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Title: The biomechanical effects of levator ani muscle laceration injuries after vaginal delivery Objectives: The aim of this thesis is to sum up current knowledge about the normal structure and function of levator ani muscle and findings about dysfunctions of a pelvic floor. By means of biomechanical instruments to analyse how the lower part of levator ani muscle closes (puborectalis muscle) during unilateral avulsion lesion. On the basis of computer simulation of biomechanical properties of the pelvic floor during avulsion lesion to describe the theoretical solutions for the therapy of the main types of dysfunctions of the pelvic floor. Methods: Biomechanical analysis was used with a help of computer model of muscular pelvic floor with a help of the ABAQUS model. This model with matched properties of muscular tissue was influenced by the standard pressure which influences the pelvic floor for a person of 80 kilos standing at rest. This model simulated unilateral avulsion lesion and biomechanical variables were observed during compensatory activation of uninjured parts of levator with the activity 100%, 50% and 10%. The map of the muscular tone and the rate of movement of the muscles of the pelvic floor were evaluated. Results: Only minimal movement is observed in the intact pelvic floor during...

Pelvic floor disorder is an emerging research area and is highlighted in many pelvic floor studies. Assessment methods for this type of injury are lacking and new methods for prevention and diagnosis are needed. Pelvic floor disorders are common among women and can lead to suffering for the patient. Levator ani muscle injuries are the main cause for pelvic floor disorders. This muscle group is an anisotropic skeletal muscle that helps support the pelvic viscera. Assessment of this muscle is difficult due to its complex geometry and location. Therefore, two muscle phantoms were constructed to mimic different properties of the levator ani muscle. The muscle phantoms provided more availability and a more controlled setting. The muscle phantoms were examined using ultrasound-based shear wave elastography which is an elastography method that can help determine the elasticity of tissue. A PVA-graphite phantom and a water-based gelatine-graphite phantom, both with fishing lines network as fibers for anisotropy, were constructed in this project. Shear wave elastography results of the PVA phantom indicated no anisotropy but visually resembled a muscle. Although not achieving anisotropy, the shear modulus of the PVA did match the shear modulus of skeletal muscle tissue. Shear wave elastography results of the gelatine phantom indicated anisotropy but visually did not resemble a muscle due to the low shear modulus of the gelatine. A 3D model of the female bony pelvis, that was provided for this project, was measured, and compared with reference value of previous study for future construction and 3D printing of the model. Results of measurements showed similarities between the 3D model and the female pelvis except for the sagittal outlet which had a deviant value. For future work, the muscle phantom can be developed by applying the complex geometry of the levator ani muscle, assembly of the muscle phantom, and the 3D rendering of the pelvis. The combination of these two parts provides a more complete phantom where shear wave elastography can be applied in the same way as in female patients. / Bäckenbottenbesvär är ett framväxande forskningsområde och lyfts fram i många bäckenbottenstudier. Bedömningsmetoder för denna typ av skador saknas och det behövs nya metoder för förebyggande och diagnostik. Bäckenbottenbesvär är vanliga bland kvinnor och kan leda till lidande för patienten. Levator ani muskelskador är den främsta orsaken till bäckenbottensjukdomar. Denna muskelgrupp är en anisotrop skelettmuskel som hjälper till att stödja inälvorna i bäckenet. Bedömning av denna muskel är svår på grund av dess komplexa geometri och läge. Därför konstruerades två muskelfantomer för att efterlikna olika egenskaper hos levator ani-muskeln. Muskelfantomerna gav mer tillgänglighet och en mer kontrollerad inställning. Muskelfantomerna undersöktes med hjälp av ultraljudsbaserad skjuvvågselastografi som är en metod som kan hjälpa till att bestämma vävnadens elasticitet. En PVA-grafitfantom och en vattenbaserad gelatin-grafitfantom, båda med fiskelinsnätverk som fibrer för anisotropi, konstruerades i detta projekt. Resultat från skjuvvågselastografi på PVA-fantomen indikerade ingen anisotropi, men liknade visuellt en muskel. Även då anisotropi inte uppnåddes, så matchade skjuvmodulen för PVA skjuvmodulen för skelettmuskelvävnad. Resultat från skjuvvågselastografi på gelatinfantomen indikerade anisotropi dock visade resultatet ingen visuell liknelse av en skelettmuskel på grund av gelatinets låga skjuvmodul. En 3D modell av bäckenbenet, som förseddes det här projektet, mättes och jämfördes med referensvärde av tidigare studie för framtid 3D friformsframställning av modellen. Resultat av mätningar visade på liknelser mellan 3D modellen och det kvinnliga bäckenbenet förutom sagittal outlet som hade ett avvikande värde. Inför fortsättning av det här projektet kan en utveckling av muskel fantomen ske genom applicering av den komplexa geometrin hos levator ani muskeln samt sammansättning av muskel fantomen och 3D framställningen av bäckenbenet. Sammansättningen av dessa två delar ger en mer komplett fantom där skjuvvågselastografi kan appliceras på samma sätt som hos kvinnliga patienter. / Ja

During repetitive stimulation of motor nerve terminals, mitochondrial Ca2+ uptake limits increases in free cytosolic [Ca2+] and helps ensure faithful neuromuscular transmission. Changes in cytosolic [Ca2+] and in mitochondrial [Ca2+] as well as changes in mitochondrial membrane potential (Psi m) were studied in mouse motor nerve terminals using Ca2+ sensitive indicator and potentiometric dyes, respectively. Trains of action potentials (APs) at 50 to 100 Hz produced a rapid increase in mitochondrial [Ca2+] followed by a plateau which usually continued beyond the end of stimulation. After stimulation, mitochondrial [Ca2+] decayed back to baseline over the course of tens of seconds to minutes. Increasing the Ca2+ load delivered to the terminal by increasing the number of stimuli (500-2000), increasing bath [Ca2+], or prolonging the AP with 3,4-diaminopyridine (3-4, DAP, 100 micromolar), prolonged the post-stimulation decay of mitochondrial [Ca2+] without increasing the amplitude of the plateau. Inhibiting openings of the mitochondrial permeability transition pore with cyclosporin A (5 micromolar) had no significant effect on the decay of mitochondrial [Ca2+]. Inhibition of the mitochondrial Na+-Ca2+ exchanger with CGP-37157 (50 micromolar) dramatically prolonged the post-stimulation decay of mitochondrial [Ca2+], reduced post-stimulation residual cytosolic [Ca2+], and reduced the amplitude of end-plate potentials evoked after the end of stimulation. Stimulation-induced mitochondrial Ca2+ uptake resulted in Psi m depolarizations that were small or undetectable at near-physiological temperatures (~30 degrees C). Their amplitude became larger at lower temperatures (~20 degrees C), or when AP duration was increased with 3,4-DAP (20 micromolar). Psi m depolarizations were inhibited by lowering bath [Ca2+] or by blocking P/Q-type Ca2+ channels with omega-agatoxin (0.3 micromolar). Partial inhibition of complex I of the electron transport chain (ETC) with rotenone (50 nM) increased the amplitude of stimulation-induced Psi m depolarizations. These findings suggest that: (1) Ca2+ extrusion from motor terminal mitochondria occurs primarily via the Na+-Ca2+ exchanger and helps sustain post-tetanic transmitter release, and (2) that the depolarization of Psi m that accompanies Ca2+ uptake is limited by accelerated proton extrusion via the ETC.

Purpose: Intravaginal probes used for recording electromyography (EMG) from the pelvic floor muscles (PFMs) likely record activity from nearby muscles (crosstalk), and move during functional tasks, causing motion artifact data contamination, threatening the validity of results obtained. This study investigated the test-retest reliability and validity of surface EMG recordings from the PFMs using a novel, theoretically superior electrode in comparison to a commercially available intravaginal probe, the FemiscanTM. Methods: Healthy subjects (n=20) performed tasks with each vaginal electrode in situ: i) PFM maximal voluntary contractions (MVC), ii) coughs, iii) unilateral hip adductor/external rotator contractions at 25%MVC, 50%MVC, and MVC while keeping the PFMs relaxed or maximally contracted, and iv) transversus abdominis contractions (TrA; recorded using fine-wires) at 25%MVC, 50%MVC, MVC. Analyses: i) Intraclass correlation coefficients (ICC), ii) t-tests of proportions (α=0.05), iii) repeated measures ANOVAs and Tukey’s post-hoc testing (α=0.05) and iv) cross-correlation functions between peaks of transversus abdominis and PFM activity were used to determine the between-trial and between-day reliability of each vaginal electrode, a difference in prevalence of motion artifact contamination between electrodes, and the presence of crosstalk from the hip and TrA, respectively. Results: Between-trial reliability of both vaginal electrodes was excellent (ICC(3,1)=0.943-0.974). Between-day reliability was less consistent (ICC(3,1)=0.788-0.924 and 0.648-0.715 for the FemiscanTM and novel electrode, respectively). No significant difference in the proportion of files contaminated with motion artifact using each electrode existed. At submaximal intensities of hip muscle contractions, the FemiscanTM recorded significantly higher EMG amplitudes compared to what it recorded when the hip was relaxed, whereas the novel electrode did not, indicating that the FemiscanTM recorded crosstalk from the hip musculature. Low cross-correlation coefficients (<0.90) and large time delays (≥ 0.5 milliseconds) between peaks of PFM and TrA activity indicated that neither vaginal electrode recorded crosstalk from the TrA. Conclusion: The novel electrode is a promising tool to record EMG from the PFMs, as it records less crosstalk from the hip musculature than current technology while maintaining a high degree of reliability when comparing results collected within the same session; however, this electrode should not be used to compare one’s muscle activity between days. / Thesis (Master, Rehabilitation Science) -- Queen's University, 2011-02-07 14:46:30.811

The sexual differentiation of the spinal nucleus of bulbocavernosus (SNB) and the bulbocavernosus (BC) and levator ani (LA) muscles that the SNB innervates, are masculinized by androgens acting on the BC/LA. The site of androgen receptors (AR) responsible for the masculinization of the neuromuscular system is not known. A potential site of action is satellite cells: proliferation of these cells is androgen-dependent and satellite cells seem to contribute to the size of the LA. Fluorescent immunohistochemistry and confocal microscopy were used to co-localize satellite cells and AR within the LA of postnatal day one and three male and female rats. Results indicate that satellite cells express AR and reveal a difference in proportion of satellite cells expressing AR between the LA and control muscle. Interpretations of these findings, including whether the relatively small proportion of AR accounted for by satellite cells is enough to masculinize the SNB system, are discussed.

The sexual differentiation of the spinal nucleus of bulbocavernosus (SNB) and the bulbocavernosus (BC) and levator ani (LA) muscles that the SNB innervates, are masculinized by androgens acting on the BC/LA. The site of androgen receptors (AR) responsible for the masculinization of the neuromuscular system is not known. A potential site of action is satellite cells: proliferation of these cells is androgen-dependent and satellite cells seem to contribute to the size of the LA. Fluorescent immunohistochemistry and confocal microscopy were used to co-localize satellite cells and AR within the LA of postnatal day one and three male and female rats. Results indicate that satellite cells express AR and reveal a difference in proportion of satellite cells expressing AR between the LA and control muscle. Interpretations of these findings, including whether the relatively small proportion of AR accounted for by satellite cells is enough to masculinize the SNB system, are discussed.

Pelvic floor dysfunction in the form of pelvic organ prolapse (POP) is a common gynaecological condition, especially in the elderly. Although the aetiology is poorly understood, several risk factors such as vaginal childbirth, chronically raised intra-abdominal pressure (such as asthma and chronic constipation), ageing, previous hysterectomy and connective tissue disorders are thought to play a role in the pathophysiology of POP. Studies have shown that vaginal childbirth can result in both gross and micro-architectural distortion/alteration of the pelvic floor musculature and is thus considered to play a major role in the development of POP. Although ethnicity has been proposed as a risk factor, there are limited studies on this subject. Recently, transperineal ultrasound (TPUS) has been used to study the structural integrity and the dynamic interaction between the pelvic organs and pelvic floor musculature. Using a specified methodology we intended to determine and compare pelvic floor morphology, namely pelvic organ descent and levator hiatal distensibility in a multi-ethnic South African population (Asian, Caucasian and Black) in both asymptomatic nulliparous and symptomatic multiparous women. Secondly we also intended to study the association between prolapse symptoms and functional anatomy of the pelvic floor, and finally to determine the impact of vaginal childbirth on the pelvic floor morphology 3-6 month postpartum. For all the studies women were recruited from the local nursing school, general gynaecology and tertiary urogynaecology clinic. Pregnant women were recruited from the district antenatal clinic. This cohort included only Black pregnant women. After informed consent all ultrasound volumes were acquired at rest, maximal pelvic floor contraction and Valsalva maneuver. Volumes were deindentified and analysed 6-8 weeks later using GE Kretz 4D View (GE Kretztechnik Gmbh, Zipf, Austria). In the nulliparous cohort, we found that Black South African women had greater pelvic organ descent on ultrasound and clinically and greater distensibility compared to South Asian and Caucasian women. Multivariate modelling revealed that Black 2 ethnicity remained a significant factor for pelvic organ mobility on clinical examination, (P=0.024). In women with symptomatic POP, there was significant variation in clinical prolapse stage, levator distensibility and pelvic organ descent in this racially diverse population presenting with pelvic organ prolapse, with South Asians having a lower avulsion rate than the other two ethnic groups (P= 0.014). As regards the association between prolapse symptoms and functional anatomy of the pelvic floor we found a significant association between awareness, visualization and/or feeling of a vaginal lump and abnormal pelvic floor functional anatomy, that is, hiatal ballooning and levator avulsion (all P< 0.05). The fourth part of the study included eighty four women who returned at a mean of 4.8 months postpartum. We found significant alteration in pelvic organ support and levator hiatal distensibility after vaginal delivery i.e. a significant increase in mean values from ante to postpartum measurements, more so for the vaginal delivery group. 15% of Black primiparous women sustained levator trauma after their first vaginal delivery. In conclusion, to the author‘s knowledge this is the first study on pelvic floor morphology in South African women. Contrary to previous publications inferring that Black women rarely develop PFD, we have shown that this particular ethnic group had significantly different pelvic floor dynamics than Caucasian and South Asian women for both nulliparous and multiparous symptomatic women. Levator trauma occurs in 15% of Black women after vaginal childbirth. / Thesis (PhD)--University of Pretoria, 2017. / Obstetrics and Gynaecology / PhD / Unrestricted

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