The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction

Abstract

Objective To establish the relationship between postpartum levator ani muscle (LAM) avulsion and signs and/or symptoms of pelvic floor dysfunction (PFD).Design Observational longitudinal cohort study.Setting District General University Hospital, UK.Population or sample Primigravida at 36 weeks' gestation and 3 months postpartum.Methods Pelvic floor muscle strength (PFMS) and pelvic organ prolapse were assessed clinically using validated methods. Transperineal ultrasound was performed to identify LAM avulsion and measure hiatus dimensions. Validated questionnaires evaluated sexual function, urinary and faecal incontinence.Main outcome measures PFD signs and symptoms related to LAM avulsion.Results Two hundred and sixty nine primigravida without LAM avulsion participated and 71% (n = 191) returned postpartum. LAM avulsion was found in 21% of vaginal deliveries (n = 30, 95%CI 15.1-28.4%). Women with minor and major avulsion had worse PFMS (P < 0.038) and more anterior compartment prolapse (maximum stage 2; P < 0.024). Antenatal hiatus antero-posterior diameter on ultrasound was significantly smaller in women sustaining avulsion (P = 0.011). Postnatal measurements were significantly increased following avulsion. Women with major avulsion were less sexually active at both antenatal and postnatal periods (P < 0.030). These women had more postnatal urinary incontinence and symptoms such as reduced vaginal sensation and 'too loose vagina'. No postnatal differences were found for faecal incontinence, prolapse symptoms or quality of life. The correlation of differences in variables was only slight-fair with avulsion severity.Conclusions Twenty one percent of women sustain LAM avulsion during their first vaginal delivery with significant impact on signs and symptoms of PFD. As avulsion has been described as the missing link in the development of prolapse; longer term follow-up is vital.Keywords Childbirth, incontinence, levator ani avulsion, pelvic floor dysfunction, pelvic organ prolapse, transperineal ultrasound.Please cite this paper as: van Delft K, Sultan AH, Thakar R, Schwertner-Tiepelmann N, Kluivers K. The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction.

Agreement of Manual Exam (POP-Q) with Pelvic MRI in Assessment of Anterior Pelvic Organ Prolapse

“…It could not yield any data on fasciae and pelvic floor muscles. MRI especially dynamic MRI is one of the most important methods that has been considered in the recent years as it is not invasive and could yield visualization of all soft tissues and pelvic compartments (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). Different MRI sequences and protocols could assess these structures.…”

Alteration of anal sphincter function in patients with levator avulsion: observational study

“…Is rehabilitation effective in a damaged muscle? Several authors found decreased pelvic floor muscle contraction after delivery in women with LAM avulsion when studying these parameters with vaginal manometry [30] and clinically using either the modified Oxford scale [31] or digital palpation [18]. The novelty of our work is that it offers a functional study of LAM avulsion using AM.…”

“…Complete LAM avulsion is currently associated with an increased risk of prolapse and recurrence [15], but no statistically significant association with UI [16] or FI has been found [17]. Because the role of the PRM in the physiology of fecal continence is well known, this lack of association may be due to studies where the role of the sphincter complex was not objectively quantified [18].…”

Postpartum stress urinary incontinence, is it related to vaginal delivery?

“…During vaginal childbirth, the baby's head distends and stretches the pelvic floor muscles, connective tissue, and nerves, which may then become compromised. The use of forceps, anal sphincter rupture, and episiotomy were found to be the risk factors associated with vaginal delivery [9]. Lenis et al [10] reported that vaginal distention upregulated urethral expression of CCL7 and CD195 immediately after tissue injury in postpartum rats.…”