Hans Peter Dietz

Levator trauma after vaginal delivery.

OBJECTIVE: To date, the evidence on pelvic floor injury in labor remains sketchy due to a lack of prospective studies comparing pelvic floor imaging before and after childbirth. We intended to define the incidence of major trauma to the pubovisceral muscle. METHODS: A total of 61 nulliparous women were seen at 36–40 weeks of gestation in a prospective observational study. The assessment included an interview and 3-dimensional translabial ultrasound and was repeated 2–6 months postpartum. RESULTS: Fifty women (82%) were seen postpartum. Of the 39 women delivered vaginally, levator avulsion was diagnosed in 14 (36%, 95% confidence interval 21–51%). Among those delivered vaginally, there were associations with higher maternal age (P = .10), vaginal operative delivery (P = .07), and worsened stress incontinence postpartum (P = .02). CONCLUSIONS: Avulsion of the inferomedial aspects of the levator ani from the pelvic sidewall occurred in approximately one third of all women delivered vaginally and was associated with stress incontinence 3 months after childbirth. LEVEL OF EVIDENCE: II-3

Levator trauma is associated with pelvic organ prolapse

Objective  To estimate the risk of prolapse associated with levator avulsion injury among a urogynaecological clinic population.

Biometry of the pubovisceral muscle and levator hiatus by three‐dimensional pelvic floor ultrasound

Until recently, magnetic resonance was the only imaging method capable of assessing the levator ani in vivo. Three‐dimensional (3D) ultrasound has recently been shown to be able to demonstrate the pubovisceral muscle. The aim of this study was to define the anatomy of the levator hiatus in young nulliparous women with the help of 3D ultrasound.

Ultrasound imaging of the pelvic floor. Part II: three-dimensional or volume imaging

In this second part of a review of pelvic floor ultrasound imaging, current three‐dimensional (3D) ultrasound technology and its use for imaging pelvic floor structure and function is described. Recent technical developments enable rapid automated volume acquisition in real time, and currently available transducers designed for abdominal use are well suited for translabial/transperineal imaging. To date, such systems have been used to image the urethra, the levator ani and paravaginal supports, prolapse and implants used in pelvic floor reconstruction and anti‐incontinence surgery. While 3D pelvic floor imaging is a field that is still in its infancy, it is already clear that the method has opened up entirely new opportunities for the observation of functional anatomy. Copyright

Intrapartum risk factors for levator trauma.

Please cite this paper as: Shek K, Dietz H. Intrapartum risk factors for levator trauma. BJOG 2010;117:1485–1492.

Ultrasound imaging of the pelvic floor. Part I: two-dimensional aspects.

Ultrasound imaging is rapidly replacing radiological methods in the investigation of pelvic floor disorders. Transrectal, transvaginal/introital and transperineal/translabial methods are being employed, with the latter probably the most widespread due to ease of use and availability of equipment. Position and mobility of the bladder neck, bladder wall thickness, pelvic floor muscle activity and uterovaginal prolapse can be quantified, and color Doppler may be used to document stress urinary incontinence. Ultrasound imaging has simplified audit activities and enhanced our understanding of the effects of incontinence and prolapse surgery, such as the new synthetic suburethral slings. In recent years, imaging methods have contributed significantly to our understanding of the traumatic effects of childbirth on the pelvic floor. Finally, the assessment of pelvic floor biomechanics may have implications for clinical obstetrics and ultimately for the prevention of delivery‐related pelvic floor trauma. Copyright

The prevalence of major abnormalities of the levator ani in urogynaecological patients.

Objectives  While morphological abnormalities of the pubovisceral muscle have been described on magnetic resonance imaging (MRI), their relevance remains unclear. This study was designed to define prevalence and clinical significance of such abnormalities in urogynaecological patients.

Quantification of major morphological abnormalities of the levator ani

Morphological abnormalities of the levator ani are found in a significant minority of women presenting with symptoms of pelvic floor dysfunction. In this study quantification of such injuries using tomographic three‐dimensional (3D) pelvic floor ultrasound was attempted.

Ballooning of the levator hiatus.

The levator hiatus defines the ‘hernial portal’ through which female pelvic organ prolapse develops. Hiatal area may therefore be an independent etiological factor for this condition. In this retrospective study we defined ‘normality’ for hiatal area by assessing its relationship with symptoms and clinical signs of prolapse.

Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound

Introduction and hypothesisPuborectalis avulsion is a likely etiological factor for female pelvic organ prolapse (FPOP). We performed a study to establish minimal sonographic criteria for the diagnosis of avulsion.MethodsWe analysed datasets of 764 women seen at a urogynecological service. Offline analysis of ultrasound datasets was performed blinded to patient data. Tomographic ultrasound imaging (TUI) was used to diagnose avulsion of the puborectalis muscle.ResultsLogistic regression modelling of TUI data showed that complete avulsion is best diagnosed by requiring the three central tomographic slices to be abnormal. This finding was obtained in 30% of patients and was associated with symptoms and signs of FPOP (P < 0.001). Lesser degrees of trauma (‘partial avulsion’) were not associated with symptoms or signs of pelvic floor dysfunction.ConclusionsComplete avulsion of the puborectalis muscle is best diagnosed on TUI by requiring all three central slices to be abnormal. Partial trauma seems of limited clinical relevance.