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Systematic Review and Meta-analysis of the Prevalence of Levator Ani Avulsion with Obstetric Anal Sphincter Injury and its Effects on Pelvic Floor Dysfunction

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Abstract

Introduction and hypothesis

The objective was to evaluate the prevalence of levator ani avulsion (LAA) among primiparous women with obstetric anal sphincter injury (OASI) and how this association could affect future pelvic floor dysfunction.

Methods

Three electronic databases (MEDLINE/PubMed/EMBASE) were searched in December 2018 and again in October 2022. Nine full-text articles were included in the analysis. The exclusion criteria were language other than English, studies not based on primiparous women only, conference abstracts, and evaluation without ultrasound or MRI.

Results

The overall prevalence of LAA was 24% (95% CI: 18–30%). Those with OASI, were at a higher risk of LAA, OR 3.49 (95% CI: 1.46 to 8.35). In women with LAA + OASI versus OASI alone, Three of Five studies showed worsened AI symptoms. Three of Five studies assessing urinary incontinence (UI) reported no significant difference in UI, whereas two reported increased UI. All studies that looked at pelvic organ prolapse reported a higher incidence of symptomatic prolapse and reduced pelvic floor muscle strength in women with LAA + OASI compared with those without LAA.

Conclusion

Levator ani avulsion is prevalent following vaginal birth and is strongly associated with OASI. Incidence of AI does not increase in women with LAA and OASI, but they had greater symptom bother. OASI with LAA appears to increase the incidence of pelvic floor weakness and pelvic organ prolapse. There is no consensus agreement on the effect of LAA + OASI on UI.

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Acknowledgements

Crispin Musicha, Department of Statistics, University of Exeter, UK; Arzoo Amin: Post-CCT fellow, Royal Surrey Hospital, Guildford, UK; Caroline Evans: ST7, University Hospitals Exeter, UK; Nicola Melia, ST7, University Hospitals Plymouth, UK.

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Authors and Affiliations

  1. The Royal Oldham Hospital NHS Trust, Oldham, UK

    Zohra Amin

  2. University Hospitals of Derby & Burton NHS Trust, Derby, UK

    Ahmed Khairy El-naggar

  3. North Bristol NHS Trust, Bristol, UK

    Ifeoma Offiah

  4. University Hospitals Plymouth NHS Trust, Plymouth, UK

    Anupreet Dua & Robert Freeman

Authors
  1. Zohra Amin
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  2. Ahmed Khairy El-naggar
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  3. Ifeoma Offiah
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  4. Anupreet Dua
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  5. Robert Freeman
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Contributions

Zohra Amin: searched the literature, compiled the results, analysed them with the statistician and wrote the paper; Ahmed El-Naggar: contributed to designing the study, carried out the initial literature search, compiled the results and presented preliminary data at an international meeting; Iffy Offiah: contributed to designing the study, searching the literature and reviewing the paper; Anu Dua: contributed to designing the study and reviewing the paper; Robert Freeman: contributed to designing the study, supervising and reviewing the paper.

Corresponding author

Correspondence to Zohra Amin.

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Amin, Z., El-naggar, A.K., Offiah, I. et al. Systematic Review and Meta-analysis of the Prevalence of Levator Ani Avulsion with Obstetric Anal Sphincter Injury and its Effects on Pelvic Floor Dysfunction. Int Urogynecol J (2024). https://doi.org/10.1007/s00192-024-05756-w

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  • DOI: https://doi.org/10.1007/s00192-024-05756-w

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