International Urogynecology Journal

, Volume 28, Issue 6, pp 907–911 | Cite as

Predicting levator avulsion from ICS POP-Q findings

  • Alejandro Pattillo Garnham
  • Rodrigo Guzmán Rojas
  • Ka Lai Shek
  • Hans Peter Dietz
Original Article

Abstract

Introduction and hypothesis

Levator avulsion is a common consequence of vaginal childbirth. It is associated with symptomatic female pelvic organ prolapse and is also a predictor of recurrence after surgical correction. Skills and hardware necessary for diagnosis by imaging are, however, not universally available. Diagnosis of avulsion may benefit from an elevated index of suspicion. The aim of this study was to examine the predictive value of the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) for the diagnosis of levator avulsion by tomographic 4D translabial ultrasound.

Methods

This is a retrospective analysis of data obtained in a tertiary urogynaecological unit. Subjects underwent a standardised interview, POP-Q examination and 4D translabial pelvic floor ultrasound. Avulsion of the puborectalis muscle was diagnosed by tomographic ultrasound imaging. We tested components of the ICS POP-Q associated with symptomatic prolapse and other known predictors of avulsion, including previous prolapse repair and forceps delivery with uni- and multivariate logistic regression. A risk score was constructed for clinical use.

Results

The ICS POP-Q components Ba, C, gh and pb were all significantly associated with avulsion on multivariate analysis, along with previous prolapse repair and forceps delivery. A score was assigned for each of these variables and patients were classified as low, moderate or high risk according to total score. The odds of finding an avulsion on ultrasound in patients in the “high risk” group were 12.8 times higher than in the “low risk” group.

Conclusion

Levator avulsion is associated with ICS POP-Q measures. Together with simple clinical data, it is possible to predict the risk of avulsion using a scoring system. This may be useful in clinical practice by modifying the index of suspicion for the condition.

Keywords

Avulsion Levator ani Transperineal ultrasound Prolapse POP-Q Tomographic imaging 

Notes

Compliance with ethical standards

Conflicts of interest

None.

References

  1. 1.
    Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the women’s health initiative: gravity and gravidity. Am J Obstet Gynecol. 2002;186(6):1160–6.CrossRefPubMedGoogle Scholar
  2. 2.
    Swift S, Woodman P, O’Boyle A, Kahn M, Valley M, Bland D, et al. Pelvic organ support study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. 2005;192:795–806.CrossRefPubMedGoogle Scholar
  3. 3.
    Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311–6.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014;123(6):1201–6. doi:10.1097/aog.0000000000000286.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106(4):707–12.CrossRefPubMedGoogle Scholar
  7. 7.
    Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG. 2008;115:979–84. doi:10.1111/j.1471-0528.2008.01751.x.CrossRefPubMedGoogle Scholar
  8. 8.
    Dietz H, Chantarasorn V, Shek K. Levator avulsion is a risk factor for cystocele recurrence. Ultrasound Obstet Gynecol. 2010;36(1):76–80.CrossRefPubMedGoogle Scholar
  9. 9.
    Rodrigo N, Wong V, Shek KL, Martin A, Dietz HP. The use of 3-dimensional ultrasound of the pelvic floor to predict recurrence risk after pelvic reconstructive surgery. Aust N Z J Obstet Gynaecol. 2014;54(3):206–11. doi:10.1111/ajo.12171.CrossRefPubMedGoogle Scholar
  10. 10.
    Svabik K, Martan A, Masata J, El‐Haddad R, Hubka P. Comparison of vaginal mesh repair with sacrospinous vaginal colpopexy in the management of vaginal vault prolapse after hysterectomy in patients with levator ani avulsion: a randomized controlled trial. Ultrasound Obstet Gynecol. 2014;43(4):365–71.CrossRefPubMedGoogle Scholar
  11. 11.
    Shek K, Dietz H. Assessment of pelvic organ prolapse: a review. Ultrasound Obstet Gynecol. 2016. doi:10.1002/uog.15881.Google Scholar
  12. 12.
    DeLancey JO, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol. 2003;101(1):46–53.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Dietz HP, Shek KL. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J. 2008;19(8):1097–101.CrossRefGoogle Scholar
  14. 14.
    Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175(1):10–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Dietz H. Ultrasound imaging of the pelvic floor: part 1: 2D aspects. Ultrasound Obstet Gynecol. 2004;23:80–92.CrossRefPubMedGoogle Scholar
  16. 16.
    Dietz H, Bernardo M, Kirby A, Shek K. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J. 2011;22(6):699–704.CrossRefPubMedGoogle Scholar
  17. 17.
    Dietz HP, Shek C, Clarke B. Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol. 2005;25(6):580–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Dietz HP, Shek C, De Leon J, Steensma AB. Ballooning of the levator hiatus. Ultrasound Obstet Gynecol. 2008;31(6):676–80.CrossRefPubMedGoogle Scholar
  19. 19.
    Volloyhaug I, Wong V, Shek K, Dietz H. Does levator avulsion cause distension of the genital hiatus and perineal body? Int Urogynecol J. 2013;24(7):1161–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Model AN, Shek KL, Dietz HP. Levator defects are associated with prolapse after pelvic floor surgery. Eur J Obstet Gynecol Reprod Biol. 2010;153(2):220–3. doi:10.1016/j.ejogrb.2010.07.046.CrossRefPubMedGoogle Scholar
  21. 21.
    DeLancey JO, Morgan DM, Fenner DE, Kearney R, Guire K, Miller JM, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol. 2007;109(2, Part 1):295–302.CrossRefPubMedGoogle Scholar
  22. 22.
    Dietz HP. Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol. 2007;29(3):329–34. doi:10.1002/uog.3951.CrossRefPubMedGoogle Scholar
  23. 23.
    Zhuang RR, Song YF, Chen ZQ, Ma M, Huang HJ, Chen JH, et al. Levator avulsion using a tomographic ultrasound and magnetic resonance-based model. Am J Obstet Gynecol. 2011;205(3):232.e1–8. doi:10.1016/j.ajog.2011.03.052.CrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2016

Authors and Affiliations

  • Alejandro Pattillo Garnham
    • 1
    • 2
    • 3
    • 4
  • Rodrigo Guzmán Rojas
    • 1
    • 5
    • 6
  • Ka Lai Shek
    • 1
    • 7
  • Hans Peter Dietz
    • 1
  1. 1.Sydney Medical School NepeanNepean HospitalPenrithAustralia
  2. 2.División de Obstetricia y Ginecología, Escuela de MedicinaPontificia Universidad Católica de ChileSantiagoChile
  3. 3.Unidad de Piso Pélvico, Servicio de la MujerComplejo Asistencial Dr. Sótero Del RíoSantiagoChile
  4. 4.Unidad de Piso Pélvico, Clínica Puerto VarasPuerto VarasChile
  5. 5.Departamento de Ginecología y Obstetricia, Clínica Alemana de SantiagoFacultad de Medicina Clínica Alemana, Universidad del DesarrolloSantiagoChile
  6. 6.Departamento de Ginecología y Obstetricia, Unidad de Piso PélvicoHospital Clínico Universidad de ChileSantiagoChile
  7. 7.Department of Obstetrics and Gynaecology, Liverpool Clinical SchoolWestern Sydney UniversitySydneyAustralia

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