Interactions among pelvic organ protrusion, levator ani descent, and hiatal enlargement in women with and without prolapse

Background Pelvic organ prolapse has 2 components: (1) protrusion of the pelvic organs beyond the hymen; and (2) descent of the levator ani. The Pelvic Organ Prolapse Quantification system measures the first component, however, there remains no standard measurement protocol for the second mechanism. Objective We sought to test the hypotheses that: (1) difference in the protrusion area is greater than the area created by levator descent in prolapse patients compared with controls; and (2) prolapse is more strongly associated with levator hiatus compared to urogenital hiatus. Study Design Midsagittal magnetic resonance imaging scans from 30 controls, 30 anterior predominant, and 30 posterior predominant prolapse patients were assessed. Levator area was defined as the area above the levator ani and below the sacrococcygeal inferior pubic point line. Protrusion area was defined as the protruding vaginal walls below the levator area. The levator hiatus and urogenital hiatus were measured. Bivariate analysis and multiple comparisons were performed. Bivariate logistic regression was performed to assess prolapse as a function of levator hiatus, urogenital hiatus, levator area, and protrusion. Pearson correlation coefficients were calculated. Results The levator area for the anterior (34.0 ± 6.5 cm 2 ) and posterior (35.7 ± 8.0 cm 2 ) prolapse groups were larger during Valsalva compared to controls (20.9 ± 7.8 cm 2 , P 2 ) and posterior (14.4 ± 5.7 cm 2 ) prolapse groups were both larger compared to controls (5.0 ± 1.8 cm 2 , P P P 2 vs 9.4 ± 5.9 cm 2 , P P ≤ .001, for all comparisons). Conclusion In prolapse, the levator area increases more than the protrusion area and both the urogenital hiatus and levator hiatus are larger. The odds of prolapse for an increase in the urogenital hiatus are 3 times larger than for the levator hiatus, which leads us to reject both the original hypotheses.