Use of transrectal high frequency ultrasound in assessment of middle compartment prolapse

Use of transrectal high frequency ultrasound in assessment of middle compartment prolapse | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of transrectal high frequency ultrasound in assessment of middle compartment prolapse Yinghua Xuan, Yidan Wang, Song Yue, Juan Zhang, Yanfei Qu, Jingyan Xie, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3966977/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Jun, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted 5 You are reading this latest preprint version Abstract Objective To investigate the superiority of transrectal high frequency ultrasound(TRUS) in precise assessment of middle compartment prolapse in comparison with routine transperineal ultrasound (TPUS). Methods Prospectively analyzed and compared detection rates of entire cervical length and uterine descent on TPUS and TRUS in 101 patients with pelvic organ prolapse (POP). Results Detection rates of entire cervix on TRUS were significantly higher than those on TPUS both at rest and during Valsalva maneuver (90.10% VS 49.50%, 92.08% VS 9.90% respectively, both P ＜0.05). Uterine descent was able to be evaluated in 92.08% of patients by TRUS and in 5.94% of patients by TPUS, which was statistically significant( P ＜0.05). The interobserver repeatability for the measurements of anterior lip, cervical canal and posterior lip on TRUS were excellent. The mean lengths of anterior lip, cervical canal and posterior lip were significantly increased during Valsalva maneuver than those measured at rest ( P ＜0.05). And mean length of anterior lip was longer than posterior lip both at rest and during Valsalva( P ＜0.05). Conclusion TRUS can significantly raise detection rates of entire cervix, and make the direct evaluation of uterine descent feasible. TRUS can be used as a complementary method to TPUS to attain more comprehensive and accurate presurgical imaging information in middle compartment prolapse patients. Transrectal Ultrasonography High frequency middle compartment prolapse Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Prolapse of middle compartment generally refers to uterine prolapse, and frequently uterine prolapse is complicated with cervical elongation, less frequently middle compartment prolapse can be isolated cervical elongation. Because isolated cervical elongation is not caused by the defect of apical support, the management is different from those with uterine descent [ 1 ] .Also,40% pelvic organ prolapse(POP) is complicated with cervical elongation [ 2 ] . In POP patients, preoperative unidentified cervical elongation can result in persistent cervical elongation and dissatisfaction in patients who underwent uterine preserving surgery. So accurate preoperative assessment of middle compartment prolapse is essential [ 3 ] . On transperineal ultrasound(TPUS), middle compartment prolapse is diagnosed according to decent of leading edge of cervix, whereas detection of entire cervical length and evaluation of uterine descent are difficult on TPUS, which makes the differentiation of different conditions of middle compartment prolapse difficult. Recently, the introduction of transrectal high frequency ultrasound into assessment of pelvic floor sheds lights on more correct and precise evaluation of middle compartment, which could potentially complement TPUS. This new modality can demonstrate entire cervix more clearly in patients with prolapse and better evaluate the descent of uterus without obstruction of transducer placed on perineum. In this study, POP patients from two institutions were included to investigate the superiority of transrectal high frequency ultrasound in precise assessment of middle compartment prolapse. Materials and Methods A prospective observational study was set in the Beijing Obstetrics and Gynecology Hospital, Capital Medical University and Nanjing First Hospital from March 2023 to October 2023. The study protocol was approved by the Institutional Ethical Committee(2023-KY-001-01). One hundred and one patients who came for preoperative evaluation of pelvic organ prolapse (POP) were consecutively included in this study. The exclusion criteria were previous POP surgery, anal-rectal surgery, hysterectomy, genitourinary anomalies, pelvic radiation, anal-rectal infection. POP cases occurred after vaginal delivery within prior year were also excluded. Detailed histories and demographic data were collected, including age, height, weight, body mass index (BMI), parous status, delivery mode, and menstrual history. POP-quantification results and clinical diagnoses by gynecologists were recorded. All patients underwent transperineal ultrasound (TPUS) examinations first. The patients lay in a dorsal lithotomy position after emptying the bladder. All scans were performed using a GE Voluson E8 (GE Medical Systems, Zipf, Austria) ultrasound system with an 8–4-MHz curved-array volume transducer, or Mindray Nuewa R9 (Mindray, China) ultrasound system with an 8–1-MHz curved-array volume transducer. During TPUS, the detection rate of entire cervical length and descent of uterus was evaluated if the assessment was feasible. Subsequently, transrectal high frequency ultrasound (TRUS) was performed. A linear high frequency transducer (3.2–12.8 MHz, ELC13-4s; Mindray Nuewa R9, China) was used. Evaluation was performed on midsagittal plane, which initially included symphysis pubis disk, bladder, urethra, vagina, cervix and perineal body. The plane was adjusted upward or downward according to position of cervix, when the uterus was deviated from midline, rotation of transducer was needed to demonstrate the cervix. Detection rate of cervix was recorded. Full length of cervix was evaluated both at rest and Valsalva maneuver. The lengths of anterior lip, posterior lip, and cervical canal were measured respectively. The length was measured from the level of internal orifice of cervix to external orifice and the lowest points of anterior and posterior lip, as demonstrated on Fig. 1 . Twenty TRUS images of cervix were randomly retrieved. Two examiners (Y.X. and Y.W.) measured cervical length on these images to test interobserver repeatability. Descent of uterus was also evaluated, which was defined as the difference of distances between internal orifice of cervix and upper margin of perineal body measured at rest and on Valsalva maneuver (Fig. 2 ). SPSS version 20.0 software (IBM Corporation, Armonk, NY) was used for the statistical analysis. The mean standard deviation was used to describe the corresponding measurement data. Independent t test and chi-squared test was used to compare the data between the two groups for continuous variables and categorical variables respectively. A P-value of < 0.05 was considered statistically significant. The intraclass correlation coefficient (ICC) was calculated to test the repeatability of the measurement. Intraclass correlation coefficient values of less than 0.20 were considered poor; 0.21 to 0.40, fair; 0.41 to 0.60, moderate; 0.61 to 0.80, good; and 0.81 to 1.00, excellent [ 4 ] . Results A total of 101 subjects were recruited and finally underwent both TPUS and TRUS assessments. Demographic data and clinical characteristics are presented in table 1. Table 1. Demographic features of patients Features Value Age (years) 60.81±12.05 Body mass index 24.44±2.83 Parity number 1.66±0.78 Menopausal status 79(78.22%) Middle compartment prolapse 92(91.09%) Anterior compartment prolapse 74(73.27%) Posterior compartment prolapse 25(24.75%) Data are presented as mean ± SD (range), n (%). Detection rates of entire cervix on TRUS were significantly higher than those on TPUS both at rest and during Valsalva maneuver, as showed in table 2 (P ＜0.05),and Figure 3. Uterine descent was able to be evaluated in 93 patients by TRUS and 6 patients by TPUS, which was statistically significant(P ＜0.05). Table 2. Comparison of TPUS and TRUS in detection of cervix at rest and during Valsalva maneuver, and uterine descent TPUS TRUS P value Chi-square value Detection rate of entire cervix(%) at rest 49.50% 90.10% 0.000 39.479 Detection rate of entire cervix(%) during Valsalva 9.90% 92.08% 0.000 136.469 Uterine descent 5.94% 92.08% 0.000 149.940 TPUS: transperineal ultrasound, TRUS: transrectal high frequency ultrasound. The results of ICC analysis for the measurement of cervical length showed excellent interobserver repeatability for the measurement of anterior lip, cervical canal and posterior lip (table 3). Table 3. ICC analysis of cervical length measurement ICC Confidence interval (CI) P value Anterior lip 0.967 0.918-0.987 0.000 Cervical canal 0.965 0.913-0.986 0.000 Posterior lip 0.966 0.916-0.986 0.000 The mean lengths of anterior lip, cervical canal and posterior lip were significantly increased during Valsalva maneuver than at rest, as showed in table 4, and Figure 4. In 85 cases measurements of cervix both at rest and during Valsalva maneuver were possible. Lengths of anterior lip, cervical canal and posterior lip were increased in 84.71%, 87.06%, 85.88% of these patients respectively. And mean length of anterior lip was longer than posterior lip both at rest and during Valsalva(P=0.000). Table 4.Comparison of mean lengths of anterior lip, cervical canal and posterior lip measured by TRUS at rest and during Valsalva maneuver Length (cm) At rest(mean±SD) Valsalva(mean±SD) P value Anterior lip 4.18±0.87（n=92） 4.87+0.88（n=92） 0.000 Cervical canal 3.41±0.79（n=91） 4.88±0.89（n=92） 0.000 Posterior lip 3.02±0.82（n=92） 3.86±1.22（n=92） 0.000 Discussion TPUS has been widely used as a one of important imaging examinations to assess POP, and has showed advantages in differential diagnosis of the different conditions of anterior and posterior compartments [ 5 , 6 ] .However, it has limitations on demonstration of middle compartment structures because of some technical reasons. On TPUS, the acoustic beam is generally parallel with the cervix during Valsalva maneuver, which inhibit getting optimal images of cervix. And the level of internal cervical orifice is hard to determine with the low frequency transducer used in TPUS, so accurate measurement of cervical length is not feasible in most cases. The introduction of new modality can make up the limitations. The transducer used in TRUS Is different from that of routine one. A 6cm long linear array is lined on the side of the transducer, so the acoustic beam is perpendicular to pelvic organs, which could significantly improve the detection rate and resolution of imaging. Intracavitary high frequency ultrasound had been proved to be useful in visualizing fine structures of anterior department when used in transvaginal way [ 7 , 8 ] .And until recently, it has been used in transrectal way to evaluate POP, especially middle compartment prolapse. In our study, TRUS showed superiorities to evaluate middle compartment structures in POP patients. First, TRUS can demonstrate entire cervix clearly in most middle compartment prolapse cases both at rest and during Valsalva maneuver, with excellent interobserver repeatability. The detection rates of cervix were higher than 90% on TRUS, whereas the detection rates on TPUS was lower than 50%, and was even less than 10% during Valsalva maneuver. Second, TRUS can reliably investigate the descent of uterus. In TRUS, by being placed in rectum, the transducer does not obstruct the descent of pelvic organs during Valsalva maneuver. So, the degree of descent is closer to that of POP-Q examination. These advantages can provide sufficient information for differentiation of middle compartment prolapse. Clinically, middle compartment prolapse includes two different entities, uterine prolapse and cervical elongation. And uterine prolapse cases can coexist with cervical elongation 9 . In cases of cervical elongation without uterine prolapse, the level I support, the cardinal-uterosacral ligament complex, is not impaired. So, the surgical management for isolated cervical elongation is different from that for uterine prolapse. However, on routine TPUS, the diagnosis of uterine prolapse would be made when the leading edge of cervix is under the level of 15mm above posteroinferior margin of the symphysis pubis at maximal Valsalva. But this concept can not differentiate cervical elongation from uterine prolapse. Recently, Garcia et al [ 9 , 10 ] proposed that difference of ≥ 15 mm in the distance between uterine fundus and the pubis at rest and during the Valsalva maneuver is useful to identify uterine prolapse from cervical elongation without uterine prolapse. And the same team further proved excellent interobserver reliability of this assessment. In comparison with this indirect evaluation, TRUS can directly measure cervical length, and can show and measure the descent of internal orifice of cervix during valsalva, level of which is close to attachment of sacral ligament, D point of POP-Q system. So TRUS has great potential to differentiate isolated cervical elongation from uterine prolapse. When the cervix is significantly elongated, but the descent of the level of internal orifice is minor, the uterine prolapse can be excluded. To be noted, the original low location of internal orifice at rest, and achieving satisfactory Valsalva maneuver should be taken into consideration during evaluation of the descent. Also, accurate presurgical measurement of the cervical length by TURS can provide further information for trachelectomy in cases hysterectomy is not planned. Interestingly, our results demonstrated significant difference of cervical length at rest and during maximal Valsalva. In more than 4/5 patients, the cervical parameters were increased during Valsalva maneuver. One of the possible reasons might be that during Valsalva, the cervix will unfold completely. And also, in some cases complicated with severe anterior or posterior compartment prolapse, the cervix maybe be dragged by surrounding prolapsed organs, frequently by bladder. The length of anterior lip is significantly longer than that of posterior one, which may also be caused by the traction of prolapsed bladder. So further study is needed to determine how and when to measure cervical length to keep consistent with the result of POP-Q examinations. The strength of our study is prospective study design. The limitation is that the study is relatively small number of cases included. However, we believe that 101 cases were enough to verify the advantages of TRUS in the assessment of middle compartment prolapse. And TRUS was new technique for examiners, so the detection rate of cervix had been improved along with the research going on, so the detection rates of our study might be lower than those which could be attained after mastering this technique. In conclusion, TRUS can significantly raise detection rates of entire cervix, and make the direct evaluation of uterine descent possible in middle compartment prolapse patients. This new technique can be used as a complementary method to TPUS, to attain more comprehensive and accurate presurgical imaging information of middle compartment. Declarations Conflicts of interest None. Author Contribution Drs Xuan and Wang contributed equally to this work. References Park YJ, Kong MK, Lee J, Kim EH, Bai SW (2019) Manchester Operation: An Effective Treatment for Uterine Prolapse Caused by True Cervical Elongation. Yonsei Med J 60(11):1074–1080 Berger MB, Ramanah R, Guire KE, DeLancey JO (2012) Is cervical elongation associated with pelvic organ prolapse. Int Urogynecol J 23(8):1095–1103 Chavali K, Hiremath AC, Ramamurthy C (2021) Hegde's Modification of Fothergill Surgery for Cervical Elongation: A 7-Year Retrospective Review. J Obstet Gynaecol Can 43(3):300–305 Vieira S, Corrente JE (2011) Statistical methods for assessing agreement between double readings of clinical measurements. J Appl Oral Sci 19(5):488–492 Chantarasorn V, Dietz HP (2012) Diagnosis of cystocele type by clinical examination and pelvic floor ultrasound. Ultrasound Obstet Gynecol 39(6):710–714 Dietz HP, Steensma AB (2005) Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele. Ultrasound Obstet Gynecol 26(1):73–77 Shobeiri SA, White D, Quiroz LH, Nihira MA (2012) Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison. Int Urogynecol J 23(8):1047–1053 Xuan Y, Yue S, Sun L et al (2018) Repeatability of Female Midurethral Measurement Using High-Frequency 3-Dimensional Transvaginal Ultrasonography. J Ultrasound Med 37(6):1389–1395 García-Mejido JA, Ramos-Vega Z, Armijo-Sánchez A, Fernández-Palacín A, García-Jimenez R, Sainz JA (2021) Differential diagnosis of middle compartment pelvic organ prolapse with transperineal ultrasound. Int Urogynecol J 32(8):2219–2225 García-Mejido JA, Ramos Vega Z, Armijo Sánchez A, Fernández-Palacín A, Fernández CB, Sainz Bueno JA (2022) Interobserver variability of ultrasound measurements for the differential diagnosis of uterine prolapse and cervical elongation without uterine prolapse. Int Urogynecol J 33(10):2825–2831 Cite Share Download PDF Status: Published Journal Publication published 05 Jun, 2024 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Reviewers agreed at journal 23 Feb, 2024 Reviewers invited by journal 22 Feb, 2024 Editor invited by journal 19 Feb, 2024 Editor assigned by journal 18 Feb, 2024 First submitted to journal 17 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3966977","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":274456616,"identity":"6c529653-f065-4d44-90f8-fa3e5d4ecc71","order_by":0,"name":"Yinghua Xuan","email":"","orcid":"https://orcid.org/0000-0002-2677-7331","institution":"Beijing obstetrics and Gynecology Hospital, Capital medical university. Beijing Maternal and Child Health Care Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yinghua","middleName":"","lastName":"Xuan","suffix":""},{"id":274456617,"identity":"5d8ca8f5-ae1d-451f-8c74-babb79fd8331","order_by":1,"name":"Yidan Wang","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Yidan","middleName":"","lastName":"Wang","suffix":""},{"id":274456618,"identity":"6b9ae01b-1610-49a9-955b-08f6d691954f","order_by":2,"name":"Song Yue","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Song","middleName":"","lastName":"Yue","suffix":""},{"id":274456619,"identity":"9f0f6897-0cfb-41bc-9d4a-20c32c34b844","order_by":3,"name":"Juan Zhang","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"","lastName":"Zhang","suffix":""},{"id":274456620,"identity":"1c124f38-98a6-483a-8a08-2ae3f5d1c882","order_by":4,"name":"Yanfei Qu","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Yanfei","middleName":"","lastName":"Qu","suffix":""},{"id":274456621,"identity":"cb34c0ff-282f-4181-bbce-b0468ba13df4","order_by":5,"name":"Jingyan Xie","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Jingyan","middleName":"","lastName":"Xie","suffix":""},{"id":274456622,"identity":"341f1131-47ad-4925-991b-aa06e34098bd","order_by":6,"name":"Guohui Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYFACHsYHDAwSMjAuYwMRWpgNgFp4SNLCJgEiidci37/2WNWNGgseBvbDTzfzMNjIbjjA/OwBPi2MM96l3c45BnQYT5rZbR6GNOMNB9jMDfBpYZY4Y3Y7hw2oRYKHDajlcOKGAxCn4gRsQC3FOf/gWv4T1sLD32PGnNsG13KAsBYJCR5j6dw+oHqgX27OMUg2nnmYzQyvFvn+M4afc77VyfGzH352402FnWzf8eZneLUwSCRAPQUmQUHFjFc9EPAfIKRiFIyCUTAKRjwAABpCPGrGy0zmAAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Guohui","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-02-18 12:48:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3966977/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3966977/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-024-07515-0","type":"published","date":"2024-06-05T12:13:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51716771,"identity":"4127bd0c-a4ac-43ed-ac23-5c50bf364db1","added_by":"auto","created_at":"2024-02-27 21:10:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":564935,"visible":true,"origin":"","legend":"\u003cp\u003eOn TRUS, the lengths of anterior lip, posterior lip, and cervical canal were measured respectively. The length was measured from the level of internal orifice of cervix to external os and the lowest points of anterior and posterior lip, AL: anterior lip; CC: cervical canal; EO: external orifice of cervix; IO: internal orifice of cervix; PL: posterior lip.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3966977/v1/358a5e9406e6ec60e8e2703c.png"},{"id":51716828,"identity":"fa582a30-3dd1-48ac-8be3-f7d0476c3e4f","added_by":"auto","created_at":"2024-02-27 21:10:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":519635,"visible":true,"origin":"","legend":"\u003cp\u003eOn TRUS, descent of uterus was evaluated, defined as the difference of distances \u0026nbsp;between internal orifice of cervix and upper margin of perineal body measured at rest and on Valsalva maneuver. PB: perineal body.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3966977/v1/cce041cdea6ca144b520d3e4.png"},{"id":51716829,"identity":"954c2f4c-2b36-4045-83c2-bf89d66487f1","added_by":"auto","created_at":"2024-02-27 21:10:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":385411,"visible":true,"origin":"","legend":"\u003cp\u003eOn TPUS, Detection of entire cervix was harder, because the internal orifice is difficult to determine, especially during Valsalva maneuver.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3966977/v1/efa3a133808126da3593e698.png"},{"id":51716827,"identity":"a88a18c8-1dc9-4d6f-a624-e3a349a5f779","added_by":"auto","created_at":"2024-02-27 21:10:37","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":497183,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurements of cervix on TRUS in a patient at rest and during Valsalva, showing that lengths of anterior lip, cervical canal and posterior lip were significantly increased during Valsalva maneuver than at rest.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-3966977/v1/9458a60405ba4f12eace68e8.png"},{"id":58206378,"identity":"c615a757-5e03-402e-b1d3-3fbb63b84b3a","added_by":"auto","created_at":"2024-06-12 12:13:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2568151,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3966977/v1/5e3b98b8-0712-4967-b376-8082bbf9f01a.pdf"}],"financialInterests":"","formattedTitle":"Use of transrectal high frequency ultrasound in assessment of middle compartment prolapse","fulltext":[{"header":"Introduction","content":"\u003cp\u003eProlapse of middle compartment generally refers to uterine prolapse, and frequently uterine prolapse is complicated with cervical elongation, less frequently middle compartment prolapse can be isolated cervical elongation. Because isolated cervical elongation is not caused by the defect of apical support, the management is different from those with uterine descent \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.Also,40% pelvic organ prolapse(POP) is complicated with cervical elongation\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. In POP patients, preoperative unidentified cervical elongation can result in persistent cervical elongation and dissatisfaction in patients who underwent uterine preserving surgery. So accurate preoperative assessment of middle compartment prolapse is essential \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOn transperineal ultrasound(TPUS), middle compartment prolapse is diagnosed according to decent of leading edge of cervix, whereas detection of entire cervical length and evaluation of uterine descent are difficult on TPUS, which makes the differentiation of different conditions of middle compartment prolapse difficult.\u003c/p\u003e \u003cp\u003eRecently, the introduction of transrectal high frequency ultrasound into assessment of pelvic floor sheds lights on more correct and precise evaluation of middle compartment, which could potentially complement TPUS. This new modality can demonstrate entire cervix more clearly in patients with prolapse and better evaluate the descent of uterus without obstruction of transducer placed on perineum.\u003c/p\u003e \u003cp\u003eIn this study, POP patients from two institutions were included to investigate the superiority of transrectal high frequency ultrasound in precise assessment of middle compartment prolapse.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA prospective observational study was set in the Beijing Obstetrics and Gynecology Hospital, Capital Medical University and Nanjing First Hospital from March 2023 to October 2023. The study protocol was approved by the Institutional Ethical Committee(2023-KY-001-01).\u003c/p\u003e \u003cp\u003eOne hundred and one patients who came for preoperative evaluation of pelvic organ prolapse (POP) were consecutively included in this study. The exclusion criteria were previous POP surgery, anal-rectal surgery, hysterectomy, genitourinary anomalies, pelvic radiation, anal-rectal infection. POP cases occurred after vaginal delivery within prior year were also excluded.\u003c/p\u003e \u003cp\u003eDetailed histories and demographic data were collected, including age, height, weight, body mass index (BMI), parous status, delivery mode, and menstrual history. POP-quantification results and clinical diagnoses by gynecologists were recorded.\u003c/p\u003e \u003cp\u003eAll patients underwent transperineal ultrasound (TPUS) examinations first. The patients lay in a dorsal lithotomy position after emptying the bladder. All scans were performed using a GE Voluson E8 (GE Medical Systems, Zipf, Austria) ultrasound system with an 8\u0026ndash;4-MHz curved-array volume transducer, or Mindray Nuewa R9 (Mindray, China) ultrasound system with an 8\u0026ndash;1-MHz curved-array volume transducer. During TPUS, the detection rate of entire cervical length and descent of uterus was evaluated if the assessment was feasible.\u003c/p\u003e \u003cp\u003eSubsequently, transrectal high frequency ultrasound (TRUS) was performed. A linear high frequency transducer (3.2\u0026ndash;12.8 MHz, ELC13-4s; Mindray Nuewa R9, China) was used. Evaluation was performed on midsagittal plane, which initially included symphysis pubis disk, bladder, urethra, vagina, cervix and perineal body. The plane was adjusted upward or downward according to position of cervix, when the uterus was deviated from midline, rotation of transducer was needed to demonstrate the cervix. Detection rate of cervix was recorded. Full length of cervix was evaluated both at rest and Valsalva maneuver. The lengths of anterior lip, posterior lip, and cervical canal were measured respectively. The length was measured from the level of internal orifice of cervix to external orifice and the lowest points of anterior and posterior lip, as demonstrated on Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Twenty TRUS images of cervix were randomly retrieved. Two examiners (Y.X. and Y.W.) measured cervical length on these images to test interobserver repeatability.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDescent of uterus was also evaluated, which was defined as the difference of distances between internal orifice of cervix and upper margin of perineal body measured at rest and on Valsalva maneuver (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSPSS version 20.0 software (IBM Corporation, Armonk, NY) was used for the statistical analysis. The mean standard deviation was used to describe the corresponding measurement data. Independent t test and chi-squared test was used to compare the data between the two groups for continuous variables and categorical variables respectively. A P-value of \u0026lt; 0.05 was considered statistically significant. The intraclass correlation coefficient (ICC) was calculated to test the repeatability of the measurement. Intraclass correlation coefficient values of less than 0.20 were considered poor; 0.21 to 0.40, fair; 0.41 to 0.60, moderate; 0.61 to 0.80, good; and 0.81 to 1.00, excellent \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 101 subjects were recruited and finally underwent both TPUS and TRUS assessments. Demographic data and clinical characteristics are presented in table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Demographic features of patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.850971922246224%\" valign=\"top\"\u003e\n \u003cp\u003eFeatures\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.149028077753776%\" valign=\"top\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.850971922246224%\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.149028077753776%\" valign=\"top\"\u003e\n \u003cp\u003e60.81\u0026plusmn;12.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.850971922246224%\" valign=\"top\"\u003e\n \u003cp\u003eBody mass index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.149028077753776%\" valign=\"top\"\u003e\n \u003cp\u003e24.44\u0026plusmn;2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.850971922246224%\" valign=\"top\"\u003e\n \u003cp\u003eParity number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.149028077753776%\" valign=\"top\"\u003e\n \u003cp\u003e1.66\u0026plusmn;0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.850971922246224%\" valign=\"top\"\u003e\n \u003cp\u003eMenopausal status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.149028077753776%\" valign=\"top\"\u003e\n \u003cp\u003e79(78.22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.850971922246224%\" valign=\"top\"\u003e\n \u003cp\u003eMiddle compartment prolapse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.149028077753776%\" valign=\"top\"\u003e\n \u003cp\u003e92(91.09%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.850971922246224%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior compartment prolapse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.149028077753776%\" valign=\"top\"\u003e\n \u003cp\u003e74(73.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"62.850971922246224%\" valign=\"top\"\u003e\n \u003cp\u003ePosterior compartment prolapse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.149028077753776%\" valign=\"top\"\u003e\n \u003cp\u003e25(24.75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as mean \u0026plusmn; SD (range), n (%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDetection rates of entire cervix on TRUS were significantly higher than those on TPUS both at rest and during Valsalva maneuver, as showed in table 2 (P ＜0.05),and Figure 3. Uterine descent was able to be evaluated in 93 patients by TRUS and 6 patients by TPUS, which was statistically significant(P ＜0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2. Comparison of TPUS and TRUS in detection of cervix at rest and during Valsalva maneuver, and uterine descent\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"557\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.10951526032316%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\" valign=\"top\"\u003e\n \u003cp\u003eTPUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.0556552962298%\" valign=\"top\"\u003e\n \u003cp\u003eTRUS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.87612208258528%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003eChi-square value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.10951526032316%\" valign=\"top\"\u003e\n \u003cp\u003eDetection rate of entire cervix(%) at rest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\" valign=\"top\"\u003e\n \u003cp\u003e49.50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.0556552962298%\" valign=\"top\"\u003e\n \u003cp\u003e90.10%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.87612208258528%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e39.479\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.10951526032316%\" valign=\"top\"\u003e\n \u003cp\u003eDetection rate of entire cervix(%) during Valsalva\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\" valign=\"top\"\u003e\n \u003cp\u003e9.90%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.0556552962298%\" valign=\"top\"\u003e\n \u003cp\u003e92.08%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.87612208258528%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e136.469\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.10951526032316%\" valign=\"top\"\u003e\n \u003cp\u003eUterine descent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.26032315978456%\" valign=\"top\"\u003e\n \u003cp\u003e5.94%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.0556552962298%\" valign=\"top\"\u003e\n \u003cp\u003e92.08%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.87612208258528%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.6983842010772%\" valign=\"top\"\u003e\n \u003cp\u003e149.940\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTPUS: transperineal ultrasound, TRUS: transrectal high frequency ultrasound.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of ICC analysis for the measurement of cervical length showed excellent interobserver repeatability for the measurement of anterior lip, cervical canal and posterior lip (table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3. ICC analysis of cervical length measurement\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.942028985507246%\" valign=\"top\"\u003e\n \u003cp\u003eICC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.31159420289855%\" valign=\"top\"\u003e\n \u003cp\u003eConfidence interval (CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.746376811594203%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior lip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.942028985507246%\" valign=\"top\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.31159420289855%\" valign=\"top\"\u003e\n \u003cp\u003e0.918-0.987\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.746376811594203%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003eCervical canal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.942028985507246%\" valign=\"top\"\u003e\n \u003cp\u003e0.965\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.31159420289855%\" valign=\"top\"\u003e\n \u003cp\u003e0.913-0.986\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.746376811594203%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ePosterior lip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.942028985507246%\" valign=\"top\"\u003e\n \u003cp\u003e0.966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.31159420289855%\" valign=\"top\"\u003e\n \u003cp\u003e0.916-0.986\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.746376811594203%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe mean lengths of anterior lip, cervical canal and posterior lip were significantly increased during Valsalva maneuver than at rest, as showed in table 4, and Figure 4. In 85 cases measurements of cervix both at rest and during Valsalva maneuver were possible. Lengths of anterior lip, cervical canal and posterior lip were increased in 84.71%, 87.06%, 85.88% of these patients respectively.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;And mean length of anterior lip was longer than posterior lip both at rest and during Valsalva(P=0.000). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 4.Comparison of mean lengths of anterior lip, cervical canal and posterior lip measured by TRUS at rest and during Valsalva maneuver\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.95479204339964%\" valign=\"top\"\u003e\n \u003cp\u003eLength (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.65641952983725%\" valign=\"top\"\u003e\n \u003cp\u003eAt rest(mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003eValsalva(mean\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.64737793851718%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.95479204339964%\" valign=\"top\"\u003e\n \u003cp\u003eAnterior lip\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.65641952983725%\" valign=\"top\"\u003e\n \u003cp\u003e4.18\u0026plusmn;0.87（n=92）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e4.87+0.88（n=92）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.64737793851718%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.95479204339964%\" valign=\"top\"\u003e\n \u003cp\u003eCervical canal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.65641952983725%\" valign=\"top\"\u003e\n \u003cp\u003e3.41\u0026plusmn;0.79（n=91）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e4.88\u0026plusmn;0.89（n=92）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.64737793851718%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.95479204339964%\" valign=\"top\"\u003e\n \u003cp\u003ePosterior lip\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.65641952983725%\" valign=\"top\"\u003e\n \u003cp\u003e3.02\u0026plusmn;0.82（n=92）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.741410488245933%\" valign=\"top\"\u003e\n \u003cp\u003e3.86\u0026plusmn;1.22（n=92）\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.64737793851718%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eTPUS has been widely used as a one of important imaging examinations to assess POP, and has showed advantages in differential diagnosis of the different conditions of anterior and posterior compartments \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.However, it has limitations on demonstration of middle compartment structures because of some technical reasons. On TPUS, the acoustic beam is generally parallel with the cervix during Valsalva maneuver, which inhibit getting optimal images of cervix. And the level of internal cervical orifice is hard to determine with the low frequency transducer used in TPUS, so accurate measurement of cervical length is not feasible in most cases. The introduction of new modality can make up the limitations. The transducer used in TRUS Is different from that of routine one. A 6cm long linear array is lined on the side of the transducer, so the acoustic beam is perpendicular to pelvic organs, which could significantly improve the detection rate and resolution of imaging. Intracavitary high frequency ultrasound had been proved to be useful in visualizing fine structures of anterior department when used in transvaginal way\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e .And until recently, it has been used in transrectal way to evaluate POP, especially middle compartment prolapse. In our study, TRUS showed superiorities to evaluate middle compartment structures in POP patients. First, TRUS can demonstrate entire cervix clearly in most middle compartment prolapse cases both at rest and during Valsalva maneuver, with excellent interobserver repeatability. The detection rates of cervix were higher than 90% on TRUS, whereas the detection rates on TPUS was lower than 50%, and was even less than 10% during Valsalva maneuver. Second, TRUS can reliably investigate the descent of uterus. In TRUS, by being placed in rectum, the transducer does not obstruct the descent of pelvic organs during Valsalva maneuver. So, the degree of descent is closer to that of POP-Q examination. These advantages can provide sufficient information for differentiation of middle compartment prolapse.\u003c/p\u003e \u003cp\u003eClinically, middle compartment prolapse includes two different entities, uterine prolapse and cervical elongation. And uterine prolapse cases can coexist with cervical elongation \u003csup\u003e\u003cem\u003e9\u003c/em\u003e\u003c/sup\u003e. In cases of cervical elongation without uterine prolapse, the level I support, the cardinal-uterosacral ligament complex, is not impaired. So, the surgical management for isolated cervical elongation is different from that for uterine prolapse. However, on routine TPUS, the diagnosis of uterine prolapse would be made when the leading edge of cervix is under the level of 15mm above posteroinferior margin of the symphysis pubis at maximal Valsalva. But this concept can not differentiate cervical elongation from uterine prolapse. Recently, Garcia et al\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e proposed that difference of \u0026ge;\u0026thinsp;15 mm in the distance between uterine fundus and the pubis at rest and during the Valsalva maneuver is useful to identify uterine prolapse from cervical elongation without uterine prolapse. And the same team further proved excellent interobserver reliability of this assessment. In comparison with this indirect evaluation, TRUS can directly measure cervical length, and can show and measure the descent of internal orifice of cervix during valsalva, level of which is close to attachment of sacral ligament, D point of POP-Q system. So TRUS has great potential to differentiate isolated cervical elongation from uterine prolapse. When the cervix is significantly elongated, but the descent of the level of internal orifice is minor, the uterine prolapse can be excluded. To be noted, the original low location of internal orifice at rest, and achieving satisfactory Valsalva maneuver should be taken into consideration during evaluation of the descent. Also, accurate presurgical measurement of the cervical length by TURS can provide further information for trachelectomy in cases hysterectomy is not planned.\u003c/p\u003e \u003cp\u003eInterestingly, our results demonstrated significant difference of cervical length at rest and during maximal Valsalva. In more than 4/5 patients, the cervical parameters were increased during Valsalva maneuver. One of the possible reasons might be that during Valsalva, the cervix will unfold completely. And also, in some cases complicated with severe anterior or posterior compartment prolapse, the cervix maybe be dragged by surrounding prolapsed organs, frequently by bladder. The length of anterior lip is significantly longer than that of posterior one, which may also be caused by the traction of prolapsed bladder. So further study is needed to determine how and when to measure cervical length to keep consistent with the result of POP-Q examinations.\u003c/p\u003e \u003cp\u003eThe strength of our study is prospective study design. The limitation is that the study is relatively small number of cases included. However, we believe that 101 cases were enough to verify the advantages of TRUS in the assessment of middle compartment prolapse. And TRUS was new technique for examiners, so the detection rate of cervix had been improved along with the research going on, so the detection rates of our study might be lower than those which could be attained after mastering this technique.\u003c/p\u003e \u003cp\u003eIn conclusion, TRUS can significantly raise detection rates of entire cervix, and make the direct evaluation of uterine descent possible in middle compartment prolapse patients. This new technique can be used as a complementary method to TPUS, to attain more comprehensive and accurate presurgical imaging information of middle compartment.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch2\u003eConflicts of interest\u003c/h2\u003e\n\u003cp\u003eNone.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e \u003cp\u003eDrs Xuan and Wang contributed equally to this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePark YJ, Kong MK, Lee J, Kim EH, Bai SW (2019) Manchester Operation: An Effective Treatment for Uterine Prolapse Caused by True Cervical Elongation. Yonsei Med J 60(11):1074\u0026ndash;1080\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerger MB, Ramanah R, Guire KE, DeLancey JO (2012) Is cervical elongation associated with pelvic organ prolapse. Int Urogynecol J 23(8):1095\u0026ndash;1103\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChavali K, Hiremath AC, Ramamurthy C (2021) Hegde's Modification of Fothergill Surgery for Cervical Elongation: A 7-Year Retrospective Review. J Obstet Gynaecol Can 43(3):300\u0026ndash;305\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVieira S, Corrente JE (2011) Statistical methods for assessing agreement between double readings of clinical measurements. J Appl Oral Sci 19(5):488\u0026ndash;492\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChantarasorn V, Dietz HP (2012) Diagnosis of cystocele type by clinical examination and pelvic floor ultrasound. Ultrasound Obstet Gynecol 39(6):710\u0026ndash;714\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDietz HP, Steensma AB (2005) Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele. Ultrasound Obstet Gynecol 26(1):73\u0026ndash;77\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShobeiri SA, White D, Quiroz LH, Nihira MA (2012) Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison. Int Urogynecol J 23(8):1047\u0026ndash;1053\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXuan Y, Yue S, Sun L et al (2018) Repeatability of Female Midurethral Measurement Using High-Frequency 3-Dimensional Transvaginal Ultrasonography. J Ultrasound Med 37(6):1389\u0026ndash;1395\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Mejido JA, Ramos-Vega Z, Armijo-S\u0026aacute;nchez A, Fern\u0026aacute;ndez-Palac\u0026iacute;n A, Garc\u0026iacute;a-Jimenez R, Sainz JA (2021) Differential diagnosis of middle compartment pelvic organ prolapse with transperineal ultrasound. Int Urogynecol J 32(8):2219\u0026ndash;2225\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Mejido JA, Ramos Vega Z, Armijo S\u0026aacute;nchez A, Fern\u0026aacute;ndez-Palac\u0026iacute;n A, Fern\u0026aacute;ndez CB, Sainz Bueno JA (2022) Interobserver variability of ultrasound measurements for the differential diagnosis of uterine prolapse and cervical elongation without uterine prolapse. Int Urogynecol J 33(10):2825\u0026ndash;2831\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Transrectal, Ultrasonography, High frequency, middle compartment, prolapse","lastPublishedDoi":"10.21203/rs.3.rs-3966977/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3966977/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective \u003c/strong\u003eTo investigate the superiority of transrectal high frequency ultrasound(TRUS) in precise assessment of middle compartment prolapse in comparison with routine transperineal ultrasound (TPUS).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Prospectively analyzed and compared detection rates of entire cervical length and uterine descent on TPUS and TRUS in 101 patients with pelvic organ prolapse (POP).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e \u0026nbsp;Detection rates of entire cervix on TRUS were significantly higher than those on TPUS both at rest and during Valsalva maneuver (90.10% VS 49.50%, 92.08% VS 9.90% respectively, both \u003cem\u003eP \u003c/em\u003e＜0.05). Uterine descent was able to be evaluated in 92.08% of patients by TRUS and in 5.94% of patients by TPUS, which was statistically significant(\u003cem\u003eP \u003c/em\u003e＜0.05). The interobserver repeatability for the measurements of anterior lip, cervical canal and posterior lip on TRUS were excellent. The mean lengths of anterior lip, cervical canal and posterior lip were significantly increased during Valsalva maneuver than those measured at rest (\u003cem\u003eP\u003c/em\u003e ＜0.05). And mean length of anterior lip was longer than posterior lip both at rest and during Valsalva(\u003cem\u003eP\u003c/em\u003e ＜0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e TRUS can significantly raise detection rates of entire cervix, and make the direct evaluation of uterine descent feasible. TRUS can be used as a complementary method to TPUS to attain more comprehensive and accurate presurgical imaging information in middle compartment prolapse patients.\u003c/p\u003e","manuscriptTitle":"Use of transrectal high frequency ultrasound in assessment of middle compartment prolapse","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-27 21:10:17","doi":"10.21203/rs.3.rs-3966977/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2024-02-23T13:39:24+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-22T06:39:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Archives of Gynecology and Obstetrics","date":"2024-02-19T20:33:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-18T13:20:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Gynecology and Obstetrics","date":"2024-02-17T08:17:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"be5508ef-7544-432d-ba1f-eed2441c4229","owner":[],"postedDate":"February 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-06-12T12:13:33+00:00","versionOfRecord":{"articleIdentity":"rs-3966977","link":"https://doi.org/10.1007/s00404-024-07515-0","journal":{"identity":"archives-of-gynecology-and-obstetrics","isVorOnly":false,"title":"Archives of Gynecology and Obstetrics"},"publishedOn":"2024-06-05 12:13:33","publishedOnDateReadable":"June 5th, 2024"},"versionCreatedAt":"2024-02-27 21:10:17","video":"","vorDoi":"10.1007/s00404-024-07515-0","vorDoiUrl":"https://doi.org/10.1007/s00404-024-07515-0","workflowStages":[]},"version":"v1","identity":"rs-3966977","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3966977","identity":"rs-3966977","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}