Diagnosis of levator avulsion injury: a comparison of three methods

Abstract

Objective Levator avulsion is common after vaginal delivery and is strongly associated with prolapse and prolapse recurrence. The aim of this study was to compare assessment by digital palpation and two ultrasound methods, one using rendered volumes and the other multislice imaging, for the diagnosis of levator avulsion. Methods We retrospectively analyzed randomly identified datasets of 266 women seen at a tertiary urogynecology unit. Each patient had undergone an interview, vaginal examination and 3D/4D translabial ultrasound examination. Analysis of the retrieved ultrasound volumes was performed offline, with the operator blinded to all clinical data, using two techniques: assessment of rendered volumes and evaluation on multislice imaging. We tested agreement between the three methods and the association of each method's results with symptoms and signs of pelvic organ prolapse.Results Agreement between the findings on palpation and the two ultrasound methods with regard to diagnosis of levator avulsion ranged from 80% to 87% (Cohen's kappa,. The findings for all methods were significantly associated with symptoms, signs and ultrasound findings of pelvic organ prolapse (P = 0.007 to < 0.001), with no single method appearing superior to the others. ConclusionsDepending on the availability of local expertise and equipment, any of the three methods tested in this study may be used to document avulsion of the puborectalis muscle.

Do ultrasound findings of levator ani “avulsion” correlate with anatomical findings: A multicenter cadaveric study

“…Cadavers have previously proven to be an effective medium for validating imaging studies as the morphological findings are generally transferable to the living subject . The method used to image the pelvic floor followed the most common practice, with previous studies yielding a moderate to fair inter‐observer reproducibility agreement . The clearly defined measurement parameters and use of the highly accurate and precise dial calliper, along with the assessment of reproducibility using the Bland and Altman statistical methods, further strengthened the validity of the measurements .…”

How does 3D endovaginal ultrasound compare to magnetic resonance imaging in the evaluation of levator ani anatomy?

“…Our scientific knowledge about injuries to the pelvic floor muscles have increased dramatically by the use of techniques such as electromyography, MRI, and translabial 3D ultrasonography. Several groups have examined the correlation between imaging and clinical findings of levator ani avulsions . Both translabial ultrasound and MRI have been investigated comprehensively.…”

A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging

“…The latter might be explained by the fact that palpation of a defect supposedly relies on the comparison with an intact contra lateral side. Dietz et al [27] did, however, recently suggest to use palpation as a screening method in case surgical intervention for POP is considered. They proposed that in case of one finger space or more between the urethra and the pubovisceral muscle, some form of muscle detachment is probable.…”