Research www. AJOG.

org

GENERAL GYNECOLOGY
Comparison of bony dimensions at the level of the pelvic
floor in women with and without pelvic organ prolapse
Tamara A. Stein, MA; Gurpreet Kaur, BA; Aimee Summers, BSE, MHS; Kindra A. Larson, MD; John O. L. DeLancey, MD

OBJECTIVE: We sought to compare bony pelvis dimensions at the
level of pelvic support in women with and without pelvic organ pro-
lapse (POP).
STUDY DESIGN: Pelvic floor dimensions of 42 white women with POP
⬎ 1 cm beyond the hymen were compared with 42 age- and parity-
matched women with normal support. Bony landmarks relevant to con-
nective tissue and levator attachments were identified on magnetic res-
onance imaging. Dimensions were independently measured by 2
examiners and averaged for each subject.
RESULTS: Measurements (in centimeters) for patients and control
subjects were as follows: interspinous diameter, 11.2 ⫾ 0.8 versus
11.1 ⫾ 0.7, P ⫽ .19; anterior-posterior outlet diameter, 11.7 ⫾ 0.7
versus 11.7 ⫾ 0.8, P ⫽ .71; pubic symphysis to ischial spine left, 9.5
⫾ 0.5 versus 9.5 ⫾ 0.4, P ⫽ .91; pubic symphysis to ischial spine
right, 9.5 ⫾ 0.4 versus 9.5 ⫾ 0.5, P ⫽ .81; sacrococcygeal junction
to ischial spine left, 7.0 ⫾ 0.6 versus 7.0 ⫾ 0.5, P ⫽ .54; and sacro-
coccygeal junction to ischial spine right, 7.0 ⫾ 0.6 versus 6.9 ⫾ 0.4,
P ⫽ .32.
CONCLUSION: Bony pelvis dimensions are similar at the level of the
muscular pelvic floor in white women with and without POP.
Key words: bony pelvis, pelvic dimensions, pelvic floor, prolapse

Cite this article as: Stein TA, Kaur G, Summers A, et al. Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ
prolapse. Am j Obstet Gynecol 2009;200:241.e1-241.e5.

P elvic organ prolapse (POP) is de-

fined as the downward descent of fe-
male pelvic organs. Epidemiologic stud-
ies are lacking on the prevalence of
symptomatic prolapse; however, we do
know that by 1997 statistics, 225,000
women underwent surgery for correc-
tion of prolapse (at a cost estimated at US
$1 billion) and that prolapse is the lead-
From the Pelvic Floor Research Group (Ms
Stein, Kaur, and Summers, and Drs Larson
and DeLancey), the Division of Anatomical
Science, Office of Medical Eduction (Ms
Stein), and the Department of Obstetrics and
Gynecology (Drs Larson and DeLancey),
University of Michigan, Ann Arbor, MI.
Received May 13, 2008; revised July 30, 2008;
accepted Oct. 7, 2008.
Reprints not available from the authors.
Supported by the National Institute of Child
Health and Human Development (R01 HD
38665) and the Office for Research on
Women’s Health Special Center of Research
on Sex and Gender Factors Affecting Women’s
Health (P50 HD 044406) for investigator
support.
0002-9378/$36.00
© 2009 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2008.10.040
ing indication for postmenopausal
hysterectomy.1,2
Several hypotheses have been gener-
ated in an effort to identify risk factors
associated with POP. One of these con-
cerns the size and shape of the pelvis.
These observations have concerned tra-
ditional obstetric dimensions developed
to assess pelvic capacity for vaginal deliv-
ery. They have investigated pelvic size as
it relates to pelvic floor injury with the
hypothesis that pelvic architecture may
influence the occurrence of pelvic floor
injury during vaginal birth.3 The case-
control study of Handa et al4 using pelvic
magnetic resonance (MR) imaging
(MRI) demonstrated a wider transverse
pelvic inlet and shorter obstetric conju-
gate in women with pelvic floor disor-
ders. Sze et al5 found a wider transverse
inlet in computed tomography scans of
women with prolapse compared with
healthy control subjects.
However, there is another way in
which pelvic architecture might influ-
ence POP. The shape or dimensions
formed by the attachments of the mus-
cular floor to the bony pelvis might pre-
dispose a woman to prolapse. It is possi-
ble that different pelvic sizes or shapes
pose different mechanical challenges in
supporting the pelvic organs relevant to
the problem of POP. In a prior report we
described a series of measurements rele-
vant to the attachment points of critical
pelvic floor structures to the bony pel-
vis.6 The purpose of this study was to
compare the dimensions of the bony pel-
vis at the level of the pelvic floor in
matched cohorts of women with and
without POP.
M ATERIALS AND M ETHODS
MR scans for analysis were taken from
a larger institutional review board-
approved case-control study with group
matching for age and parity among
women with POP (patients) and women
with normal pelvic organ support (con-
trol subjects).7 These women were re-
cruited from our urogynecology clinic
and advertisements sent to the sur-
rounding community from November
2000 through October 2004. To remove
race as a confounder, all included sub-
jects were white. Patients had to have a
portion of the vaginal wall or cervix at
least 1 cm below the hymen. The control
group was recruited to match for age,
race, body mass index, parity, and hys-

MARCH 2009 American Journal of Obstetrics & Gynecology 241.e1

Research General Gynecology www.AJOG.org

FIGURE 1 FIGURE 2
Landmarks for bony pelvis dimension at level of pelvic floor Axial and sagittal
measurements

Bony landmarks used in analysis. Pubic symphysis was identified at level of arcuate pubic ligament
(APL), and sacrococcygeal junction was identified as junction between fifth sacral and first coccygeal
vertebrae (S5/Co1) to define anterior-posterior diameter (AP). Right ischial spine (ISR) and left
ischial spine (ISL) were identified at the most protuberant location to define interspinous diameter.
Stein. Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse. Am J
Obstet Gynecol 2009.

A, Axial proton density image at level of ischial

terectomy status. In control subjects, all
areas of the vagina and cervix (or apex)
had to be at least 1 cm above the hymen.
Potential control subjects were excluded
if they demonstrated stress urinary in-
continence on a prestudy full bladder
stress test.
All subjects underwent clinical exami-
nation, which included assessment of
prolapse status using the POP quantifi-
cation system. In addition, they com-
pleted a full bladder stress test and pelvic
floor functional studies as described in
the parent study.7
Sample size was chosen based on a pre-
study power calculation, which indi-
cated a sample size of 21 subjects in each
group would be needed to achieve ␣ of
0.05 and ␤ of 0.8 using the 4% difference
in means and the SD in transverse diam-
eters found by Sze et al.5 We chose to
double this number in case different val-
ues were found. The study set was assem-
bled by selecting artifact-free complete
scans from consecutively recruited
women, beginning with the most re-
cently recruited women and working
backward until the target sample was
obtained.
Imaging
All subjects underwent MR scan using
our established protocol.8 This included
axial, sagittal, and coronal 2-dimen-
sional fast-spin proton-density MR
scans (echo time: 15 milliseconds; repe-
tition time: 4000 milliseconds) obtained
in the supine position with a 1.5-T su-
perconducting magnet (Signa; General
Electric Medical Systems, Milwaukee,
WI). The slice thickness was 4 mm with a
slice gap of 1 mm, yielding an image
spacing of 5 mm using a 160- ⫻ 160-mm
field of view and an imaging matrix of
256 ⫻ 256.
Bony pelvis dimensions
Bony landmarks associated with attach-
ment sites of the muscular pelvic floor
were identified on MR scans for each
subject and included the following: (1)
the arcuate pubic ligament (APL) that
spines showing interspinous diameter. B, Mid-
line sagittal image showing anterior-posterior
diameter, between inferior pubic point and sa-
crococcygeal junction.
Stein. Comparison of bony dimensions at the level of the
pelvic floor in women with and without pelvic organ
prolapse. Am J Obstet Gynecol 2009.
forms the inferior margin of the pubic
symphysis anteriorly; (2) the left ischial
spine (ISL) and right ischial spine (ISR)
laterally; and (3) the midline sacrococcy-
geal articulation posteriorly (fifth sacral
to first coccygeal vertebrae; S5/Co1)
(Figure 1). This latter point was chosen
rather than the inferior lateral angle of
the sacrum that we used previously,6 be-
cause the thin bone in this area is not
consistently visible in MRI and because
the immediately adjacent sacral foram-
ina can confound consistent bony point
identification. The inferior extent of the
APL was identified on axial MR scans as
the midline point of the most caudal sec-
tion in which the APL spanned both
sides of midline. The sacrococcygeal ar-

241.e2 American Journal of Obstetrics & Gynecology MARCH 2009

www.AJOG.org General Gynecology Research

R ESULTS
TABLE 1
In all, 42 patients and 42 control subjects
Subject demographics
met criteria and were included in the
Patients with Healthy control study. The demographics of the cohorts
Demographic prolapsea (n ⴝ 42) subjects (n ⴝ 42) P value
are shown in Table 1, confirming suc-
Age (y) 52.8 ⫾ 13.6 52.6 ⫾ 13.2 .9548 cessful matching for age, race, parity,
..............................................................................................................................................................................................................................................
Race (white) 100% 100% number of vaginal births, and body mass
..............................................................................................................................................................................................................................................
Parity 2.6 ⫾ 1.2 2.7 ⫾ 1.4 .7439 index. As mentioned above, all subjects
..............................................................................................................................................................................................................................................
Vaginal deliveries 2.1 ⫾ 0.8 2.0 ⫾ 1.0 .40397
were white. Within the prolapse group
.............................................................................................................................................................................................................................................. 23 subjects had cystoceles, 10 had recto-
BMI (kg/m ) 2
26.2 ⫾ 5.3 25.9 ⫾ 5.2 .7658
.............................................................................................................................................................................................................................................. celes, and 9 had enteroceles.
BMI, body mass index. Table 2 illustrates the bony pelvis di-
a
Prolapse group comprised of cystoceles (n ⫽ 23), rectoceles (n ⫽ 10), and enteroceles (n ⫽ 9).
..............................................................................................................................................................................................................................................
mension measurements in women with
Stein. Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse. POP and women with normal pelvic
Am J Obstet Gynecol 2009. support. The mean distances between all
bony landmarks are identical to the
nearest millimeter in the 2 groups of
ticulation was identified on sagittal MR object and allows the evaluator to pre-
women except for the distance between
scans as the junction between the fifth cisely establish the measurement point
sacral and first coccygeal vertebrae. ISL on the original scan. All bony pelvis di- the ISR and the sacrococcygeal junction
and ISR were identified at their most me- mensions were plotted and measured in- and the distance between the 2 spines. In
dial projection on axial MR scans (Fig- dependently by 2 examiners blinded to both of these cases, however, the mean
ure 2). prolapse status. The reported value is the difference is minimal (ⱕ 1 mm) and is
Distances between points that were average of these 2 measurements. not statistically different in the 2 groups.
not in the same scan plane were calcu- Statistical analyses were performed In addition to comparing bony pelvis
lated using the Pythagorean theorem (a2 using SPSS software (SPSS, Inc, Chi- dimensions between the 2 groups, we
⫹ b2 ⫽ c2) and the fact that the slice in- cago, IL). The null hypothesis–that also tested the association between each
terval was 5 mm. The distance between there is no difference in bony dimen- dimension (eg, ISR to APL, ISR to ISL)
points would then be comparable with sions between patients and control and prolapse status. Pearson correlations
the hypotenuse and the height or y axis, subjects—was tested against each pel- for each of these measures indicated no
the measurement of the slice interval (ie, vic dimension by using the indepen- relationship between prolapse and any
10 mm if separated by 2 slices). This dent samples t test, with a value of P ⬍ pelvic dimension associated with the
technique was chosen over 3-dimen- .05 indicating significance. The rela- muscular pelvic floor.
sional model reconstruction, because it tionship between prolapse status and Interexaminer reliability for each
avoids artifacts that occur in model con- pelvic floor dimensions was tested measurement was assessed via inde-
struction as the software constructs an through a Pearson correlation. pendent samples t test and showed no

TABLE 2
Bony pelvis dimensions of patients with prolapse vs healthy control subjects
Patients with prolapse (n ⴝ 42), Healthy control subjects (n ⴝ 42),
Pelvic dimension mean ⴞ SD (cm) mean ⴞ SD (cm) P valuea
Interspinous diameter (ISR to ISL) 11.2 ⫾ 0.8 11.1 ⫾ 0.7 .19
................................................................................................................................................................................................................................................................................................................................................................................
Anterior posterior outlet (APL to S5/Co1) 11.7 ⫾ 0.7 11.7 ⫾ 0.8 .71
................................................................................................................................................................................................................................................................................................................................................................................
Pubic symphysis to IS (IS to APL)
.......................................................................................................................................................................................................................................................................................................................................................................
Left 9.5 ⫾ 0.5 9.5 ⫾ 0.4 .91
.......................................................................................................................................................................................................................................................................................................................................................................
Right 9.5 ⫾ 0.4 9.5 ⫾ 0.5 .81
................................................................................................................................................................................................................................................................................................................................................................................
Sacrococcygeal junction to IS (S5/Co1 to IS)
.......................................................................................................................................................................................................................................................................................................................................................................
Left 7.0 ⫾ 0.6 7.0 ⫾ 0.5 .54
.......................................................................................................................................................................................................................................................................................................................................................................
Right 7.0 ⫾ 0.6 6.9 ⫾ 0.4 .32
................................................................................................................................................................................................................................................................................................................................................................................
APL, arcuate pubic ligament; IS, ischial spine; ISL, left ischial spine; ISR, right ischial spine; SD, standard deviation.
a
Independent samples t test.
................................................................................................................................................................................................................................................................................................................................................................................

Stein. Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse. Am J Obstet Gynecol 2009.

MARCH 2009 American Journal of Obstetrics & Gynecology 241.e3

Research General Gynecology www.AJOG.org

cross-sectional area of the pelvic floor;

TABLE 3 therefore, if this cross-sectional area is
Interexaminer reliability larger, it is subject to more force. Con-
Interexaminer mean versely, if we consider the maximum
Bony dimension difference (cm), n ⴝ 84 P valuea downward force generated by people to
APL to ISL 0.0476 .20 be a constant, then a larger pelvic floor
..............................................................................................................................................................................................................................................
APL to ISR 0.0250 .52 gives a larger cross-sectional area across
..............................................................................................................................................................................................................................................
ISR to S5/Co1 0.0405 .29 which this force can disperse and results
..............................................................................................................................................................................................................................................
in an overall decreased intraabdominal
ISL to S5/Co1 0.0191 .63
.............................................................................................................................................................................................................................................. pressure. Although all of these theories
ISL to ISR 0.0012 .98 individually make sense, it is evident that
..............................................................................................................................................................................................................................................
Axial APL to S5/Co1 0.1107 .06
..............................................................................................................................................................................................................................................
our understanding of these potential
Sag APL to S5/Co1 0.0357 .29 mechanisms is limited and that the bio-
..............................................................................................................................................................................................................................................
APL, arcuate pubic ligament; IS, ischial spine; ISL, left ischial spine; ISR, right ischial spine; S5/Co1, fifth sacral to first
mechanics and interaction of different
coccygeal vertebrae; Sag, sagittal. forces and support structures are poorly
a
Independent samples t test. understood and would benefit from fur-
..............................................................................................................................................................................................................................................
ther investigation.
Stein. Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse.
Am J Obstet Gynecol 2009. There have been other efforts quanti-
fying differences in pelvic dimensions
among populations with prolapse when
difference between the measurements of pose to structural failure later in life.
compared with control subjects; how-
the 2 examiners (Table 3). Test/retest re- Vaginal birth is a well-recognized risk
ever, these studies used classic obstetric
liability of 1 examiner was assessed on all factor for the development of pelvic floor
measurements to describe the bony pel-
measured distances of 3 randomly se- dysfunction. There are several theories as
vic architecture, not the level of pelvic
lected control subjects. Measured di- to how different bony pelvis dimensions
floor support. Handa et al4 and Sze et al5
mensions were identical in all but 4 mea- predispose laboring women to increased
found differences in obstetric parame-
sures. In these measures, the difference rates of neuromuscular injury and thus
ters with wider transverse diameters of
was ⱕ 1 mm. subsequently the development of pelvic
the pelvic inlet in women with pelvic
floor dysfunction. Based on research
findings, Handa et al4 theorize that cer- floor disorders. Handa et al4 also identi-
C OMMENT
tain pelvic shapes, such as the platypel- fied a shorter obstetric conjugate in those
Our study indicates that pelvic dimen-
loid pelvis with its narrow anterior-pos- with pelvic floor disorders. This particu-
sions at the level of the pelvic floor sup-
port in matched cohorts of women with terior diameter, might be more likely to lar study had several limitations. The
and without POP are similar. These mea- result in a prolonged second stage of la- study examined women with a wide va-
surements (Table 2) taken at levator ani bor and increased rates of nerve injury. riety of pelvic floor disorders, with only
muscle attachment sites along the bony They also suggests that in a pelvis with a 80% of the study population having
pelvis in women who were well matched shorter obstetric conjugate, the trauma POP. In addition, there were signifi-
for age, race, and parity are a strong in- may be focused anteriorly and cause cantly different racial compositions in
dication that these dimensions are simi- more injury to the origins of the levator the patients and control subjects: the pa-
lar in white women with and without ani, uterosacral ligaments, and hypogas- tient group was 8.5% African American,
prolapse. These findings do not support tric nerve along the anterior portions of whereas the control group was 36%. This
our hypothesis that women with pro- the bony pelvis. In a different manner, is a potentially important confounder,
lapse would have different pelvic dimen- after publishing their study, Sze et al5 because these 2 racial groups are known
sions than those without. We had fully suggest that a smaller pelvis may be pro- to have different pelvic architecture,6 al-
expected to find differences between tective and that it may in fact be in- though this was controlled for statisti-
these groups, based on the presumption creased pelvic dimensions that permit cally in the analysis. In addition, racial
that a larger pelvis may subject the pelvic larger infants to pass through the birth differences have been described at the
floor structures to greater forces, result- canal, resulting in increased rates of neu- level of the pelvic floor and must be ac-
ing in a higher rate of prolapse. romuscular injury. counted for in studies of pelvic morphol-
Current theories as to how pelvic Another theory supporting that a ogy. Hoyte et al9 identified these crucial
dimensions may impact prolapse devel- larger pelvis has a predisposition to pel- differences in a study of African Ameri-
opment can be grouped into 2 main cat- vic floor dysfunction is postulated by can and white women with normal sup-
egories: (1) by influencing birth mecha- Baragi et al.6 Using basic physical princi- port: African American women had
nism in a way that might increase ples, they argue that the downward force increased muscle bulk and closer pubo-
damage at delivery or (2) by contributing generated by intraabdominal pressure is rectalis attachment than their white
to geometric factors that would predis- equal to this pressure multiplied by the counterparts.

241.e4 American Journal of Obstetrics & Gynecology MARCH 2009

www.AJOG.org
Although the inlet of the pelvis may in-
deed differ in women with prolapse com-
pared with women without, the results of
our study show that among white women
the bony dimensions do not differ at the
level of the muscular pelvic floor. This in-
fers that among the white study popula-
tion, there is no specific dimension of the
bony pelvis, with regard to its functional
role as an anchoring site for the muscular
pelvic floor, which predisposes women to
an increased risk for POP. There are cer-
tain limitations to our study design regard-
ing the measurement technique. MRI vis-
ibility necessitated the use of a simplified
version of the pelvic bony landmarks to
maintain consistent measurements across
subjects and among examiners. True pel-
vic floor geometry is hexagonal in shape,
comprised of the left and right medial pu-
bic bones, ischial spines, and lateral por-
tions of the sacrum.6 In contrast, the di-
mensions in this study formed a diamond-
shaped pelvic floor, as the lateral margins
of the sacrum were difficult to locate in ei-
ther axial or sagittal MR scans. Instead,
measures were taken from the midline sa-
crococcygeal junction as the attachment
site for the posterior (or dorsal) portion of
the pelvic floor. However, the exact simi-
larity in the 2 groups makes it unlikely that
other dimensions at the level of the pelvic
floor will be of a major magnitude. In ad-
dition, our study was limited to the white
population and, therefore, cannot be gen-
eralized to other racial populations. Fi-
General Gynecology
nally, it is not possible to completely blind
observers to overt prolapse that may be vis-
ible in MR scans; however, the good repro-
ducibility of our measurements suggests it
is not a major problem.
The scientific study of the pelvic floor
has been greatly enhanced by the advent
of modern imaging. The ability to see the
structural geometry and integrity of spe-
cific pelvic floor elements now allows
measurements of properly matched co-
horts by investigators blinded to subject
status. This will allow us to make
progress in evaluating structure-func-
tion hypotheses and identify structures
that underlie mechanisms of disease.
Further studies of pelvic functional mor-
phology might consider the interaction
between soft tissue and bone in relation
to prolapse development by taking into
account measurements of the pelvic
floor muscle strength, thickness, fiber
length, and visible defects, making sure
to account for racial disparities. The size
of the pelvis at the level where the pelvic
floor attaches to the body pelvis is similar
in white women with and without POP,
suggesting that increased (or decreased)
size in this area is not related to prolapse.
There may be differences between dif-
ferent racial groups in pelvic size or the
occurrence of prolapse, but these find-
ings suggest that pelvic size alone at the
level of the pelvic floor is probably not
the causal factor. f 193:2035-40.
MARCH 2009 American Journal of Obstetrics & Gynecology
Research
REFERENCES
1. Jelovsek JE, Maher C, Barber MD. Pelvic or-
gan prolapse. Lancet 2007;369:1027-38.
2. Boyles SH, Weber AM, Meyn L. Procedures
for pelvic organ prolapse in the United States,
1979-1997. Am J Obstet Gynecol 2003;
188:108-15.
3. Frudinger A, Halligan S, Spencer JA, Bartram
CL, Kamm MA, Winter R. Influence of the sub-
pubic arch angle on anal sphincter trauma and
anal incontinence following childbirth. Br J Ob-
stet Gynecol 2002;109:1207-12.
4. Handa VL, Pannu HK, Sidique S, Gutman R,
VanRooyen J, Cundiff G. Architectural differ-
ences in the bony pelvis of women with and
without pelvic floor disorders: the American
College of Obstetricians and Gynecologists.
2003;102:1283-90.
5. Sze E, Kohli N, Miklos JR, Roat T, Karram
MM. Computed tomography comparison of
bony pelvis dimensions between women with
and without genital prolapse. Obstet Gynecol
1999;93:229-32.
6. Baragi RV, DeLancey JOL, Caspari R,
Howard DH, Ashton-Miller JA. Differences in
pelvic floor area between African American and
European women. Am J Obstet Gynecol
2002;187:111-5.
7. DeLancey JO, Morgan DM, Fenner DE, et al.
Comparison of levator ani muscle defects and
function in women with and without pelvic or-
gan prolapse. Obstet Gynecol 2007;109:
295-302.
8. Chou O, DeLancey JO. A structured system
to evaluate urethral support anatomy in mag-
netic resonance images. Am J Obstet Gynecol
2001;185:44-50.
9. Hoyte L, Thomas J, Foster R, Shott S, Jakab
M, Weidner A. Racial differences in pelvic mor-
phology among asymptomatic nulliparous
women as seen on three-dimensional magnetic
resonance images. Obstet Gynecol 2005;
241.e5