Proceedings of the ASME 2016 International Mechanical Engineering Congress and Exposition
IMECE2016
November 11-17, 2016, Phoenix, Arizona, USA
COMPUTATIONAL MODELING OF ANTERIOR AND POSTERIOR PELVIC ORGAN
PROLAPSE (POP)
Arnab Chanda
Department of Aerospace Engineering,
University of Alabama
Tuscaloosa, Alabama, USA
Holly E. Richter
Department of Obstetrics and Gynecology,
Division of Urogynecology and Pelvic
Reconstructive Surgery, University of Alabama at
Birmingham
Birmingham, Alabama, USA
ABSTRACT
Pelvic Organ Prolapse (POP) is a condition of the female
pelvic system suffered by a significant proportion of women in
the U.S. and more across the globe, every year. POP is caused
by the weakening of the pelvic floor muscles and musculo-
connective tissues due to child birth, menopause and morbid
obesity. Prolapse of the pelvic organs namely the urinary
bladder, uterus, and rectum into the vaginal canal can cause
vaginal discomfort, strained urination or defecation, and sexual
dysfunction. To date, success rates of native tissue POP
surgeries vary from 50-70% depending on the definition of cure
and time-point of assessment. A better understanding of the
mechanics of prolapse may lead to improvement in surgical
outcomes. In the current work, the mechanics of progression of
anterior and posterior vaginal prolapse were modeled to
understand the effect of bladder fill and posterior vaginal
stresses using computational approaches. A realistic and full-
scale female pelvic system model, comprised of the urinary
bladder, vaginal canal, uterus, rectum, and fascial connective
tissue, was developed using image segmentation methods. All of
the relevant loads and boundary conditions were applied based
on a comprehensive study of the anatomy and functional
morphology of the female pelvis. Hyperelastic material models
were adopted to characterize all pelvic tissues, and a non-linear
analysis was invoked. In the first set of simulations, a realistic
bladder filling and vaginal tissue stiffening in prolapse were
modeled and their effects on the anterior vaginal wall (AVW)
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IMECE2016-67949
Vinu Unnikrishnan
Department of Aerospace Engineering,
University of Alabama
Tuscaloosa, Alabama, USA
Mark E. Lockhart
Department of Radiology, University of Alabama at
Birmingham
Birmingham, Alabama, USA
were estimated in terms of the induced stresses, strains and
displacements. The degree of bladder filling was found to be a
strong indicator of stress build-up on the AVW. Also, vaginal
tissue stiffening was found to increase the size of the high stress
zone on the AVW. The second simulation consisted of modeling
the different degrees of posterior vaginal wall (PVW) prolapse,
in the presence of an average abdominal pressure. The vaginal
length was segmented into four sections to study the localized
stresses and strains. Also, a clinically well-known phenomena
known as the kneeling effect was observed with the PVW in
which the vaginal wall displaces away from the rectum and
downward towards the vaginal hiatus. All of these results have
relevant clinical implications and may provide important
perspective for better understanding the mechanics of POP
pathophysiology.
INTRODUCTION
The female pelvic floor is a complex system that goes
through drastic changes during puberty, labor with vaginal
delivery and menopause. Pelvic organ prolapse (POP) [1, 2] is a
condition in which the pelvic floor muscles and connective
tissue weaken progressively causing prolapse of the pelvic
organs namely the urinary bladder, uterus or rectum into the
vaginal walls or vagina, and consequently may lead to vaginal
discomfort, strained urination or defection, and sexual
dysfunction. A cystocele or prolapse of the Anterior Vaginal
Wall (AVW), is the most common type of POP suffered by over
 300,000 women in the US [3]. Figure 1 depicts the AVW
prolapse conditions compared to normal female pelvis anatomy.
Posterior vaginal wall (PVW) prolapse occurs in the form of a
rectocele (the distal portion of the rectum pushes against and
moves the back wall of the vagina) or enterocele (the small
bowel presses against and moves the upper wall of the vagina or
dissects between the rectum and vagina).

FIGURE 2: MRI IMAGE SEGMENTATION IN

TURTLESEG SOFTWARE

FINITE ELEMENT MODELING

True 1:1 scale MRI Images of the female pelvis were

FIGURE 1: NORMAL PELVIC ANATOMY COMPARED
WITH VARIOUS PROLAPSE CONDITIONS
Finite element modeling (FEM) has been used to simulate
complex mechanisms of the female pelvic floor observed
through imaging techniques such as the Magnetic Resonance
Imaging (MRI), ultrasound and Diffusion Tensor MRI (DT-
MRI) [3]. The effect of abdominal pressure on the vaginal canal
has been studied under varying pelvic floor conditions.
Additionally, POP conditions have been investigated using
various phenomenological numerical modeling techniques [3].
In most such computational models, unrealistic and
oversimplified loads and boundary conditions, and material
models (for tissues) have been assumed. Further studies have to
be conducted to realistically model the interaction between the
pelvic organs and actual loading conditions such as urine filling,
or rectal bulging into the vagina due to prolapse.
obtained from the Korean Female database [5], and converted
into Digital Imaging and Communications in Medicine
(DICOM) format. These images were loaded into an image
segmentation software, TurtleSeg [6] and contoured in the
transverse, coronal and sagittal planes to obtain the crude outer
surfaces for the urinary bladder, vaginal canal (and uterus) and
the rectum (See Figure 2). The outer surfaces were exported as
stereolithographic (STL) files and imported in Meshlab
software for smoothening. The smooth surfaces from Meshlab
were taken into Hypermesh software (Altair Inc.) and corrected
appropriately to begin meshing. An iterative process of surface
correction followed by meshing was carried out over 50 times
to ensure a good mesh with no failing elements. The surface
meshes of all the pelvic organs in true 1:1 scale (Figure 3) were
converted into tetrahedral volume meshes. A higher order 3D
20-node Solid 186 type quadratic tetrahedral element type was
used generating 15851, 5658, and 21477 elements in number
for the urinary bladder, vaginal canal (and uterus) and the
rectum respectively. The FE meshes were imported into ANSYS
APDL software, and a non-linear analysis was invoked.

In the current work, a full scale computational model of the

female pelvic system comprising the urinary bladder, vaginal
canal, uterus and the rectum has been developed using an MRI
based image segmentation from the visible Korean human
database [4]. The assignment of realistic loads and boundary
conditions are discussed in the upcoming sections. The current
numerical models would be indispensable for better
understanding of the mechanics of anterior and posterior FIGURE 3: COMPUTATIONAL MODELS OF PELVIC
vaginal wall prolapse, and may provide important guidelines to ORGANS IN 1:1 SCALE
urogynecologic surgeons for improved surgical planning.

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 NONLINEAR MATERIAL MODELING muscles and ligaments have been neglected to simplify
Non-linear mechanical behavior of soft tissues are precisely computations, however their effects have been considered
characterized using hyperelastic constitutive equations such as appropriately in choosing the loads and boundary conditions.
Mooney-Rivlin, Yeoh, Neo-Hookean, and Ogden models [7]. In The fascial contacts between the pelvic organs were modeled
an isotropic hyperelastic model, the strain-energy density with a flexible and bonded contact pair in the FE framework.
function (ψ) is a linear function of strain invariants I1, I2 and I3 Based on prior works by DeLancey et al. [10] on the functional
along the three principal directions (see Equation 1). anatomy of the pelvic floor, the fundus of the uterus, urethra,
the vaginal and rectal hiatus were constrained in all degrees of
   ( I1 , I 2 , I3 ) (1) freedom. Also, for the first set of simulations involving the
3 urinary bladder and the vaginal canal, the posterior vaginal wall
I1   i2 (2) was constrained to assume absolutely no posterior prolapse
i 1
3
effects. In the second set of simulations involving the vaginal
I2   
i , j 1
i
2 2
j
(3) canal and the rectum, the posterior rectal wall was constrained
in all degrees of freedom to simulate its strong attachment with
I 3  i 1 i2 the pelvis through ligaments. Additionally, a novel forced
3
(4)
volume expansion technique was employed (based on previous
work by Chanda et al. [11]) to simulate the varying degrees of
The strain invariants are functions of the principal stretches bladder fill (Figure 4) and rectal prolapse into the vagina in the
λ1, λ2 and λ3 given by equations 2-4. In the current work, the first and second set of simulations, respectively. The method
rectal, bladder and vaginal tissues were modeled using Yeoh’s involves the specification of a hypothetical thermal expansion
hyperelastic model [8]. Equation 5 gives the isotropic strain coefficient (k) of 10-4 for the volume mesh elements. Every
energy functions of the Yeoh’s model, where C10, C20, and C30 mesh element was then assigned an initial reference
are the three material constants. ‘K’ is the material specific bulk (hypothetical) temperature (To) of 0 C, and a final temperature
modulus and ‘J’ is the Jacobian which accounts for the (T) to invoke volume expansion for every mesh element (and
compressibility property of the material (J=1 in case of a thus the entire volume), given by equation 7. It should be
completely incompressible material). Based on the experimental mentioned here that hypothetical temperatures have been used
studies on pelvic tissues in literature [9], the Yeoh’s curve fitting just to simulate a forced volume expansion, and not to include
parameters adopted (estimated using equation 6) in our study any thermal effects. Also, this forced thermal expansion is
are listed in Table 1. independent of the material property of the tissue. Only the
induced effect of this expansion has been utilized to simulate
3
K
 Yeoh   Ci 0 ( I1  3)i  ( J  1)2 (5) bladder filling or rectal bulging phenomena.
i 1 2
1 
 Yeoh  2( 2  )(c10  2c20 ( I1  3)  3c30 ( I1  3)2 ) (6) % Volume Expansion  100  k T , T  T  To (7)
 

TABLE 1: YEOH’S HYPERELASTIC MATERIAL

MODEL PARAMETERS ADOPTED FOR PELVIC
TISSUES IN THE ANALYSES

LOADS AND BOUNDARY CONDITIONS FIGURE 4: NOVEL FORCED VOLUME EXPANSION

TECHNIQUE USED TO SIMULATE URINE FILLING IN
The female pelvic organs are connected to each other, with THE BLADDER
pelvic floor muscles, and various connective tissue elements,
For the first set of simulations, the stresses induced due to
which are complex to visualize and recreate in a computational
bladder filling on the AVW were estimated. Also, a novel
model [3]. In the current work, only the urinary bladder, vaginal
vaginal stiffening material model was developed to look at the
canal, uterus and rectum have been modeled. Pelvic floor

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 AVW changes due to vaginal tissue stiffening secondary to
prolapse. The model was comprised of defining vaginal tissue
properties in normal, low and high degrees of prolapse (Figure
5). Eight cases were simulated within the upper and lower
bounds of prolapsed vaginal tissue conditions, in different
bladder fill conditions (empty through full), to look at the
combined effects of bladder filling and vaginal tissue stiffening
FIGURE 5: VAGINAL TISSUE STIFFENING
MATERIAL MODEL WITH UPPER AND LOWER
BOUNDS USED IN OUR ANALYSES
in prolapse.
In the second part of the work, different degrees of rectal
prolapse were simulated. Based on literature [12] on functional
anatomy of rectal prolapse, the degree of prolapse was
quantified based on the maximum distance estimated from the
anorectal axis (line passing through the centroidal axis of rectal
hiatus or the anus in Figure 6) to the farthest point of the
prolapsed rectum [12]. The vaginal length was divided into four
equal sections in the Y-Z plane as shown in Figure 7. The
average cross-sections of the vaginal canal (along the Y
direction) were estimated in the four sections. An average
abdominal pressure of 30 cm H2O (or 2.94 kPa) was applied in
FIGURE 6: EXAMPLE OF POSTERIOR VAGINAL
WALL PROLAPSE SIMULATION AND
QUANTIFICATION
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the Y-direction, and the changes in the vaginal cross-sections in
the four regions were tracked for different cases of rectal
prolapse.
FIGURE 7: VAGINAL LENGTH DIVIDED INTO FOUR
EQUAL SECTIONS FOR ANALYSES
RESULTS AND DISCUSSION
The urinary bladder volume was forced to expand from 0
through 100 percent (based on assignment of different final
temperatures T, and equation 6), to simulate varying degrees of
bladder fill. Figure 8 shows the effects of an empty bladder and
fully filled bladder conditions respectively on the AVW. Three
main observations were recorded. First, bladder filling was
found to cause a more uniform stress distribution at the AVW.
Second, despite a more uniform stress redistribution, at high
bladder fills, some small areas developed high stress
concentrations, which may potentially cause vaginal discomfort.
Third, compared to a maximum stress value of 0.12 MPa at an
empty bladder condition, a very high maximum stress build-up
of 5.16 MPa was observed at the AVW fully filled bladder
condition. Additionally, it was found that the maximum
displacement was induced on the AVW in the negative Y
direction (pushing the AVW towards the vaginal hiatus). At a
fully filled bladder condition, a 7.98 mm maximum negative Y
displacement was estimated. Also, a reasonably high [13, 14]
mechanical strain of 0.27 was found for the vaginal tissues at
fully filled bladder condition, which was almost four times that
in case of an empty bladder condition.
Eight cases of vaginal tissue stiffening were simulated for
different bladder fill conditions. At a particular bladder fill
condition (Figure 9 shows a 50% bladder fill situation), the
stress distribution at AVW was observed to be uniform with a
small zone of high stress concentration at the mid-vagina. With
increasing vaginal tissue stiffening, the size of this high stress
concentration zone was found to increase without any
significant change in the stress value (1.98 ± 0.05 MPa), which
may represent an etiology for progressive vaginal discomfort
[15]. A 3D plot was generated for four of the ten bladder fill
cases simulated (Figure 10), and five of the eight prolapse cases
to study the combined effect of bladder fill and vaginal tissue
stiffening due to prolapse on the maximum stress build-up at the

Empty Bladder Fully Filled Bladder
FIGURE 8: STRESSES (MPA) INDUCED AT THE AVW
DUE TO AN EMPTY AND FULLY FILLED BLADDER
Normal Case Prolapse Maximum Prolapse Minimum
FIGURE 9: STRESS (MPA) INDUCED ON AVW FOR A
50% BLADDER FILL AND VARYING VAGINAL
STIFFENING CONDITIONS
AVW. Until a 60% bladder fill, the maximum stress at the AVW
was found to gradually intensify without any significant effect
of vaginal tissue stiffening. However, beyond 60% fill, a more
rapid intensification of the maximum induced stresses at the
AVW was observed. The maximum stress build-up due to the
combined effect of bladder fill and vaginal tissue stiffening was
estimated to occur for the upper bound prolapse case with a
fully filled bladder. Therefore, it was concluded that clinical
examinations of prolapse may be carried out with at least 60 %
bladder fill to quantify vaginal discomfort appropriately.
FIGURE 10: INDUCED MAXIMUM STRESSES (MPA)
AT THE AVW AT DIFFERENT PERCENTAGES OF
BLADDER FILL AND PROLAPSE CASES
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In the second set of simulations, a constrained expansion of
the rectum (0-100%) was invoked in the presence of an average
abdominal pressure on the AVW, and its effects on the vaginal
walls were quantified. The 0% rectum expansion was
considered to refer to a normal vaginal case (with no prolapse),
and the 10% and 100% rectum expansions leading to low and
high posterior prolapse cases respectively (Figure 11).
Assuming as per Figure 7, all the positive displacements occur
in positive Y direction (a posterior displacement) and the
negative displacements occur in negative Y direction (an
anterior displacement), a negative Y (or anterior displacement)
of the PVW was seen (Figure 11) in all cases of rectocele at
sections 3 and 4 (as per Figure 7), indicating that rectocele has
more intense effect on the sections 3 and 4 compared to sections
1 and 2. In sections 1 and 2, the abdominal pressure on the
AVW was seen to have a more pronounced effect on the Y
displacement causing it to stay positive (a posterior
displacement of vaginal wall) unless the case of rectocele was
fairly intense (with over 60% bulge). Beyond the case with 60%
rectal bulge into the vagina, the rectocele effect dominated over
the abdominal pressure causing the AVW to displace towards
the negative Y direction. The maximum PVW displacements
(up to 24 mm) were observed in section 3 and 4, which may to
Anterior Vaginal Wall (PVW)
Posterior Vaginal Wall (AVW)
Low Posterior Prolapse High Posterior Prolapse
FIGURE 11: Y DISPLACEMENTS (mm) (ALONG THE
VAGINAL CROSS-SECTION) FOR THE AVW AND
PVW IN LOW AND HIGH DEGREES OF RECTAL
PROLAPSE
be the “possible” regions causing vaginal discomfort. The most
positive (posterior-anterior) vaginal wall displacement was in
 section 1 (along positive Y direction), mainly due to the
significant effect of abdominal pressure.
A maximum of 4.6 mm (or 8.3 %), 0.6 mm (or 1.6 %), 9.0
mm (or 39.6%), and 5.0 mm (or 32 %) decrease in vaginal
cross-section (along the Y direction) were estimated for sections
1 through 4, respectively for a 100 % (high prolapse) rectocele
bulge condition (see Table 2 based on Figures 7 and 11)
compared to the normal vaginal case with no prolapse (in Table
2). Thus, section 3 of the vaginal canal was noted as the most
deformed region due to rectocele prolapse, followed by section
4, section 1 and section 2. The maximum PVW displacement
reported at the high prolapse case (with 100% rectocele bulge)
was approximately 23 mm in the negative Y direction.
Additionally, a resultant “kneeling” effect was observed at the
PVW, which involved the negative Y displacement of PVW
(mainly at the deep blue colored region in Figure 10)
TABLE 2: CHANGES IN CROSS-SECTIONAL
DIMENSIONS OF THE FOUR VAGINAL SECTIONS
FROM NORMAL PELVIS CONDITION TO PROLAPSE
accompanied with its downward displacement (along Z
direction with a maximum value of 7 mm). This effect has been
reported previously in literature [16, 17] due to the simulation
of the impairment of pelvic floor muscles and connective tissues
in PVP cases.
CONCLUSIONS
In the current work, a full-scale realistic computational
model of the female pelvic anatomy was developed to look at
the complex mechanics of anterior and posterior pelvic organ
prolapse (POP). The various steps of geometrical and material
modeling were discussed and appropriate loads and boundary
conditions adopted from extensive study of the functional
anatomy of the pelvic floor were outlined. Two sets of novel
simulations were conducted in the finite element software
ANSYS. In the first batch, the stand-alone and combined effects
of realistic bladder filling and vaginal tissue stiffening on the
anterior vaginal wall (AVW) were investigated thoroughly. In
the second batch, varying degrees of rectocele prolapse
conditions were simulated in presence of an average abdominal
pressure on the AVW, and its effect on the vaginal walls were
studied. An innovative forced volume expansion technique was
employed to simulate urine filling in the bladder and the
rectocele bulging in prolapse for the two batches of simulations
respectively.
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The results from the analyses may have significant clinical
implications. From the AVW prolapse simulations, it was found
that at a certain bladder fill, a stress concentration zone appears
on the AVW at the mid-vagina, which grows in size with an
increased vaginal tissue stiffening, but with a minimal change in
the value of the peak stress. This finding suggests that if a
prolapse condition is not treated in a timely fashion (and the
vaginal tissue has progressive stiffening), the AVW discomfort
zone size (or area) will continue increasing without any
significant change in the intensity of discomfort. Thus, no
prolapse based changes (stress or pressure) on the AVW may be
detected clinically using a vaginal probe or any other measuring
device, while the AVW condition deteriorates. From the
posterior POP simulations, it was observed that for larger
rectoceles, the posterior vaginal wall displacement is greater in
the lower half of the vaginal canal. Also, in isolated rectoceles,
the degree of anterior displacement of the PVW may contribute
more to patient’s perception of vaginal discomfort compared to
the stress measured in the vaginal wall. These relevant findings
can be only obtained from a subject-specific computational
model and not by MRI or ultrasound image, which may help
urogynecology surgeons decide whether a surgical intervention
is necessary or not.
There are several limitations of the current model. First is
the non-inclusion of the geometrical models of the pelvic floor
muscles, and ligaments. This was done to simplify
computations, and focus only on studying the effect of
interaction between the pelvic organs through fascial contacts.
Second, the current material model neglects tissue anisotropy
(like in most computational models) due lack of an
experimental test framework for multiaxial testing, and non-
availability of pelvic tissues due to biosafety and ethical issues.
Third, the urethra, vaginal and recto-anal hiatus were
constrained which is an idealized case of strong connective
tissue attachments. All these assumptions play an important role
in the POP mechanics, which will be considered in future
studies to more realistically model prolapse conditions.
ACKNOWLEDGMENTS
VU would like to acknowledge faculty start-up funds from
The University of Alabama, and VU and HER acknowledge the
UA System Collaborative Research Initiation Grants from The
University of Alabama (UA), System.
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