Levator Trauma Research Articles

Coronal Plane Assessment for Levator Trauma.

Levator avulsion is a major etiological factor of pelvic organ prolapse (POP) and is primarily diagnosed on tomographic axial plane imaging. Two-dimensional imagingcan also image the levator. The objective was to test reproducibility and validity of coronal plane assessment for diagnosis of levator trauma by assessing the coronal plane obtained on tomographic ultrasound imaging. A retrospective study of women who had undergone an interview, POPQ and four-dimensional translabial ultrasound at a tertiary urogynecological unit. Post-processing of archived volume data was performed for assessment; and levator muscle area and estimate of remnant muscle mass in the coronal plane. Interobserver reproducibility of the latter two measures and associations between various measures of levator trauma and POP were tested. Interobserver agreement was good for percentage estimates (ICC 0.743), but fair for area measurements (ICC 0.482). Six hundred and twenty four women were seen, 468 (75%) had significant clinical prolapse. Full levator avulsions were diagnosed in 137 (22%). Mean TTS was 2.7 (range 0-12). On coronal plane assessment average muscle area was 1.47 (SD 0.76) cm2 and 1.55 (SD 0.74) cm2 on the right and left, respectively (P = .005). It was 76% and 79% for average estimates of muscle mass (P = .021). Both measures were strongly associated with POP; however, they were not superior to TTS in predicting POP. Coronal plane assessment in volume data is reproducible and valid for evaluation of levator trauma. Muscle mass estimate may be a better measure than muscle area.

All or nothing? A second look at partial levator avulsion.

To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP). This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression. Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva. Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

EP48.03: Coronal plane assessment of levator trauma

EP48.03: Coronal plane assessment of levator trauma

Timing of caesarean section and its impact on levator ani musle avulsion at the first subsequent vaginal birth - a pilot study.

The aim of this multicentric observational study was to explore the impact of the timing of cesarean section (SC) on levator (MLA - levator ani musle) avulsion at the first subsequent vaginal birth. All women after term vaginal birth following a cesarean section (VBAC) for their second delivery at the Departments of Gynecology and Obstetrics, Faculty of Medicine, Charles University and University Hospital in Pilsen and the 1st Faculty of Medicine, Charles University and General Hospital in Prague, between 2012 and 2016 were identified. Hospital database and surgical notes were used to collect basic characteristics of the patients including the indication and course of their previous delivery. These women were divided into two groups according to indication of prior SC in the previous delivery to women with elective SC and acute SC. All participants were invited for a 4D pelvic floor ultrasound to assess levator trauma. Levator avulsion and the levator hiatus area were assessed off-line from the stored pelvic floor volumes. Data were statistically assessed. A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for 141 women for statistical analyses. These were further divided into 80 women after acute SC and 61 women after elective SC. The levator avulsion rate was higher in the elective SC subgroup, but the difference was not significant (26.3 vs. 41.0%, P = 0.0645). No statistical differences in urogenital hiatus enlargement and ballooning were observed. VBAC is associated with a significantly higher rate of levator ani avulsion compared to the first vaginal birth in nulliparous women. However, it seems that risk of levator ani avulsion doesnt depend on the timing of SC in previous labor. More studies are needed to confirm the results of this pilot study.

Is levator trauma an independent risk factor for anal incontinence?

To determine the role of levator ani trauma in anal incontinence (AI), whilst controlling for anal sphincter injury. The records of 1273 patients who had attended a tertiary urogynaecology unit between 1st of January to 31st December 2016 were reviewed. AI was assessed using St Mark's score and visual analogue scale (VAS). Levator muscle and anal sphincter trauma were examined by translabial ultrasound using tomographic imaging, with archived data sets investigated blinded against all clinical data. A complete avulsion was diagnosed if at least three central tomographic slices showed an abnormal muscle insertion, rated separately for each side. A significant anal sphincter defect was diagnosed if at least four out of six slices showed a defect of ≥30°. Avulsion was associated with St Mark's score (P=0.005) and VAS bother of AI (P=0.022) both on univariate analysis and when controlling for external anal sphincter (EAS) trauma on translabial imaging, forceps, body mass index (BMI) and age (P=0.011 and P=0.04, respectively). AI expressed as a binary variable was significantly associated with avulsion on univariate analysis (P=0.011), although the association became nonsignificant after controlling for anal sphincter trauma, age, BMI and forceps delivery (P=0.084). In this retrospective observational study, we found a weak association between levator ani avulsion and measures of AI, which largely remained significant when controlling for anal sphincter trauma. However, given the large data set, any clinical effect of levator trauma on AI is likely to be minor.

Episiotomy: the biomechanical impact of multiple small incisions during a normal vaginal delivery.

Childbirth-related injuries are one of the main causes of pelvic floor dysfunction. To attempt to avoid serious tears during delivery, an episiotomy can be performed. In this study, we intended to investigate the biomechanical performance of the pelvic floor muscles after performing different episiotomies using a physics-based computational model which includes the pelvic floor muscles and the fetus. Previous biomechanical studies have analysed the mechanical effects of single incisions of different lengths; in this study, we intend to analyse the implications of multiple small incisions, evaluating the reaction forces, the stress on the muscles and the loss of tissue integrity sustained by the pelvic floor. The obtained results predict that an episiotomy delivery reduces the likelihood of macroscopic levator trauma by decreasing the stress on the region of insertion of the rectal area of the levator ani in the symphysis pubis. From the mechanical point of view, multiple incisions do not bring benefits compared to larger incisions. However, nothing can be ascertained about the clinical benefit of such an approach.

Vaginal Birth and Pelvic Floor Trauma

Over the last two to three decades, a growing body of research has shown that vaginal childbirth is more traumatic to mothers than generally assumed. Apart from obstetric anal sphincter tears which have been extensively studied, trauma to the levator ani muscle is a form of maternal injury that is less well recognised and often undiagnosed. In the context of an increasing push towards vaginal birth, this article will review the recent literature to better inform health care providers regarding the significance of pelvic floor trauma. Imaging studies have shown that levator avulsion, where the puborectalis muscle has detached from the os pubis, occurs in up to 1/3 of vaginally primiparous women, depending on demographic factors and obstetric management. Forceps is a well-established risk factor for levator avulsion with an odds ratio of 4–5 compared to vacuum, which does not seem to convey additional risk over unassisted vaginal birth. Levator injuries are significantly associated with pelvic organ prolapse and treatment failure. Such trauma can also lead to significant psychological morbidity, up to and including post-traumatic stress disorder. Antenatal prediction does not appear feasible. Modification of obstetric practice by abandoning forceps would significantly reduce pelvic floor trauma and the future need for prolapse surgery. Vaginal childbirth is more traumatic than commonly assumed. Levator trauma is associated with significant physical and psychological morbidity. Perinatal health care providers need to understand and recognise the significance of maternal birth trauma and its potential impact on women’s health.

Atraumatic normal vaginal delivery: how many women get what they want?

Trauma to the perineum, levator ani complex, and anal sphincter is common during vaginal childbirth, but often clinically underdiagnosed, and many women are unaware of the potential for long-term damage. In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery. This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma. A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035). The prevalence of significant pelvic floor trauma aftervaginal child birth is much higher than generally assumed. Ratesofobstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33-40%) of primiparous women achieved an atraumatic normal vaginal delivery.

Prevalence of Maternal Birth Trauma in Nepali Women.

Pelvic organ prolapse is very common among women in Nepal, especially uterine prolapse. This would suggest a high rate of levator trauma, which is a strong predictor of such prolapse in the Western world. Hence, we decided to study the prevalence of maternal birth trauma in Nepali women. In November 2016, we offered an interview, clinical examination, and 4-dimensional translabial sonography to women attending a gynecology clinic. Of 129 women seen, 5 were excluded due to previous pelvic surgery. Translabial sonography volume data sets were obtained and analyzed by tomographic imaging for levator ani and anal sphincter trauma at a later date, blinded against all clinical data. Mean age was 39 (21-74) years, median vaginal parity was 2 (0-9), mean age at first delivery 21 (14-40). Seventeen (14%) had not given birth vaginally; of these, 14 (11%) delivered by cesarean only, and 3 (2%) were nulliparous. Tomographic assessment for levator avulsion and anal sphincter trauma was possible in 124 women and performed as previously described. We found 2 (2%) unilateral avulsions and significant external anal sphincter defects in another 2 women. Levator and anal sphincter trauma are significantly less prevalent in Nepali women in comparison to Western populations. This is intriguing, especially in view of the high prevalence of prolapse in Nepali women.

Can pelvic floor trauma be predicted antenatally?

Levator trauma is a risk factor for the development of pelvic organ prolapse. We aimed to identify antenatal predictors for significant damage to the levator ani muscle during a first vaginal delivery. A retrospective observational study utilizing data from two studies with identical inclusion criteria and assessment protocols between 2005 and 2014. A total of 1148 primiparae with an uncomplicated singleton pregnancy were recruited and assessed with translabial ultrasound at 36 weeks antepartum and 871 (76%) returned for reassessment 3-6 months postpartum. The ultrasound data of vaginally parous women were analyzed for levator avulsion and microtrauma. The former was diagnosed if the muscle insertion at the inferior pubic ramus in the plane of minimal hiatal dimensions and within 5 mm above were abnormal on tomographic ultrasound imaging. Microtrauma was diagnosed in women with an intact levator and if there was a postpartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2 . The complete datasets of 844 women were analyzed. Among them, 609 delivered vaginally: by normal vaginal delivery in 452 (54%), a vacuum birth in 102 (12%) and a forceps delivery in 55 (6%). Levator avulsion was diagnosed in 98 and microtrauma in 97. On multivariate analysis, increasing maternal age, lower body mass index and lower bladder neck descent were associated with avulsion. Increased bladder neck descent and a family history of cesarean section (CS) were associcated with microtrauma. Maternal age, body mass index, bladder neck descent and family history of CS are antenatal predictors for levator trauma.

The impact of childbirth on pelvic floor morphology in primiparous Black South African women: a prospective longitudinal observational study.

There is a lack of prospective studies evaluating the impact of childbirth on the pelvic floor in non-white populations. We intended to study delivery-related changes in pelvic floor morphology in Black South African primiparae. We also intended to determine the impact of anatomical changes on symptoms in the postpartum period. A total of 153 nulliparous women between 35 and 39weeks gestation were recruited from a district antenatal clinic. All women had a standardized interview, completed the International Consultation on Incontinence Vaginal Symptoms questionnaire followed by three/four dimensional transperineal ultrasonography. This was repeated at 3-6months postpartum. Of the 153 women, 84 (54.9%) returned at a mean of 4.8months postpartum. Of these women, 60 (71.4%) had a vaginal delivery and the remainder a caesarean section (20 emergency and 4 elective). Overall, there were statistically significant increases in bladder neck descent (P = 0.003), pelvic organ descent and levator hiatal distensibility (all P < 0001) at the postpartum assessment. Levator avulsion was diagnosed in nine (15%) of those delivered vaginally. Postpartum vaginal laxity was the commonest bothersome vaginal symptom, reported by 51 women (60.7%). There is significant alteration in pelvic organ support and levator hiatal distensibility postpartum, with more marked effects in women after vaginal delivery. Of Black primiparous women, 15% sustained levator trauma after their first vaginal delivery.

P07.02: Anal sphincter trauma and parity

Obstetric anal sphincter trauma is common in women after vaginal childbirth. Prevalence is reported to be 12-35% using endoanal ultrasonography in primiparae. It is assumed that subsequent vaginal deliveries convey a small risk of repeat sphincter trauma although lower than the index vaginal delivery. We aimed to determine the prevalence of anal sphincter (EAS) trauma in relation to vaginal parity in a large cohort of women presenting to a urogynecology service. This is a retrospective study analysing 1273 archived datasets of women who attended a tertiary urogynecological unit between January 2014 and December 2016. All underwent a standardised interview, clinical examination and 4D transperineal ultrasound (TPUS). Tomographic ultrasound imaging (TUI) was used to evaluate the anal sphincter, blinded against all clinical data including parity. We categorised vaginal parity groups into 0, 1, 2, 3 and ≥4. Of 1273 women, 1143 (90%) were vaginally parous with average vaginal parity of 2 (1-8). Average age was 54.4 (17- 89) years, while average body mass index (BMI) was 29.4 (14.7-67.8) kg/m2. Anal incontinence was reported in 186 women (15%) with an average St. Mark's incontinence score (SMIS) of 12(1-23). In our study, 148 (12%) women were diagnosed with significant EAS defects. On univariate analysis, there was no significant difference in the prevalence of sphincter trauma in vaginally primiparous and multiparous women (p=0.460) (table 1). There is no significant difference in the prevalence of sphincter trauma between vaginally primiparous and multiparous women. This argues against an additional traumatic effect of subsequent vaginal births after a first vaginal delivery and is consistent with similar data obtained for levator trauma.

P07.05: Prevalence of levator trauma and delivery mode

P07.05: Prevalence of levator trauma and delivery mode

Avulsion of the Levator Ani at First Pregnancy

Objective: To investigate whether demographic and obstetric risk factors are associated with avulsion of the levator ani at first pregnancy.&#x0D; &#x0D; Methods: A series of case was undertaken on 4 pregnant nulliparous women seen with a gestational age of more than 37 weeks. We analyzed with 3D/4D translabial ultrasound and digital assessment data of 4 women seen in a tertiary Urogynecological clinic. The use of 3D/4D ultrasound as a means of detection of trauma to the&#x0D; levator ani.&#x0D; &#x0D; Result: We had 4 women who had levator ani avulsion. Diagnosis of levator trauma (avulsion) on tomographic ultrasound was correlated with predelivery demographic variables and ultrasound parameters.&#x0D; &#x0D; Conclusion: With a greater understanding on the function of pelvic floor muscles, risk factors for trauma and damage as a result of pregnancy and birth, healthcare professionals will have better ability to meet the needs of women in the childbearing year. This study utilized&#x0D; a scoring system that can be used to predict the occurrence of levator ani muscle damage. In the end, the decline in quality of life for women, especially after a birth, can be prevented.&#x0D; &#x0D; [Indones J Obstet Gynecol 2013; 37-1: 51-6]&#x0D; &#x0D; Keywords: 3D/4D translabial ultrasound, demographic, levator ani avulsion, obstetric risk factors

Maternal birth trauma: why should it matter to urogynaecologists?

There is increasing awareness of the importance of intrapartum events for future pelvic floor morbidity in women. In this review, we summarize recent evidence and potential consequences for clinical practice. Both epidemiological evidence and data from perinatal imaging studies have greatly improved our understanding of the link between childbirth and later morbidity. The main consequences of traumatic childbirth are pelvic organ prolapse (POP) and anal incontinence. In both instances the primary etiological pathways have been identified: levator trauma in the case of POP and anal sphincter tears in the case of anal incontinence. As most such trauma is occult, imaging is required for diagnosis. Childbirth-related major maternal trauma is much more common than generally assumed, and it is the primary etiological factor in POP and anal incontinence. Both sphincter and levator trauma can now be identified on imaging. This is crucial not only for clinical care and audit, but also for research. Postnatally diagnosed trauma can serve as intermediate outcome measure in intervention trials, opening up multiple opportunities for clinical research aimed at primary and secondary prevention.

EP31.02: Is there an association between diastasis rectus abdominis (DRA) and levator trauma in primiparous women after traumatic labour?

EP31.02: Is there an association between diastasis rectus abdominis (<scp>DRA</scp>) and levator trauma in primiparous women after traumatic labour?

Postpartum pelvic therapy and sexual function.

Postpartum women are often distressed by changes that happen to their bodies after delivery, especially if these changes persist past what they perceive as an acceptable recovery time. There is the desire to ‘have my body back’ as part of a fulfilling quality of life. Women having children now are less likely to accept symptoms like incontinence of urine or faeces, vaginal wind, or sexual dysfunction than women of past generations. Because surgery is often not the answer for a woman considering future childbearing, pelvic floor physical therapy (PFPT) has been posited as a solution. Strong radiological data have determined that musculoskeletal trauma results from vaginal delivery. It is a logical extrapolation from the sports and rehabilitation literature that this trauma should respond well to physical therapy. The authors of this secondary analysis of a randomised controlled trial investigate female sexual dysfunction (FSD) in primiparous women having a term singleton delivery without major tears. FSD is an under-studied area that is now receiving greater scientific attention, paralleling population interest in this important arena of a woman's life. The positive effects of PFPT for urinary incontinence, at least in the short term, are better known, but few trials have looked at FSD. For the whole cohort, the authors did not see a difference, which is common in studies concerning physical therapy. Most women (88%) were able to happily resume intercourse with few complaints in either group. As a secondary analysis, this trial is not powered for this outcome and is probably hampered by small numbers. PFPT is not a ‘one size fits all’ treatment, and can be difficult to study objectively; sexual function is also a highly subjective concept with few robust, validated measures in this population, as the authors mention. But as with any novel area of study, this trial could help to power and design future work. Most interestingly, the authors report on a subgroup of women diagnosed using ultrasound with levator trauma from their deliveries, and in this most at-risk group, PFPT was beneficial at reducing the sensation of vaginal laxity. As this is a particularly vexing complaint after a ‘normal’ delivery, this finding carries strong potential. Work at other centres is focusing on levator trauma and pelvic floor complaints. Focusing rehabilitation resources on these women immediately after injury is logically the most efficient course. Like many other PFPT studies, heterogeneity of the intervention and then outcome quantification are limiting factors. The authors here mention these difficulties in establishing power. A Cochrane review of peripartum physical therapy was sharply limited by this problem, precluding meta-analysis (Boyle et al. Neurourol Urodyn 2014;33:269–76). In this review, continent women showed some benefit from PFPT, staying continent after delivery. But the authors concluded that the variety of PFPT options combined with the variety of needs with which postpartum women present precluded a universal answer. This study, particularly with the results in women specifically with levator injury, may provide an evidence-based focus of therapy and, hence, its best utility. None declared. Completed disclosure of interests form available to view online as supporting Information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Perineal and vaginal tears are clinical markers for occult levator ani trauma: a retrospective observational study.

Levator avulsion has been shown to be associated with anterior and central compartment prolapse and is a risk factor for prolapse recurrence. Diagnosis in the delivery room is usually impossible, as levator avulsion is commonly occult. The objective of this study was to determine if vaginal and major perineal tears are clinical markers of levator trauma as diagnosed by four-dimensional (4D) translabial ultrasound 3-6 months postpartum. This was a retrospective observational study using data obtained in two perinatal trials. A total of 774 women seen, on average, 5 (range, 2.3-22.4) months after their first delivery of a term singleton cephalic baby underwent a standardized interview, clinical assessment and 4D translabial ultrasound examination. Clinical data were obtained from the institutional obstetric database, including information on vaginal and perineal tears. Levator avulsion was diagnosed using tomographic ultrasound, with operators blinded to the clinical data. Both third- and fourth-degree perineal tears and vaginal sidewall tears were independently associated with levator avulsion (P = 0.004 and P = 0.012, respectively). The odds ratio for avulsion in women suffering from such overt trauma was 3.44 (95% CI, 1.47-8.03) for third-/fourth-degree perineal tears and 3.35 (95% CI, 1.30-8.61) for vaginal sidewall tears. Vaginal sidewall and third-/fourth-degree perineal tears were found to be independent clinical indicators of an increased risk of levator trauma, as diagnosed by 4D translabial ultrasound 3-6 months postpartum. Such clinical markers may become useful in the identification of women at high risk of levator trauma and future pelvic floor disorders.

Postpartum levator ani muscle injuries. Diagnosis and treatment

Levator ani muscle (LAM) injuries are much more frequent than trauma to sphincter ani muscles, but so far they have been omitted in obstetric handbooks. Levator ani avulsion is observed only after vaginal delivery. Forceps delivery second stage of labor ≥ 110 min., fetal head circumference ≥ 35 cm, episiotomy and coincidence of anal sphincter trauma are risk factors for levator ani avulsion. The most vital issue in that type of trauma is pelvic organ prolapse and 2-4-fold higher risk of recurrence after prolapse surgery. The current level of evidence does not allow to conclusively determine the of role of levator avulsion in urinary incontinence. Levator injuries are occult, what constitutes the main diagnostic problem. Until recently magnetic resonance imaging has been the only diagnostic method until the development of 3-dimensional ultrasound. Nowadays, 3-D ultrasound is an essential technique in static and functional diagnosis of the levator ani. There are no effective methods of levator trauma prevention. Except the risk factors reduction, there are some pilot data about positive role of antepartal perineal muscle training. Physiotherapy plays the main role in reducing the effects of levator trauma. Mesh techniques are the most effective operative methods in coincident pelvic organ prolapse with levator avulsion, but there is still a 2-fold higher risk of recurrence.

Can we identify changes in fascial paravaginal supports after childbirth?

Defects of anterior vaginal wall fascia are generally assumed to be factors in the aetiology of cystocele. However, to date, there is very little information on diagnosis by imaging. To document the appearance of vaginal fornices before and after childbirth using 4D ultrasound volume data sets as an aid in diagnosing paravaginal defects of the anterior vaginal wall. This study was performed by re-analysing data sets obtained in a previously published study involving ante- and postpartum pelvic floor assessment by ultrasound. Two hundred and two nulliparous women had been seen at a mean gestation of 37.2weeks at two tertiary hospitals. One hundred and sixty-three returned 3months postpartum. All the participants underwent an interview and 4D translabial ultrasound at both antepartum and postpartum appointments. The integrity of vaginal fornices and levator ani was assessed by tomographic ultrasound. Vaginal fornices were assessed in both ante- and postnatal volumes, and loss of forniceal tenting was found in 85 patients (52%). On average, seven slices were affected (range, 1-16). On multivariate analysis, controlling for potential confounders, including partial/complete avulsion, loss of forniceal tenting remained independently associated with increased cystocele descent (P=0.005). Vaginal childbirth is associated with loss of tenting of the vaginal fornices, independent of levator trauma, and also with impaired anterior vaginal wall support. This evidence suggests the existence of paravaginal defects and may imply a role for such defects in the causation of anterior vaginal wall prolapse.