Skip to main content

Advertisement

SpringerLink
Log in

Levator ani defects in patients with stress urinary incontinence: three-dimensional endovaginal ultrasound assessment

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction and hypothesis

To determine the prevalence of levator ani (LA) muscle subdivision defects in patients with SUI using three-dimensional endovaginal ultrasound (3D EVUS).

Methods

This is a prospective cohort study of 100 patients with pure or predominant urodynamic SUI who underwent 3D EVUS. The 3D cubes obtained were analyzed and the LA muscle was divided into three subgroups: the puboperinealis/puboanalis, the puborectalis, and the iliococcygeus/pubococcygeus. Each LA muscle subdivision was individually scored on each side (0: no defect, 1: ≤50 % muscle loss, 2: > 50 % muscle loss, and 3: total absence of the muscle) and a cumulative score, categorized as 0 (no defect), mild (total score 1–6), moderate (7–12), and severe (≥13) was calculated.

Results

The number of women with no LA muscle defect or a mild defect was significantly higher than the number of those with a moderate or severe defect (p < 0.001). Apart from the small inverse relationship of the total puborectalis muscle score and the cumulative subdivision score with maximal urethral closure pressure (r value > −0.3; p < 0.05), the muscle defect scores were not found to correlate with urodynamic parameters (p > 0.05). Although all muscle subdivisions contributed to the overall LA muscle defect score, the association was strongest for the puborectalis component (r = 0.9; p < 0.001). The prevalence of the LA muscle defect in patients with intrinsic sphincter deficiency (ISD) was not significantly different from that in patients without ISD.

Conclusion

Patients with SUI have a higher prevalence of no or mild LA defect compared with a moderate or severe LA defect.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Mant J, Painter R, Vessey M (1997) Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 104:579–585

    Article  CAS  PubMed  Google Scholar 

  2. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S (2001) Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol 98:1004–1010

    CAS  PubMed  Google Scholar 

  3. Kearney R, Miller JM, Ashton-Miller JA, DeLancey JOL (2006) Obstetrical factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107(1):144–149

    Article  PubMed  PubMed Central  Google Scholar 

  4. Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106(4):707–712

    Article  PubMed  Google Scholar 

  5. Svabik K, Shek KL, Dietz HP (2009) How much does the levator hiatus have to stretch during childbirth? BJOG 116(12):1657–1662

    Article  CAS  PubMed  Google Scholar 

  6. DeLancey J, Morgan D, Fenner D, 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 109:295–302

    Article  PubMed  Google Scholar 

  7. Dietz HP, Steensma AB (2006) The prevalence of major abnormalities of the levator ani in urogynaecological patients. BJOG 113:225–230

    Article  CAS  PubMed  Google Scholar 

  8. Adekanmi OA, Freeman RM, Jackson SA, Puckett M, Bombieri L, Waterfield MR (2009) Do the anatomical defects associated with cystocele affect the outcome of the anterior repair? A clinical and radiological study. Int Urogynecol J Pelvic Floor Dysfunct 20(11):1369–1377

    Article  PubMed  Google Scholar 

  9. Rortveit G, Subak LL, Thom DH, Creasman JM, Vittinghoff E, Van Den Eeden SK, Brown JS (2010) Urinary incontinence, fecal incontinence and pelvic organ prolapse in a population-based, racially diverse cohort: prevalence and risk factors. Female Pelvic Med Reconstr Surg 16(5):278–283

    Article  PubMed  PubMed Central  Google Scholar 

  10. DeLancey JOL, Kearney R, Chou Q, Speights S, Binno S (2003) The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 101(1):46–53

    PubMed  PubMed Central  Google Scholar 

  11. Dietz HP, Kirby A, Shek KL, Bedwell PJ (2009) Does avulsion of the puborectalis muscle affect bladder function? Int Urogynecol J 20:967–972

    Article  CAS  Google Scholar 

  12. Morgan DM, Cardoza P, Guire K, Fenner DE, DeLancey JOL (2010) Levator ani defect status and lower urinary tract symptoms in women with pelvic organ prolapse. Int Urogynecol J 21:47–52

    Article  PubMed  Google Scholar 

  13. Shobeiri SA, LeClaire E, Nihira MA, Quiroz LH, O’Donaghue D (2009) Appearance of the levator ani muscle subdivisions in endovaginal three-dimensional ultrasonography. Obstet Gynecol 114:66–72

    Article  PubMed  Google Scholar 

  14. Shobeiri SA, Rostaminia G, White D, Hegde A, Mukati M, Quiroz L (2012) How much levator muscle defect is associated with female pelvic organ prolapse? Int Urogynecol J 23(S2):S163

    Google Scholar 

  15. Dietz HP, Simpson JM (2008) Levator trauma is associated with pelvic organ prolapse. BJOG 115:979–984

    Article  CAS  PubMed  Google Scholar 

  16. Derpapas A, Digesu AG, Hamady M, Gallo P, Dell’Utri C, Vijaya G, Khullar V (2013) Prevalence of pubovisceral muscle avulsion in a general gynecology cohort: a computed tomography study. Neurourol Urodyn 32(4):359–362

    Article  PubMed  Google Scholar 

  17. DeLancey JOL (1997) The pathophysiology of stress urinary incontinence and its implications for surgical treatment. World J Urol 15:268–274

    Article  CAS  PubMed  Google Scholar 

  18. Muellner SR (1951) Physiology of micturition. J Urol 65:805–810

    CAS  PubMed  Google Scholar 

  19. Parks AG, Porter NH, Melzak (1962) Experimental study of the reflex mechanism controlling muscles of the pelvic floor. Dis Colon Rectum 5:407–414

    Article  CAS  PubMed  Google Scholar 

  20. Hanzal E, Berger E, Koelbl H (1993) Levator ani muscle morphology and recurrent genuine stress incontinence. Obstet Gynecol 81:426–429

    CAS  PubMed  Google Scholar 

  21. Snooks SJ, Badenoch DF, Tiptaft RC, Swash M (1985) Perineal nerve damage in genuine stress urinary incontinence. An electrophysiological study. Br J Urol 57:422–426

    Article  CAS  PubMed  Google Scholar 

  22. Smith AR, Hosker GL, Warrell DW (1989) The role of partial denervation of the pelvic floor in the aetiology of genitourinary prolapse and stress incontinence of urine. A neurophysiological study. Br J Obstet Gynaecol 96(1):29–32

  23. Sajadi KP, Lin DL, Steward JE, Balog B, Dissaranan C, Zaszczurynski P, Gill BC, Jiang HH, Kerns JM, Damaser MS (2012) Pudendal nerve stretch reduces external urethral sphincter activity in rats. J Urol 188(4):1389–1395

    Article  PubMed  Google Scholar 

  24. Bakas P, Liapis A, Karanreas A, Creatsas G (2001) Pudendal nerve terminal motor latency in women with genuine stress incontinence and prolapse. Gynecol Obstet Invest 51:187–190

    Article  CAS  PubMed  Google Scholar 

  25. Da Silva AS, Digesu A, Dell’Utri C, Fritsch H, Piffarotti P, Khullar V (2015) Do ultrasound findings of levator ani “avulsion” correlate with anatomical findings: a multicenter cadaveric study. Neurourol Urodyn DOI: 10.1002/nau.22781

    Google Scholar 

  26. Kapoor DS, Housami F, White P, Swithinbank L, Drake M (2012) Maximum urethral closure pressure in women: normative data and evaluation as a diagnostic test. Int Urogynecol J 23(11):1613–1618

    Article  PubMed  Google Scholar 

  27. Goepel C, Thomssen C (2006) Changes in the extracellular matrix in periurethral tissue of women with stress urinary incontinence. Acta Histochem 108(960):441–445

    Article  PubMed  Google Scholar 

  28. Javadian P, O’Leary D, Rostaminia G et al (2015) How does 3D endovaginal ultrasound compare to magnetic resonance imaging in the evaluation of levator ani anatomy? Neurourol Urodyn DOI: 10.1002/nau.22944

    PubMed  Google Scholar 

  29. Lien KC, Mooney B, DeLancey JO (2004) Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol 103:31–40

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Centre for Urogynecology and Pelvic Health (C.U.P), New Delhi, India

    Aparna Hegde

  2. Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, FL, USA

    Aparna Hegde & G. Willy Davila

  3. Department of Obstetrics and Gynecology, University of Texas at Austin, Dell School of Medicine, Austin, Texas, USA

    Vivian C. Aguilar

Authors
  1. Aparna Hegde
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vivian C. Aguilar
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. G. Willy Davila
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Aparna Hegde.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hegde, A., Aguilar, V.C. & Davila, G.W. Levator ani defects in patients with stress urinary incontinence: three-dimensional endovaginal ultrasound assessment. Int Urogynecol J 28, 85–93 (2017). https://doi.org/10.1007/s00192-016-3068-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-016-3068-7

Keywords

Search

Navigation