Abstract
Introduction and hypothesis
Test the hypotheses that (1) cardinal ligament (CL) straightening and lengthening occur with parity and prolapse, (2) CL straightening occurs before lengthening, and (3) CL length is correlated with level III measures.
Methods
We performed a secondary analysis of MRIs from women in three groups: (1) nulliparous with normal support, (2) parous with normal support, and (3) uterine prolapse (POP-Q point C > − 4 and Ba > 1 cm). The 3D stress MRI images at rest and maximal Valsalva were analyzed. CLs were traced from their origin to cervico-vaginal insertions. Curvature ratio was calculated as curved length/straight length. Level III measures included urogenital hiatus (UGH), levator hiatus (LH), and levator bowl volume (LBV), and their correlations with CL length were calculated.
Results
Ten women were included in each group. Compared to the nulliparous group, CL length was 18% longer in parous controls (p = .04) and 59% longer with prolapse (p < .01) at rest, while at Valsalva, CL length was 10% longer in parous controls (p = .21) and 49% longer with prolapse (p < .01). Curvature ratios showed 18% more straightening in women with prolapse compared to parous controls (p < .01). Curved CL length and level III measures were moderately to strongly correlated: UGH (rest: R = 0.68, p < .01; Valsalva: R =0.80, p < .01), LH (rest: R = 0.60, p < .01; Valsalva: R = 0.78, p < .01), and LBV (rest: R = 0.71, p < .01; Valsalva: R =0.89, p < .01).
Conclusion
Our findings suggest that the CLs undergo three times as much lengthening with prolapse as with parity; however, straightening only occurs with prolapse. Strong correlations exist between level I and level III support.
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References
Kieserman-Shmokler C, Swenson CW, Chen L, et al. From molecular to macro: the key role of the apical ligaments in uterovaginal support. Am J Obstet Gynecol. 2020;222(5):427–36.
Berger MB, Kolenic GE, Fenner DE, et al. Structural, functional, and symptomatic differences between women with rectocele versus cystocele and normal support. Am J Obstet Gynecol. 2018;218(5):510.e1–8.
Rooney K, Kenton K, Mueller ER, FitzGerald MP, Brubaker L. Advanced anterior vaginal wall prolapse is highly correlated with apical prolapse. Am J Obstet Gynecol. 2006;195(6):1837–40.
Chen L, Ashton-Miller JA, Hsu Y, DeLancey JO. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. Obstet Gynecol. 2006;108(2):324–32.
Luo J, Chen L, Fenner DE, Ashton-Miller JA, DeLancey JO. A multi-compartment 3-D finite element model of rectocele and its interaction with cystocele. J Biomech. 2015;48(9):1580–6.
Luo J, Betschart C, Chen L, Ashton-Miller JA, DeLancey JO. Using stress MRI to analyze the 3D changes in apical ligament geometry from rest to maximal Valsalva: a pilot study. Int Urogynecol J. 2014;25(2):197–203.
Smith TM, Luo J, Hsu Y, et al. A novel technique to measure in vivo uterine suspensory ligament stiffness[J]. Am J Obstet Gynecol. 2013;209(5):484.e1–7.
Swenson CW, Masteling M, DeLancey JO, et al. Aging effects on pelvic floor support: a pilot study comparing young versus older nulliparous women[J]. Int Urogynecol J. 2019:1–9.
Chen L, Lisse S, Larson K, et al. Structural failure sites in anterior vaginal wall prolapse: identification of a collinear triad. Obstet Gynecol. 2016;128(4):853.
Betschart C, Chen L, Ashton-Miller JA, et al. On pelvic reference lines and the MR evaluation of genital prolapse: a proposal for standardization using the pelvic inclination correction system. Int Urogynecol J. 2013;24(9):1421–8.
DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166(6 Pt 1):1717–24; discussion 1724-8. https://doi.org/10.1016/0002-9378(92)91562-o.
Nandikanti L, Sammarco AG, Chen L, et al. Levator bowl volume during straining and its relationship to other levator measures. Int Urogynecol J. 2019;30(9):1457–63.
Lowder JL, Oliphant SS, Shepherd JP, Ghetti C, Sutkin G. Genital hiatus size is associated with and predictive of apical vaginal support loss. Am J Obstet Gynecol. 2016;214(6):718 e711–718.
Handa VL, Blomquist JL, Caroll M, et al. Longitudinal changes in the genital Hiatus preceding the development of pelvic organ prolapse. Am J Epidemiol. 2019.
Luo J, Smith TM, Ashton-Miller JA, DeLancey JO. In vivo properties of uterine suspensory tissue in pelvic organ prolapse. J Biomech Eng. 2014;136(2):021016.
Ewies AA, Al-Azzawi F, Thompson J. Changes in extracellular matrix proteins in the cardinal ligaments of post-menopausal women with or without prolapse: a computerized immunohistomorphometric analysis. Hum Reprod. 2003;18(10):2189–95. https://doi.org/10.1093/humrep/deg420.
Salman MC, Ozyuncu O, Sargon MF, et al. Light and electron microscopic evaluation of cardinal ligaments in women with or without uterine prolapse. Int Urogynecol J. 2010;21(2):235–9.
Orlicky DJ, Guess MK, Bales ES, et al. Using the novel pelvic organ prolapse histologic quantification system to identify phenotypes in uterosacral ligaments in women with pelvic organ prolapse[J]. Am J Obstet Gynecol. 2021;224(1):67.e1–67.e18.
Acknowledgments
Data used in this study were acquired with funding from the following grants: National Institute on Aging, Claude D. Pepper Older Americans Independence Centers AG024824, Michigan Institute for Clinical and Health Research UL1TR002240, and National Institute of Child Health and Human Development P50 HD044406.
Investigator support for C.W.S. was provided by the National Institute of Child Health and Human Development WRHR Career Development Award # K12 HD065257.
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Cheng, W., Thibault, M.D., Chen, L. et al. Changes in cardinal ligament length and curvature with parity and prolapse and their relation to level III hiatus measures. Int Urogynecol J 33, 107–114 (2022). https://doi.org/10.1007/s00192-021-04824-9
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DOI: https://doi.org/10.1007/s00192-021-04824-9