Transperineal and endovaginal ultrasound can both be used to analyze hiatus area and anteroposterior diameter with the patient at rest and to diagnose levator avulsion. Palpation correlates only fairly with both methods.

To analyse the efficacy of sacrospinous ligament (SSL) suture removal on the reduction of pain symptoms in the case of suspected pudendal nerve entrapment after sacrospinous ligament fixation (SSLF). Design: Retrospective cohort study.Setting: Tertiary referral centre, the Netherlands.Population: A cohort of 21 women having their SSLF sutures removed because of SSLF-related pain symptoms.Methods: Clinical record review. Main outcome measures:The primary outcome was reduction of pain after SSL suture removal. Secondary outcome measures were time interval between suture placement and suture removal, complete suture removal, adverse events and recurrence of pelvic organ prolapse (POP).Results: A total of 21 women underwent SSL suture removal for severe and/or persistent pain, which was confirmed on clinical examination: 95% of the women (20/21) reported pain reduction after suture removal, and 57% reported complete pain relief.The time interval between suture placement and suture removal was at a median of 414 days (range 8-1855 days). Sutures could be completely removed in 86% of cases (18/21). One woman had excessive blood loss (520 ml) without blood transfusion. At 6-8 weeks after surgery, 10% of the women (2/21) had renewed symptomatic POP, stage ≥ 2, for which additional POP surgery was indicated.Conclusions: When performed by an experienced clinician, SSL suture removal is feasible and efficacious, with low morbidity. In addition, the risk of recurrent POP in the short term appeared to be low.

Abstract. Treatment strategies for cervical intraepithelial neoplase (CIN)2 lesions differ among gynaecologists. To evaluate the differences in management of treatment with subsequent implications, all surgical treatment strategies and follow-up methods were retrospectively analysed for patients with intermediate dysplasia of the cervix. This study aimed to evaluate expectant management strategies and the effect of biopsy prior to radical surgery in CIN2. Patients diagnosed with a CIN2 lesion at the Orbis Medical Center in The Netherlands between 2006 and 2007 were retrospectively analysed. The follow-up ended on 1st January 2009. All 141 patients with CIN2 lesions were included; 109 had no previous history of any CIN lesion. Of the 109 patients, 12% (n=13) underwent an immediate radical surgical excision of the transformation zone (LLETZ procedure) and 85% (n=93) underwent a local biopsy. After the lesion was biopsied, expectant management was selected for 59% of the patients. Subsequent smears were normal in 40% of the patients. Of the patients with abnormal smears in follow-up, the LLETZ procedure was performed in 86% of the patients (n=25). Of these cases, persistent disease was observed in 14% of the patients. After an immediate LLETZ procedure without prior biopsy, follow-up smears were abnormal in 31% of the patients. Persistent disease was significantly lower following radical excision of the lesion with a diagnostic biopsy versus without one (14 versus 31%). After expectant management, the rate of persistent disease was 53% (p<0.001). Overall, the rate of persistent disease was 7%. Due to the high rate of persistent disease and the lower rate of overtreatment, CIN2 lesions should be treated by the excisional procedure. To restrict persistent disease, a biopsy is recommended prior to the actual treatment, since a higher rate of abnormal smears was observed in the follow-up after immediate radical excisions in the first visit.

Objectives The primary aim was to evaluate prospectively the natural history of levator ani muscle (LAM) avulsion 4 years following first delivery and its correlation with signs and symptoms of pelvic floor dysfunction (PFD). The secondary aim was to investigate the effect of a second vaginal delivery on the incidence of LAM avulsion and PFD. Methods This was a prospective longitudinal study of nulliparous women recruited antenatally, who were assessed at 36 weeks' gestation and 3 months, 1 year and 4 years postpartum for signs and symptoms of PFD and presence of LAM avulsion. Pelvic floor muscle strength was assessed by digital palpation, and pelvic organ prolapse (POP) was assessed using the POP quantification (POP‐Q) system. Validated questionnaires were used to evaluate urinary, bowel and sexual function and symptoms of POP. Transperineal ultrasound was performed to assess LAM integrity and hiatal biometry. Differences in signs and symptoms of PFD over time were evaluated using a linear mixed model, separately in women who had had one delivery and in those who had two or more deliveries during the study period. Results Of 269 women recruited, 147 (55%) attended the 4‐year follow‐up and were examined at a mean interval of 3.8 ± 0.4 years after their first delivery. Of these, 74 (50%) had a subsequent delivery. The prevalence of LAM avulsion 4 years after a first vaginal delivery was 13%, with no difference between women who had one and those who had two or more vaginal deliveries. Women with an intact LAM and one or more deliveries showed no change in signs and symptoms of PFD at 4 years compared with the previous assessments. Of women with one vaginal delivery who were diagnosed with LAM avulsion 3 months or 1 year postpartum, those in whom the LAM avulsion was no longer evident at 4 years (42%) showed worsening of POP‐Q measurements, whereas those with persistent LAM avulsion (58%) showed significant worsening in pelvic floor muscle strength and hiatal area on ultrasound. After a second vaginal delivery, no new avulsions were diagnosed, however, previous LAM avulsion became more extensive in 44% of women and hiatal area increased in women with persistent LAM avulsion. Conclusions The first vaginal delivery carries the greatest risk for LAM avulsion, with impact on signs of PFD 4 years later. A second vaginal delivery could result in deterioration of LAM avulsion, but no new avulsions were found. © 2020 International Society of Ultrasound in Obstetrics and Gynecology