Biomechanical paradigm and interpretation of female pelvic floor conditions before a treatment

Figures & data

Figure 1 Preferred process in urogynecology.

Figure 2 Vaginal tactile imaging probe.

Note: Pressure sensors are aligned on the opposite sides of the probe (highlighted on the image).

Figure 3 Vaginal tactile imaging probe during pelvic floor examination.

Figure 4 (A) VTI probe insertion to deform vaginal walls in a definitive manner and (B) a tactile image for VTI probe insertion into a silicone model with known elasticity distribution.

Abbreviation: VTI, vaginal tactile imaging.

Figure 5 Test 1 (VTI probe insertion) results for two patients with (A) stiff and (B) much softer vaginal tissue.

Notes: White lines show spatial pressure gradients for anterior and posterior compartments. Panels (C) and (D) are the same data as in panel (A) and (B), but with maximum pressure graphs (green lines) along the anterior and posterior compartments.
Abbreviation: VTI, vaginal tactile imaging.

Figure 6 (A) VTI probe elevation to acquire tactile feedback from deep structures and (B) a tactile image for VTI probe elevation inside a silicone model with known elasticity distribution.

Abbreviation: VTI, vaginal tactile imaging.

Figure 7 Test 2 (VTI probe elevation) results for two patients with (A; Case A) weak and (B; Case B) strong pelvic floor support.

Abbreviation: VTI, vaginal tactile imaging.

Figure 8 (A) VTI probe rotation to acquire circumferential tactile feedback from the vaginal walls and (B) tactile images acquired inside a silicone model with known elasticity distribution.

Abbreviation: VTI, vaginal tactile imaging.

Figure 9 Test 3 (VTI probe rotation) results for two patients with normal pelvic floor support and (A) irregular strong and (B) weak vaginal wall response.

Abbreviation: VTI, vaginal tactile imaging.

Figure 10 Test 4 (Valsalva maneuver) results for a 51-year-old patient with normal pelvic support.

Notes: (A, D) Anterior and posterior pressure patterns at Valsalva maneuver (red lines) and at rest (light brown lines); (B, E) anterior and posterior dynamic pressure pattern along the vagina; (C, F) pressure dynamic at specific locations (see dotted lines in B, E).

Figure 11 Test 4 (Valsalva maneuver) results for a 52-year-old patient with normal pelvic floor support.

Notes: (A, D) Anterior and posterior pressure patterns at Valsalva maneuver (red lines) and at rest (light brown lines); (B, E) anterior and posterior dynamic pressure pattern along the vagina; (C, F) pressure dynamic at specific locations (see dotted lines in B, E).

Figure 12 Test 4 (Valsalva maneuver) results for a 66-year-old patient with Stage IV prolapse.

Notes: (A, D) Anterior and posterior pressure patterns at Valsalva maneuver (red lines) and at rest (light brown lines); (B, E) anterior and posterior dynamic pressure pattern along the vagina; (C, F) pressure dynamic at specific locations (see dotted lines in B, E).

Figure 13 Test 4 (Valsalva maneuver) results for an 84-year-old patient with Stage III prolapse.

Notes: (A, D) Anterior and posterior pressure patterns at Valsalva maneuver (red lines) and at rest (light brown lines); (B, E) anterior and posterior dynamic pressure pattern along the vagina; (C, F) pressure dynamic at specific locations (see dotted lines in B, E).

Figure 14 Test 5 (voluntary muscle contraction) results for a 35-year-old patient with normal pelvic floor support.

Notes: (A, D) Anterior and posterior pressure patterns at muscle contraction (red lines) and at rest (light brown lines); (B, E) dynamic pressure pattern along the vagina; (C, F) muscle contraction dynamic at specific locations (see dotted lines in B, E).

Figure 15 Test 6 (voluntary muscle contraction) results for a 35-year-old patient with normal pelvic floor support.

Notes: (A, D) Right and left side pressure patterns at muscle contraction (red lines) and at rest (light brown lines); (B, E) dynamic pressure pattern along the vagina; (C, F) muscle contraction dynamic at specific locations (see dotted lines in B, E).

Figure 16 Test 5 (voluntary muscle contraction) results for an 80-year-old patient with Stage II prolapse.

Notes: (A, D) Anterior and posterior pressure patterns at muscle contraction (red lines) and at rest (light brown lines); (B, E) dynamic pressure pattern along the vagina; (C, F) muscle contraction dynamic at specific locations (see dotted lines in B, E).

Figure 17 Test 6 (voluntary muscle contraction) results for an 80-year-old patient with Stage II prolapse.

Notes: (A, D) Right and left side pressure patterns at muscle contraction (red lines) and at rest (light brown lines); (B, E) dynamic pressure pattern along the vagina; (C, F) muscle contraction dynamic at specific locations (see dotted lines in B, E).

Figure 18 Test 7 (involuntary muscle relaxation) results for a 74-year-old patient with normal pelvic floor support.

Notes: (A, D) Anterior and posterior pressure patterns at muscle relaxation (from red to light brown lines); (B, E) dynamic pressure pattern along the vagina; (C, F) muscle relaxation dynamic at specific locations (see dotted lines in B, E).

Figure 19 Test 8 (involuntary muscle relaxation) results for a 71-year-old patient with Stage II prolapse.

Notes: (A, D) Anterior and posterior pressure patterns at muscle relaxation (from red to light brown lines); (B, E) anterior and posterior dynamic pressure pattern along the vagina; (C, F) muscle relaxation dynamic at specific locations (see dotted lines in B, E).

Figure 20 Test 8 (involuntary muscle contraction) results for a 51-year-old patient with normal pelvic floor support.

Notes: (A, D) Pressure patterns at muscle contraction (red lines) and at rest (light brown lines); (B, E) anterior and posterior dynamic pressure pattern along the vagina; (C, F) muscle contraction dynamic at specific locations (see dotted lines in B, E).

Figure 21 Test 8 (involuntary muscle contraction) results for a 64-year-old patient with Stage IV prolapse.

Notes: (A, D) Pressure patterns at muscle contraction (red lines) and at rest (light brown lines); (B, E) right and left side dynamic pressure pattern along the vagina; (C, F) muscle contraction dynamic at specific locations (see dotted lines in B, E).

Table 1 VTI parameters, pelvic floor structures, clinical value, and relevant clinical conditions for VTI tests 1–8

VTI test	Test output	VTI parameters and pelvic structures to be characterized	Clinical value
Test 1 Probe insertion	• 2D tactile image of anterior vs posterior • Maximum pressure (P) graphs along posterior and anterior • Maximum pressure gradient (∂P/∂y) graphs along posterior and anterior	• Vaginal tissue elasticity distribution (∂P/∂y) along anterior and posterior compartments • Strength (P) and, possibly, elasticity (∂P/∂y) of urethra (U) in distal anterior • Strength (P) and elasticity (∂P/∂y) of the ZCE in mid-anterior • Strength (P) and elasticity (∂P/∂y) of the USL/CL in apical anterior • Strength (P) and elasticity (∂P/∂y) of PB in distal posterior • Rest tone (P) and elasticity (∂P/∂y) of levator ani muscles and, possibly, PRM in mid-posterior • Strength (P) of LP in apical posterior • Hiatus strength as combined distal anterior and posterior pressure (P)	• Detection defects in vaginal wall • PB characterization for diagnosis of defects • PRM characterization for diagnosis of defects • LP characterization for diagnosis of defects • USL/CL characterization for diagnosis of defects • Urethra characterization • Monitoring of vaginal elasticity changes after applied treatment (surgery, physiotherapy, RF, or laser procedures) • Scar detection and characterization of ZCE for UI diagnosis (tethered vagina syndrome) • Characterization of postpartum pelvic floor remodeling • Vaginal elasticity changes with age
Test 2 Probe elevation	• 2D tactile image of anterior and posterior under significant vaginal wall deformation (up to 40 mm) • Pressure (P) values at selected locations • Pressure gradients data/image (∂P/∂y) of anterior and posterior compartments	• Strength (P) of pelvic floor support structures along the posterior compartment • Elasticity (∂P/∂y) of urethra (U) in distal anterior • Elasticity (∂P/∂y) of the USL/CL in apical anterior • Elasticity (∂P/∂y) of PRM, PAM, PVM, and ICM at rest • Elasticity of (∂P/∂y) of LP • PUL and ATFP assessment at maximum posterior deformation is under question	• Detection of defects in pelvic floor support structures including PRM, PAM, PVM, ICM and USL/CL • Comparative analysis of pelvic floor support after applied treatment (surgery, physiotherapy, RF, or laser procedures) • Characterization of postpartum pelvic floor remodeling • Pelvic support changes with age
Test 3 Probe rotation	• 2D tactile image of circumferential vaginal walls • Pressure (P) values at selected locations • Integral contact pressure	• Vaginal “tightness” • Irregularities on the vaginal walls along the entire vagina as pressure peak value (P) and its size • Asymmetry in pelvic floor structures behind the vaginal walls • Cumulative (integral) contact pressure inside the vagina (“vaginal strength”)	• Irregularities detection/characterization on vaginal walls • Monitoring of vaginal wall changes after applied treatment (surgery, physiotherapy, RF, or laser procedures) • Postpartum vaginal wall changes
Tests 5 and 6 Voluntary muscle contraction (anterior vs posterior)	• Dynamic pressure (P(t)) signals • Pressure patterns at rest (P1(x)) and at contraction (P2(x)) • MS = P2(x) – P1(x) • Structure mobility (Δx) • Contractive desynchronization or not full synchronization • Left Pl(x) vs right Pr(x) side contraction pattern • Phases of contraction	• PPM, PRM, PVM, and ICM strength • Contractive capability (P) of urethra (U) • Contractive desynchronization or not full synchronization among levator ani muscles • Muscle asymmetry (left vs right) in levator ani muscles (weakness or avulsion) • Muscle mobility along the vagina in mid-posterior compartment • Contractive width of levator ani muscles • Multiphase muscle contraction	• Detection of defects in pelvic floor muscle PPM, PRM, PVM, ICM • Contractive capability of urethra (U) • Comparative analysis of pelvic floor MS after pelvic floor treatment • Muscle characterization of postpartum pelvic floor remodeling • Muscle changes with lifestyle: sport, military load influence, and so on • Muscle changes with age
Test 7 Involuntary muscle relaxation (left vs right side)	• Muscle relaxation rate (ΔP/Δt) • Uniformity of muscle relaxation • Stages of relaxation	• PVM, PRM, and ICM to keep the load measured as MRR (mmHg/s) • Uniformity/nonuniformity of muscle relaxation • Multistage muscle relaxation	• Detection of muscle relaxation defects in PVM, PRM, ICM • Comparative analysis of pelvic floor MS after pelvic floor treatment • Muscle characterization of postpartum pelvic floor remodeling • Muscle changes with lifestyle: sport, military load influence, and so on • Muscle changes with age
Test 8 Involuntary muscle contraction (cough)	• Dynamic pressure (P(t)) signals • Pressure patterns at rest (P1(x)) and at contraction (P2(x)) • Involuntary muscle contractive component IMC = P2(x) − P1(x) − ΔP • Urethra mobility (Δx) • Uniform pressure change (ΔP) at cough	• Contractive capability (P) of urethra (U) • Mobility of the urethra (U) • Uniform pressure increase (P) under along the entire vagina in anterior and posterior compartments • Levator ani muscles IMC	• Detection of defects in urethra (U) • Availability of involuntary component in levator ani muscles • Urethra (U) and levator ani changes with age

Abbreviations: 2D, two-dimensional; ATFP, arcus tendineus fascia pelvis ligament; CL, cardinal ligament; ICM, iliococcygeal muscle; IMC, involuntary muscle contraction components; LP, levator plate; MRR, muscle relaxation rate; MS, muscle strength; PAM, puboanal muscle; PB, perineal body; PPM, puboperineal muscle; PRM, puborectal muscle; PVM, pubovaginal muscle; PUL, pubourethral ligament; RF, radio frequency; UI, urinary incontinence; USL, uterosacral ligament; VTI, vaginal tactile imaging; ZCE, zone of critical elasticity.