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Architectural Differences in the Bony Pelvis of Women With and Without Pelvic Floor Disorders

From the Department of Gynecology and Obstetrics and the Russell H. Morgan Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address reprint requests to: Victoria L. Handa, MD, 600 N Wolfe Street, Harvey 319, Baltimore, MD 21287; E-mail: Vhanda1{at}jhmi.edu.

	ABSTRACT

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
OBJECTIVE: To investigate the hypothesis that the architecture of the bony pelvis differs between women with and without pelvic floor disorders.

METHODS: We designed a case-control study of women who had undergone magnetic resonance imaging (MRI) of the pelvis at our institution. Records were reviewed to identify women with and without pelvic floor disorders (urinary or anal incontinence, other symptoms of urinary tract dysfunction, or pelvic organ prolapse). Pelvimetry techniques were standardized. Relevant measures included transverse diameter of the inlet, angle of the pubic arch, intertuberous diameter, interspinous diameter, sacrococcygeal length, depth of sacral curvature, anteroposterior conjugate, obstetrical conjugate, and anteroposterior outlet. Multiple logistic regression analysis was used to identify women with pelvic floor disorders as a function of their pelvic dimensions, controlling for potentially confounding variables.

RESULTS: Subjects included 59 women with pelvic floor disorders and 39 women without pelvic floor disorders. Women with pelvic floor disorders had a wider transverse inlet, wider intertuberous diameter, wider interspinous diameter, greater sacrococcygeal length, deeper sacral curvature, and narrower anteroposterior outlet. When controlling for the confounding effects of age, race, and parity, we found that a wider transverse inlet (odds ratio 3.425) and a shorter obstetrical conjugate (odds ratio 0.233) were significantly associated with pelvic floor disorders.

CONCLUSION: A wide transverse inlet and narrow obstetrical conjugate are associated with pelvic floor disorders. We speculate that these features of bony pelvic architecture may predispose the patient to neuromuscular and connective tissue injuries, leading to the development of pelvic floor disorders.

Pelvic floor disorders, including pelvic organ prolapse and urinary incontinence, are prevalent among adult women. By age 80, 11% of women have undergone surgery for pelvic organ prolapse or urinary incontinence.¹ The etiology of pelvic floor disorders is unknown but probably multifactorial. Most pelvic floor disorders, including urinary incontinence² and pelvic organ prolapse,³ are associated with parity. There is increasing evidence that the levator ani and pelvic floor soft tissues may be injured at the time of vaginal delivery.⁴ As a result, some have advocated cesarean delivery to reduce these injuries and their sequelae.^5–7

Several studies have attempted to identify patient parameters that predict women at greatest risk for obstetrical trauma. Although intrapartum parameters (including use of episiotomy and operative delivery) are associated with trauma,⁸ they are not useful to predict trauma a priori. Antepartum risk factors include nulliparity, maternal Asian race, and fetal macrosomia,^8,9 although the predictive value of these variables is insufficient to recommend changing mode of delivery. Consequently, further research is warranted to determine methods to identify women at highest risk of intrapartum trauma before the onset of labor.

The purpose of this investigation is to determine whether certain features of pelvic bony anatomy are associated with pelvic floor disorders. The rationale for this research arises from the recognition that differences in pelvic architecture affect the progress of parturition and thus might predispose to soft tissue injury during labor. A recent retrospective study of primiparous women identified a strong association between certain pelvic dimensions and postpartum incontinence.¹⁰ In a study comparing computed tomography of women with and without pelvic organ prolapse,¹¹ the transverse diameter of the pelvic inlet was significantly greater in women with prolapse.

Our hypothesis is that the dimensions of the bony pelvis differ between women with and without pelvic floor disorders. To test this hypothesis, we designed a case-control study of women who had undergone magnetic resonance imaging (MRI) of the pelvis at our institution. Although many pelvimetry techniques are available, we elected to use MRI pelvimetry^12,13 because of the ability to delineate bony and soft tissue structures and to perform multiplanar images.

	MATERIALS AND METHODS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Case patients and controls were selected from 904 women who underwent pelvic MRI at our institution between 1998 and 2002. On the basis of published data,¹¹ we estimated that a sample size of 64 subjects (32 in each group) would be adequate to compare the transverse inlet diameter of women with and without pelvic floor disorders (two-tailed = .05, ß = .20). We planned a sample size of 80 subjects to account for cases with incomplete magnetic resonance images or poor image quality.

We defined pelvic floor disorders as symptoms of urinary or fecal incontinence, other symptoms of urinary tract dysfunction (including frequent urination and urinary tract pain), defecation disorders, or pelvic organ prolapse. When we reviewed the indications for MRI, we identified 101 women whose MRI study was performed specifically to evaluate a pelvic floor disorder. We selected 40 consecutive women from this subgroup. Medical records were reviewed to confirm documentation of a pelvic floor disorder in each case.

Control subjects were drawn from among the 803 women whose MRI study was performed for an unrelated indication (ie, pelvic mass). In this group, we anticipated that the medical records would be insufficient in many cases to establish the presence or absence of a pelvic floor disorder. To accurately classify each woman as either a case patient (with pelvic floor disorder) or a control (without a pelvic floor disorder), we included only control subjects with adequate documentation, which was defined as a full gynecologic history and physical examination by a faculty gynecologist. We selected 100 consecutive women from this subgroup, anticipating that this sample would allow us to identify an adequate number of control subjects. Among these 100 women, the most common MRI indications were leiomyomata, pelvic mass, and known or suspected pelvic neoplasm.

From the medical record, we abstracted the subject’s age, parity, and race. We also recorded pelvic floor symptoms for patients with pelvic floor disorders. Because this was a retrospective study of existing records, this study received an exemption from formal review by the institutional review board.

The MRI studies were performed with the patient in the supine position with a pelvic coil. In most cases, fast-spin echo T2-weighted sequences were used. Among control subjects, the axial images were performed as T1-weighted sequences. According to our institution’s MRI protocol, cuts were taken 2 mm apart. The scans were performed on a 1.5-T system (General Electric, Milwaukee, WI), and images were reviewed on a General Electric Medical Systems Advantage workstation AW3.1. Investigators were blinded to the subjects’ pelvic floor symptoms.

Pelvimetry techniques were standardized between the investigators. Pelvimetry measurements were obtained from coronal, axial, and midsagittal images. By means of a coronal image that included the femoral heads and fovea, we measured the diameter of the transverse inlet (Figure 1). The transverse inlet was defined as the distance between the most superior aspects of the iliopectineal line. On the axial images, we measured the angle of the pubic arch (Figure 2), the intertuberous diameter (Figure 2), and the interspinous diameter (Figure 3). Finally, we used the midsagittal image (Figure 4) to measure the anteroposterior (AP) conjugate (defined as the distance from the sacral promontory to the most superior aspect of the symphysis), the obstetrical conjugate (the shortest distance between the sacral promontory and the symphysis), and the AP outlet (which we defined as the shortest distance between the symphysis and the tip of the coccyx). We also included two measures of sacral contour (Figure 5): the sacrococcygeal length (the distance from the sacral promontory to the tip of the coccyx), and the depth of the sacral curvature (measured as a perpendicular from the line defining sacrococcygeal length to the deepest portion of the sacral hollow).

View larger version (159K): [in this window] [in a new window]   Figure 1. Coronal image illustrating the transverse diameter of the inlet. Arrows indicate the iliopectinal line. Handa. Differences in the Bony Pelvis. Obstet Gynecol 2003.

View larger version (142K): [in this window] [in a new window]   Figure 2. Axial image at the level of the pubic arch and pubic tubercles, illustrating the angle of the pubic arch (white arrow) and the intertuberous diameter. Gray arrowheads mark the ischial tuberosities. Handa. Differences in the Bony Pelvis. Obstet Gynecol 2003.

View larger version (142K): [in this window] [in a new window]   Figure 3. Axial image at the level of the ischial spines. The interspinous diameter, defined as the distance between the apices of the spines, is shown. Handa. Differences in the Bony Pelvis. Obstet Gynecol 2003.

View larger version (174K): [in this window] [in a new window]   Figure 4. The midsagittal image illustrates three anteroposterior (AP) diameters. 1 = AP conjugate (defined as the distance from the sacral promontory to the most superior aspect of the symphysis); 2 = obstetrical conjugate (the shortest distance between the sacral promontory and the symphysis); 3 = AP outlet (which we defined as the shortest distance between the symphysis and the tip of the coccyx). Handa. Differences in the Bony Pelvis. Obstet Gynecol 2003.

View larger version (174K): [in this window] [in a new window]   Figure 5. Midsagittal image illustrating two measures of sacral contour. 1 = the sacrococcygeal length (the distance from the sacral promontory to the tip of the coccyx); 2 = the depth of the sacral curvature (measured as a perpendicular line from the sacrococcygeal length to the deepest portion of the sacral hollow). Handa. Differences in the Bony Pelvis. Obstet Gynecol 2003.

We used the three-dimensional capabilities of MRI to identify and characterize the posterior pelvis. Each point in the three-dimensional pelvis can be described by three coordinates (ie, superior–inferior, anterior–posterior, and right–left). We were able to identify the three-dimensional coordinates of the transverse inlet diameter (Figure 1) and to use these coordinates to divide the pelvis into anterior and posterior segments. Specifically, the superior–inferior and anterior–posterior MRI coordinates of this line were identified on the coronal image (Figure 1). Then, the point corresponding to these coordinates was plotted on the midsagittal image (Figure 6). This point was used to divide the pelvis into anterior and posterior segments. A similar process was used to divide the AP outlet into anterior and posterior segments; we used the intertuberous diameter (identified on the axial images) to separate these segments.

View larger version (173K): [in this window] [in a new window]   Figure 6. Illustration of our technique for dividing the anteroposterior (AP) diameter into its anterior and posterior segments. The superoinferior and AP coordinates of the diameter of the pelvic inlet are taken from the coronal image (as in Figure 1) and plotted on the midsagittal image (*). A perpendicular line through this point is drawn from these coordinates to the AP diameter. Thus, the arrows mark the line that defines the AP diameter of the posterior segment. Handa. Differences in the Bony Pelvis. Obstet Gynecol 2003.

Continuous variables are presented as mean and standard deviation. For comparisons between groups, significant differences were identified by alpha < .05. Continuous variables were compared by unpaired t test. An assumption of equal variance between groups was evaluated for each continuous variable by the F test. Categorical variables were compared by ² analysis or the Fisher exact test. We then used multiple logistic regression analysis to identify differences in the pelvic measurements of women with and without pelvic floor disorders. Variables that were of marginal significance in the initial analysis (P < .10) were included in the multivariable model. Finally, we examined the correlation between pelvimetry measures via a correlation matrix. All statistical analysis was performed with Stat-View 5.0.1 (SAS Institute, Cary, NC.)

	RESULTS

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Of 140 medical records reviewed, 42 were excluded because of insufficient data. For the remaining 98 subjects, the medical record included a full gynecologic history and physical examination by a faculty gynecologist. From this group, we identified 59 women with pelvic floor disorders and 39 women without pelvic floor disorders.

Among the 59 women with pelvic floor disorders, the most common complaints were stress incontinence (81.4%) and symptomatic pelvic organ prolapse (79.7%). Other complaints included urinary urge incontinence (47.5%), fecal incontinence (32.2%), defecation disorders (28.8%), and other chronic lower urinary tract complaints (10.2%). There was overlap of these disorders: 8.5% had one disorder, 35.6% had two disorders, and 55.9% had three or more disorders.

The demographic characteristics of the subjects are shown in Table 1. As noted, women with pelvic floor disorders were more likely to be older, white, and of higher parity than women without pelvic floor disorders.

We observed significant differences in mean pelvimetry measurements between women with and without pelvic floor disorders (Table 2). Specifically, women with pelvic floor disorders had a wider transverse inlet diameter (P < .01), wider intertuberous diameter (P < .01), wider interspinous diameter (P < .01), narrower AP outlet (P = .05), longer sacrococcygeal length (P = .04), and deeper sacral curvature (P < .01). For all measures, the variances did not differ significantly between groups.

In a separate analysis, we compared the pelvimetry measures of white and black women. We found that black women had narrower intertuberous diameters (12.2 ± 1.4 cm versus 13.0 ± 1.5 cm, P = .05), narrower obstetrical conjugates (11.4 ± 1.0 cm versus 12.0 ± 1.0 cm, P = .03), narrower AP conjugates (11.5 ± 1.1 cm versus 12.2 ± 0.9 cm, P = .01), and wider AP outlets (11.1 ± 1.2 cm versus 9.7 ± 1.4 cm, P < .01).

As expected, many of the pelvimetry measures were strongly correlated with each other. We identified strong correlations between the intertuberous diameter and three other measurements: the transverse diameter of the inlet (correlation coefficient = 0.56), the angle of the pubic arch (0.67), and the interspinous diameter (0.61). There was also a strong correlation between the AP conjugate and obstetrical conjugate (0.89). Finally, there were also strong inverse correlations between the depth of the sacral curvature and the AP outlet (-0.71) and the sacrococcygeal length (-0.64).

We used multiple regression analysis to identify characteristics associated with pelvic floor dysfunction. Variables that were of marginal significance in the initial analysis (P < .10) were included in the multivariable model. However, because of the correlation between interspinous and intertuberous diameters, and because of the poor interobserver reliability for the intertuberous diameter, this variable was dropped from the model. We elected to include the obstetrical conjugate in the multivariable model because of the traditional emphasis on the clinical relevance of this measure in obstetrics. The regression model is shown in Table 3. Pelvic floor disorders were significantly associated with increasing age, a wider transverse pelvic inlet, and a shorter obstetrical conjugate. There was a nonsignificant association between pelvic floor disorders and a wider interspinous diameter. The apparent effect of race was not significant after controlling for these pelvic dimensions.

Finally, we examined the effect of the traditional obstetrical criteria for a normal or "adequate" pelvis. These are the dimensions traditionally used to identify women whose pelvis is of adequate size for vaginal delivery.¹⁵ These criteria include a transverse inlet 12 cm or more, an interspinous diameter 10 cm or more, and an obstetrical conjugate 10 cm or more. By use of these criteria, we found that 9.5% (8 of 84) had an inadequate transverse diameter of the inlet, 13.3% (12 of 90) had an inadequate interspinous diameter, and 3.3% (3 of 91) had an inadequate obstetrical conjugate. Overall, 18 women (22% of 79 with complete data) had at least one inadequate pelvic diameter. Women with pelvic floor disorders were less likely to have inadequate pelvimetry: at least one inadequate measurement was observed in 8 (15%) of 45 of women with pelvic floor disorders, compared with 10 (38%) of 26 of women without pelvic floor disorders (P < .02).

	DISCUSSION

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Historically, clinical and x-ray pelvimetry were used to determine candidates for cesarean delivery in cases of suspected cephalopelvic disproportion, after a previous cesarean, or in breech presentation.^16–18 More recently, the clinical utility of this approach has been questioned,¹⁹ and its use has been largely abandoned in modern obstetrics.

In recent times, interest has emerged in the use of elective cesarean delivery to reduce maternal birth trauma and decrease long-term morbidity.^5,7 However, at this point, we do not have reliable antepartum criteria to identify women most likely to develop pelvic floor injuries during childbirth. In one study, the angle of the pubic arch, measured at physical examination, was found to be strongly associated with postpartum anal incontinence.¹⁰ This study was undertaken to address our hypothesis that there is a bony pelvic phenotype associated with an increased risk of pelvic floor disorders.

We found that a wider transverse inlet and a shorter obstetrical conjugate were significantly associated with pelvic floor disorders. Most notably, women with a transverse outlet greater than 13.9 cm were 7.2 times more likely to have a pelvic floor disorder. Our results are consistent with an earlier study of computed tomographic pelvimetry in women with pelvic organ prolapse and hospital controls.¹¹ In that study, women with prolapse had a wider transverse inlet.

By use of traditional categories for pelvic type, our findings suggest that women with a platypelloid pelvic shape (wide, ovoid inlet) are at greatest risk for pelvic floor disorders. The pelvic type at lowest risk may be the anthropoid (heart-shaped) pelvis, with a narrow transverse inlet, wide obstetrical conjugate, and narrow spines. The anthropoid pelvis is more prevalent in black women,^14,15 who have a lower prevalence of pelvic organ prolapse³ and stress urinary incontinence.²⁰ These observations raise the question of whether differences in pelvic architecture might be responsible for observed differences in racial patterns of pelvic floor disorders. In our study cohort, white women were more likely to have pelvic floor disorders, but this association disappeared once we controlled for the effects of age and pelvic dimensions. However, further studies are necessary to confirm our observations and to identify the mechanism for observed associations. We speculate that certain pelvic types put women at increased risk of neuromuscular injury to the pelvic floor. We further speculate that these injuries may occur in association with pregnancy and delivery, or may be associated with other conditions and events unrelated to childbearing. Specifically, the short obstetrical conjugate may result in more trauma to the structures along the anterior sacrum, including the origins of the levator ani, the uterosacral ligaments, and the hypogastric nerve. Alternatively, the platypelloid pelvis, which has been associated with deep transverse arrest in labor, may predispose the patient to neuropathy through its association with a prolonged second stage of labor.

Despite our attempts to examine the effect of the posterior pelvic segment on pelvic floor disorders, we were unable to identify significant differences in these measures between women with and without pelvic floor disorders. Our measures had relatively high standard deviations, suggesting that a larger study would be needed to examine this question. We believe that the multiplanar images obtained with MRI will facilitate further research on the significance of the posterior pelvis.

We were not able to confirm the findings of Frudinger and colleagues,¹⁰ who found that a narrow pubic arch (less than 90°) was associated with postpartum anal incontinence. We did not observe an association between a narrow arch and pelvic floor disorders. There are several possible reasons for this discrepancy. First, the Frudinger study measured the arch clinically, whereas we measured the arch on axial magnetic resonance images. The median angle in the Frudinger study was 106°, whereas the mean angle in the present study was 84°. Thus, we speculate that these two techniques may not be measuring the same anatomic feature. Second, we considered women with a variety of pelvic floor disorders. We cannot therefore exclude the possibility that a narrow arch is associated with fecal incontinence but not with other pelvic floor disorders. Finally, the Frudinger study failed to find an association between the angle of the arch and maternal trauma. Thus, the decline in continence observed 3 to 8 months after delivery was not explained by sphincter trauma or perineal lacerations. Further research is needed to determine the relationship between maternal bony pelvimetry and obstetrical injuries. To further examine whether obstetrical trauma is associated with certain features of bony pelvic anatomy, we plan a case-control study of MRI pelvimetry in primiparous women with and without obstetrical lacerations.

We found that the measure of the intertuberous diameter had poor reproducibility. This has been previously reported.¹³ The ischial tuberosities are relatively large, irregular structures, making the medial edge of the tuberosity difficult to identify. Improved standardization of measures might improve the interobserver reliability of this measure.

Finally, we should acknowledge the limitations of the present study. Our study was limited by its retrospective design. Also, we considered all pelvic floor disorders as a single group. Unfortunately, we did not have a sufficient sample size to examine disorders individually. A larger sample size would have allowed us to estimate the odds ratios with greater precision. In addition, we did not have detailed information about the subjects’ obstetrical history, limiting our ability to control for obstetrical interventions such as forceps deliveries. Finally, our participants were selected from a group of women undergoing MRI of the pelvis at our institution, and this cohort is probably not typical of all adult women. A larger, prospective case-control study of women with and without pelvic floor disorders is planned. We hope that these future studies will improve our understanding of the apparent association between bony pelvic architecture and pelvic floor disorders.

	Footnotes

 
doi:10.1016/j.obstetgynecol.2003.08.022

Received June 6, 2003. Received in revised form August 7, 2003. Accepted August 19, 2003.

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3. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women’s Health Initiative: Gravity and gravidity. Am J Obstet Gynecol 2002;186:1160–6.[Medline]

4. DeLancey JO, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 2003;101:46–53.[Abstract/Free Full Text]

5. Faridi A, Willis S, Schelzig P, Siggelkow W, Schumpelick V, Rath W. Anal sphincter injury during vaginal delivery—An argument for cesarean section on request? J Perinat Med 2002;30:379–87.[Medline]

6. O’Boyle AL, Davis GD, Calhoun BC. Informed consent and birth: Protecting the pelvic floor and ourselves. Am J Obstet Gynecol 2002;187:981–3.[Medline]

7. Heit M, Mudd K, Culligan P. Prevention of childbirth injuries to the pelvic floor. Curr Womens Health Rep 2001;1:72–80.[Medline]

8. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol 2001;98:225–30.[Abstract/Free Full Text]

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14. Moloy HC, Steer CM. Moloy’s evaluation of the pelvis in obstetrics. Philadelphia: Saunders, 1959.

15. Cunningham FG, Williams JW. Williams obstetrics. Norwalk, Connecticut: Appleton & Lange, 1993.

16. Christian SS, Brady K, Read JA, Kopelman JN. Vaginal breech delivery: A five-year prospective evaluation of a protocol using computed tomographic pelvimetry. Am J Obstet Gynecol 1990;163:848–55.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Handa, V. L. Articles by Cundiff, G. Search for Related Content PubMed PubMed Citation Articles by Handa, V. L. Articles by Cundiff, G.