International Urogynecology Journal

, Volume 27, Issue 1, pp 39–45 | Cite as

Association between pelvic floor muscle trauma and pelvic organ prolapse 20 years after delivery

  • Ingrid Volløyhaug
  • Siv Mørkved
  • Kjell Å. Salvesen
Original Article


Introduction and hypothesis

It is known that pelvic floor muscle trauma (PFMT) after vaginal delivery is associated with pelvic organ prolapse (POP) symptoms (sPOP) and signs (POP-Q ≥2) in patient populations. Our aims were to establish the prevalence and investigate a possible association between PFMT and sPOP and POP-Q ≥2 in healthy women 20 years after their first delivery.


During 2013 and 2014 we conducted a cross-sectional study among 847 women who delivered their first child between 1990 and 1997. Women responded to a postal questionnaire and were offered a clinical examination including prolapse grading and pelvic floor ultrasonography. The main outcome measures were sPOP, POP-Q ≥2 and PFMT, defined by levator avulsion or a levator hiatal area on Valsalva manoeuvre of >40 cm2 on ultrasonography.


Of the 847 eligible women, 608 (72 %) were examined. Data on POP symptoms, POP-Q stage, levator avulsion and levator hiatal area were available in 598, 608, 606 and 554 women, respectively, and of these 75 (13 %) had sPOP, 275 (45 %) had POP-Q ≥2, 113 (19 %) had levator avulsion and 164 (30 %) had a levator hiatal area >40 cm2. Levator avulsion was associated with POP-Q ≥2 with an odds ratio (OR) of 9.91 and a 95 % confidence interval (CI) of 5.73 – 17.13, and with sPOP (OR 2.28, 95 % CI 1.34 – 3.91). Levator hiatal area >40 cm2 was associated with POP-Q ≥2 (OR 6.98, 95 % CI 4.54, – 10.74) and sPOP (OR 3.28, 95 % CI 1.96 – 5.50).


Many healthy women selected from the general population have symptoms and signs of POP 20 years after their first delivery, and PFMT is associated with POP-Q ≥2 and sPOP.


Levator avulsion Levator hiatus area Pelvic floor muscle trauma Pelvic organ prolapse 



We thank Christine Østerlie and Tuva K. Halle for help with identifying potential study participants, Johan Morten Dreier and Berit Marianne Bjelkaasen for help with questionnaires, and Guri Kolberg for help with coordination of clinical examinations.


This project was financially supported by the Norwegian Women’s Public Health Association/the Norwegian Extra Foundation for Health and Rehabilitation through EXTRA funds, St. Olavs Hospital, Trondheim University Hospital and the Norwegian University of Science and Technology. The funders played no role in the study design, in the collection, analysis and interpretation of data, or in the writing of the report and the decision to submit the article for publication. All researchers were independent of the funders.

Conflicts of interest


Supplementary material

192_2015_2784_MOESM1_ESM.docx (29 kb)
ESM 1 (DOCX 28 kb)


  1. 1.
    Dietz HP, Steensma AB (2006) The prevalence of major abnormalities of the levator ani in urogynaecological patients. BJOG 113:225–230PubMedCrossRefGoogle Scholar
  2. 2.
    Dietz HP, Simpson JM (2008) Levator trauma is associated with pelvic organ prolapse. BJOG 115:979–984PubMedCrossRefGoogle Scholar
  3. 3.
    Dietz HP, Franco AV, Shek KL, Kirby A (2012) Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? An observational study. Acta Obstet Gynecol Scand 91:211–214PubMedCrossRefGoogle Scholar
  4. 4.
    Durnea CM, Khashan AS, Kenny LC, Durnea UA, Smyth MM, O'Reilly BA (2014) Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women. Int Urogynecol J 25:1463–1470PubMedCrossRefGoogle Scholar
  5. 5.
    Dietz HP (2007) Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29:329–334PubMedCrossRefGoogle Scholar
  6. 6.
    Dietz HP, Bernardo MJ, Kirby A, Shek KL (2011) Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J 22:699–704PubMedCrossRefGoogle Scholar
  7. 7.
    Dietz HP, Shek C, De Leon J, Steensma AB (2008) Ballooning of the levator hiatus. Ultrasound Obstet Gynecol 31:676–680PubMedCrossRefGoogle Scholar
  8. 8.
    Heilbrun ME, Nygaard IE, Lockhart ME et al (2010) Correlation between levator ani muscle injuries on magnetic resonance imaging and fecal incontinence, pelvic organ prolapse, and urinary incontinence in primiparous women. Am J Obstet Gynecol 202(488):e481–e486Google Scholar
  9. 9.
    Lammers K, Futterer JJ, Inthout J, Prokop M, Vierhout ME, Kluivers KB (2013) Correlating signs and symptoms with pubovisceral muscle avulsions on magnetic resonance imaging. Am J Obstet Gynecol 208(148):e141–e147Google Scholar
  10. 10.
    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 185:11–19PubMedCrossRefGoogle Scholar
  11. 11.
    DeLancey JO, Morgan DM, Fenner DE et al (2007) Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol 109:295–302PubMedCrossRefGoogle Scholar
  12. 12.
    Kearney R, Miller JM, Ashton-Miller JA, DeLancey JO (2006) Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107:144–149PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Krofta L, Otcenasek M, Kasikova E, Feyereisl J (2009) Pubococcygeus-puborectalis trauma after forceps delivery: evaluation of the levator ani muscle with 3D/4D ultrasound. Int Urogynecol J Pelvic Floor Dysfunct 20:1175–1181PubMedCrossRefGoogle Scholar
  14. 14.
    Shek KL, Dietz HP (2010) Intrapartum risk factors for levator trauma. BJOG 117:1485–1492PubMedCrossRefGoogle Scholar
  15. 15.
    van Delft K, Thakar R, Sultan AH, Schwertner-Tiepelmann N, Kluivers K (2014) Levator ani muscle avulsion during childbirth: a risk prediction model. BJOG: Int J Obstet Gynaecol 121:1155–1163, discussion 1163CrossRefGoogle Scholar
  16. 16.
    Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ (2015) Forceps is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross sectional study 16–24 years after first delivery. Ultrasound Obstet Gynecol. doi: 10.1002/uog.14891 Google Scholar
  17. 17.
    Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ (2015) Pelvic organ prolapse and incontinence 15–23 years after first delivery: a cross-sectional study. BJOG 122:964–971PubMedCrossRefGoogle Scholar
  18. 18.
    Barber MD, Walters MD, Bump RC (2005) Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 193:103–113PubMedCrossRefGoogle Scholar
  19. 19.
    Bump RC, Mattiasson A, Bo K et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10–17PubMedCrossRefGoogle Scholar
  20. 20.
    Orejuela FJ, Shek KL, Dietz HP (2012) The time factor in the assessment of prolapse and levator ballooning. Int Urogynecol J 23:175–178PubMedCrossRefGoogle Scholar
  21. 21.
    Dietz HP, Wong V, Shek KL (2011) A simplified method for determining hiatal biometry. Aust N Z J Obstet Gynaecol 51:540–543PubMedCrossRefGoogle Scholar
  22. 22.
    Model AN, Shek KL, Dietz HP (2010) Levator defects are associated with prolapse after pelvic floor surgery. Eur J Obstet Gynecol Reprod Biol 153:220–223PubMedCrossRefGoogle Scholar
  23. 23.
    Morgan DM, Larson K, Lewicky-Gaupp C, Fenner DE, DeLancey JO (2011) Vaginal support as determined by levator ani defect status 6 weeks after primary surgery for pelvic organ prolapse. Int J Gynaecol Obstet 114:141–144PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Weemhoff M, Vergeldt TF, Notten K, Serroyen J, Kampschoer PH, Roumen FJ (2012) Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study. Int Urogynecol J 23:65–71PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, Steegers-Theunissen RP, Burger CW, Vierhout ME (2009) The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct 20:1037–1045PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    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 185:1332–1337PubMedCrossRefGoogle Scholar
  27. 27.
    Bradley CS, Zimmerman MB, Wang Q, Nygaard IE, Women's Health I (2008) Vaginal descent and pelvic floor symptoms in postmenopausal women: a longitudinal study. Obstet Gynecol 111:1148–1153PubMedCrossRefGoogle Scholar
  28. 28.
    Lowenstein E, Ottesen B, Gimbel H (2015) Incidence and lifetime risk of pelvic organ prolapse surgery in Denmark from 1977 to 2009. Int Urogynecol J 26:49–55PubMedCrossRefGoogle Scholar
  29. 29.
    Thomas V, Shek K, Rojas RG, Dietz HP (2013) The latency between pelvic floor trauma and presentation for prolapse surgery. Ultrasound Obstet Gynecol 42(S1):39CrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2015

Authors and Affiliations

  • Ingrid Volløyhaug
    • 1
    • 2
  • Siv Mørkved
    • 3
    • 4
  • Kjell Å. Salvesen
    • 1
    • 5
  1. 1.Department of Laboratory Medicine, Children’s and Women’s HealthNorwegian University of Science and TechnologyTrondheimNorway
  2. 2.Department of Obstetrics and GynecologyTrondheim University HospitalTrondheimNorway
  3. 3.Department of Public Health and General PracticeNorwegian University of Science and TechnologyTrondheimNorway
  4. 4.Clinical ServiceTrondheim University HospitalTrondheimNorway
  5. 5.National Center for Fetal MedicineTrondheim University HospitalTrondheimNorway

Personalised recommendations