A novel measurement of pelvic floor cross-sectional area in older and younger women with and without prolapse

Published:August 08, 2019DOI:


      An increase in size of the aperture of the pelvis that must be spanned by pelvic floor support structures translates to an increase in the force on these structures. Prior studies have measured the bony dimensions of the pelvis, but the effect of changes in muscle bulk that may affect the size of this area are unknown.


      To develop a technique to evaluate the aperture size in the anterior pelvis at the level of the levator ani muscle attachments, and to identify age-related changes in women with and without prolapse.

      Materials and Methods

      This was a technique development and pilot case-control study evaluating pelvic magnetic resonance imaging from 30 primiparous women from the Michigan Pelvic Floor Research Group MRI Data Base: 10 younger women with normal support, 10 older women with prolapse, and 10 older menopausal women without prolapse. Anterior pelvic area measurements were made in a plane that included the bilateral ischial spines and the inferior pubic point, approximating the level of the arcus tendineus fascia pelvis. Measurements of the anterior pelvic area, obturator internus muscles, and interspinous diameter were made by 5 independent raters from the Society of Gynecologic Surgeons Pelvic Anatomy Group who focused on developing pelvic imaging techniques, and evaluating interrater reliability. Demographic characteristics were compared across groups of interest using the Wilcoxon rank sum test, χ2, or Fisher exact test where appropriate. Multiple linear regression models were created to identify independent predictors of anterior pelvic area.


      Per the study design, groups differed in age and prolapse stage. There were no differences in race, height, body mass index, gravidity, or parity. Patients with prolapse had a significantly longer interspinous diameter, and more major (>50% of the muscle) levator ani defects when compared to both older and younger women without prolapse. Interrater reliability was high for all measurements (intraclass correlation coefficient = 0.96). The anterior pelvic area (cm2) was significantly larger in older women with prolapse compared to older (60 ± 5.1 vs 53 ± 4.9, P = .004) and younger (60 ± 5.1 vs 52 ± 4.6, P = .001) women with normal support. The younger and older women with normal support did not differ in anterior pelvic area (52 ± 4.6 vs 53 ± 4.9, P = .99). After adjusting for race and body mass index, increased anterior pelvic area was significantly associated with the following: being an older woman with prolapse (β = 6.61 cm2, P = .004), and interspinous diameter (β = 4.52 cm2, P = .004).


      Older women with prolapse had the largest anterior area, suggesting that the anterior pelvic area is a novel measure to consider when evaluating women with prolapse. Interspinous diameter, and being an older woman with prolapse, were associated with a larger anterior pelvic area. This suggests that reduced obturator internus muscle size with age may not be the primary factor in determining anterior pelvic area, but that pelvic dimensions such as interspinous diameter could play a role. The measurements were highly repeatable. The high intraclass correlation coefficient indicates that all raters were able to successfully learn the imaging software and to perform measurements with high reproducibility.

      Key words

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        • Olsen A.L.
        • Smith V.J.
        • Bergstrom J.O.
        • Colling J.C.
        • Clark A.L.
        Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence.
        Obstet Gynecol. 1997; 89: 501-506
        • Hendrix S.L.
        • 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: 1160-1166
        • Wu J.M.
        • Matthews C.A.
        • Conover M.M.
        • Pate V.
        • Jonsson Funk M.
        Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery.
        Obstet Gynecol. 2014; 123: 1201-1206
        • Friedman T.
        • Eslick G.D.
        • Dietz H.P.
        Risk factors for prolapse recurrence: systematic review and meta-analysis.
        Int Urogynecol J. 2018; 29: 13-21
        • Jelovsek J.E.
        • Barber M.D.
        • Brubaker L.
        • et al.
        Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcomes and prolapse symptoms at 5 years in the OPTIMAL randomized clinical trial.
        JAMA. 2018; 319: 1554-1565
        • Nygaard I.
        • Brubaker L.
        • Zyczynski H.M.
        • et al.
        Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse.
        JAMA. 2013; 309: 2016-2024
        • Wu J.M.
        • Kawasaki A.
        • Hundley A.F.
        • Dieter A.A.
        • Myers E.R.
        • Sung V.W.
        Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050.
        Am J Obstet Gynecol. 2011; 205: 230
        • Nygaard I.
        • Barber M.D.
        • Burgio K.L.
        • et al.
        Prevalence of symptomatic pelvic floor disorders in US women.
        JAMA. 2008; 300: 1311-1316
      1. Sze EH, Sherard GB, 3rd, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol 2002;100:981-986.

        • DeLancey J.O.L.
        • Morgan D.M.
        • Fenner D.E.
        • et al.
        Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse.
        Obstet Gynecol. 2007; 109: 295-302
        • Berger M.B.
        • Doumouchtsis S.K.
        • Delancey J.O.
        Are bony pelvis dimensions associated with levator ani defects? A case-control study.
        Int Urogynecol J. 2013; 24: 1377-1383
        • Sze E.H.
        • Kohli N.
        • Miklos J.R.
        • Roat T.
        • Karram M.M.
        Computed tomography comparison of bony pelvis dimensions between women with and without genital prolapse.
        Obstet Gynecol. 1999; 93: 229-232
        • Handa V.L.
        • Pannu H.K.
        • Siddique S.
        • Gutman R.
        • VanRooyen J.
        • Cundiff G.
        Architectural differences in the bony pelvis of women with and without pelvic floor disorders.
        Obstet Gynecol. 2003; 102: 1283-1290
        • Morris V.C.
        • Murray M.P.
        • Delancey J.O.
        • Ashton-Miller J.A.
        A comparison of the effect of age on levator ani and obturator internus muscle cross-sectional areas and volumes in nulliparous women.
        Neurourol Urodynam. 2012; 31: 481-486
        • Chen L.
        • Lisse S.
        • Larson K.
        • Berger M.B.
        • Ashton-Miller J.A.
        • DeLancey J.O.
        Structural failure sites in anterior vaginal wall prolapse: identification of a collinear triad.
        Obstet Gynecol. 2016; 128: 853-862
        • DeLancey J.O.
        • 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
        • DeLancey J.O.
        • Morgan D.M.
        • Fenner D.E.
        • et al.
        Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse.
        Obstet Gynecol. 2007; 109: 295-302
        • Brown K.M.
        • Handa V.L.
        • Macura K.J.
        • DeLeon V.B.
        Three-dimensional shape differences in the bony pelvis of women with pelvic floor disorders.
        Int Urogynecol J. 2013; 24: 431-439
        • Stein T.A.
        • Kaur G.
        • Summers A.
        • Larson K.A.
        • DeLancey J.O.
        Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse.
        Am J Obstet Gynecol. 2009; 200: 241
        • Baragi R.V.
        • Delancey J.O.
        • Caspari R.
        • Howard D.H.
        • Ashton-Miller J.A.
        Differences in pelvic floor area between African American and European American women.
        Am J Obstet Gynecol. 2002; 187: 111-115
        • Handa V.L.
        • Lockhart M.E.
        • Fielding J.R.
        • et al.
        Racial differences in pelvic anatomy by magnetic resonance imaging.
        Obstet Gynecol. 2008; 111: 914-920
        • Tracy P.V.
        • DeLancey J.O.
        • Ashton-Miller J.A.
        A geometric capacity-demand analysis of maternal levator muscle stretch required for vaginal delivery.
        J Biomech Eng. 2016; 138: 021001
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174