{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T19:07:42Z","timestamp":1792782462788,"version":"4.5.0"},"reference-count":28,"publisher":"Springer Science and Business Media LLC","issue":"6","license":[{"start":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T00:00:00Z","timestamp":1776211200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T00:00:00Z","timestamp":1776211200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000062","name":"National Institute of Diabetes and Digestive and Kidney Diseases","doi-asserted-by":"publisher","award":["RC2 DK122379"],"award-info":[{"award-number":["RC2 DK122379"]}],"id":[{"id":"10.13039\/100000062","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000062","name":"National Institute of Diabetes and Digestive and Kidney Diseases","doi-asserted-by":"publisher","award":["U2C DK129445"],"award-info":[{"award-number":["U2C DK129445"]}],"id":[{"id":"10.13039\/100000062","id-type":"DOI","asserted-by":"publisher"}]},{"name":"The De Luca Foundation, Inc.","award":["Early Career Grant"],"award-info":[{"award-number":["Early Career Grant"]}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Int Urogynecol J"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Failure of the urogenital hiatus to remain closed in women is a major contributor to prolapse operation failure and development of prolapse after childbirth. This article presents a conceptual framework, the Urogenital Hiatus Closure System (UHCS), that explains how anatomic and neuromuscular elements interact to maintain, or fail to maintain, hiatal closure. Clinical observations demonstrate that no single structure reliably predicts hiatus size; instead, hiatal behavior results from the integrated functional components. The UHCS has three primary elements: the levator ani muscle, neuromotor control, and Level III connective tissues of the perineal complex\u2014each of which can be injured, partially compensated, or overloaded. These structures form a neuromechanically integrated unit in which the medial levator ani, the perineal membrane and its central connection, and the afferent\u2013efferent control loops work to provide resting tone, active contraction, resistance to dilation, and spatial alignment. A principle of the model is redundancy: failure in one component may not enlarge the hiatus, but combinations of failures exceed compensatory capacity and result in failure. It links Level III mechanics to Level I\u2013II support by demonstrating how an open hiatus increases forces on apical and paravaginal tissues, driving a feed-forward cycle of prolapse dilation and muscle elongation. Conceptually, the UHCS is an interacting triad influenced by functional modifiers\u2014loading conditions, prolapse effects, muscle length, motor activation, and connective-tissue properties\u2014that determine hiatus size. This systems-based approach can guide classification of failure patterns to inform biomechanical, anatomical, and therapeutic research.<\/jats:p>","DOI":"10.1007\/s00192-026-06641-4","type":"journal-article","created":{"date-parts":[[2026,4,15]],"date-time":"2026-04-15T13:21:30Z","timestamp":1776259290000},"page":"1491-1501","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Urogenital Hiatus Closure System: A Framework for Understanding how Muscle, Motor Control, and Fascial Connections Interact in Normal and Failed Closure"],"prefix":"10.1007","volume":"37","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1012-7713","authenticated-orcid":false,"given":"John O. L.","family":"DeLancey","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James A.","family":"Ashton-Miller","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jennifer","family":"LaCross","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Payton","family":"Schmidt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariana","family":"Masteling","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fernanda","family":"Pipitone","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher X.","family":"Hong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luyun","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,4,15]]},"reference":[{"key":"6641_CR1","volume-title":"Anatomie und Atiologie der Genital prolapse biem Weibe","author":"J Halban","year":"1907","unstructured":"Halban J, Tandler J. Anatomie und Atiologie der Genital prolapse biem Weibe. Vienna and Leipzig: Wilhelm Braum\u00fcller; 1907."},{"issue":"6","key":"6641_CR2","first-page":"677","volume":"97","author":"B Berglas","year":"1953","unstructured":"Berglas B, Rubin IC. Study of the supportive structures of the uterus by levator myography. Surg Gynecol Obstet. 1953;97(6):677\u201392.","journal-title":"Surg Gynecol Obstet"},{"issue":"3","key":"6641_CR3","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1016\/S0029-7844(97)00682-0","volume":"91","author":"JO DeLancey","year":"1998","unstructured":"DeLancey JO, Hurd WW. Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse. Obstet Gynecol. 1998;91(3):364\u20138.","journal-title":"Obstet Gynecol"},{"issue":"2","key":"6641_CR4","doi-asserted-by":"publisher","first-page":"327","DOI":"10.1007\/s00192-022-05354-8","volume":"34","author":"W Cheng","year":"2023","unstructured":"Cheng W, English E, Horner W, Swenson CW, Chen L, Pipitone F, et al. Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors. Int Urogynecol J. 2023;34(2):327\u201343. https:\/\/doi.org\/10.1007\/s00192-022-05354-8.","journal-title":"Int Urogynecol J"},{"issue":"8","key":"6641_CR5","doi-asserted-by":"publisher","first-page":"1923","DOI":"10.1007\/s00192-023-05482-9","volume":"34","author":"CX Hong","year":"2023","unstructured":"Hong CX, Nandikanti L, Shrosbree B, Delancey JO, Chen L. Variations in structural support site failure patterns by prolapse size on stress 3D MRI. Int Urogynecol J. 2023;34(8):1923\u201331.","journal-title":"Int Urogynecol J"},{"issue":"2","key":"6641_CR6","doi-asserted-by":"publisher","first-page":"e448","DOI":"10.1097\/SPV.0000000000000960","volume":"27","author":"VL Handa","year":"2021","unstructured":"Handa VL, Blomquist JL, Carroll MK, Munoz A. Genital hiatus size and the development of prolapse among parous women. Female Pelvic Med Reconstr Surg. 2021;27(2):e448\u201352. https:\/\/doi.org\/10.1097\/SPV.0000000000000960.","journal-title":"Female Pelvic Med Reconstr Surg"},{"issue":"6","key":"6641_CR7","doi-asserted-by":"publisher","first-page":"1137","DOI":"10.1097\/AOG.0000000000002593","volume":"131","author":"MH Vaughan","year":"2018","unstructured":"Vaughan MH, Siddiqui NY, Newcomb LK, Weidner AC, Kawasaki A, Visco AG, et al. Surgical alteration of genital hiatus size and anatomic failure after vaginal vault suspension. Obstet Gynecol. 2018;131(6):1137\u201344. https:\/\/doi.org\/10.1097\/AOG.0000000000002593.","journal-title":"Obstet Gynecol"},{"key":"6641_CR8","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2023.11.1247","author":"JO DeLancey","year":"2023","unstructured":"DeLancey JO, Mastrovito S, Masteling M, Horner W, Ashton-Miller JA, Chen L. A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity. Am J Obstet Gynecol. 2023. https:\/\/doi.org\/10.1016\/j.ajog.2023.11.1247.","journal-title":"Am J Obstet Gynecol"},{"key":"6641_CR9","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2025.01.011","author":"JOL DeLancey","year":"2025","unstructured":"DeLancey JOL, Mastrovito S, Masteling M, Hong CX, Ashton-Miller JA, Chen L. Hiatus and pelvic floor failure patterns in pelvic organ prolapse: a 3D MRI study of structural interactions using a level III conceptual model. Am J Obstet Gynecol. 2025. https:\/\/doi.org\/10.1016\/j.ajog.2025.01.011.","journal-title":"Am J Obstet Gynecol"},{"issue":"2","key":"6641_CR10","doi-asserted-by":"publisher","first-page":"441","DOI":"10.1007\/s00192-023-05708-w","volume":"35","author":"JO DeLancey","year":"2024","unstructured":"DeLancey JO, Pipitone F, Masteling M, Xie B, Ashton-Miller JA, Chen L. Functional anatomy of urogenital hiatus closure: the perineal complex triad hypothesis. Int Urogynecol J. 2024;35(2):441\u20139.","journal-title":"Int Urogynecol J"},{"key":"6641_CR11","doi-asserted-by":"publisher","DOI":"10.1007\/s00192-025-06153-7","author":"JOL DeLancey","year":"2025","unstructured":"DeLancey JOL, Ashton-Miller JA, LaCross J, Pipitone F, Schmidt P, Chen L. Urogenital hiatus closure: facts, fallacies, and why a unified theory of hiatal failure is needed. Int Urogynecol J. 2025. https:\/\/doi.org\/10.1007\/s00192-025-06153-7.","journal-title":"Int Urogynecol J"},{"issue":"12","key":"6641_CR12","doi-asserted-by":"publisher","first-page":"2313","DOI":"10.1007\/s00192-024-05851-y","volume":"35","author":"S Muro","year":"2024","unstructured":"Muro S, Chikazawa K, Delancey JOL, Akita K. Skeletal muscle complex between the vagina and anal canal: implications for perineal laceration. Int Urogynecol J. 2024;35(12):2313\u201322.","journal-title":"Int Urogynecol J"},{"issue":"4","key":"6641_CR13","doi-asserted-by":"publisher","first-page":"488","DOI":"10.1016\/0029-7844(94)00443-h","volume":"85","author":"LL Wall","year":"1995","unstructured":"Wall LL, Hewitt JK, Helms MJ. Are vaginal and rectal pressures equivalent approximations of one another for the purpose of performing subtracted cystometry? Obstet Gynecol. 1995;85(4):488\u201393. https:\/\/doi.org\/10.1016\/0029-7844(94)00443-h.","journal-title":"Obstet Gynecol"},{"issue":"4","key":"6641_CR14","doi-asserted-by":"publisher","first-page":"815","DOI":"10.1016\/S0002-9378(99)70652-6","volume":"180","author":"JO DeLancey","year":"1999","unstructured":"DeLancey JO. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol. 1999;180(4):815\u201323.","journal-title":"Am J Obstet Gynecol"},{"issue":"9","key":"6641_CR15","doi-asserted-by":"publisher","first-page":"2413","DOI":"10.1007\/s00192-021-04795-x","volume":"32","author":"F Pipitone","year":"2021","unstructured":"Pipitone F, Swenson CW, DeLancey JOL, Chen L. Novel 3D MRI technique to measure perineal membrane structural changes with pregnancy and childbirth: technique development and measurement feasibility. Int Urogynecol J. 2021;32(9):2413\u201320. https:\/\/doi.org\/10.1007\/s00192-021-04795-x.","journal-title":"Int Urogynecol J"},{"issue":"1","key":"6641_CR16","doi-asserted-by":"publisher","first-page":"73","DOI":"10.1007\/s00192-011-1527-8","volume":"23","author":"JO DeLancey","year":"2012","unstructured":"DeLancey JO, Sorensen HC, Lewicky-Gaupp C, Smith TM. Comparison of the puborectal muscle on MRI in women with POP and levator ani defects with those with normal support and no defect. Int Urogynecol J. 2012;23(1):73\u20137.","journal-title":"Int Urogynecol J"},{"issue":"1","key":"6641_CR17","doi-asserted-by":"publisher","first-page":"80","DOI":"10.1002\/mp.16810","volume":"51","author":"S Zhang","year":"2024","unstructured":"Zhang S, Blokker AM, Borazjani A, Hong CX, Chaikof M, Giroux M, et al. A feasibility study of three-dimensional ultrasound imaging of the vagina under distension. Med Phys. 2024;51(1):80\u201392. https:\/\/doi.org\/10.1002\/mp.16810.","journal-title":"Med Phys"},{"issue":"3","key":"6641_CR18","doi-asserted-by":"publisher","first-page":"543","DOI":"10.23919\/JSEE.2023.000080","volume":"34","author":"K Yang","year":"2023","unstructured":"Yang K, Li J, Liu M, Lei T, Xu X, Wu H, et al. Complex systems and network science: a survey. J Syst Eng Electron. 2023;34(3):543\u201373. https:\/\/doi.org\/10.23919\/JSEE.2023.000080.","journal-title":"J Syst Eng Electron"},{"key":"6641_CR19","doi-asserted-by":"publisher","DOI":"10.3390\/jcm13247536","author":"E Swieten","year":"2024","unstructured":"Swieten E, Stralen KJV, Vollebregt A, Roovers JWR. Opinions of gynecologists about indication and technique of perineoplasty. J Clin Med. 2024. https:\/\/doi.org\/10.3390\/jcm13247536.","journal-title":"J Clin Med"},{"issue":"2","key":"6641_CR20","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1016\/j.ajog.2019.08.024","volume":"222","author":"G Sutkin","year":"2020","unstructured":"Sutkin G, Zyczynski HM, Sridhar A, Jelovsek JE, Rardin CR, Mazloomdoost D, et al. Association between adjuvant posterior repair and success of native tissue apical suspension. Am J Obstet Gynecol. 2020;222(2):161\u2013161. https:\/\/doi.org\/10.1016\/j.ajog.2019.08.024.","journal-title":"Am J Obstet Gynecol"},{"issue":"26","key":"6641_CR21","doi-asserted-by":"publisher","first-page":"1905","DOI":"10.1056\/NEJM199312233292601","volume":"329","author":"AH Sultan","year":"1993","unstructured":"Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329(26):1905\u201311. https:\/\/doi.org\/10.1056\/NEJM199312233292601.","journal-title":"N Engl J Med"},{"issue":"9","key":"6641_CR22","doi-asserted-by":"publisher","first-page":"1839","DOI":"10.1007\/s00192-024-05881-6","volume":"35","author":"H Hesham","year":"2024","unstructured":"Hesham H, Orejuela F, Rood KM, Turrentine M, Casey B, Khandelwal M, et al. Effect of an intrapartum pelvic dilator device on levator ani muscle avulsion during primiparous vaginal delivery: a pilot randomized controlled trial. Int Urogynecol J. 2024;35(9):1839\u201349. https:\/\/doi.org\/10.1007\/s00192-024-05881-6.","journal-title":"Int Urogynecol J"},{"issue":"2","key":"6641_CR23","doi-asserted-by":"publisher","first-page":"341","DOI":"10.1097\/AOG.0000000000003653","volume":"135","author":"I Bergman","year":"2020","unstructured":"Bergman I, Westergren Soderberg M, Ek M. Perineorrhaphy compared with pelvic floor muscle therapy in women with late consequences of a poorly healed second-degree perineal tear: a randomized controlled trial. Obstet Gynecol. 2020;135(2):341\u201351. https:\/\/doi.org\/10.1097\/AOG.0000000000003653.","journal-title":"Obstet Gynecol"},{"issue":"10","key":"6641_CR24","doi-asserted-by":"publisher","first-page":"1338","DOI":"10.1111\/aogs.14666","volume":"102","author":"E Rotstein","year":"2023","unstructured":"Rotstein E, Ullemar V, Engberg H, Linden Hirschberg A, Ajne G, Tegerstedt G. One-year follow-up after standardized perineal reconstruction in women with deficient perineum after vaginal delivery. Acta Obstet Gynecol Scand. 2023;102(10):1338\u201346. https:\/\/doi.org\/10.1111\/aogs.14666.","journal-title":"Acta Obstet Gynecol Scand"},{"issue":"4","key":"6641_CR25","doi-asserted-by":"publisher","first-page":"400","DOI":"10.1111\/codi.13119","volume":"18","author":"GA Santoro","year":"2016","unstructured":"Santoro GA, Shobeiri SA, Petros PP, Zapater P, Wieczorek AP. Perineal body anatomy seen by three-dimensional endovaginal ultrasound of asymptomatic nulliparae. Colorectal Dis. 2016;18(4):400\u20139. https:\/\/doi.org\/10.1111\/codi.13119.","journal-title":"Colorectal Dis"},{"issue":"6","key":"6641_CR26","doi-asserted-by":"publisher","first-page":"1545","DOI":"10.1007\/s00192-020-04651-4","volume":"32","author":"EM English","year":"2021","unstructured":"English EM, Chen L, Sammarco AG, Kolenic GE, Cheng W, Ashton-Miller JA, et al. Mechanisms of hiatus failure in prolapse: a multifaceted evaluation. Int Urogynecol J. 2021;32(6):1545\u201353. https:\/\/doi.org\/10.1007\/s00192-020-04651-4.","journal-title":"Int Urogynecol J"},{"issue":"3","key":"6641_CR27","doi-asserted-by":"publisher","first-page":"647","DOI":"10.1007\/s00192-025-06045-w","volume":"36","author":"T Liu","year":"2025","unstructured":"Liu T, Muro S, Tharnmanularp S, Akita K. Three-dimensional analysis of the distribution of smooth and skeletal muscle tissue around the female urethra. Int Urogynecol J. 2025;36(3):647\u201354. https:\/\/doi.org\/10.1007\/s00192-025-06045-w.","journal-title":"Int Urogynecol J"},{"issue":"2","key":"6641_CR28","doi-asserted-by":"publisher","first-page":"324","DOI":"10.1097\/01.AOG.0000227786.69257.a8","volume":"108","author":"L Chen","year":"2006","unstructured":"Chen L, Ashton-Miller JA, Hsu Y, DeLancey JO. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. Obstet Gynecol. 2006;108(2):324\u201332. https:\/\/doi.org\/10.1097\/01.AOG.0000227786.69257.a8.","journal-title":"Obstet Gynecol"}],"container-title":["International Urogynecology Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00192-026-06641-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00192-026-06641-4","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00192-026-06641-4.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T12:04:42Z","timestamp":1782475482000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00192-026-06641-4"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,15]]},"references-count":28,"journal-issue":{"issue":"6","published-print":{"date-parts":[[2026,6]]}},"alternative-id":["6641"],"URL":"https:\/\/doi.org\/10.1007\/s00192-026-06641-4","relation":{},"ISSN":["0937-3462","1433-3023"],"issn-type":[{"value":"0937-3462","type":"print"},{"value":"1433-3023","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,15]]},"assertion":[{"value":"1 December 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"11 February 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 April 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical Approval"}},{"value":"None.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflicts of interest"}}]}}