Address correspondence to S. Abbas Shobeiri, MD, MBA, System Division Chief of Benign Gynecology, INOVA Health System, 3300 Gallows Road, Second-floor South Tower; Biomedical Engineering, George Mason University, Falls Church, VA 22042-3307, USA.

E-mail: [email protected]

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Yael Baumfeld MD,

Yael Baumfeld MD

Department of Obstetrics & Gynecology, INOVA Women's Hospital, Falls Church, VA, USA

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Qi Wei PhD,

Qi Wei PhD

Department of Bioengineering, George Mason University, Fairfax, VA, USA

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Jittima Manonai MD, MHA,

Jittima Manonai MD, MHA

Department of Obstetrics & Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

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Jonia Alshiek MD, MSc,

Jonia Alshiek MD, MSc

Department of Obstetrics & Gynecology, INOVA Women's Hospital, Falls Church, VA, USA

Department of Bioengineering, George Mason University, Fairfax, VA, USA

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S. Abbas Shobeiri MD, MBA,

Corresponding Author

S. Abbas Shobeiri MD, MBA

[email protected]

orcid.org/0000-0001-5513-5955

Department of Obstetrics & Gynecology, INOVA Women's Hospital, Falls Church, VA, USA

Department of Bioengineering, George Mason University, Fairfax, VA, USA

E-mail: [email protected]

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First published: 03 March 2025

https://doi.org/10.1002/jum.16671

The authors have no conflict of interest to declare.

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Abstract

Objectives

This study aimed to assess the architecture of the levator plate and anal complex in women with fecal incontinence using 3-dimensional endoanal ultrasound (EAUS).

Methods

A retrospective cohort study reviewed EAUS examinations performed on women with fecal incontinence. The anal complex and levator plate architecture were examined and compared to a control group of women without fecal incontinence. The anal canal was divided into 6 different areas, and the visibility of specific structures was recorded. Measurements of the external anal sphincter (EAS) length, levator plate length, and the distance between the EAS and the levator plate were taken.

Results

The study included 31 patients with fecal incontinence and 30 nulliparous controls. Significant differences were observed in the anal complex anatomy between the 2 groups. The fecal incontinence group had a higher prevalence of abnormal levator plate anatomy (84%) than the control group (3%). The EAS size was significantly smaller in the fecal incontinent group (16 versus 18 mm, P = .04), and there was a shorter distance between the EAS and the levator plate (22 versus 28 mm, P = .001).

Conclusions

Women with fecal incontinence exhibited significant changes in the anatomy of the anal canal, particularly in caudad structures of the anal sphincter complex. Additionally, a shorter distance between the levator plate and the EAS was observed in fecal incontinent patients. Sonographic assessment adds much to the evaluation of defecatory disorders.

Open Research

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

References

1Haylen BT, Maher CF, Barber MD, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Neurourol Urodyn 2016; 35: 137–168. https://doi.org/10.1002/nau.22922.
10.1002/nau.22922
PubMed Web of Science® Google Scholar
2Mundet L, Rofes L, Ortega O, Cabib C, Clavé P. Kegel exercises, biofeedback, electrostimulation, and peripheral neuromodulation improve clinical symptoms of fecal incontinence and affect specific physiological targets: an randomized controlled trial. J Neurogastroenterol Motil 2021; 27: 108.
10.5056/jnm20013
PubMed Web of Science® Google Scholar
3Andy UU, Harvie HS, Pahwa AP, Markland A, Arya LA. The relationship between fecal incontinence, constipation and defecatory symptoms in women with pelvic floor disorders. Neurourol Urodyn 2017; 36: 495–498.
10.1002/nau.22964
PubMed Web of Science® Google Scholar
4Shobeiri SA, Rostaminia G, White DE, Quiroz LH. The determinants of minimal levator hiatus and their relationship to the puborectalis muscle and the levator plate. BJOG 2012; 120: 205–211. https://doi.org/10.1111/1471-0528.12055.
10.1111/1471-0528.12055
PubMed Web of Science® Google Scholar
5Shobeiri SA, Leclaire E, Nihira MA, Quiroz LH, O'Donoghue D. Appearance of the levator ani muscle subdivisions in endovaginal three-dimensional ultrasonography. Obstet Gynecol 2009; 114: 66–72.
10.1097/AOG.0b013e3181aa2c89
PubMed Web of Science® Google Scholar
6Rostaminia G, White D, Hegde A, Quiroz LH, Davila GW, Shobeiri SA. Levator ani deficiency and pelvic organ prolapse severity. Obstet Gynecol 2013; 121: 1017–1024. https://doi.org/10.1097/AOG.0b013e31828ce97d.
10.1097/AOG.0b013e31828ce97d
PubMed Web of Science® Google Scholar
7Rostaminia G, White DE, Quiroz LH, Shobeiri SA. Levator plate descent correlates with levator ani muscle deficiency. Neurourol Urodyn 2013; 34: 55–59. https://doi.org/10.1002/nau.22509.
10.1002/nau.22509
PubMed Google Scholar
8Mundet L, Cabib C, Ortega O, et al. Defective conduction of anorectal afferents is a very prevalent pathophysiological factor associated to fecal incontinence in women. J Neurogastroenterol Motil 2019; 25: 423.
10.5056/jnm18196
PubMed Web of Science® Google Scholar
9Quander CR, Morris MC, Melson J, Bienias JL, Evans DA. Prevalence of and factors associated with fecal incontinence in a large community study of older individuals. Am J Gastroenterol 2005; 100: 905–909.
10.1111/j.1572-0241.2005.30511.x
PubMed Web of Science® Google Scholar
10Siproudhis L, Pigot F, Godeberge P, Damon H, Soudan D, Bigard MA. Defecation disorders: a French population survey. Dis Colon Rectum 2006; 49: 219–227.
10.1007/s10350-005-0249-8
PubMed Web of Science® Google Scholar
11Bharucha AE, Zinsmeister AR, Locke GR, et al. Risk factors for fecal incontinence: a population-based study in women. Am J Gastroenterol 2006; 101: 1305–1312.
10.1111/j.1572-0241.2006.00553.x
PubMed Web of Science® Google Scholar
12Whitehead WE, Borrud L, Goode PS, et al. Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 2009; 137: 512–517, 517.e1-2.
10.1053/j.gastro.2009.04.054
PubMed Web of Science® Google Scholar
13Nelson RL. Epidemiology of fecal incontinence. Gastroenterology 2004; 126: S3–S7.
10.1053/j.gastro.2003.10.010
PubMed Web of Science® Google Scholar
14Fernández–Fraga X, Azpiroz F, Malagelada JR. Significance of pelvic floor muscles in anal incontinence. Gastroenterology 2002; 123: 1441–1450.
10.1053/gast.2002.36586
PubMed Web of Science® Google Scholar
15Terra MP, Beets-Tan RG, Vervoorn I, et al. Pelvic floor muscle lesions at endoanal MR imaging in female patients with faecal incontinence. Eur Radiol 2008; 18: 1892–1901.
10.1007/s00330-008-0951-8
PubMed Web of Science® Google Scholar
16Donnelly V, O'Connell PR, O'Herlihy C. The influence of oestrogen replacement on faecal incontinence in postmenopausal women. BJOG 1997; 104: 311–315.
10.1111/j.1471-0528.1997.tb11459.x
CAS Web of Science® Google Scholar
17Rostaminia G, Peck J, Quiroz L, Shobeiri SA. Levator plate upward lift on dynamic sonography and levator muscle strength. J Ultrasound Med 2015; 34: 1787–1792. https://doi.org/10.7863/ultra.15.14.11075.
10.7863/ultra.15.14.11075
PubMed Web of Science® Google Scholar
18Shobeiri SA, White D, Quiroz LH, Nihira MA. Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison. Int Urogynecol J 2012; 23: 1047–1053. https://doi.org/10.1007/s00192-012-1721-3.
10.1007/s00192-012-1721-3
PubMed Web of Science® Google Scholar
19Alshiek J, O'Leary D, Marroquin J, Chastain J, Shobeiri S, Gallucci R. Histologic and Immunologic Characterization of Pelvic Floor in Women, 1: Inflammatory Cytokine Expression in Pelvic Floor Muscle of a Mouse Model. Hoboken, New Jersey: Wiley; 2020: S178-S179.
Google Scholar
20Asif Z, Tomashev R, Peterkin V, et al. Levator ani muscle volume and architecture in normal vs. muscle damage patients using 3D endovaginal ultrasound: a pilot study. Int Urogynecol J 2023; 34: 581–587. https://doi.org/10.1007/s00192-022-05366-4.
10.1007/s00192-022-05366-4
PubMed Web of Science® Google Scholar
21Denson LE, Terrell DR, Vesely SK, Peck JD, Quiroz LH, Shobeiri SA. The prevalence of pelvic floor hematoma after vaginal delivery. Female Pelvic Med Reconstr Surg 2020; 27: 393–397. https://doi.org/10.1097/SPV.0000000000000895.
10.1097/SPV.0000000000000895
Google Scholar
22Javadian P, O'Leary D, Rostaminia G, et al. How does 3D endovaginal ultrasound compare to magnetic resonance imaging in the evaluation of levator ani anatomy? Neurourol Urodyn 2017; 36: 409–413.
10.1002/nau.22944
PubMed Web of Science® Google Scholar
23Kirss J, Huhtinen H, Niskanen E, et al. Comparison of 3D endoanal ultrasound and external phased array magnetic resonance imaging in the diagnosis of obstetric anal sphincter injuries. Eur Radiol 2019; 29: 5717–5722.
10.1007/s00330-019-06125-8
PubMed Web of Science® Google Scholar
24Xia W, Ameri G, Fakim D, et al. Automatic plane of minimal hiatal dimensions extraction from 3D female pelvic floor ultrasound. IEEE Trans Med Imaging 2022; 41: 3873–3883.
10.1109/TMI.2022.3199968
PubMed Web of Science® Google Scholar
25Rabbat N, Qureshi A, Hsu K-T, et al. Automated segmentation of levator ani muscle from 3D endovaginal ultrasound images. Bioengineering 2023; 10: 894.
10.3390/bioengineering10080894
PubMed Web of Science® Google Scholar
26Baumfeld Y, Wei Q, Chitnis P, Marroquin J, Shobeiri SA, Alshiek J. Does aging affect the elastic properties of the bladder and the urethra in nulliparous women: an ultrasound shear-wave elastography study. Neurourol Urodyn 2022; 41: 797–805.
10.1002/nau.24877
PubMed Web of Science® Google Scholar
27Rostaminia G, Manonai J, Leclaire E, et al. Interrater reliability of assessing levator ani deficiency with 360° 3D endovaginal ultrasound. Int Urogynecol J 2014; 25: 761–766. https://doi.org/10.1007/s00192-013-2286-5.
10.1007/s00192-013-2286-5
CAS PubMed Web of Science® Google Scholar
28van Delft K, Shobeiri SA, Thakar R, Schwertner-Tiepelmann N, Sultan AH. Intra- and inter-rater reliability of levator ani muscle biometry and avulsion using three-dimensional endovaginal sonography. Ultrasound Obstet Gynecol 2014; 43: 202–209. https://doi.org/10.1002/uog.13193.
10.1002/uog.13193
PubMed Web of Science® Google Scholar
29Alshiek J, Jalalizadeh M, Wei Q, Chitnis P, Shobeiri SA. Ultrasonographic age-related changes of the pelvic floor muscles in nulliparous women and their association with pelvic floor symptoms: a pilot study. Neurourol Urodyn 2019; 38: 1305–1312. https://doi.org/10.1002/nau.23979.
10.1002/nau.23979
PubMed Web of Science® Google Scholar
30Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform 2019; 95:103208.
10.1016/j.jbi.2019.103208
PubMed Web of Science® Google Scholar

Volume44, Issue7

July 2025

Pages 1175-1183

The Levator Plate Architecture Is Altered in Women With Fecal Incontinence

Abstract

Objectives

Methods

Results

Conclusions

Open Research

Data Availability Statement

References

References

Information

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The Levator Plate Architecture Is Altered in Women With Fecal Incontinence

Abstract

Objectives

Methods

Results

Conclusions

Open Research

Data Availability Statement

References

References

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