Is the levator–urethra gap helpful for diagnosing avulsion?

Dietz, Hans Peter; Garnham, Alejandro Pattillo; Rojas, Rodrigo Guzmán

doi:10.1007/s00192-015-2909-0

Cited by 31 publications

(30 citation statements)

References 23 publications

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“…Trauma of the pelvic floor occurs mainly during the very first birth and often results in a widened genital hia tus or in a partial or complete avulsion of the levator ani muscle (LAM) in 6-63 % of cases [1][2][3][4][5][6][7][8][9]. These LAM avulsions can most reliably be diagnosed by 3-dimensional (3D) translabial ultrasound (TLUS), as described by Dietz et al [10][11][12][13]. Women with pelvic floor damage frequently experience severe short and longterm morbidity, such as pain, a widened vagina, urine or fecal incontinence, sexual disorders, psychological distress, uterine prolapse, or the need for repetitive surgeries at immense cost to the health system [3,[14][15][16][17][18].…”

Section: Introductionmentioning

confidence: 99%

Association between the side of levator Ani muscle trauma and fetal position at birth – a prospective observational study

Kimmich

Birri

Zimmermann

et al. 2020

Z Geburtshilfe Neonatol

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Introduction Trauma of the levator ani muscle (LAM) is common after vaginal birth and can most reliably be diagnosed by 3-dimensional (3D) translabial ultrasound (TLUS). Multiple risk factors are known in general, but not in association to a specific side of the body. Therefore, our aim was to evaluate different impact factors which cause LAM trauma on either side of the body or bilateral by focusing on the fetal position at birth. Material and Methods As part of a prospective cohort study between 3/2017 and 4/2019, we analyzed vaginal births of nulliparous women with singletons in vertex presentation≥36+0 gestational weeks. We evaluated their pelvic floor for hematomas, partial and complete LAM avulsions by 3D TLUS 2–4 days postpartum and searched for an association between the affected body side and different fetal, maternal and obstetrical factors. Results 71 out of 213 women (33.3%) suffered from LAM trauma – 17 (23.9%) on the right side, 20 (28.2%) on the left side and 34 (47.9%) bilateral. No association between the different evaluated factors and the affected body side could be identified, except for the quality of fetal heart rate tracing. Conclusions No significant impact factors of LAM trauma could be associated with a specific side of the body. Other possible mechanisms need investigation in the future, such as the time of the birth canal and the fetus to adapt to each other, including adequate time for the tissue to stretch and the fetus to rotate into the ideal position within the LAM hiatus.

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Section: Introductionmentioning

confidence: 99%

Association between the side of levator Ani muscle trauma and fetal position at birth – a prospective observational study

Kimmich

Birri

Zimmermann

et al. 2020

Z Geburtshilfe Neonatol

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“…In unclear cases, a levator-urethra gap more than 2.5 cm was used to define an abnormal insertion. 35 Axial slices were obtained at 2.5 mm intervals from the PMD. The three central slices were identified as follows: the first slice to the left showed pubic symphysis separation, the second slice showed a closed pubic symphysis, and in the slice to the right, the pubis was not visible at all, showing instead an acoustic shadow.…”

Section: Methodsmentioning

confidence: 99%

Type of levator ani muscle avulsion as predictor for the disappearance of avulsion

García‐Mejido

Bueno

2020

Neurourology and Urodynamics

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Objectives: The objective of our study was to establish whether the type of levator ani muscle (LAM) avulsion diagnosed 6 months after delivery influences the integrity of the LAM at 1 year after delivery and determine its influence on the levator hiatus area. Study Design: This observational prospective cohort study included 192 primiparous women with vaginal delivery. Transperineal ultrasound examinations were performed at 6 months and 1 year postpartum. Levator hiatus measurements (anteroposterior diameter, transverse diameter, and area) were performed in the plane of minimal dimensions. Complete avulsion was defined based on maximum contraction in multislice mode. Type I LAM avulsion was present when most lateral fibers of the pubovisceral muscle were observed at its insertion at the pubic level (the arch of the elevator remained intact). Type II LAM avulsion was defined as a complete detachment of the pubovisceral muscle from its insertion at the pubic level. Results: In total, 192 patients were recruited after delivery; 48 patients were diagnosed with complete LAM avulsion, and 13 patients with avulsion did not attend the second ultrasound follow-up at 1 year after delivery. Thirty-five patients with complete LAM avulsion were included in the study. At 6 months after delivery, 51 LAM avulsions were observed in 35 patients (including bilateral LAM avulsion in 16 cases), of which 54.9% were right avulsions and 45.1% left avulsions. Furthermore, 11 (five right and six left) were type I LAM avulsions at the 6-month assessment, and all of these had disappeared 1 year after delivery. However, none of the type II LAM avulsions (23 right and 17 left) observed at 6 months had disappeared at the second ultrasound examination. There were no differences between the LAM areas detected at the first and second ultrasound examinations (10.2 ± 3.3 vs 9.3 ± 1.8; P = .404). Conclusions: The type of LAM avulsion observed at 6 months after childbirth predicts LAM persistence at 1 year postpartum.

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“…The levator‐urethra gap (LUG) is the distance between the urethral lumen center and the levator insertion site on the inferior pubic rami. Previous studies evaluating LUG measurements have shown different cutoff values for the LUG 1,10,12‐17 . A cutoff of 2.5 cm has been reported in Australian women, 13 while in Chinese women, the cutoff was 2.365 cm 10 .…”

Section: Introductionmentioning

confidence: 95%

The optimal cutoff value for levator‐urethra gap measurements using tomographic ultrasound imaging in avulsion diagnosis is population specific

Greenbaum

Klein

Alcalay

et al. 2020

Neurourology and Urodynamics

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Aims The levator‐urethra gap (LUG), the distance between the urethral lumen center and levator insertion on the inferior pubic rami, can be used for diagnosing levator avulsion, with a previously suggested cutoff of LUG ≥2.5 cm. The aim of this study is to determine an optimal cutoff value for LUG measurements in a high‐risk patient population. Methods Women followed prospectively after sustaining obstetric anal sphincter injury underwent an interview pelvic examination questionnaires and four‐dimensional‐transperineal ultrasound examination. Levator avulsion was diagnosed on contraction using tomographic ultrasound imaging. Ultrasound datasets were analyzed offline at a later time blinded to previous data. LUG was measured on each side of the three central slices, yielding six measurements and the highest available value was obtained on each side. Different cutoffs were evaluated using receiver‐operating characteristics (ROC) curve analysis and Youden's test. The cutoff was validated against symptoms and signs, and sonographic findings using logistic regression analysis. Results A total of 618 complete datasets were available for analysis, median age 29 years, median body mass index of 23.4 kg/m2, parity 1, and 26.4% instrumental deliveries. Youden's test and ROC curve analysis gave the best area under the curve of 0.869 for a cutoff of 2.305 (95% confidence interval, 0.839‐0.9). Women diagnosed with avulsion based on this cutoff were more symptomatic, whereas using larger cutoffs missed more avulsion defects. Conclusion LUG measurement is useful but should be individualized to the population studied, in our case, in a high‐risk population, 2.305 cm was the optimal cutoff. Using larger cutoffs may be more specific but is likely to miss more cases.

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Is the levator–urethra gap helpful for diagnosing avulsion?

Cited by 31 publications

References 23 publications

Association between the side of levator Ani muscle trauma and fetal position at birth – a prospective observational study

Association between the side of levator Ani muscle trauma and fetal position at birth – a prospective observational study

Type of levator ani muscle avulsion as predictor for the disappearance of avulsion

The optimal cutoff value for levator‐urethra gap measurements using tomographic ultrasound imaging in avulsion diagnosis is population specific

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