly BA. An insight into pelvic
floor status in nulliparous women. Int Urogynecol J 2014; 25: 337345.
12. Baessler K, ONeill SM, Maher CF, Battistutta D. Australian pelvic floor
questionnaire: a validated interviewer-administered pelvic floor questionnaire for
ACKNOWLEDGMENTS routine clinic and research. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:
149158.
SCOPE Ireland is funded by Health Research Board of 13. Orejuela FJ, Shek KL, Dietz HP. The time factor in the assessment of prolapse and
levator ballooning. Int Urogynecol J 2012; 23: 175178.
Ireland (grant reference CSA 2007/2). The study was sup- 14. Dietz HP, Mann KP. What is clinically relevant prolapse? An attempt at defining
ported by Continence Foundation Ireland and INFANT cutoffs for the clinical assessment of pelvic organ descent. Int Urogynecol J 2014;
25: 451455.
Centre, UCC. L.C.K. is a Science Foundation Ireland Prin- 15. Dietz HP, Haylen BT, Broome J. Ultrasound in the quantification of female pelvic
cipal Investigator (08/IN.1/B2083) and the Director of the organ prolapse. Ultrasound Obstet Gynecol 2001; 18: 511514.
16. Durnea CM, Khashan AS, Kenny LC, Durnea UA, Smyth MM, OReilly BA.
SFI funded Centre, INFANT (12/RC/2272). Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal
We would like to thank all SCOPE Ireland participants, primiparous women. Int Urogynecol J 2014; 25: 14631470.
17. Dietz HP, Lekskulchai O. Ultrasound assessment of pelvic organ prolapse: the
Continence Foundation Ireland and the Irish Centre for relationship between prolapse severity and symptoms. Ultrasound Obstet Gynecol
Fetal and Neonatal Translational Research (INFANT) for 2007; 29: 688691.
18. Dietz HP, Abbu A, Shek KL. The levatorurethra gap measurement: a more objective
their input into this research project and Dr Lynne Kelly means of determining levator avulsion? Ultrasound Obstet Gynecol 2008; 32:
(PhD), research bioscientist, for helping to perform ELISA 941945.
19. Dietz HP, Bernardo MJ, Kirby A, Shek KL. Minimal criteria for the diagnosis of
collagen analysis. avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J
H.P.D. has received unrestricted educational grants 2011; 22: 699704.
20. Dietz HP, Shek C, De Leon J, Steensma AB. Ballooning of the levator hiatus.
from GE Medical. Ultrasound Obstet Gynecol 2008; 31: 676680.
21. Albrich SB, Laterza RM, Skala C, Salvatore S, Koelbl H, Naumann G. Impact of
mode of delivery on levator morphology: a prospective observational study with
three-dimensional ultrasound early in the postpartum period. BJOG 2012; 119:
REFERENCES 5160.
22. Fonti Y, Giordano R, Cacciatore A, Romano M, La Rosa B. Post partum pelvic floor
1. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor changes. J Prenat Med 2009; 3: 5759.
disorders and their relationship to gender, age, parity and mode of delivery. BJOG 23. Orno AK, Dietz HP. Levator co-activation is a significant confounder of pelvic organ
2000; 107: 14601470. descent on Valsalva maneuver. Ultrasound Obstet Gynecol 2007; 30: 346350.
2. Braekken IH, Majida M, Ellstrm-Engh M, Dietz HP, Umek W, B K. Testretest and 24. Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. BJOG 2010; 117:
intra-observer repeatability of two-, three- and four-dimensional perineal ultrasound 14851492.
of pelvic floor muscle anatomy and function. Int Urogynecol J Pelvic Floor Dysfunct 25. Chan SS, Cheung RY, Yiu AK, Lee LL, Pang AW, Choy KW, Leung TY, Chung
2008; 19: 227235. TK. Prevalence of levator ani muscle injury in Chinese women after first delivery.
3. Dietz HP. Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume Ultrasound Obstet Gynecol 2012; 39: 704709.
imaging. Ultrasound Obstet Gynecol 2004; 23: 615625. 26. Adisuroso T, Shek KL, Dietz HP. Tomographic ultrasound imaging of the pelvic
4. Barry CL, Dietz HP, Bhuta S, Lim YN, Greenland H, Muller R. MRI versus floor in nulliparous pregnant women: limits of normality. Ultrasound Obstet Gynecol
3-dimensional ultrasound: a comparative study of levator hiatal dimensions in 2012; 39: 698703.
women with pelvic organ prolapse. Aust N Z Cont J 2006; 12: 6166. 27. Blasi I, Fuchs I, DAmico R, Vinci V, La Sala GB, Mazza V, Henrich W. Intrapartum
5. Valsky DV, Lipschuetz M, Bord A, Eldar I, Messing B, Hochner-Celnikier D, Lavy Y, translabial three-dimensional ultrasound visualization of levator trauma. Ultrasound
Cohen SM, Yagel S. Fetal head circumference and length of second stage of labor are Obstet Gynecol 2011; 37: 8892.
risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal 28. Shek KL, Dietz HP. Can levator avulsion be predicted antenatally? Am J Obstet
ultrasound in primiparous women. Am J Obstet Gynecol 2009; 201: 91.e17. Gynecol 2010; 202: 586.e16.
The following supporting information may be found in the online version of this article:
Table S1 Medical conditions shown previously to be associated with pelvic floor dysfunction (PFD) and pelvic
organ prolapse (POP)
Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.