Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse

Adi Y Weintraub, Hannah Glinter, Naama Marcus-Braun, Adi Y Weintraub, Hannah Glinter, Naama Marcus-Braun

Abstract

The exact prevalence of pelvic organ prolapse is difficult to establish. The anatomical changes do not always consist with the severity or the symptoms associated with prolapse. There are many risk factors associated with pelvic organ prolapse and this review aims to identify the epidemiology and pathophysiology while looking at the known risk factors for pelvic organ prolapse. PubMed search involved a number of terms including: epidemiology, risk factors, reoccurrence indicators, management and evaluation. Several risk factors have been associated with pelvic organ prolapse, all contribute to weakening of the pelvic floor connective tissue/collagen, allowing the pelvic organs to prolapse through the vaginal walls. Among the risk factors are genetic background, childbirth and mode of delivery, previous hysterectomy, menopausal state and the ratio between Estrogen receptors. The "Integral theory" of Petros and the "Levels of Support" model of Delancey enable us to locate the defect, diagnose and treat pelvic organ prolapse. The currently available demographic data is not reliable enough to properly estimate the true extent of pelvic organ prolapse in the population. However, standardization of the diagnosis and treatment may significantly improve our ability to estimate the true incidence and prevalence of this condition in the coming years.

Keywords: Epidemiology; Pelvic Organ Prolapse; physiopathology [Subheading].

Conflict of interest statement

None declared.

Copyright® by the International Brazilian Journal of Urology.

Figures

Figure 1. Risk factors for pelvic organ…
Figure 1. Risk factors for pelvic organ prolapse, causing collagen weakness.
Figure 2*. Schematic diagram of the pelvis…
Figure 2*. Schematic diagram of the pelvis organs, ligaments, muscles and the connection between them according to the integral theory of Peter Petros.
*source www.intergraltheory.com, Petros with permission PUL = Pubourethral ligament; PCF = Pubocervocal fascia; ATFP = Arcus tendineus fascia pelvis; CL = Cardinal ligament/cervical ring; USL = Uterosacral ligament; RVF = Rectovaginal fascia; PB = Perineal body

References

    1. Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24:1783–1790.
    2. 1. Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24:1783-90.
    1. Tegerstedt G, Maehle-Schmidt M, Nyrén O, Hammarström M. Prevalence of symptomatic pelvic organ prolapse in a Swedish population. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:497–503.
    2. 2. Tegerstedt G, Maehle-Schmidt M, Nyrén O, Hammarström M. Prevalence of symptomatic pelvic organ prolapse in a Swedish population. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:497-503.
    1. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300:1311–1316.
    2. 3. Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300:1311-6.
    1. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol. 2003;189:372–377.
    2. 4. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol. 2003;189:372-7.
    1. Shah AD, Kohli N, Rajan SS, Hoyte L. The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:421–428.
    2. 5. Shah AD, Kohli N, Rajan SS, Hoyte L. The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:421-8.
    1. Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand Suppl. 1990;153:7–31.
    2. 6. Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand Suppl. 1990;153:7-31.
    1. 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;186:1160–1166.
    2. 7. 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.
    1. Summers A, Winkel LA, Hussain HK, DeLancey JO. The relationship between anterior and apical compartment support. Am J Obstet Gynecol. 2006;194:1438–1443.
    2. 8. Summers A, Winkel LA, Hussain HK, DeLancey JO. The relationship between anterior and apical compartment support. Am J Obstet Gynecol. 2006;194:1438-43.
    1. Aigmueller T, Dungl A, Hinterholzer S, Geiss I, Riss P. An estimation of the frequency of surgery for posthysterectomy vault prolapse. Int Urogynecol J. 2010;21:299–302.
    2. 9. Aigmueller T, Dungl A, Hinterholzer S, Geiss I, Riss P. An estimation of the frequency of surgery for posthysterectomy vault prolapse. Int Urogynecol J. 2010;21:299-302.
    1. Wu JM, Vaughan CP, Goode PS, Redden DT, Burgio KL, Richter HE, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014;123:141–148.
    2. 10. Wu JM, Vaughan CP, Goode PS, Redden DT, Burgio KL, Richter HE, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014;123:141-8.
    1. Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. Women: 2010 to 2050. Obstet Gynecol. 2009;114:1278–1283.
    2. 11. Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor disorders in U.S. Women: 2010 to 2050. Obstet Gynecol. 2009;114:1278-83.
    1. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol. 2001;184:1496–1501.
    2. 12. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol. 2001;184:1496-501.
    1. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89:501–506.
    2. 13. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89:501-6.
    1. Smith FJ, Holman CD, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 2010;116:1096–1100.
    2. 14. Smith FJ, Holman CD, Moorin RE, Tsokos N. Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol. 2010;116:1096-100.
    1. Toozs-Hobson P, Freeman R, Barber M, Maher C, Haylen B, Athanasiou S, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for reporting outcomes of surgical procedures for pelvic organ prolapse. Int Urogynecol J. 2012;23:527–535.
    2. 15. Toozs-Hobson P, Freeman R, Barber M, Maher C, Haylen B, Athanasiou S, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for reporting outcomes of surgical procedures for pelvic organ prolapse. Int Urogynecol J. 2012;23:527-35.
    1. Hallock JL, Handa VL. The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstet Gynecol Clin North Am. 2016;43:1–13.
    2. 16. Hallock JL, Handa VL. The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstet Gynecol Clin North Am. 2016;43:1-13.
    1. Ramalingam K, Monga A. Obesity and pelvic floor dysfunction. Best Pract Res Clin Obstet Gynaecol. 2015;29:541–547.
    2. 17. Ramalingam K, Monga A. Obesity and pelvic floor dysfunction. Best Pract Res Clin Obstet Gynaecol. 2015;29:541-7.
    1. de Sam Lazaro S, Nardos R, Caughey AB. Obesity and Pelvic Floor Dysfunction: Battling the Bulge. Obstet Gynecol Surv. 2016;71:114–125.
    2. 18. de Sam Lazaro S, Nardos R, Caughey AB. Obesity and Pelvic Floor Dysfunction: Battling the Bulge. Obstet Gynecol Surv. 2016;71:114-25.
    1. Lince SL, van Kempen LC, Vierhout ME, Kluivers KB. A systematic review of clinical studies on hereditary factors in pelvic organ prolapse. Int Urogynecol J. 2012;23:1327–1336.
    2. 19. Lince SL, van Kempen LC, Vierhout ME, Kluivers KB. A systematic review of clinical studies on hereditary factors in pelvic organ prolapse. Int Urogynecol J. 2012;23:1327-36.
    1. Segev Y, Auslender R, Feiner B, Lissak A, Lavie O, Abramov Y. Are women with pelvic organ prolapse at a higher risk of developing hernias? Int Urogynecol J Pelvic Floor Dysfunct. 2009;20:1451–1453.
    2. 20. Segev Y, Auslender R, Feiner B, Lissak A, Lavie O, Abramov Y. Are women with pelvic organ prolapse at a higher risk of developing hernias? Int Urogynecol J Pelvic Floor Dysfunct. 2009;20:1451-3.
    1. Alcalay M, Stav K, Eisenberg VH. Family history associated with pelvic organ prolapse in young women. Int Urogynecol J. 2015;26:1773–1776.
    2. 21. Alcalay M, Stav K, Eisenberg VH. Family history associated with pelvic organ prolapse in young women. Int Urogynecol J. 2015;26:1773-6.
    1. Veit-Rubin N, Cartwright R, Singh AU, Digesu GA, Fernando R, Khullar V. Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis. Int Urogynecol J. 2016;27:1469–1478.
    2. 22. Veit-Rubin N, Cartwright R, Singh AU, Digesu GA, Fernando R, Khullar V. Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis. Int Urogynecol J. 2016;27:1469-78.
    1. Reid RI, You H, Luo K. Site-specific prolapse surgery. I. Reliability and durability of native tissue paravaginal repair. Int Urogynecol J. 2011;22:591–599.
    2. 23. Reid RI, You H, Luo K. Site-specific prolapse surgery. I. Reliability and durability of native tissue paravaginal repair. Int Urogynecol J. 2011;22:591-9.
    1. Ward RM, Velez Edwards DR, Edwards T, Giri A, Jerome RN, Wu JM. Genetic epidemiology of pelvic organ prolapse: a systematic review. Am J Obstet Gynecol. 2014;211:326–335.
    2. 24. Ward RM, Velez Edwards DR, Edwards T, Giri A, Jerome RN, Wu JM. Genetic epidemiology of pelvic organ prolapse: a systematic review. Am J Obstet Gynecol. 2014;211:326-35.
    1. Patel DA, Xu X, Thomason AD, Ransom SB, Ivy JS, DeLancey JO. Childbirth and pelvic floor dysfunction: an epidemiologic approach to the assessment of prevention opportunities at delivery. Am J Obstet Gynecol. 2006;195:23–28.
    2. 25. Patel DA, Xu X, Thomason AD, Ransom SB, Ivy JS, DeLancey JO. Childbirth and pelvic floor dysfunction: an epidemiologic approach to the assessment of prevention opportunities at delivery. Am J Obstet Gynecol. 2006;195:23-8.
    1. Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. 2015;26:1559–1573.
    2. 26. Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. 2015;26:1559-73.
    1. Sze EH, Sherard GB, 3rd, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol. 2002;100(5 Pt 1):981–986.
    2. 27. Sze EH, Sherard GB 3rd, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol. 2002;100(5 Pt 1):981-6.
    1. Khunda A, Shek KL, Dietz HP. Can ballooning of the levator hiatus be determined clinically? Am J Obstet Gynecol. 2012;206:246.e1–244.e1.
    2. 28. Khunda A, Shek KL, Dietz HP. Can ballooning of the levator hiatus be determined clinically? Am J Obstet Gynecol. 2012;206:246.e1-4.
    1. Leijonhufvud A, Lundholm C, Cnattingius S, Granath F, Andolf E, Altman D. Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Am J Obstet Gynecol. 2011;204:70–70.
    2. 29. Leijonhufvud A, Lundholm C, Cnattingius S, Granath F, Andolf E, Altman D. Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Am J Obstet Gynecol. 2011;204:70.
    1. Handa VL, Blomquist JL, McDermott KC, Friedman S, Muñoz A. Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol. 2012;119(2 Pt 1):233–239.
    2. 30. Handa VL, Blomquist JL, McDermott KC, Friedman S, Muñoz A. Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol. 2012;119(2 Pt 1):233-9.
    1. Berger MB, Ramanah R, Guire KE, DeLancey JO. Is cervical elongation associated with pelvic organ prolapse? Int Urogynecol J. 2012;23:1095–1103.
    2. 31. Berger MB, Ramanah R, Guire KE, DeLancey JO. Is cervical elongation associated with pelvic organ prolapse? Int Urogynecol J. 2012;23:1095-103.
    1. Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol. 2008;198:572.e1–576.e1.
    2. 32. Altman D, Falconer C, Cnattingius S, Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol. 2008;198:572.e1-6.
    1. Blandon RE, Bharucha AE, Melton LJ 3rd, Schleck CD, Babalola EO, Zinsmeister AR, et al. Incidence of pelvic floor repair after hysterectomy: A population-based cohort study. Am J Obstet Gynecol. 2007;197:664–664.
    2. 33. Blandon RE, Bharucha AE, Melton LJ 3rd, Schleck CD, Babalola EO, Zinsmeister AR, et al. Incidence of pelvic floor repair after hysterectomy: A population-based cohort study. Am J Obstet Gynecol. 2007;197:664.
    1. Tinelli A, Malvasi A, Rahimi S, Negro R, Vergara D, Martignago R, et al. Age-related pelvic floor modifications and prolapse risk factors in postmenopausal women. Menopause. 2010;17:204–212.
    2. 34. Tinelli A, Malvasi A, Rahimi S, Negro R, Vergara D, Martignago R, et al. Age-related pelvic floor modifications and prolapse risk factors in postmenopausal women. Menopause. 2010;17:204-12.
    1. Sze EH, Hobbs G. A prospective cohort study of pelvic support changes among nulliparous, multiparous, and preand post-menopausal women. Eur J Obstet Gynecol Reprod Biol. 2012;160:232–235.
    2. 35. Sze EH, Hobbs G. A prospective cohort study of pelvic support changes among nulliparous, multiparous, and preand post-menopausal women. Eur J Obstet Gynecol Reprod Biol. 2012;160:232-5.
    1. Jackson SR, Avery NC, Tarlton JF, Eckford SD, Abrams P, Bailey AJ. Changes in metabolism of collagen in genitourinary prolapse. Lancet. 1996;347:1658–1661.
    2. 36. Jackson SR, Avery NC, Tarlton JF, Eckford SD, Abrams P, Bailey AJ. Changes in metabolism of collagen in genitourinary prolapse. Lancet. 1996;347:1658-61.
    1. Vardy MD, Lindsay R, Scotti RJ, Mikhail M, Richart RM, Nieves J, et al. Short-term urogenital effects of raloxifene, tamoxifen, and estrogen. Am J Obstet Gynecol. 2003;189:81–88.
    2. 37. Vardy MD, Lindsay R, Scotti RJ, Mikhail M, Richart RM, Nieves J, et al. Short-term urogenital effects of raloxifene, tamoxifen, and estrogen. Am J Obstet Gynecol. 2003;189:81-8.
    1. Albertazzi P, Sharma S. Urogenital effects of selective estrogen receptor modulators: a systematic review. Climacteric. 2005;8:214–220.
    2. 38. Albertazzi P, Sharma S. Urogenital effects of selective estrogen receptor modulators: a systematic review. Climacteric. 2005;8:214-20.
    1. Goldstein SR, Neven P, Zhou L, Taylor YL, Ciaccia AV, Plouffe L. Raloxifene effect on frequency of surgery for pelvic floor relaxation. Obstet Gynecol. 2001;98:91–96.
    2. 39. Goldstein SR, Neven P, Zhou L, Taylor YL, Ciaccia AV, Plouffe L. Raloxifene effect on frequency of surgery for pelvic floor relaxation. Obstet Gynecol. 2001;98:91-6.
    1. Hendrix SL, McNeeley SG. Effect of selective estrogen receptor modulators on reproductive tissues other than endometrium. Ann N Y Acad Sci. 2001;949:243–250.
    2. 40. Hendrix SL, McNeeley SG. Effect of selective estrogen receptor modulators on reproductive tissues other than endometrium. Ann N Y Acad Sci. 2001;949:243-50.
    1. Goldstein SR, Nanavati N. Adverse events that are associated with the selective estrogen receptor modulator levormeloxifene in an aborted phase III osteoporosis treatment study. Am J Obstet Gynecol. 2002;187:521–527.
    2. 41. Goldstein SR, Nanavati N. Adverse events that are associated with the selective estrogen receptor modulator levormeloxifene in an aborted phase III osteoporosis treatment study. Am J Obstet Gynecol. 2002;187:521-7.
    1. Rechberger T, Donica H, Baranowski W, Jakowicki J. Female urinary stress incontinence in terms of connective tissue biochemistry. Eur J Obstet Gynecol Reprod Biol. 1993;49:187–191.
    2. 42. Rechberger T, Donica H, Baranowski W, Jakowicki J. Female urinary stress incontinence in terms of connective tissue biochemistry. Eur J Obstet Gynecol Reprod Biol. 1993;49:187-91.
    1. Lang JH, Zhu L, Sun ZJ, Chen J. Estrogen levels and estrogen receptors in patients with stress urinary incontinence and pelvic organ prolapse. Int J Gynaecol Obstet. 2003;80:35–39.
    2. 43. Lang JH, Zhu L, Sun ZJ, Chen J. Estrogen levels and estrogen receptors in patients with stress urinary incontinence and pelvic organ prolapse. Int J Gynaecol Obstet. 2003;80:35-9.
    1. Ewies AA, Thompson J, Al-Azzawi F. Changes in gonadal steroid receptors in the ardinal ligaments of prolapsed uteri: immunohistomorphometric data. Hum Reprod. 2004;19:1622–1628.
    2. 44. Ewies AA, Thompson J, Al-Azzawi F. Changes in gonadal steroid receptors in the ardinal ligaments of prolapsed uteri: immunohistomorphometric data. Hum Reprod. 2004;19:1622-8.
    1. Zbucka-Kretowska M, Marcus-Braun N, Eboue C, Abeguile G, Wolczynski S, Kottler ML, et al. Expression of estrogen receptors in the pelvic floor of pre- and post-menopausal women presenting pelvic organ prolapse. Folia Histochem Cytobiol. 2011;49:521–527.
    2. 45. Zbucka-Kretowska M, Marcus-Braun N, Eboue C, Abeguile G, Wolczynski S, Kottler ML, et al. Expression of estrogen receptors in the pelvic floor of pre- and post-menopausal women presenting pelvic organ prolapse. Folia Histochem Cytobiol. 2011;49:521-7.
    1. Spence-Jones C, Kamm MA, Henry MM, Hudson CN. Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and urinary stress incontinence. Br J Obstet Gynaecol. 1994;101:147–152.
    2. 46. Spence-Jones C, Kamm MA, Henry MM, Hudson CN. Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and urinary stress incontinence. Br J Obstet Gynaecol. 1994;101:147-52.
    1. Jørgensen S, Hein HO, Gyntelberg F. Heavy lifting at work and risk of genital prolapse and herniated lumbar disc in assistant nurses. Occup Med (Lond) 1994;44:47–49.
    2. 47. Jørgensen S, Hein HO, Gyntelberg F. Heavy lifting at work and risk of genital prolapse and herniated lumbar disc in assistant nurses. Occup Med (Lond). 1994;44:47-9.
    1. Carley ME, Schaffer J. Urinary incontinence and pelvic organ prolapse in women with Marfan or Ehlers Danlos syndrome. Am J Obstet Gynecol. 2000;182:1021–1023.
    2. 48. Carley ME, Schaffer J. Urinary incontinence and pelvic organ prolapse in women with Marfan or Ehlers Danlos syndrome. Am J Obstet Gynecol. 2000;182:1021-3.
    1. Isık H, Aynıoglu O, Sahbaz A, Selimoglu R, Timur H, Harma M. Are hypertension and diabetes mellitus risk factors for pelvic organ prolapse? Eur J Obstet Gynecol Reprod Biol. 2016;197:59–62.
    2. 49. Isık H, Aynıoglu O, Sahbaz A, Selimoglu R, Timur H, Harma M. Are hypertension and diabetes mellitus risk factors for pelvic organ prolapse? Eur J Obstet Gynecol Reprod Biol. 2016;197:59-62.
    1. Petros PE, Woodman PJ. The Integral Theory of continence. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:35–40.
    2. 50. Petros PE, Woodman PJ. The Integral Theory of continence. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:35-40.
    1. Petros P. The integral system. Cent European J Urol. 2011;64:110–119.
    2. 51. Petros P. The integral system. Cent European J Urol. 2011;64:110-19.
    1. Petros PE. New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge and abnormal emptying. Int Urogynecol J Pelvic Floor Dysfunct. 1997;8:270–277.
    2. 52. Petros PE. New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge and abnormal emptying. Int Urogynecol J Pelvic Floor Dysfunct. 1997;8:270-7.
    1. DeLancey JO. Anatomy and biomechanics of genital prolapse. Clin Obstet Gynecol. 1993;36:897–909.
    2. 53. DeLancey JO. Anatomy and biomechanics of genital prolapse. Clin Obstet Gynecol. 1993;36:897-909.
    1. DeLancey JO. The anatomy of the pelvic floor. Curr Opin Obstet Gynecol. 1994;6:313–316.
    2. 54. DeLancey JO. The anatomy of the pelvic floor. Curr Opin Obstet Gynecol. 1994;6:313-16.
    1. 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: pilot study. Int Urogynecol J. 2014;25:197–203.
    2. 55. 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: pilot study. Int Urogynecol J. 2014;25:197-203.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner