Levator ani defect status and lower urinary tract symptoms in women with pelvic organ prolapse

  • Daniel M. Morgan
  • Pamela Cardoza
  • Kenneth Guire
  • Dee E. Fenner
  • John O. L. DeLancey
Original Article


Introduction and hypothesis

Among women with pelvic organ prolapse, compare rates of lower urinary tract symptoms by levator ani defect (LAD) status.


Urinary incontinence and obstructive voiding are analyzed among 151 women with prolapse whose LAD status was determined with magnetic resonance imaging.


Women with major LAD are less likely to experience stress incontinence when “coughing, laughing, or sneezing” (odds ratio (OR) 0.27) and when “twisting, reaching, lifting, or bending over” (OR 0.26) than women with normal muscles. They are less likely to have obstructive symptoms characterized by assuming an “unusual toileting position” or “changing positions…to start or complete urination” (OR 0.27). Women with minor LAD are more likely to experience stress incontinence with exercise (OR 3.1) and urge incontinence (OR 4.0) than those with normal muscles.


Lower urinary tract symptoms are less common among women with prolapse and major levator ani defects and more common among those with minor defects.


Levator ani Obstructive voiding Pelvic organ prolapse Urinary incontinence 



We gratefully acknowledge the support of Public Health Service grant number R01 HD038665 from the Office of Women's Health and NICHD SCOR P50 HD 44406.

Conflicts of interest



  1. 1.
    Weber AM, Abrams P, Brubaker L, Cundiff G, Davis G, Dmochowski RR et al (2001) The standardization of terminology for researchers in female pelvic floor disorders. Int Urogynecol J Pelvic Floor Dysfunct 12:178–186CrossRefPubMedGoogle Scholar
  2. 2.
    Mouritsen L (2005) Classification and evaluation of prolapse. Best Pract Res Clin Obstet Gynaecol 19:895–911CrossRefPubMedGoogle Scholar
  3. 3.
    Cannon TW, Damaser M (2004) Pathophysiology of the lower urinary tract: continence and incontinence. Clin Obstet Gynecol 47:28–35CrossRefPubMedGoogle Scholar
  4. 4.
    Long CY, Hsu SC, Wu TP, Sun DJ, Su JH, Tsai EM (2004) Urodynamic comparison of continent and incontinent women with severe uterovaginal prolapse. J Reprod Med 49:33–37PubMedGoogle Scholar
  5. 5.
    Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE (2001) Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 185:1332–1337 discussion 1337-8CrossRefPubMedGoogle Scholar
  6. 6.
    Yalcin OT, Yildirim A, Hassa H (2001) The effects of severe cystocele on urogynecologic symptoms and findings. Acta Obstet Gynecol Scand 80:423–427CrossRefPubMedGoogle Scholar
  7. 7.
    Romanzi LJ, Chaikin DC, Blaivas JG (1999) The effect of genital prolapse on voiding. J Urol 161:581–586CrossRefPubMedGoogle Scholar
  8. 8.
    DeLancey JO, Morgan DM, Fenner DE, Kearney R, Guire K, Miller JM et al (2007) Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol 109:295–302PubMedGoogle Scholar
  9. 9.
    Hoyte L, Schierlitz L, Zou K, Flesh G, Fielding JR (2001) Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse. Am J Obstet Gynecol 185:11–19CrossRefPubMedGoogle Scholar
  10. 10.
    Dietz HP, Simpson JM (2008) Levator trauma is associated with pelvic organ prolapse. BJOG 115:979–984CrossRefPubMedGoogle Scholar
  11. 11.
    DeLancey JO, Miller JM, Kearney R, Howard D, Reddy P, Umek W, Guire KE, Margulies RU, Ashton-Miller JA (2008) Vaginal birth and de novo stress incontinence: relative contributions of urethral dysfunction and mobility. Obstet Gynecol 110:354–362Google Scholar
  12. 12.
    Dietz H, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106:707–712PubMedGoogle Scholar
  13. 13.
    DeLancey JO, Trowbridge ER, Miller JM, Morgan DM, Guire K, Fenner DE, Weadock WJ, Ashton-Miller JA (2008) Stress urinary incontinence: relative importance of urethral support and urethral closure pressure. J Urol 179:2286–2290CrossRefPubMedGoogle Scholar
  14. 14.
    Dietz HP, Steensma AB (2006) The prevalence of major abnormalities of the levator ani in urogynaecological patients. BJOG: An International Journal of Obstetrics and Gynaecology 113:225–230Google Scholar
  15. 15.
    Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10–17CrossRefPubMedGoogle Scholar
  16. 16.
    Morgan DM, Umek W, Stein T, Hsu Y, Guire K, DeLancey JO (2007) Interrater reliability of assessing levator ani muscle defects with magnetic resonance images. Int Urogynecol J Pelvic Floor Dysfunct 18:773–778CrossRefPubMedGoogle Scholar
  17. 17.
    Dietz HP, Kirby A, Shek KL, Bedwell PJ (2009) Does avulsion of the puborectalis muscle affect bladder function? Int Urogynecol J Pelvic Floor Dysfunct. Apr 28 [Epub ahead of print]PubMedGoogle Scholar
  18. 18.
    Kearney R, Miller JM, Ashton-Miller JA, DeLancey JO (2006) Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107:144–149PubMedGoogle Scholar

Copyright information

© The International Urogynecological Association 2009

Authors and Affiliations

  • Daniel M. Morgan
    • 1
    • 3
  • Pamela Cardoza
    • 1
  • Kenneth Guire
    • 2
  • Dee E. Fenner
    • 1
  • John O. L. DeLancey
    • 1
  1. 1.Pelvic Floor Research Group, Division of Gynecology, Department of Obstetrics and GynecologyUniversity of Michigan Medical SchoolAnn ArborUSA
  2. 2.Department of BiostatisticsUniversity of Michigan Medical SchoolAnn ArborUSA
  3. 3.Ann ArborUSA

Personalised recommendations