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Obstet Gynecol. Author manuscript; available in PMC 2008 Dec 3.
Obstet Gynecol. 2008 Apr; 111(4): 914–920.
From the Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland; Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama; Department of Radiology, University of North Carolina, Chapel Hill, North Carolina; Department of Obstetrics and Gynecology, University of Iowa Carver College of Medicine, Iowa City, Iowa; Department of Obstetrics and Gynecology and Urology, Loyola University Medical Center, Maywood, Illinois; University of British Columbia, Vancouver, British Columbia, Canada; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan; and Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama.
Corresponding author: Victoria L. Handa, MD, 4940 Eastern Avenue, Baltimore, MD 21224; e-mail: .ude.imhj@1adnahV
See other articles in PMC that cite the published article.
* P values are adjusted for delivery cohort.
† Adjusted for cohort and for significant interaction of cohort and race. P values for interaction of cohort and race: interspinous distance=0.004; anteroposterior outlet=0.016.
‡ P values adjusted for cohort and age and restraining analysis to a subpopulation younger than 30 years of age.
* P values are adjusted for delivery cohort.
† P value for difference between African-American and white women, restricted to women who delivered by vaginal birth without sphincter tear. P values are listed only if there is a significant interaction between delivery group and race.
‡ Adjusted for cohort and for significant interaction of cohort and race.
§ P values are adjusted for cohort and age and restraining analysis to a subpopulation younger than 30 years of age.
* P value for ϰ 2 test (controlling for cohort).
† Mean descent was quantified only for those with abnormal descent. P value for analysis of variance (controlling for cohort).
‡ Adjusted for significant interaction for cohort and race ( P value for interaction is .020).
1. Stark DD, McCarthy SM, Filly RA, Parer JT, Hricak H, Callen PW. Pelvimetry by magnetic resonance imaging. AJR Am J Roentgenol. 1985; 144 :947–50. [ PubMed ] [ Google Scholar ]
2. Macura KJ. Magnetic resonance imaging of pelvic floor defects in women. Top Magn Reson Imaging. 2006; 17 :417–26. [ PubMed ] [ Google Scholar ]
3. Baragi RV, Delancey JO, Caspari R, Howard DH, Ashton-Miller JA. Differences in pelvic floor area between African American and European American women. Am J Obstet Gynecol. 2002; 187 :111–5. [ PubMed ] [ Google Scholar ]
4. Cheng YW, Shaffer BL, Caughey AB. Associated factors and outcomes of persistent occiput posterior position: a retrospective cohort study from 1976 to 2001. J Matern Fetal Neonatal Med. 2006; 19 :563–8. [ PubMed ] [ Google Scholar ]
5. Chung JH, Garite TJ, Kirk AM, Hollard AL, Wing DA, Lagrew DC. Intrinsic racial differences in the risk of cesarean delivery are not explained by differences in caregivers or hospital site of delivery. Am J Obstet Gynecol. 2006; 194 :1323–8. [ PubMed ] [ Google Scholar ]
6. Hollard AL, Wing DA, Chung JH, Rumney PJ, Saul L, Nageotte MP, et al. Ethnic disparity in the success of vaginal birth after cesarean delivery. J Matern Fetal Neonatal Med. 2006; 19 :483–7. [ PubMed ] [ Google Scholar ]
7. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002; 186 :1160–6. [ PubMed ] [ Google Scholar ]
8. Kim S, Harvey MA, Johnston S. A review of the epidemiology and pathophysiology of pelvic floor dysfunction: do racial differences matter? J Obstet Gynaecol Can. 2005; 27 :251–9. [ PubMed ] [ Google Scholar ]
9. Bump RC. Racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse. Obstet Gynecol. 1993; 81 :421–5. [ PubMed ] [ Google Scholar ]
10. Rortveit G, Brown JS, Thom DH, Van Den Eeden SK, Creasman JM, Subak LL. Symptomatic pelvic organ prolapse: prevalence and risk factors in a population-based, racially diverse cohort. Obstet Gynecol. 2007; 109 :1396–403. [ PubMed ] [ Google Scholar ]
11. Thom DH, van den Eeden SK, Ragins AI, Wassel-Fyr C, Vittinghof E, Subak LL, et al. Differences in prevalence of urinary incontinence by race/ethnicity. J Urol. 2006; 175 :259–64. [ PMC free article ] [ PubMed ] [ Google Scholar ]
12. Steer CM. 2nd Saunders; Philadelphia (PA): 1959. Moloy’s evaluation of the pelvis in obstetrics. [ Google Scholar ]
13. Borello-France D, Burgio KL, Richter HE, Zyczynski H, Fitzgerald MP, Whitehead W, et al. Fecal and urinary incontinence in primiparous women. Obstet Gynecol. 2006; 108 :863–72. [ PubMed ] [ Google Scholar ]
14. Richter HE, Fielding JR, Bradley CS, Handa VL, Fine P, FitzGerald MP, et al. Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears. Obstet Gynecol. 2006; 108 :1394–401. [ PubMed ] [ Google Scholar ]
15. Handa VL, Pannu HK, Siddique S, Gutman R, VanRooyen J, Cundiff G. Architectural differences in the bony pelvis of women with and without pelvic floor disorders. Obstet Gynecol. 2003; 102 :1283–90. [ PubMed ] [ Google Scholar ]
16. Cunningham FG, Williams JW. Williams obstetrics. 19th Appleton & Lange; Norwalk (CT): 1993. [ Google Scholar ]
17. Moloy HC, Steer CM. Moloy’s evaluation of the pelvis in obstetrics. 3d Plenum Medical Books Co.; New York (NY): 1975. [ Google Scholar ]
18. Zaretsky MV, Alexander JM, McIntire DD, Hatab MR, Twickler DM, Leveno KJ. Magnetic resonance imaging pelvimetry and the prediction of labor dystocia. Obstet Gynecol. 2005; 106 :919–26. [ PubMed ] [ Google Scholar ]
19. Gordon A, Pinchen C, Walker E, Tudor J. The changing place of radiology in obstetrics. Br J Radiol. 1984; 57 :891–3. [ PubMed ] [ Google Scholar ]
20. Jagani N, Schulman H, Chandra P, Gonzalez R, Fleischer A. The predictability of labor outcome from a comparison of birth weight and x-ray pelvimetry. Am J Obstet Gynecol. 1981; 139 :507–11. [ PubMed ] [ Google Scholar ]
21. Varner MW, Cruikshank DP, Laube DW. X-ray pelvimetry in clinical obstetrics. Obstet Gynecol. 1980; 56 :296–300. [ PubMed ] [ Google Scholar ]
22. van Loon AJ, Mantingh A, Serlier EK, Kroon G, Mooyaart EL, Huisjes HJ. Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term. Lancet. 1997; 350 :1799–804. [ PubMed ] [ Google Scholar ]
23. Howard D, Davies PS, DeLancey JO, Small Y. Differences in perineal lacerations in black and white primiparas. Obstet Gynecol. 2000; 96 :622–4. [ PMC free article ] [ PubMed ] [ Google Scholar ]
24. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol. 2001; 98 :225–30. [ PubMed ] [ Google Scholar ]
25. Liu X, Zhao Y, Pawlyk B, Damaser M, Li T. Failure of elastic fiber homeostasis leads to pelvic floor disorders. Am J Pathol. 2006; 168 :519–28. [ PMC free article ] [ PubMed ] [ Google Scholar ]
1. Stark DD, McCarthy SM, Filly RA, Parer JT, Hricak H, Callen PW. Pelvimetry by magnetic resonance imaging. AJR Am J Roentgenol. 1985; 144 :947–50. [ PubMed ] [ Google Scholar ] [ Ref list ]
2. Macura KJ. Magnetic resonance imaging of pelvic floor defects in women. Top Magn Reson Imaging. 2006; 17 :417–26. [ PubMed ] [ Google Scholar ] [ Ref list ]
3. Baragi RV, Delancey JO, Caspari R, Howard DH, Ashton-Miller JA. Differences in pelvic floor area between African American and European American women. Am J Obstet Gynecol. 2002; 187 :111–5. [ PubMed ] [ Google Scholar ] [ Ref list ]
4. Cheng YW, Shaffer BL, Caughey AB. Associated factors and outcomes of persistent occiput posterior position: a retrospective cohort study from 1976 to 2001. J Matern Fetal Neonatal Med. 2006; 19 :563–8. [ PubMed ] [ Google Scholar ] [ Ref list ]
6. Hollard AL, Wing DA, Chung JH, Rumney PJ, Saul L, Nageotte MP, et al. Ethnic disparity in the success of vaginal birth after cesarean delivery. J Matern Fetal Neonatal Med. 2006; 19 :483–7. [ PubMed ] [ Google Scholar ] [ Ref list ]
7. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002; 186 :1160–6. [ PubMed ] [ Google Scholar ] [ Ref list ]
11. Thom DH, van den Eeden SK, Ragins AI, Wassel-Fyr C, Vittinghof E, Subak LL, et al. Differences in prevalence of urinary incontinence by race/ethnicity. J Urol. 2006; 175 :259–64. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ Ref list ]
9. Bump RC. Racial comparisons and contrasts in urinary incontinence and pelvic organ prolapse. Obstet Gynecol. 1993; 81 :421–5. [ PubMed ] [ Google Scholar ] [ Ref list ]
12. Steer CM. 2nd Saunders; Philadelphia (PA): 1959. Moloy’s evaluation of the pelvis in obstetrics. [ Google Scholar ] [ Ref list ]
13. Borello-France D, Burgio KL, Richter HE, Zyczynski H, Fitzgerald MP, Whitehead W, et al. Fecal and urinary incontinence in primiparous women. Obstet Gynecol. 2006; 108 :863–72. [ PubMed ] [ Google Scholar ] [ Ref list ]
14. Richter HE, Fielding JR, Bradley CS, Handa VL, Fine P, FitzGerald MP, et al. Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears. Obstet Gynecol. 2006; 108 :1394–401. [ PubMed ] [ Google Scholar ] [ Ref list ]
15. Handa VL, Pannu HK, Siddique S, Gutman R, VanRooyen J, Cundiff G. Architectural differences in the bony pelvis of women with and without pelvic floor disorders. Obstet Gynecol. 2003; 102 :1283–90. [ PubMed ] [ Google Scholar ] [ Ref list ]
16. Cunningham FG, Williams JW. Williams obstetrics. 19th Appleton & Lange; Norwalk (CT): 1993. [ Google Scholar ] [ Ref list ]
17. Moloy HC, Steer CM. Moloy’s evaluation of the pelvis in obstetrics. 3d Plenum Medical Books Co.; New York (NY): 1975. [ Google Scholar ] [ Ref list ]
18. Zaretsky MV, Alexander JM, McIntire DD, Hatab MR, Twickler DM, Leveno KJ. Magnetic resonance imaging pelvimetry and the prediction of labor dystocia. Obstet Gynecol. 2005; 106 :919–26. [ PubMed ] [ Google Scholar ] [ Ref list ]
19. Gordon A, Pinchen C, Walker E, Tudor J. The changing place of radiology in obstetrics. Br J Radiol. 1984; 57 :891–3. [ PubMed ] [ Google Scholar ] [ Ref list ]
21. Varner MW, Cruikshank DP, Laube DW. X-ray pelvimetry in clinical obstetrics. Obstet Gynecol. 1980; 56 :296–300. [ PubMed ] [ Google Scholar ] [ Ref list ]
22. van Loon AJ, Mantingh A, Serlier EK, Kroon G, Mooyaart EL, Huisjes HJ. Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term. Lancet. 1997; 350 :1799–804. [ PubMed ] [ Google Scholar ] [ Ref list ]
23. Howard D, Davies PS, DeLancey JO, Small Y. Differences in perineal lacerations in black and white primiparas. Obstet Gynecol. 2000; 96 :622–4. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ Ref list ]
24. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol. 2001; 98 :225–30. [ PubMed ] [ Google Scholar ] [ Ref list ]
25. Liu X, Zhao Y, Pawlyk B, Damaser M, Li T. Failure of elastic fiber homeostasis leads to pelvic floor disorders. Am J Pathol. 2006; 168 :519–28. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ Ref list ]

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To use static and dynamic magnetic resonance imaging (MRI) to compare dimensions of the bony pelvis and soft tissue structures in a sample of African-American and white women.
This study used data from 234 participants in the Childbirth and Pelvic Symptoms Imaging Study, a cohort study of 104 primiparous women with an obstetric anal sphincter tear, 94 who delivered vaginally without a recognized anal sphincter tear and 36 who underwent by cesarean delivery without labor. Race was self-reported. At 6–12 months postpartum, rapid acquisition T2-weighted pelvic MRIs were obtained. Bony and soft tissue dimensions were measured and compared between white and African-American participants using analysis of variance, while controlling for delivery type and age.
The pelvic inlet was wider among 178 white women than 56 African-American women (10.7±0.7 cm compared with 10.0.±0.7 cm, P <.001). The outlet was also wider (mean intertuberous diameter 12.3±1.0 cm compared with 11.8±0.9 cm, P <.001). There were no significant differences between racial groups in interspinous diameter, angle of the subpubic arch, anteroposterior conjugate, levator thickness, or levator hiatus. In addition, among women who delivered vaginally without a sphincter tear, African-American women had more pelvic floor mobility than white women. This difference was not observed among women who had sustained an obstetric sphincter tear.
White women have a wider pelvic inlet, wider outlet, and shallower anteroposterior outlet than African-American women. In addition, after vaginal delivery, white women demonstrate less pelvic floor mobility. These differences may contribute to observed racial differences in obstetric outcomes and to the development of pelvic floor disorders.
Magnetic resonance imaging (MRI) has been in use in the characterization of the female pelvis since the mid 1980s. 1 Advantages of MRI include multiplanar images as well as dynamic visualization of the soft tissues of the female pelvic floor. As a result, MRI has become an important adjunct to physical examination and fluoroscopy for the evaluation of pelvic anatomy. 2
Before MRI, conventional radiography suggested that the architecture of the bony pelvis differs between white and African-American women. More recently, differences in the dimensions of the posterior pelvis 3 have been observed with MRI. The potential clinical implications of racial differences in anatomy include a possible association with variations in obstetric outcomes 4 – 6 and in the incidence of pelvic floor disorders. 7 – 11 In fact, stress urinary incontinence and pelvic organ prolapse appear to be less common among African-American than white women. 7 , 9 – 11 These observations have led us to hypothesize that racial differences in pelvic anatomy might be responsible for observed differences in racial patterns of pelvic floor disorders.
The objective of this study was to compare MRI dimensions of the bony pelvis in African-American and white women. In addition, the study evaluated MRI measurements based upon soft tissues within the pelvis, including static images at rest and dynamic measurements at rest and during Valsalva. Our goal is to confirm earlier data 12 suggesting racial differences in pelvic anatomy between African-American and white women.
The Childbirth and Pelvic Symptoms study (CAPS) 13 was performed by the Pelvic Floor Disorders Network, a multicenter network supported by the National Institute of Child Health and Human Development. The CAPS study was a prospective cohort study of primiparous women designed to study the relationship between vaginal delivery with a sphincter laceration and subsequent incontinence. Women in this study were recruited from the 921 participants in CAPS. Methods of the CAPS study have been reported in detail 13 and are briefly summarized here. Enrollment into this study was conducted from September 2003 to February 2005. Three cohorts of primiparous women were recruited while the women were hospitalized after a singleton delivery. The primary cohort of interest consisted of women with an anal sphincter tear (n=104). Two comparison groups were recruited: women who delivered vaginally without a clinically recognized anal sphincter tear (n=94) and women who underwent cesarean delivery without labor (n=36). We attempted to include all women who delivered with a sphincter laceration. For each woman with an anal sphincter tear recruited for this study, we recruited the next consecutive woman who delivered vaginally without a clinically recognized sphincter tear. We attempted to include all women who delivered by cesarean without labor.
At the time of (or shortly after) their 6-month telephone interviews for the CAPS study, CAPS participants were approached to join the CAPS Imaging Study, 14 which correlated standardized imaging (MRI and endoanal ultrasonography), physical examination findings, and symptom assessment. The MRIs obtained for the CAPS Imaging Study provided the data for this secondary analysis.
This research protocol was approved at the institutional review boards at all clinical sites and the central data coordinating center. All women provided informed consent for participation. Data for this investigation were obtained 6–12 months after delivery. Weight and height were measured, and body mass index was calculated for each subject. Race was self-reported. Subjects were allowed to report more than one race but were asked to select a primary racial category if more than one race was indicated.
The MRI protocol was standardized at a 1-day training session, led by the expert consulting radiologist at the central site before study initiation. After centralized training, images were acquired using a 1.5T magnet with the patient in a supine position and a surface array coil wrapped around the pelvis. Ultrasound gel (60 mL) was placed in the rectum. After localizer images, we obtained sagittal ultra-fast T2-weighted images (rest and strain), and transverse and coronal T2-weighted images (rest). For straining images, participants were coached to strain without elevating the lumbosacral spine or thighs. Each dynamic image required 2 seconds for acquisition.
On sagittal images, the pubococcygeal line was used to represent the normal location of the pelvic floor. Rest and maximal strain midsagittal images were obtained to evaluate the descent of the bladder neck and anorectal junction, anteropo
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