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Prevalence of levator ani muscle avulsion and effect on quality of life in women with pelvic organ prolapse

Abstract

Introduction and hypothesis

Levator ani muscle (LAM) avulsion is associated with pelvic organ prolapse (POP). There is limited information on the prevalence of LAM avulsion in Chinese women with POP. This study evaluated the prevalence of LAM avulsion in women presenting with POP and the effects on their quality of life (QoL).

Methods

This prospective study was conducted in a tertiary urogynecology center. Chinese women presenting with POP were recruited and completed standardized questionnaires exploring their symptoms and QoL and underwent gynecological examination to assess the stage of POP and involved compartments. Four-dimensional translabial ultrasound (US) was performed on all women, and evaluation of LAM avulsion was done offline.

Results

Three hundred and ninety-eight women completed the study. The prevalence of LAM avulsion was 38.9% [95% confidence interval (CI) 34.1–43.7%]; 31 (7.8%), 26 (6.5%), and 98 (24.6%) had left, right, and bilateral LAM avulsion, respectively. LAM avulsion was associated with a more advanced stage of prolapse (P < 0.005) and prolapse of stage ≥II of all three compartments. Bilateral LAM avulsion was associated with a more severe stage of prolapse. More women with LAM avulsion reported bothersome symptoms of prolapse and had higher Pelvic Organ Prolapse Distress Inventory (POPDI) and Urinary Incontinence Questionnaire (UIQ) scores, implying more impairment in QoL. However, after multivariate linear regression analysis, POP stage remained a significant predictor of POPDI and UDI scores (P ≤ 0.006); LAM avulsion was not a predictor (P = 0.2 and 0.27, respectively).

Conclusions

LAM avulsion was detected in 39% of Chinese women with POP. It was associated with a more advanced POP stage, and these women had more impairment of QoL. However, LAM avulsion was not an independent factor influencing the QoL of these women.

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References

  1. 1.

    DeLancey JO. The anatomy of the pelvic floor. Curr Opin Obstet Gynecol. 1994;6:313–6.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Chan SC, Cheung YK, Yiu KW, Lee LL, Pang WL, Choy KW, et al. Prevalence of levator ani muscle injury in Chinese women after first delivery. Ultrasound Obstet Gynaecol. 2012;39:704–9.

    CAS  Article  Google Scholar 

  3. 3.

    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. BJOG. 2014;121:1164–71. discussion 1172

    Article  PubMed  Google Scholar 

  4. 4.

    Guzman Rojas R, Wong V, Shek KL, Dietz HP. Impact of levator trauma on pelvic floor muscle function. Int Urogynecol J. 2014;25:375–80.

    Article  PubMed  Google Scholar 

  5. 5.

    Chan SS, Cheung RY, Lee LL, Choy KW, Chung TKH. A longitudinal follow-up of levator ani muscle avulsion: Does a second delivery affect it? Ultrasound Obstet Gynecol. 2016; https://doi.org/10.1002/uog.16009. Chan SS, Cheung RY, Lee LL, Choy KW, Chung TKH. A longitudinal follow-up of levator ani muscle avulsion: Does a second delivery affect it? Ultrasound Obstet Gynecol. 2017;50:110–5.

  6. 6.

    Chung MY, Wan OY, Cheung RY, Chung TK, Chan SS. Prevalence of levator ani muscle injury and health-related quality of life in primiarous Chinese women after instrumental delivery. Ultrasound Obstet Gynecol. 2015;45:728–33.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Steensma AB, Konstantinovic ML, Burger CW, de Ridder D, Timmerman D, Deprest J. Prevalence of major levator abnormalities in symptomatic patients with an underactive pelvic floor contraction. Int Urogynecol J. 2010;21:861–7.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Chan SS, Cheung RY, Yiu KW, Lee LL, Chung TK. Effect of levator ani muscle injury on primiparous women during the first year after childbirth. Int Urogynecol J. 2014;25:1381–8.

    Article  PubMed  Google Scholar 

  9. 9.

    Thomas V, Shek KL, Guzman Rojas R, Dietz HP. Temporal latency between pelvic floor trauma and presentation for prolapse surgery: A retrospective observational study. Int Urogynecol J. 2015;26:1185–9.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Chan SS, Cheung RY, Yiu KW, Lee LL, Pang AW, Chung TK. Symptoms, quality of life, and factors affecting women’s treatment decisions regarding pelvic organ prolapse. Int Urogynecol J. 2012;23:1027–33.

    Article  PubMed  Google Scholar 

  11. 11.

    Abdul Jalil SS, Guzman Rojas R, Dietz HP. Does it matter whether levator avulsion is diagnosed pre- or postoperatively? Ultrasound Obstet Gynecol. 2016;10(48):516–9.

    Article  Google Scholar 

  12. 12.

    Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG. 2008;115:979–84.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Cheung RY, Shek KL, Chan SS, Chung TK, Dietz HP. Pelvic floor muscle biometry and pelvic organ mobility in east Asian and Caucasian nulliparae. Ultrasound Obstet Gynecol. 2015;45:599–604.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. BJOG. 2010;117:1485–92.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Chan SS, Cheung RY, Yiu AK, Li JC, Lai BP, Choy KW, et al. Chinese validation of pelvic floor distress inventory and pelvic floor impact questionnaire. Int Urogynecol J. 2011;22:1305–12.

    Article  PubMed  Google Scholar 

  16. 16.

    Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Karskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10–7.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Dietz HP. Pelvic floor ultrasound: A review. Am J Obstet Gynecol. 2010;202:321–34.

    Article  PubMed  Google Scholar 

  18. 18.

    Dietz HP, Bernado MJ, Kirby A, Shek KL. Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J. 2011;22:699–704.

    Article  PubMed  Google Scholar 

  19. 19.

    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;205:232.e1–8.

    Article  Google Scholar 

  20. 20.

    Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An international Urogynecologic association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21:5–26.

    Article  PubMed  Google Scholar 

  21. 21.

    Trutnovsky G, Kamisan Atan I, Ulrich D, Martin A, Dietz HP. Levator ani trauma and pelvic organ prolapse – A comparison of three translabial ultrasound scoring system. Acta Obstet Gynecol Scand. 2016;95:1411–7.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Dietz HP, Steensma AB. Prevalence of major abnormalities of the levator ani in urogynaecological patients. BJOG. 2006;113:225–30.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Cheung RY, Lee JH, Lee LL, Chung TK, Chan SS. Levator ani muscle avulsion is a risk factor for vaginal pessary expulsion within 1 year for pelvic organ prolapse. Ultrasound Obstet Gynecol. 2017; https://doi.org/10.1002/uog.17407.

  24. 24.

    Dietz HP, Shek KL, Chantarasorn V, Langer SE. Do women notice the effect of childbirth-related pelvic floor trauma? Aust N Z J Obstet Gynecol. 2012;52:277–81.

    Article  Google Scholar 

  25. 25.

    Abdool Z, Dietz HP, Lindeque BG. Prolapse symptoms are associated with abnormal functional anatomy of the pelvic floor. Int Urogynecol J. 2017; https://doi.org/10.1007/s00192-017-3280-0.

  26. 26.

    Endress E, Shek KL, Dietz HP. Levator avulsion is not associated with symptom bother of female pelvic organ prolapse. Arch Gynecol Obstet. 2015;292:629–33.

    Article  PubMed  Google Scholar 

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Correspondence to Symphorosa Shing Chee Chan.

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Yu, C.H., Chan, S.S.C., Cheung, R.Y.K. et al. Prevalence of levator ani muscle avulsion and effect on quality of life in women with pelvic organ prolapse. Int Urogynecol J 29, 729–733 (2018). https://doi.org/10.1007/s00192-017-3454-9

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Keywords

  • Levator ani muscle avulsion
  • Levator ani muscle injury
  • Pelvic organ prolapse
  • PFDI
  • PFIQ