Pelvic organ prolapse occurs when pelvic organs descend from their normal position, while urinary incontinence involves involuntary urine leakage. Both conditions are common and can require an assortment of assessments and interventions, from conservative management and medication to surgery and electrical nerve stimulation. Such options make a shared clinical framework important, but the new research suggests that hospital practice can diverge sharply even when specialists agree broadly on how many procedures should occur. The authors say the results provide a practical method for finding areas where hospital-level consistency may be improving or requires closer review.

The researchers used a mixed-methods design spanning 90 combinations of diagnoses, procedures and medical specialties. They systematically assessed Dutch clinical practice guidelines, mapped what specialists expected in terms of treatment volumes and variation between hospitals, and then compared those expectations with actual patterns in nationwide claims data. The claims analysis was cross-sectional, providing a snapshot rather than following patients over time. Two complementary measures quantified differences: coefficients of variation, which describe dispersion around the average, and treatment rate ratios, which compare rates in hospitals with the highest activity against those with the lowest.

Variation was substantial in both diagnosis and surgery. For diagnostic procedures, coefficients of variation ranged from 0.4 to 2.7, while treatment rate ratios ranged from 5.1 to 94.7. That upper ratio means the rate of a diagnostic procedure could be almost 95 times higher at the high end than at the low end of the hospital distribution. Surgical procedures also showed wide differences, with coefficients of variation of 0.6 to 2.9 and treatment rate ratios of 4.0 to 33.9. In other words, a patient’s chances of receiving a particular test or operation could depend considerably on which hospital she or he visited.

Clinical guidelines were the study’s main candidate explanation. Recommendations can standardize who should receive a diagnostic test, which procedures are appropriate and how treatment choices should be made, thereby reducing the scope for hospitals to diverge. Yet the analysis found that 54% of the 90 treatment combinations had no guideline recommendation. The result is important because a substantial part of routine pelvic floor care operates in areas where clinicians are not given a single, explicit standard to follow. Even where recommendations exist, the evidence did not reveal a simple, universal relationship between how clear the guidance is and how much hospitals vary.

There were important condition-specific exceptions. For both stress and urge urinary incontinence, procedures supported by clear recommendations were associated with less variation between hospitals. The same pattern was not observed for pelvic organ prolapse, where practice differences remained even when guidance was available. This distinction suggests that a guideline’s presence alone is not enough to produce uniformity. Recommendation clarity may matter, but implementation, local organizational capacity, patient selection and the interpretation of clinical evidence can also shape how a procedure is used. The observational data cannot establish which of these factors directly caused the differences.

Doctors’ forecasts revealed another layer of the problem. Specialists were generally accurate when estimating how many cases or procedures hospitals would handle, suggesting that they had a good grasp of overall workload. They were much less accurate at predicting the degree of practice variation between institutions. In other words, clinicians may know the scale of a service without recognizing how differently that service is delivered across the country. Such a blind spot matters because routine professional experience is often drawn from a handful of hospitals and may not capture the full national picture.

The study’s combination of methods is its most consequential feature. Claims data reveal what happened in practice, but by themselves they cannot show whether the resulting patterns are appropriate. Specialist expectations provide a reference point for identifying differences that the profession may not have anticipated. Guideline analysis then helps determine whether a particular practice falls into a well-defined standard, an underspecified area or a domain where recommendations exist but have not produced consistency. Linking these three sources does not automatically label a hospital as an outlier or an outlier as wrong, but it can prioritize cases for clinical review and quality-improvement work.

For patients, the practical implication is that hospital choice may matter more than expected in pelvic floor care. The results do not mean that every difference in treatment is undesirable: hospitals may serve populations with different ages, comorbidities, severity, prior treatments or preferences, and those differences can legitimately affect what clinicians do. But the scale of the reported disparities means that raw differences cannot simply be assumed to reflect patient mix. Some may be warranted, while others could reflect divergent referral patterns, inconsistent thresholds for testing and surgery, or uneven adoption of treatments.

The authors emphasize that the framework can help distinguish unwarranted variation from justified clinical difference and direct interventions toward areas where care quality may be improved. More complete recommendations could address the many combinations now lacking guidance, while clearer implementation pathways might help hospitals apply existing advice consistently. The study was funded by the Foundation for Quality Funds for Medical Specialists, which was jointly governed by the federation of medical specialists and an umbrella organization representing health-care insurers; the funders had no role in conducting the research or publishing it.

What the analysis ultimately reveals is a common health-systems paradox: a condition can be well known, clinically studied and supported by a national network of specialists while still being treated quite differently from one hospital to another. For pelvic floor disorders, clear guidance was associated with more consistent care in some forms of urinary incontinence, but the effect did not extend across every diagnosis. The next challenge is to move beyond counting differences and determine which ones matter for outcomes, access and patient experience, then use that knowledge to make care more predictable without suppressing clinically justified customization.

Subject of Research: Hospital practice variation in the diagnosis and treatment of pelvic organ prolapse and urinary incontinence

Article Title: Practice variation in hospital care for pelvic organ prolapse and urinary incontinence: an analysis of specialists’ expectations, cross-sectional claims data, and the role of clinical guidelines

Article References: Loop, S. J. L. M., Stam, P. J. A., Stadhouders, N., Mostovaya, I., van Barneveld, T., Engberts, M. K., van Eijndhoven, H. W. F., Veen, J., Hermans, K. E. P. E., & van der Hijden, E. J. E. (2026). Practice variation in hospital care for pelvic organ prolapse and urinary incontinence: an analysis of specialists’ expectations, cross-sectional claims data, and the role of clinical guidelines. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15634-4

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15634-4

Keywords: pelvic floor disorders, pelvic organ prolapse, urinary incontinence, practice variation, clinical guidelines, hospital care, claims data, urogynecology, health services research, quality improvement, Practice, variation

The study, led by Ling Li and Daoming Tian of the Center for Pelvic Floor Disorders at the First Affiliated Hospital of Kunming Medical University, recruited sixteen healthy Asian women between the ages of eighteen and thirty who had never been pregnant. This nulligravid population is a crucial reference point. Pelvic floor dysfunction, including prolapse and incontinence, affects a large share of women worldwide, but clinicians still lack a firm baseline for what the uninjured, youthful pelvic floor does when asked to perform. Without that baseline, it is difficult to say whether a given measurement in a patient is abnormal or simply part of natural variation.

To capture the pelvic floor in action, the team used a 3.0 Tesla MRI scanner, a field strength high enough to resolve fine soft-tissue detail in the midsagittal plane, the side-on view that slices the pelvis down the middle. Each participant was imaged three times in quick succession: once at rest, once while performing a maximal Valsalva maneuver, meaning a forced exhalation against a closed airway that raises intra-abdominal pressure, and once while performing a maximal voluntary pelvic floor contraction, the deliberate squeeze familiar to anyone who has practiced Kegel exercises. The researchers then measured a battery of anatomical landmarks in each state, from the position of the bladder neck and anorectal junction to the angle of the levator plate, the length of the urethra and vaginal walls, and the area of the levator hiatus, the opening through which the urethra, vagina, and rectum pass.

One of the study’s technical strengths lies in how those measurements were made. Rather than relying on raw scanner coordinates, which shift depending on how a patient is positioned on the table, the team applied a Pelvic Inclination Correction System, or PICS, coordinate framework. This approach corrects for pelvic tilt and establishes a reproducible reference line running from the pubis to the sacrococcygeal joint, allowing landmarks measured in different women and different states to be compared on equal footing. All measurements were performed independently by two radiologists using specialized segmentation software, and the average of their readings was used in the final analysis.

The reliability of those readings was generally strong. Intraclass correlation coefficients, which quantify how closely two observers agree, ranged from 0.858 to 0.999 across the three states, values that in most imaging studies would be considered excellent. The authors were careful, however, to note that some of the confidence intervals around those estimates were wide and dipped below 0.75, particularly during the Valsalva and contraction maneuvers. In a cohort of only sixteen participants, a single outlier can stretch those intervals considerably, a limitation the researchers acknowledge openly.

When the three states were compared statistically using repeated-measures analysis of variance, with a false discovery rate correction applied across thirty-three endpoint tests to guard against spurious findings, thirty-two of the thirty-three endpoints showed evidence of state-related differences. In other words, nearly every measurable feature of pelvic floor morphology changed significantly depending on whether the woman was resting, straining, or squeezing. The largest differences emerged between the two active maneuvers, Valsalva and voluntary contraction, which turned out to be far from mirror images of each other.

The numbers tell a striking story. During voluntary contraction compared with Valsalva, the anorectal junction moved upward by an average of 18.50 millimeters, the upper levator plate angle decreased by about 30.44 degrees, the M-line displacement, a measure of pelvic floor descent, was smaller by 12.69 millimeters, and the levator hiatus area shrank by 2.41 square centimeters. In plain terms, when these women actively squeezed their pelvic muscles, the entire pelvic floor lifted, the muscular plate behind the anus tilted into a more horizontal, supportive orientation, and the opening in the levator muscle narrowed. During straining, the opposite occurred: the hiatus widened, the organs descended, and the pelvic floor flattened under pressure.

Perhaps the most intriguing observation concerns the uterovaginal axis, the line running from the uterine fundus down through the cervix and vagina. The researchers sampled points along this axis and tracked their displacement across states, finding hints that different segments of the axis move by different amounts during contraction. This suggests that the pelvic floor does not behave as a single rigid sheet but as a segmented, coordinated system in which the upper and lower portions may respond differently to muscular effort. The authors describe this as a hypothesis-generating finding, one that will require three-dimensional imaging and concurrent functional measurements to confirm.

The clinical implications could be substantial. Dynamic MRI of the pelvic floor is already used to diagnose prolapse and obstructed defecation, but interpretation depends on reference values, and most existing norms come from older or parous women. By documenting how a healthy young pelvic floor responds to maximal effort, this study provides a physiological anchor for distinguishing normal function from early dysfunction. It also highlights a subtlety that matters in the clinic: straining and squeezing are not simply opposite ends of one spectrum but distinct neuromuscular configurations, and a patient’s ability to perform each correctly can reveal different problems. A woman who bears down when she intends to squeeze, a common error in pelvic floor rehabilitation, would show a pattern on dynamic MRI that is unmistakably different from a correct contraction.

The authors are appropriately cautious about how far these findings can be pushed. Sixteen women, all from a single ethnic group and a single hospital, cannot define the full range of human pelvic floor anatomy, and the nonparametric sensitivity analyses were not fully concordant with the primary results, a reminder that some findings may not survive in larger samples. Still, as an exploratory map of the living pelvic floor in motion, the study is a valuable first step. It shows that with careful coordinate correction, rigorous observer agreement, and modern 3.0 Tesla imaging, the invisible mechanics of pelvic support can be measured with precision, opening the door to better baselines, better diagnostics, and perhaps one day, imaging-guided pelvic floor training tailored to each woman’s own anatomy.

Subject of Research: Dynamic MRI assessment of pelvic floor morphology in young healthy nulligravid women during rest, Valsalva, and voluntary contraction

Article Title: Dynamic MRI of pelvic floor morphology in young, healthy Asian nulligravid women: an exploratory study across rest, Valsalva, and voluntary contraction

Article References: Li, L., Tian, D., Zeng, Y., Wang, X., Luo, Q., & Shen, J. (2026). Dynamic MRI of pelvic floor morphology in young, healthy Asian nulligravid women: an exploratory study across rest, Valsalva, and voluntary contraction. BMC Medical Imaging. https://doi.org/10.1186/s12880-026-02853-8

Image Credits: AI Generated

DOI: 10.1186/s12880-026-02853-8

Keywords: pelvic floor, dynamic MRI, nulligravid women, Valsalva maneuver, pelvic floor contraction, levator hiatus, pelvic organ prolapse, PICS coordinates, 3.0 Tesla MRI, pelvic floor dysfunction, levator ani, urogynecology