Ambulatory Urology and Urogynaecology by Rane Abhay; Rane Ajay; & Ajay Rane

Author:Rane, Abhay; Rane, Ajay; & Ajay Rane [Rane, Abhay & Rane, Ajay]
Language: eng
Format: epub
Publisher: John Wiley & Sons, Incorporated
Published: 2021-01-21T00:00:00+00:00

Levator Ani Muscle Avulsion

Pelvic floor disorders, urinary incontinence, and pelvic organ prolapse have been identified as important long‐term complications of perineal trauma. Apart from the neurological damage and stretching of pelvic floor muscles in vaginal deliveries, the avulsion injury sustained to pelvic floor muscles is attributed as an important causative factor in pelvic floor disorders.

Levator avulsion (LA) is the detachment of the pubovisceral muscle (PVM) component of the levator ani muscle from its insertion into the pubic bone. There is wide variation in the reported incidence of avulsion injury, which ranges from 13 to 36% after the first birth. The risk is significantly higher following operative vaginal birth especially with forceps. The difference in incidence is also contributed to by the variation in the method and timing of diagnosis. LA can be complete or partial and either unilateral or bilateral. Although partial avulsions are more likely to improve over time, they are still associated with subjective and objective pelvic floor dysfunction. Palpation of the site of insertion of the PVM is sometimes recommended as a method of screening for LA, however, the diagnostic accuracy of this method relies on the skill of the examiner and the presence of an intact side to act as a reference. Nonetheless, natural variation in PVM insertions is a real limitation to this technique. Therefore, accurate diagnosis relies on imaging techniques, mainly in the form of 3D ultrasonography or magnetic‐resonance imaging (MRI). For this reason, the diagnosis tends to be made a long time after birth. Good agreement between MRI and 3D TPUS has been reported with the ultrasound assessment being more reproducible, more convenient and more cost‐effective. The TPUS assessment for LA should be undertaken upon pelvic muscle contraction for better tissue enhancement and with a volume acquisition angle of at least 70°. On TUI sub‐analysis, LA is diagnosed when abnormal insertion is detected in three central slices or with a levator‐urethral‐gap (LUG) of >2.5 cm (Figures 10.1–10.4).

Although LA is known to increase a woman's long‐term risk of prolapse, there is currently no policy or recommendation for routine screening even in high‐risk women (e.g., after forceps deliveries or births complicated by OASIs). If there is a clinical need to confirm or refute the possibility of an LA, the presence of clinical expertise and an imaging facility within the ambulatory clinic is beneficial. At present, there are no effective surgical interventions for the repair of LA. There does, however, seem to be potential benefits in structured antenatal pelvic floor muscle exercises and alteration of avoidable risk factors such as obesity and constipation to reduce the individual woman's likelihood of developing significant pelvic floor disorders in the future.

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