Ultrasound Obstet Gynecol 2012; 39: 367–371
Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.11141
Opinion
Clinical consequences of levator trauma
Overview
The last decade has seen substantial progress in the field
of pelvic floor medicine. Nowhere is this more obvious
than in the diagnosis and treatment of female pelvic organ
prolapse. Most practitioners in female urology and urogy-
necology would identify this progress mainly through the
introduction of a succession of new surgical procedures.
These procedures are backed by commercial interests and
often lack proper outcome data. We don’t understand
how they work, or how and why they may fail. There is
a widespread lack of understanding of the pathophysiol-
ogy of female pelvic organ prolapse. However, this last
decade has also brought substantial progress in diagnos-
tics, with a concomitant boost in clinical research into
the etiology of pelvic floor disorders. In fact, imaging spe-
cialists have been at the forefront of recent developments,
and the White Journal has been one of the main sources
of new, original research undertaken in this field. Three-
dimensional (3D) and 4D ultrasound have been crucial for
a better understanding of the pelvic floor. Modern imag-
ing techniques are teaching us how to use our own senses,
both vision and palpation, more effectively, and to diag-
nose abnormalities that were entirely unknown 10 years
ago. In this Opinion I will summarize the current sta-
tus regarding the clinical and imaging diagnosis of pelvic
floor muscle impairment, outline its clinical relevance, and
develop perspectives for clinical research and patient care.
Introduction
Dr Schwertner-Tiepelmann and colleagues have provided
a timely and comprehensive overview of the current status
Figure 1 Right-sided levator avulsion after normal vaginal delivery at term as seen in delivery suite (a), on translabial ultrasound (b) and on
magnetic resonance imaging 3 months later (c). Reprinted with permission from Dietz45 .
Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
of delivery-related levator ani trauma in this issue of
Ultrasound in Obstetrics & Gynecology1 . Over the last
decade it has become clear that, apart from anal sphincter
trauma, there is another form of maternal trauma that is
more common and probably of greater long-term clinical
significance. In 10–30% of all women having a normal
vaginal delivery, the puborectalis muscle is traumatically
disconnected from its insertion on the inferior ramus and
body of the os pubis2 (‘avulsion’), resulting in a defect that
can occasionally be seen in the delivery suite3 (Figure 1),
that can be palpated4 and that can be demonstrated
with magnetic resonance imaging (MRI)5 and ultrasound,
both two-dimensional6 and 3D/4D7 translabial tech-
niques (Figure 2). Avulsion injury to the levator ani seems
to be the main etiological link between childbirth and
female pelvic organ prolapse. This condition is common
and much more likely to result in surgical intervention
than fecal incontinence, with a lifetime risk of surgery
of 10–20%8,9 . While anal sphincter trauma has enjoyed
much clinical and research attention for the last 20 years,
this is not the case for levator trauma. This is likely due
to the fact that such trauma is mostly occult, and only
occasionally is it evident in the delivery suite3 , although
common sense should have made it clear long ago that
vaginal childbirth must inevitably be associated with a
degree of distension of the puborectalis muscle in excess
of the level that skeletal muscle is designed to withstand10 .
The first case diagnosed immediately after childbirth
was only published in 20073 , and the entire topic is so far
absent from obstetrics and midwifery textbooks. While
the first mention of levator trauma in the world literature
dates back to 194311 , the realization that abnormali-
ties detected on postnatal pelvic floor imaging are due
OPINION
368
Figure 2 Right-sided levator avulsion on tomographic pelvic floor imaging. The defect is visible on the left (*) in all eight axial slices
(2.5-mm interslice interval).
to actual tears is less than 10 years old12,13 . The first
series comparing antenatal and postnatal imaging was
published in 200514 , and the main consequence of such
defects, prolapse of the anterior and central compart-
ments, has been known since 200615,16 . It is only 2 years
since levator trauma was identified as a major risk fac-
tor for prolapse recurrence17 (Table 1), a finding that
has since been confirmed by four other studies18 – 21 . In
addition, we now suspect that damage to the levator ani
does not just include macroscopically visible tears. There
is also irreversible overdistension of the levator hiatus,
which seems to affect more women than does avulsion22
(Figure 3). Excessive distensibility (‘ballooning’) of the
levator hiatus, the largest potential hernial portal in the
human body, is associated with prolapse23 , and this effect
seems to be independent of levator avulsion24 . In fact,
ballooning also seems to be an independent risk factor for
prolapse recurrence (own unpubl. data).
Obstetrics
The first area to be impacted by these findings should of
course be clinical obstetrics. It seems impossible to predict
avulsion sufficiently accurately to make elective Cesarean
delivery an attractive proposition, especially given the
inevitable political resistance to such a concept25 . How-
ever, a number of ante- and intrapartum risk factors for
levator trauma and irreversible overdistension of the lev-
ator hiatus have been described. Higher maternal age5,14 ,
forceps delivery5,22,26,27 , especially rotational forceps28 ,
the length of the second stage of labor5,22,29 and head
circumference29 have been identified as risk factors, while
elevated maternal body mass index (BMI) and epidural
use may be protective22 .
Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
Dietz
Table 1 Relative risks for recurrence of significant cystocele in
women with avulsion, determined using clinical and sonographic
examinations
Relative risk (95% CI)
Clinical cystocele Cystocele to
Stage 2+ ≥ 10 mm below
ICS POP-Q symphysis on US
No avulsion (n = 54) 1 1
Unilateral avulsion (n = 17) 2.9 (1.7–4.4) 3.8 (2.1–5.5)
Bilateral avulsion (n = 12) 2.8 (1.4–4.3) 4.1 (2.2–5.4)
Reproduced from Dietz et al.17 . Average follow-up was 4.5 years.
ICS POP-Q, prolapse quantification system of the International
Continence Society by clinical examination44 ; US, translabial
ultrasound.
These findings have implications for clinical obstetrics.
Rotational forceps can safely be considered obsolete now,
and non-rotational forceps should be limited to emergency
situations. A trial of forceps in theater prior to a Cesarean
section for failure to progress seems highly inappropri-
ate, since there are anecdotal reports of levator avulsion
after attempted forceps delivery that ended as emergency
Cesarean section. A trial of forceps risks leaving the par-
turient with the worst of both worlds – the Cesarean scar
on her uterus and abdomen and a torn pelvic floor. Vac-
uum, on the other hand, does not seem to convey any
additional risk22 – which is plausible, since it does not
add to the maximal muscle stretch required.
In addition, the current state of our knowledge argues
against excessively long second stages of labor and poten-
tially in favor of epidural analgesia. It is not clear what
mediates the latter effect, but it is plausible that epidural
Ultrasound Obstet Gynecol 2012; 39: 367–371.
Opinion
Figure 3 Irreversible overdistension of the levator hiatus after vaginal childbirth: the hiatus on maximal Valsalva at 38 weeks (a) and
3 months postpartum (b).
may at times result in partial or even complete paralysis
of the levator ani muscle, and a paralyzed muscle is
likely to stretch better and tear less30 . The current trend
towards more shallow epidurals that avoid any kind of
motor block may turn out to be counterproductive. Future
research should include intervention trials that examine
the effect of motor blockade on the pelvic floor during
parturition.
The inexorably rising Cesarean section rate worldwide
has resulted in increasing pressure from administrators
and natural childbirth advocates to change obstetric man-
agement in a direction that maximises the likelihood of
vaginal delivery. In Australia and New Zealand, this is
anecdotally evident in longer second stages, more aggres-
sive use of Syntocinon (oxytocin), a bias against epidural
pain relief and increasing use of trial of forceps. Cesarean
section numbers are becoming the primary quality indi-
cator for obstetric services31 , which is a deeply worrying
trend and likely to increase the incidence of pelvic floor
trauma. Even worse, research that would test interven-
tions in contradiction to this philosophy is becoming
difficult or impossible to perform in the challenging envi-
ronment of the delivery suite.
Antenatal intervention may hold more promise. It seems
theoretically possible to change the biomechanics of pelvic
floor structures in an attempt to reduce the likelihood of
structural failure during crowning, and there is a com-
mercially available device, the EpiNo, which has shown
promise in a pilot randomized controlled trial32 . It may
also be possible to extend the period of perineal and
hiatal dilatation by utilizing the first stage of labor, but
any such attempt would be associated with major logis-
tic problems and would very likely require effective pain
relief.
Increasingly, levator trauma will be diagnosed intra-
partum, in women in whom a large vaginal tear exposes
the disconnected muscle and its insertion on the inferior
Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
369
pubic ramus (Figure 1). Initial attempts at repair have been
disappointing3 , and our experience with interval avulsion
repairs33 suggests that the macroscopic tear itself is only
part, and possibly not even the most substantial or com-
mon part, of the damage done in childbirth. For the time
being, it remains to be shown that such reconstruction
of a disconnected puborectalis muscle can be performed
successfully after childbirth, let alone result in positive
effects on subjective or objective outcome measures.
More and more levator trauma is diagnosed postpar-
tum, especially in women after overtly traumatic child-
birth. There are many obstetric units that follow up third-
and fourth-degree perineal trauma, and levator avulsion
is rather common in this group of women34 . It is not clear
what advice we should give women who have suffered
major levator trauma in addition to anal sphincter tears,
but surely these women deserve our special attention and
should be encouraged to continue indefinitely with pelvic
floor muscle exercises. Levator trauma on its own should
probably not influence decisions regarding future delivery
mode, since most of the damage seems to occur with a
first vaginal delivery. Second births in women after levator
trauma seem unlikely to do much additional harm unless
they involve forceps35 , but research into the effect of a
second pregnancy and delivery is ongoing.
Gynecology
The consequences of recent research on pelvic floor
trauma should be particularly valuable to urogynecolo-
gists, especially in view of the increasingly strident debate
on mesh use in pelvic surgery. In a recent opinion piece36 ,
adversaries of mesh use predicted the ‘perfect storm’ of
medicolegal consequences, and there seem to be two firmly
opposed camps – users and non-users. It seems to escape
most colleagues that the solution may lie somewhere in
between with correct patient selection, as for most surgical
Ultrasound Obstet Gynecol 2012; 39: 367–371.
370
procedures. Even a recent US Food and Drug Adminis-
tration report37 completely ignores the issue of patient
selection.
Recurrence after anterior compartment prolapse repair
is common, and up to one third of all procedures are
performed because of failed previous surgery9 . It is not
surprising, therefore, that there has been an ongoing
search for surgical innovation that could deliver higher
success rates. Anterior compartment meshes seem able to
do that38 , although recurrence rates in some subgroups
of patients remain unacceptably high19 , and although
there are substantial downsides to mesh use, including
mesh erosion and chronic pain syndromes which can be
difficult, if not impossible, to treat39 .
It may be prudent to limit the use of mesh to women
at high risk of recurrence, especially in view of the sig-
nificant medicolegal risks involved. Several studies have
investigated risk factors for recurrence, and younger age40 ,
a family history of prolapse21 , a larger prolapse21,40 – 42 ,
poor pelvic floor muscle contractility43 , previous hysterec-
tomy, BMI41 , previous prolapse surgery, a larger genital
hiatus43 , levator avulsion17,18,21 and hiatal ballooning
(own unpubl. data) all seem to be associated with recur-
rence. In a study on 83 women on average 4.5 years after
traditional anterior colporrhaphy, we found an overall
recurrence rate (stage 2+ anterior compartment pro-
lapse) of 40% and a relative risk of 2.9 in women with
avulsion17 . Weemhoff et al.21 found an odds ratio of 2.4
for recurrence in 156 women seen on average 31 months
after anterior colporrhaphy, with an overall recurrence
rate of 51%. Other risk factors were advanced preopera-
tive stage, a family history of prolapse and sacrospinous
fixation. The impact of levator avulsion has been con-
firmed with MRI: Morgan et al.20 reported a series of 83
women 6 weeks after vaginal prolapse surgery and found
poorer support in those with avulsion. This predictive
effect of avulsion on prolapse recurrence seems to hold
true even in women after anterior compartment mesh pro-
cedures, as Wong et al. showed in a series of 219 women
on average 2.1 years after anterior Prolift or Perigee mesh
placement19 . My group’s unpublished modeling of recur-
rence risk after 2.5 years based on 334 women yielded
risk projections of between 12% and 95% for different
patients with the same degree of cystocele, based only on
avulsion and hiatal ballooning.
It seems that information on the state of the pelvic
floor can help select women at high risk of prolapse
recurrence. Imaging, especially modern 4D pelvic floor
ultrasound, can contribute substantially to patient selec-
tion by diagnosing levator avulsion and excessive hiatal
distensibility or ballooning. In view of the acrimonious
discussion regarding mesh use and the increasing medi-
colegal relevance of mesh complications, it seems prudent
to limit mesh use to the anterior compartment, and to
patients at high risk of prolapse recurrence, at least for
the time being. Future research will hopefully allow us
to estimate more accurately the likelihood of recurrence
in an individual patient, so that informed consent can be
undertaken based on individualized data.
Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
Dietz
There are other consequences for urogynecology. Mod-
ern pelvic floor imaging opens up a new, promising field
for clinical research into all forms of pelvic floor dysfunc-
tion. While it is likely that a defective or dysfunctional
levator ani would affect the outcome of conservative
management with pelvic floor muscle exercises and/or
vaginal pessaries, there is no published research to date. As
regards stress urinary incontinence and fecal incontinence,
the available data are contradictory and require further
research, as suggested by Schwertner-Tiepelmann et al.1 .
The one conclusion of their review with which I disagree
is the contention that further comparative studies between
MRI and translabial ultrasound are needed before we can
identify high-risk groups and consider preventative strate-
gies. I suggest that we do not need to establish consensus
regarding different imaging modalities and methodolo-
gies, and to require such a precondition would massively
slow down progress. Research progresses along Dar-
winian lines: the method best suited to clinical practice
eventually wins through. This is clearly evident in the
diagnosis of pelvic floor trauma, on which MRI papers
are now a small minority compared with pelvic floor ultra-
sound, and for which I believe tomographic ultrasound
imaging7 has become the de facto standard (see Figure 2).
The optimal diagnostic algorithms will be evident from
the current literature and will keep changing over time.
There is nothing wrong with that. In fact, I sincerely hope
that we’ll be doing things differently, and hopefully better,
in the future.
H. P. Dietz
Sydney Medical School Nepean, Nepean Hospital,
Penrith, NSW, 2750, Australia
(e-mail: hpdietz@bigpond.com.au)
Conflict of interest
H. P. Dietz has acted as a consultant for AMS, CCS and
Materna, has accepted Speaker’s fees from GE, AMS and
Astellas and has benefited from equipment loans provided
by GE, Bruel and Kjaer and Toshiba.
REFERENCES
1. Schwertner-Tiepelmann N, Thakar R, Sultan AH, Tunn R.
Obstetric levator ani muscle injuries : current status. Ultrasound
Obstet Gynecol 2012; 39: 372–383.
2. Dietz HP. Pelvic floor assessment: a review. Fetal Matern Med
Rev 2009; 20: 49–66.
3. Dietz H, Gillespie A, Phadke P. Avulsion of the pubovisceral
muscle associated with large vaginal tear after normal vaginal
delivery at term. Aust N Z J Obstet Gynaecol 2007; 47:
341–344.
4. Dietz HP, Shek KL. Validity and reproducibility of the digital
detection of levator trauma. Int Urogynecol J 2008; 19:
1097–1101.
5. Kearney R, Miller J, Ashton-Miller J, Delancey J. Obstetric
factors associated with levator ani muscle injury after vaginal
birth. Obstet Gynecol 2006; 107: 144–149.
6. Dietz HP, Shek KL. Levator trauma can be diagnosed by 2D
translabial ultrasound. Int Urogynecol J 2009; 20: 807–811.
Ultrasound Obstet Gynecol 2012; 39: 367–371.
Opinion
7. 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: 699–704.
8. Smith F, Holman D, Moorin R, Tsokos N. Lifetime risk of
undergoing surgery for pelvic organ prolapse. Obstet Gynecol
2010; 116: 1096–1100.
9. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL.
Epidemiology of surgically managed pelvic organ prolapse and
urinary incontinence. Obstet Gynecol 1997; 89: 501–506.
10. Svabik K, Shek K, Dietz H. How much does the levator hiatus
have to stretch during childbirth? Br J Obstet Gynaecol 2009;
116: 1657–1662.
11. Gainey HL. Post-partum observation of pelvic tissue damage.
Am J Obstet Gynecol 1943; 46: 457–466.
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: 46–53.
13. Dietz H. Ultrasound imaging of the pelvic floor: 3D aspects.
Ultrasound Obstet Gynecol 2004; 23: 615–625.
14. Dietz H, Lanzarone V. Levator trauma after vaginal delivery.
Obstet Gynecol 2005; 106: 707–712.
15. Dietz HP, Steensma AB. The prevalence of major abnormalities
of the levator ani in urogynaecological patients. BJOG 2006;
113: 225–230.
16. DeLancey J, Morgan D, Fenner D, Kearney R, Guire K,
Miller JM, Hussain H, Umek W, Hsu Y, Ashton-Miller JA.
Comparison of levator ani muscle defects and function in
women with and without pelvic organ prolapse. Obstet Gynecol
2007; 109: 295–302.
17. Dietz HP, Chantarasorn V, Shek KL. Levator avulsion is a risk
factor for cystocele recurrence. Ultrasound Obstet Gynecol
2010; 36: 76–80.
18. Model A, Shek KL, Dietz HP. Levator defects are associated
with prolapse after pelvic floor surgery. Eur J Obstet Gynecol
Reprod Biol 2010; 153: 220–223.
19. Wong V, Shek K, Goh J, Rane A, Dietz HP. Is levator avul-
sion a predictor for cystocele recurrence following anterior
compartment mesh? Neurourol Urodyn 2011; 30: 879–880.
20. Morgan D, Larson K, Lewicky-Gaupp C, Fenner D, DeLancey
J. Vaginal support as determined by levator ani defect status
6 weeks after primary surgery for pelvic organ prolapse. Int J
Gynaecol Obstet 2011; 114: 141–144.
21. Weemhoff M, Vergeldt T, Notten K, Serroyen J, Kampschoer P,
Roumen F. Avulsion of puborectalis muscle and other risk
factors for cystocele recurrence: a 2-year follow-up study. Int
Urogynecol J 2011; DOI: 10.1007/s00192-011-1524-y.
22. Shek K, Dietz H. Intrapartum risk factors of levator trauma.
BJOG 2010; 117: 1485–1492.
23. Dietz H, De Leon J, Shek K. Ballooning of the levator hiatus.
Ultrasound Obstet Gynecol 2008; 31: 676–680.
24. Dietz H, Franco A, Shek K, Kirby A. Avulsion injury and levator
hiatal ballooning: two independent risk factors for prolapse?
An observational study. Acta Obstet Gynecol Scand 2012; 91:
211–214.
25. Shek K, Chantarasorn V, Dietz H. Can levator avulsion be
predicted antenatally? Am J Obstet Gynecol 2010; 202:
586.e1–6.
26. Cassado Garriga J, Pessarodona Isern A, Espuna Pons M, Duran
Retamal M, Felgueroso Fabregas A, Rodriguez-Carballeira M.
Tridimensional sonographic anatomical changes on pelvic floor
muscle according to the type of delivery. Int Urogynecol J 2011;
22: 1011–1018.
27. Chan S, Cheung R, Yiu A, Loreta LL Lee, Albe WL Pang,
Choy KW, Leung TY and Tony KH Chung. Prevalence of
Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
371
levator ani muscle injury in Chinese primiparous women
after first delivery. Ultrasound Obstet Gynecol 2011; DOI:
10.1002/uog.10132.
28. Krofta L, Otcenasek M, Kasikova E, Feyereisl J. Pubococcygeus-
puborec talis trauma after forceps delivery: evaluation of the
levator ani muscle with 3D/4D ultrasound. Int Urogynecol J
2009; 20: 1175–1181.
29. Valsky DV, Lipschuetz M, Bord A, Eldar I, Messing B,
Hochner-Celnikier D, Lavy Y, Cohen SM, Yagel S. Fetal
head circumference and length of second stage of labor are
risk factors for levator ani muscle injury, diagnosed by 3-
dimensional transperineal ultrasound in primiparous women.
Am J Obstet Gynecol 2009; 201: 91.e1–7.
30. Brooks S, Zerba E, Faulkner J. Injury to muscle fibres after
single stretches of passive and maximally stimulated muscle in
mice. J Physiol 1995; 488: 459–469.
31. Trivedi A, Singh R. Is the Caesarean Section rate really a
performance indicator of an obstetric unit? J Maternofetal
Neonatal Med 2011.
32. Shek K, Chantarasorn V, Langer S, Phipps H, Dietz H. Does
the Epi-No birth trainer reduce levator trauma? A randomised
controlled trial. Int Urogynecol J 2011; 22: 1521–1528.
33. Dietz H, Shek K, Korda A. Can levator avulsion be corrected
surgically? Neurourol Urodyn 2011; 30: 877–879.
34. Eisenberg V, Brecher S, Yodfat I, Bitman G, Achiron R,
Schiff E, Alcalay M. OC29.04: Risk factors for levator avul-
sion trauma in women with obstetric anal sphincter injuries.
Ultrasound Obstet Gynecol 2011; 38: 52.
35. Dietz H, Kirby A. Modelling the likelihood of levator avulsion
in a urogynaecological population. Aust N Z J Obstet Gynaecol
2010; 50: 268–272.
36. Brubaker L, Shull B. A perfect storm. Int Urogynecol J 2012;
23: 3–4.
37. FDA Safety Communication: Update on serious complica-
tions associated with transvaginal placement of surgical mesh
for pelvic organ prolapse, 2011 (vol 2012). http://www.
fda.gov/medicaldevices/safety/alertsandnotices/ucm262435.htm
38. Altman D, Väyrynen T, Ellström Engh M, Axelsen S, Fal-
coner C. Anterior colporrhaphy versus transvaginal mesh for
pelvic-organ prolapse. N Engl J Med 2011; 364: 1826–1836.
39. Maher C, Feiner B, Baessler K, Adams EJ, Hagen S, Glazener C.
Surgical management of pelvic organ prolapse in women.
Cochrane Database Syst Rev 2010; Apr 14; (4): CD004014.
Review.
40. Whiteside J, Weber A, Meyn L, Walters MD. Risk factors for
prolapse recurrence after vaginal repair. Am J Obstet Gynecol
2004; 191: 1533–1538.
41. Diez-Itza I, Aizpitarte I, Becerro A. Risk factors for the
recurrence of pelvic organ prolapse after vaginal surgery: a
review at 5 years after surgery. Int Urogynecol J 2007; 18:
1317–1324.
42. Jeon M, Chung S, Jung H, Kim S, Bai S. Risk factors for the
recurrence of pelvic organ prolapse. Gynecol Obstet Invest
2008; 66: 268–273.
43. Vakili B, Zheng Y, Loesch H, Echols K, Franco N, Chesson RR.
Levator contraction strength and genital hiatus as risk factors
for recurrent pelvic organ prolapse. Am J Obstet Gynecol 2005;
192: 1592–1598.
44. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO,
Klarskov P, Shull BL, Smith AR. The standardization of
terminology of female pelvic organ prolapse and pelvic floor
dysfunction. Am J Obstet Gynecol 1996; 175: 10–17.
45. Dietz HP. Pelvic floor ultrasound. ASUM Ultrasound Bulletin
2007; 10: 17–23.
Ultrasound Obstet Gynecol 2012; 39: 367–371.