Pelvic Floor Disorders After Obstetric Avulsion of the Levator Ani Muscle

Abstract

Objectives With vaginal childbirth, 10% to 30% of women sustain levator ani muscle avulsion. The objective of this study was to estimate the cumulative incidence of prolapse and other pelvic floor disorders (PFDs), comparing vaginally parous women with and without levator avulsion. Methods Parous women enrolled in a longitudinal study were assessed annually for PFDs with the Pelvic Organ Prolapse Quantification Examination (for prolapse) and the Epidemiology of Prolapse and Incontinence Questionnaire (for stress incontinence, overactive bladder, and anal incontinence). Three-dimensional transperineal ultrasound was used to identify levator avulsion. Women with and without levator avulsion after vaginal delivery were compared for the cumulative incidence of PFDs. Further analysis also stratified by forceps delivery. Results At the time of assessment, 453 participants were 6 to 17 years from first delivery (median, 11 years). Levator avulsion was identified in 15% (66/453) and was more common among those who had undergone forceps-assisted delivery (P < 0.001). Levator avulsion was strongly associated with prolapse beyond the hymen (odds ratio, 2.7; 95% confidence interval, 1.3–5.7) and with symptoms of prolapse (odds ratio, 3.0; 95% confidence interval–1.2, 7.3). These associations persisted after controlling for forceps-assisted delivery. In contrast, the odds of stress incontinence, overactive bladder, and anal incontinence were marginally (but not significantly) increased among women with levator avulsion in this cohort. Conclusions Obstetric levator avulsion is strongly associated with pelvic organ prolapse. The relationship between levator avulsion and other PFDs may not be significant.

Pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery

“…For example, levator ani avulsions, which are seen in 10e20% of vaginal deliveries, 3,4 are associated with pelvic organ prolapse (POP). 5,6 Levator ani avulsions are also associated with weaker pelvic floor muscles. 7 This finding, along with a computer simulation model showing that pelvic muscle weakness results in progressive uterovaginal prolapse, 8 suggests that pelvic floor muscle strength may be important in the development of PFDs.…”

Predictive factors for time to cessation of urinary incontinence in primiparous adolescents after vaginal delivery

“…Episiotomy increases the risk of injury to the levator ani muscle due to distension of the pubococcygeus muscle during the expulsion stage of delivery, 19 negatively influencing the contraction capacity of pelvic floor muscles, something essential for the conservation of urethral closing pressure above bladder pressure for the maintenance of urinary continence. 20 The findings of previous studies on the association between episiotomy and UI after delivery are inconsistent. While some studies suggested increased frequency and intensity of the complaint of postpartum UI in the presence of episiotomy, 21,22 others concluded that the procedure is not associated with the dysfunction.…”

Klinische Relevanz des Ultraschalls in der Urogynäkologie

“…Vor allem die vagi- nal operative Geburt stellt eine Risikosituation dar. Durch eine Entbindung per Forzeps erhöht sich das Risiko eines Levatorabrisses um den Faktor 7, durch eine Vakuumextraktion um den Faktor 4,5 im Vergleich zu einer nicht operativen vaginalen Geburt [13,14].…”