Our implementation of the flipped classroom curriculum for the gynaecologic oncology topics successfully demonstrates a promising platform for using technology to make better use of our students' time, and for increasing their satisfaction with the necessary didactic learning of the clerkship.

Objective To describe a framework for visualizing the perineal body's complex anatomy using thin-slice MR imaging. Study Design Two mm-thick MR images were acquired in 11 women with normal pelvic support and no incontinence/prolapse symptoms. Anatomic structures were analyzed in axial, sagittal and coronal slices. 3-D models were generated from these images. Results Three distinct perineal body regions are visible on MRI: (1) a superficial region at the level of the vestibular bulb, (2) a mid region at the proximal end of the superficial transverse perineal muscle, and (3) a deep region at the level of the midurethra and puborectalis muscle. Structures are best visualized on axial scans while cranio-caudal relationships are appreciated on sagittal scans. The 3-D model further clarifies inter-relationships. Conclusion Advances in MR technology allow visualization of perineal body anatomy in living women and development of 3D models which enhance our understanding of its three different regions: superficial, mid and deep.

Objective To compare pelvic floor structure and function between older women with and without fecal incontinence (FI) and young continent women. Study Design Young (YC, n=9) and older (OC, n=9) continent women were compared to older women with FI (OI, n=8). Patients underwent a POP-Q, measurement of levator ani (LA) force at rest (FLAR) and with maximum contraction (FLAC), and MRI. Displacement of structures and LA defects were determined on dynamic MRI. Results LA defects were more common in the OI v. the YC (75% v. 11%, p=0.01) and OC groups (22%, p=0.14); women with FI were more likely to have LA defects than women without (OR 14.0, 95% CI: 1.8-106.5). OI women generated 27.0% and 30.1% less FLAC v. the OC group (p=0.13) and YC groups (p=0.04). During Kegel, OI absolute structural displacements were smaller than in the OC group (p=0.01). Conclusions OI women commonly have LA defects, and cannot augment pelvic floor strength.

Objective The arcus tendineus fascia pelvis (ATFP) and arcus tendineus levator ani (ATLA) are elements of anterior vaginal support. This study describes their geometry in women with unilateral levator ani muscle defects and associated “architectural distortion.” Study Design Fourteen subjects with unilateral defects underwent MRI. 3-D models of the arcus were generated. Locations of these relative to an ilial reference line were compared between unaffected and affected sides. Results Pronounced changes occurred on the defect sides’ ventral region. The furthest point of the ATLA lay up to a mean 10.2mm (p=0.01) more inferior and 6.5mm (p=0.02) more medial than that on the intact side. Similarly, the ATFP lay 6 mm (p=0.01*) more inferior than on the unaffected side. Conclusion The ventral arcus anatomy is significantly altered in the presence of levator defects and architectural distortion. Alterations of these key fixation points will change supportive force direction along the lateral anterior vaginal wall, increasing the risk for anterior vaginal wall prolapse.

Objective Determine the effect of levator defects on perineal position and movement irrespective of prolapse status. Study Design Forty women from an ongoing study were divided into two groups of 20 women with and without severe levator defects. Prolapse status was matched between groups with 50% having stage III or greater anterior wall prolapse. Perineal structure locations were measured against standard axes on MR scans at rest, maximum contraction (Kegel), and maximum Valsalva. Differences in location were calculated and compared. Results In women with levator defects, independent of prolapse status: (1) at rest the perineal body was 1.3 cm and the anal sphincter 1.0 cm more caudal (p≤ 0.01); at maximum contraction the perineal body and the anal sphincter were both 1.2 cm more caudal (p≤ 0.01); with maximum Valsalva the perineal body was 1.3 cm more caudal and the anal sphincter was 1.2 cm more caudal (p≤ 0.01). (2) At rest the levator hiatus was 0.8 cm larger and the urogenital hiatus was 1.0 cm larger (p≤ 0.01). (3) At rest the bladder was 0.07 cm more posterior (p≤ 0.02) and with maximum contraction 1.9 cm lower (p≤ 0.02). (4) With maximum Valsalva the bladder was 1.5 cm lower and displaced further caudally (p≤ 0.03). Conclusions Controlling for prolapse, women with levator defects have a more caudal location of their perineal structures and larger hiatuses at rest, maximum contraction, and maximum Valsalva.