Dear Editor,

I read the recent article by Lavy et al. [1] with interest, but also with increasing bewilderment. On the second page, the authors state: “How pregnancy and delivery injure the pelvic floor has not been conclusively shown.” That is a statement that is difficult to take at face value. After all, International Urogynecology Journal (IUJ) has published at least ten papers on this topic over the past 5 years (see a recent review in this journal [2]).

Levator ani trauma is common. Every one of us in this area of medicine encounters it just about every day, if one only bothers to look, or palpate. It is very likely the single most important etiological factor in female pelvic organ prolapse. In fact, on page 5 of their paper, Lavy et al. report their own data, which makes no sense unless one accepts this basic premise. However, as if they were completely unaware of the literature on the issue, the authors of this supposed review omit to reference any of the dozens of papers published on this topic since 2004. It is plainly astounding: the authors mention the Epi-No device in one of their algorithms and in the text, but not the randomised controlled trial (RCT) that was very recently published in this journal [3] and presented at a meeting in 2010 that the senior author attended.

And then the authors report their own data using an unreferenced methodology, as if they had invented it themselves rather than recognising that it was developed, first published in 2004 and extensively used by others in many thousands of patients over a period of 9 years! The authors quote their own data on risk factors for levator trauma when there are at least seven papers since 2005 reporting such risk factors, reports by authors who, incidentally, all paid the appropriate respect to prior discovery. I cannot believe that Lavy et al. were unaware of all this material, seeing that there have been several recent review articles on this issue in IUJ [2], and seeing that there were at least four original papers published on this topic in IUJ in 2011 alone.