International Urogynecology Journal

, Volume 28, Issue 9, pp 1387–1391 | Cite as

Prolapse symptoms are associated with abnormal functional anatomy of the pelvic floor

  • Zeelha Abdool
  • Hans Peter Dietz
  • Barend Gerhardus Lindeque
Original Article

Abstract

Introduction and hypothesis

The etiology of pelvic organ prolapse (POP) likely includes over-distension or tears (avulsion) of the levator ani muscle. However, there is a lack of studies evaluating the association between symptoms of POP and these factors. This study was designed to determine the association between POP symptoms and clinical prolapse stage on the one hand, and pelvic floor functional anatomy on the other hand.

Methods

This prospective observational study included 258 patients seen at a tertiary urogynecological unit with symptoms of POP as defined by pertinent ICIQ questions. After informed consent and a detailed history including ICIQ responses, 3D transperineal ultrasonography was performed using a GE Voluson i ultrasound system. Offline analysis was performed on de-identified datasets.

Results

The mean age of the patients was 60.6 years (25–91 years) and their mean BMI was 29.8 kg/m2 (18–53 kg/m2). Levator defects were found in 78 (32.4%) of the patients and the defect was bilateral in almost half of these patients (n = 36). There were significant associations between awareness and visualization of a vaginal lump on the one hand and hiatal area measurements as well as diagnosis of avulsion on the other. Interference with everyday life was significantly associated with hiatal area and prolapse stage, but not with avulsion.

Conclusions

There is a significant association between awareness, visualization and/or feeling of a vaginal lump and abnormal pelvic floor functional anatomy, that is, hiatal ballooning and levator avulsion.

Keywords

Levator avulsion Pelvic organ descent Prolapse symptoms 

Notes

Acknowledgements

The authors thank Susan Terblanch, B.Com (Hons. Statistics), OLRAC SPS, South Africa, for assistance with the statistical analysis.

Compliance with ethical standards

Conflicts of interest

None.

References

  1. 1.
    Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:122–127.CrossRefPubMedGoogle Scholar
  2. 2.
    Dietz H. Clinical consequences of levator trauma. Ultrasound Obstet Gynecol. 2012;39:367–371.CrossRefPubMedGoogle Scholar
  3. 3.
    Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106:707–712.CrossRefPubMedGoogle Scholar
  4. 4.
    Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. Br J Obstet Gynaecol. 2010;117:1485–1492.CrossRefGoogle Scholar
  5. 5.
    van Delft K, Sultan AH, Thakar R, Schwertner-Tiepelmann N, Kluivers K. The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. Br J Obstet Gynaecol. 2014;121:1164–1171.CrossRefGoogle Scholar
  6. 6.
    Dietz HP, Steensma AB. The prevalence of major abnormalities of the levator ani in urogynaecological patients. Br J Obstet Gynaecol. 2006;113:225–230.CrossRefGoogle Scholar
  7. 7.
    Weemhoff M, Vergeldt TF, Notten K, Serroyen J, Kampschoer PH, Roumen FJ. Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study. Int Urogynecol J Pelvic Floor Dysfunct. 2012;23:65–71.CrossRefGoogle Scholar
  8. 8.
    Model AN, Shek KL, Dietz HP. Levator defects are associated with prolapse after pelvic floor surgery. Eur J Obstet Gynecol Reprod Biol. 2010;153:220–223.CrossRefPubMedGoogle Scholar
  9. 9.
    Dietz H, Simpson J. Levator trauma is associated with pelvic organ prolapse. Br J Obstet Gynaecol. 2008;115:979–984.CrossRefGoogle Scholar
  10. 10.
    Vergeldt TF, Notten KJ, Weemhoff M, van Kuijk SM, Mulder FE, Beets-Tan RG, et al. Levator hiatal area as a risk factor for cystocele recurrence after surgery: a prospective study. Br J Obstet Gynaecol. 2015;122:1130–1137.CrossRefGoogle Scholar
  11. 11.
    Price N, Jackson SR, Avery K, Brookes ST, Abrams P. Development and psychometric evaluation of the ICIQ vaginal symptoms questionnaire: the ICIQ-VS. Br J Obstet Gynaecol. 2006;113:700–712.CrossRefGoogle Scholar
  12. 12.
    Burrows LJ, Meyn LA, Walters MD, Weber AM. Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol. 2004;104:982–988.CrossRefPubMedGoogle Scholar
  13. 13.
    Romanzi LJ, Chaikin DC, Blaivas JG. The effect of genital prolapse on voiding. J Urol. 1999;161(2):581–586.CrossRefPubMedGoogle Scholar
  14. 14.
    Bump RC, Mattiasson A, Bo 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;175:10–17.CrossRefPubMedGoogle Scholar
  15. 15.
    Dietz HP, Wong V, Shek KL. A simplified method for determining hiatal biometry. Aust N Z J Obstet Gynaecol. 2011;51:540–543.CrossRefPubMedGoogle Scholar
  16. 16.
    Dietz HP. Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol. 2007;29:329–34.CrossRefPubMedGoogle Scholar
  17. 17.
    Dietz HP, Haylen BT, Broome J. Ultrasound in the quantification of female pelvic organ prolapse. Ultrasound Obstet Gynecol. 2001;18:511–514.CrossRefPubMedGoogle Scholar
  18. 18.
    Dietz HP, Korda A. Which bowel symptoms are most strongly associated with a true rectocele? Aust N Z J Obstet Gynaecol. 2005;45:505–508.CrossRefPubMedGoogle Scholar
  19. 19.
    Dietz HP, Franco AV, Shek KL, Kirby A. Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? Acta Obstet Gynecol Scand. 2012;91:211–214.CrossRefPubMedGoogle Scholar
  20. 20.
    Andrew B, Shek KL, Chantarasorn V, Dietz HP. Enlargement of the levator hiatus in female pelvic organ prolapse: cause or effect. Aust N Z J Obstet Gynaecol. 2013;53:74–78.CrossRefPubMedGoogle Scholar
  21. 21.
    Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol. 2001;185:1332–1337.CrossRefPubMedGoogle Scholar
  22. 22.
    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;109:295–302.CrossRefPubMedGoogle Scholar
  23. 23.
    Abdool Z, Shek KL, Dietz HP. The effect of levator avulsion on hiatal dimension and function. Am J Obstet Gynecol. 2009;201:89.e1–89.e5.CrossRefGoogle Scholar
  24. 24.
    Otcenasek M, Krofta L, Baca V, Grill R, Kucera E, Herman H, et al. Bilateral avulsion of the puborectal muscle: magnetic resonance imaging-based three-dimensional reconstruction and comparison with a model of a healthy nulliparous woman. Ultrasound Obstet Gynecol. 2007;29:692–696.CrossRefPubMedGoogle Scholar
  25. 25.
    Dietz HP, Kirby A, Shek KL, Bedwell P. Does avulsion of the puborectalis muscle affect bladder function? Int Urogynecol J. 2009;20:967–972.CrossRefGoogle Scholar
  26. 26.
    Dietz HP, Pattillo Garnham A, Guzmán Rojas R. Is it necessary to diagnose levator avulsion on pelvic floor muscle contraction? Ultrasound Obstet Gynecol. 2015. doi:10.1002/uog.15832.Google Scholar

Copyright information

© The International Urogynecological Association 2017

Authors and Affiliations

  1. 1.Division of Urogynaecology, Department of Obstetrics and Gynaecology, University of PretoriaSteve Biko Academic HospitalPretoriaSouth Africa
  2. 2.Faculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
  3. 3.Department of Obstetrics and GynaecologyUniversity of Sydney Medical School NepeanKingswoodAustralia
  4. 4.Department of Obstetrics and Gynaecology, University of PretoriaSteve Biko Academic HospitalPretoriaSouth Africa

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