Fetal and Maternal Medicine Review 2009; 20:1 4966 C 2009 Cambridge University Press doi:10.

1017/S096553950900237X First published online 17 March 2009

PELVIC FLOOR ASSESSMENT

HANS PETER DIETZ
Nepean Clinical School, University of Sydney, Penrith, Australia

INTRODUCTION The topic of pelvic oor assessment is increasingly attracting attention from gynaecologists, colorectal surgeons, urologists and physiotherapists. This is not surprising, many women who have given birth naturally are affected by pelvic oor trauma, and so are their partners. Health professionals deal with the eventual consequences of such trauma, especially pelvic organ prolapse and faecal incontinence. Until recently pelvic oor trauma meant perineal and vaginal tears, and damage to the anal sphincter. In developing countries especially, pelvic oor trauma also includes vesicovaginal, urethrovaginal and rectovaginal stulae, but these are uncommon in developed countries with good intrapartum care. Anal sphincter trauma has received much attention over the last 20 years and will not be dealt with here. We now know that pelvic oor trauma also affects the levator muscle. In 15 30% of all women who have given birth normally there is serious damage to the puborectalis component of the levator ani muscle.13 This is a very recent discovery and has not yet found its way into most textbooks. The levator ani is a muscular plate surrounding a central v-shaped hiatus, forming the caudal part of the abdominal envelope. As such, it encloses the largest potential hernial portal in the human body, the levator hiatus, containing the urethra, vagina, and anorectum. Its peculiar shape and function is a compromise between priorities that are virtually impossible to reconcile. On the one hand, abdominal contents have to be secured against gravity, on the other hand solid and liquid wastes have to be evacuated. In addition, and most importantly, there are the requirements of reproduction: intercourse and childbirth. The latter is the most extreme of tasks required of the pelvic oor, in particular in view of the size of the babys head. There are other mammalian species in whom giving birth is fraught with danger, but homo sapiens ranks near the top of the list when it comes to the hazards of reproduction. The levator ani is thought to consist of several major subdivisions, and there is considerable confusion in the literature as regards nomenclature and distinctions between pubococcygeus, pubovaginalis, puboperinealis, puborectalis and iliococcygeus muscles. Since these muscles cannot currently be distinguished easily,
Hans Peter Dietz, Professor in Obstetrics and Gynaecology, Nepean Clinical School, University of Sydney, Nepean Hospital, Penrith NSW 2750 Australia.

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Figure 1 Intact puborectalis muscle in a fresh cadaver. The vulva, mons pubis, clitoris, perineal muscles and perineum to the anus, as well as peri- and postanal skin and some of the brofatty tissue of the ischiorectal fossa have been removed to allow access to the puborectalis muscle.

neither clinically nor on ultrasound or magnetic resonance imaging or even cadaver dissection, the author considers only the puborectalis muscle (as the v-shaped muscle originating on the os pubis/the inferior pubic ramus and surrounding the anorectal angle posteriorly) and the pubococcygeus/iliococcygeus muscle. The latter is a sheet of muscle that acts as a continuation of the puborectalis cranially and laterally. While the bre direction is different from the puborectalis (from ventromedial to dorsolateral rather than almost ventrodorsal as for the puborectalis), on vaginal palpation the pubococcygeus/ iliococcygeus is palpable as a continuation of the puborectalis above the inferior pubic ramus in the lateral vagina, extending from the pelvic sidewall to the ischial spine and the coccyx. Figure 1 shows a fresh cadaver dissection of the levator ani muscle, with the puborectalis forming a V shaped structure about as thick as a 5th nger, anchored to the inferior pubic ramus and the body of the os pubis ventrally. This dissection approach demonstrates the muscle as seen from below or caudally. The left side of the image is the patients right side, the symphysis pubis is at the top. Figure 2 demonstrates the appearance of the puborectalis on 3D pelvic oor ultrasound, in a rendered volume ie, a semitransparent representation of volume data. The arrows indicate the gap between muscle insertion and urethra which is important for palpation.

THE PELVIC FLOOR IN CHILDBIRTH The levator ani muscle plays a major role in childbirth. It has to distend enormously, and the degree of required distension varies greatly between individuals, by at least

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Figure 2 The appearance of the puborectalis muscle in a rendered volume in the axial plane, using translabial 3D ultrasound with speckle reduction imaging (SRI). The two arrows indicate the gap between urethra and puborectalis insertion that can conveniently be palpated to determine muscle integrity.

a factor of 5.4,5 It is generally assumed that skeletal muscle will not stretch to more than twice its length without tearing. It is remarkable that in many women the puborectalis does not suffer any signicant trauma despite much greater degrees of distension. In about half of all women there is no appreciable change in distensibility or morphological appearance after vaginal delivery. It is not understood how this is possible, but we assume that it is somehow due to protective hormonal effects of pregnancy. It is not difcult to appreciate that the biomechanical properties of this muscle might have some effect on the progress of labor: a more elastic muscle seems to be associated with a shorter 2nd stage of labor and possibly also with delivery mode.6,7 Trauma to the puborectalis muscle as a consequence of childbirth was rst reported in 1943, only to be forgotten for 60 years. This major form of maternal birth trauma, easily palpable vaginally and occasionally visible in women with large vaginal tears8 is missing from our obstetric and midwifery textbooks, and has only recently been rediscovered by imaging specialists using magnetic resonance and 3D/4D ultrasound (see Figure 3). Most commonly, appearances are those of an avulsion that is, a traumatic dislodgment of the muscle from its bony insertion. There are other forms of localized or generalized morphological abnormalities, but they are much less common. Appearances are rarely consistent with pudendal neuropathy which in the past was considered the main aetiological factor in pelvic oor dysfunction.9,10

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Figure 3 Right-sided puborectalis avulsion after normal vaginal delivery at term. The left hand image shows appearances immediately postpartum, with the avulsed muscle exposed by a large vaginal tear. The torn muscle is retracted and visible between the gloved ngers at 67 oclock. The middle image shows a rendered volume (axial plane, translabial 3D ultrasound) 3 months postpartum, and the right hand image shows magnetic resonance ndings (single slice in the axial plane) at 3.5 months postpartum. With permission, from: Dietz HP et al.8

DIAGNOSIS BY PALPATION As mentioned, diagnosis of such injuries is possible by palpation, although this requires substantial teaching, and the learning curve seems to be quite long.1114 Until recently, assessment of levator function, if undertaken at all, was limited to grading muscle strength and endurance, using the modied Oxford Grading system rst suggested by Laycock15 (Table 1). Physiotherapists have a long history of using palpation to assess skeletal muscle and some, with appropriate postgraduate training, have extended their skills to include digital assessment of pelvic oor muscle by the vaginal or transanal route. In the physiotherapy literature there are many reports of palpation to assess pelvic oor muscle contraction, and some describe the identication of pain and trigger points, and even evaluation of muscle tone.16

Table 1 Modied Oxford Grading (according to Laycock, L: Assessment and treatment of pelvic oor dysfunction [PhD]. University of Bradford, 1992)15 0: 1: 2: 3: 4: 5: no contraction icker weak moderate (with lift) good (with lift) strong (wift)

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Figure 4 Digital palpation of the puborectalis muscle insertion. The left image shows a normal muscle, the right an avulsion injury. With permission, from: Dietz HP, Shek KL.13

However, although clinical anecdote suggests some physiotherapists recognize other characteristics concerning muscle morphology (e.g. holes, gaps, ridges, scarring), it is difcult to nd any literature describing the techniques needed to do this or their accuracy or repeatability. Mantle17 noted that with training and experience a physiotherapist might be able to discern muscle integrity, scarring, and the width between the medial borders of the pelvic oor muscles by palpation. It is not clear to what extent physiotherapists are able to do this reliably or how such characteristics are to be recorded. In 1943, an obstetrician from Kansas City published the ndings of a palpatory assessment of 1000 women delivered by him personally.18 Gainey described trauma to what he called the pubococcygeus muscle, and from his description it is quite clear that he did detect avulsion injuries of the puborectalis. In fact, the prevalence of such defects quoted by him (about 20% in primiparous women) agrees very well with modern work using MR19 and Pelvic Floor Ultrasound.1,3 Evidently, if it was possible to palpate such trauma in 1943, it should be possible today. Figures 2 and 4 explain how palpatory assessment of the puborectalis muscle may be undertaken. To assess morphological integrity the palpating nger is placed parallel to the urethra, with the tip of the nger at the bladder neck, and its palmar surface pressed against the posterior/dorsal surface of the symphysis pubis. If the muscle is intact then there will be just enough room to t the palpating nger between the urethra medially and the insertion of the puborectalis muscle laterally. If there is no muscle palpable on the posterior surface of the os pubis and the inferior pubic ramus immediately lateral to a nger placed parallel to the urethra, and if this nger can be moved over the inferior pubic ramus without encountering any contractile tissue for another 23 cm, then this implies an avulsion injury on that side. Assessment is helped by asking the patient to perform a petvic oor muscle contraction while palpating the area. The extent of avulsion varies enormously and there are several

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types of incomplete injuries: generalized thinning of the muscle, partial avulsion of the most inferior aspects (with the most cranial aspects of the puborectalis still adhering to the os pubis) and partial avulsion of more cranial aspects, palpable as a hole, slit or gap in the insertion of the superior aspects of the puborectalis, or in the inferior aspects of the pubococcygeus/iliococcygeus muscle. While the importance of such partial trauma is unclear, a complete avulsion detected on palpation is clearly associated with reduced contraction strength of the muscle, as well as with symptoms and signs of prolapse.12,14 Avulsion often seems to have an impact on adjacent or contralateral intact muscle. After unilateral avulsion, the intact contralateral puborectalis may become spastic and very tender, a hitherto unrecognized cause of chronic pelvic pain and dyspareunia. After bilateral avulsion there is marked hypertrophy of the pubococcygeus/iliococcygeus, resulting in a levator shelf that is almost as strong as the original, just somewhat higher and wider. Currently the assessment of levator function by physiotherapists, nurse continence advisors, gynaecologists and urologists is (at best) limited to grading squeeze and lift. We propose a visual recording system for ndings obtained on palpation of the puborectalis muscle (Figure 5). Such a system should include both some form of strength grading for squeeze and lift bilaterally, as well as grading for resting tone (conveniently graded 05 to accord with the Oxford system, see Table 2 for a suggested scale).
Table 2 A proposed scale for the grading of levator resting tone 0: 1: 2: 3: 4: 5: muscle not palpable muscle palpable but very accid, wide hiatus, minimal resistance to distension hiatus wide but some resistance to distension hiatus fairly narrow, fair resistance to palpation but easily distended hiatus narrow, muscle can be distended but high resistance to distension, or pain hiatus very narrow, no distension possible, woody feel, possibly with pain: vaginismus

In addition, one should attempt a morphological assessment of the puborectalis muscle and document ndings either as defects or gaps (outlined and shaded area on the muscle diagram) or thinning (outlined and hatched obliquely). While there is currently no data on the relevance of minor abnormalities that fall short of a complete avulsion, the spectrum of traumatic changes to the puborectalis is very wide. It is likely to receive much more attention in the future, and imaging will be essential in determining the functional consequences of minor trauma. The documentation system proposed in Figure 5 could form the basis of teaching efforts to improve on palpatory assessment skills and allow easier communication amongst clinical practitioners and researchers. Clearly, assessment of the puborectalis muscle by palpation is a skill that requires signicant teaching, most conveniently in a unit that allows for instant comparison with ndings on imaging. Without additional training, agreement between a clinical assessor and imaging is likely to be poor.1113 However, there is no doubt that

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Figure 5 Suggested schematic for the documentation of puborectalis trauma, modied Oxford grading and grading of resting tone. With permission, from: Dietz HP, Shek KL.13

assessment of the puborectalis muscle by palpation is within the capability of any practitioner in the eld. The emerging literature on the clinical relevance of levator defects detected on imaging implies that this skill should be well worth acquiring.

DIAGNOSIS BY ULTRASOUND IMAGING It seems that the diagnosis of levator trauma is more repeatable when undertaken by imaging. While magnetic resonance was the rst method used to assess the levator ani,20 it suffers from a number of obvious shortcomings: cost, accessibility, the inability to use MR in women with ferrous implants, issues with claustrophobia in some women, the lack of dynamic imaging and problems with dening correct planes, since very few currently used systems allow true volume imaging. Most of those shortcomings do not apply to ultrasound, especially not to translabial 3D/4D ultrasound. This method uses technology that was developed for fetal imaging and that is now available in virtually all major obstetrics and gynaecology units in the developed world. While transvaginal ultrasound has been used to image the levator ani,7,21,22 this requires side-ring endoprobes which are not in general use and rarely found in obstetrics and gynaecology imaging departments.

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Figure 6 Typical right- sided avulsion injury in a rendered volume, axial plane. It is evident that the pelvic sidewall is blank, i.e., that the morphological abnormality documented here is an avulsion of the puborectalis muscle insertion.

The diagnosis of levator trauma by transperineal (or perineal, or introital) ultrasound was rst described in 200423 on rendered volumes, that is, semi- transparent representations of blocks of volume ultrasound data (see Figure 6), using Volusontype systems and 3D/4D curved array volume transducers that were developed for fetal imaging. This form of 3D ultrasound relies on fast mechanical movement of a curved array within the 3D transducer, acquiring volume data without any need for manual transducer movement or external position sensors. Acceptable quality can be obtained with acquisition angles of up to 85 degrees, encompassing the entire levator hiatus even on maximal Valsalva in a patient with severe prolapse, and at a volume frequency of about 2 Hz. At lower acquisition angles and quality, frequency of up to 20 Hz can be reached. This implies that temporal resolution in any plane is superior to MR, while spatial resolution of structures within the levator hiatus up to about 4 cm depth is comparable to MR. The diagnosis of avulsion by 3D ultrasound has been shown to be highly reproducible, in particular as compared to palpation.3,13 In a further technical innovation, modern 3D ultrasound systems commonly allow tomographic imaging, ie, serial cross-sections at arbitrarily variable inter-slice intervals and angles. Diagnosis by tomographic ultrasound is probably currently the most repeatable technique.24 Figure 7 shows identication of the plane of minimal dimensions as a reference plane, and Figure 8 demonstrates a tomographic representation of the entire puborectalis muscle, based on this reference plane. Tomographic ultrasound is probably best

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Figure 7 Identication of the plane of minimal hiatal dimensions in an oblique axial plane (B) as identied in the midsagittal plane (A). This plane, while not always sufcient to diagnose avulsion injury, denes the levator hiatus and is used to determine hiatal dimensions and distensibility. It also serves as a convenient reference plane for tomographic ultrasound imaging.

performed by bracketing the area of interest, with the lowermost slice just below the insertion of the puborectalis muscle25 as shown in Figure 8. Avulsion can be diagnosed with 2D ultrasound, using the simplest and most commonly available abdominal curved array transducers (Figure 9). However, since there is no clearly identiable point of reference for parasagittal translabial planes, it is more difcult to be certain of a complete avulsion, and, as a result, repeatability is probably inferior.26 Regardless of which imaging method is used, palpation and imaging are best seen as complementary rather than mutually exclusive. Frequently, one method will allow a better appreciation of ndings obtained by the other method. The palpating nger provides biomechanical information on tone and contractility that is not currently available on imaging. On the other hand. imaging information is more objective and reproducible, and provides information on deeper structures that are not accessible on palpation.

RISK FACTORS All cases of avulsion documented so far, whether by magnetic resonance imaging, palpation or by ultrasound, were found in women who had delivered vaginally.2729 It is likely that factors such as birthweight, length of second stage, size of the fetal head, and vacuum/forceps delivery increase the probability of avulsion injury,1,2,30 but such predictors are of very limited use since they are not available prior to the onset of labour.

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Figure 8 Assessment of the puborectalis muscle by tomographic or multislice ultrasound. The top left hand image (0) represents a reference image in the coronal plane. Images 18 show slices parallel to the plane of minimal hiatal dimensions. Slices 1 and 2 are 5 and 2.5 mm below this plane, slice 3 represents the plane of minimal dimensions, and slices 48 are 2.512.5 mm above this plane, likely encompassing the entire insertion of the puborectalis. Slice 1 is clearly below the muscle insertion, guaranteeing that the area of interest is imaged in its entirety.

In order to prevent levator avulsion, we need predictors that can be determined during pregnancy. It is plausible that the risk of trauma to the insertion of the puborectalis muscle, ie, damage to the muscle-bone interface, will depend not just on the required distension, but also on the biomechanical properties of muscle and muscle-bone interface (which are hitherto undened). It is therefore not surprising that avulsion seems associated with maternal age at rst delivery1,2,31 a worrying nding in view of the continuing trend towards delayed childbearing in developed societies. The likelihood of major levator trauma at vaginal delivery more than triples during the reproductive years; from under 15% at age 20 to over 50% at 4031 (Figure 10). Taken together with the increasing likelihood of caesarean section, it seems that the probability of a successful vaginal delivery without levator trauma decreases from over 80% at age 20 to less than 30% at age 40 (unpublished data). Maternal age is the rst predictor of trauma that may in future form part of a prelabour predictive model, allowing preventative intervention.

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Figure 9 2D parasagittal oblique views of the puborectalis muscle obtained by translabial ultrasound (A showing an avulsion on the patients right, marked by a , B an intact muscle on the patients left). Image C shows a tomographic representation of the puborectalis muscle in the same patient, with the avulsion evident in most slices (marked by ).

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Figure 10 The relationship between age at rst delivery and levator avulsion. With permission from: Dietz HP, Simpson JM.31 Abbreviation: FVD, forceps delivery or vacuum delivery.

CONSEQUENCES OF LEVATOR TRAUMA The effect of avulsion on muscle function is substantial. Contraction strength as estimated by Oxford grading14 and instrumented speculum27 is reduced by about 1/3, an observation that may help diagnose levator trauma. Avulsion results in a hiatus that is larger (by 2030%), especially in the coronal plane,32 more distensible and less contractile.27,29 Figure 11 shows the effect of avulsion on hiatal dimensions in a patient after forceps delivery at term.

Prolapse Levator avulsion is associated with anterior and central compartment prolapse and likely represents the missing link (or a large part of the missing link) between childbirth and prolapse.33 The larger a defect is, both in width and depth, the more likely are symptoms and/or signs of prolapse.24 Levator avulsion seems to at least triple the risk of signicant anterior and central compartment prolapse (Table 3), with less of an effect on posterior compartment descent. This effect seems largely independent of ballooning (unpublished data), or abnormal distensibility of the levator hiatus, which also is associated with prolapse.34

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Figure 11 The effect of levator avulsion on hiatal dimensions. Antepartum and postpartum ultrasound images (single slice axial planes in the plane of minimal hiatal dimensions) of a patient with left sided avulsion after forceps delivery. The hiatal area on maximum Valsalva at 38 weeks (on the left, image A) was 15.6 cm2 . It was measured at 29.3 cm2 at 4 months postpartum (image B).

Table 3 Relative risk (95% condence interval) of each type of prolapse (stage 2 and higher) in women with levator avulsion relative to women with intact levator ani. *Excludes 100 women who had had a hysterectomy (Dietz H, Simpson J33 with permission) Cystocele (n = 781) Unilateral avulsion Bilateral avulsion Any levator avulsion 2.2 (1.92.7) 2.5 (2.13.0) 2.3 (2.02.7) Uterine prolapse (m = 681) 2.0 (1.04.1) 7.1 (4.311.6) 4.0 (2.56.5) Rectocele (n = 781) 1.2 (0.91.7) 1.6 (1.22.1) 1.4 (1.11.7)

It is not clear as to why it often takes decades for symptoms to develop, although DeLanceys ship in dock hypothesis provides a plausible explanation.35 One should also point out that there are many women who present with prolapse without having suffered an avulsion injury. There are other deleterious effects of childbirth on the levator, resulting in traumatic, irreversible overdistension,36 and then there are young nulliparous women who show evidence of abnormal hiatal distensibility and pelvic organ descent that is very likely congenital.37 Our modeling suggests that avulsion in itself is probably only responsible for 3040% of cases of symptomatic prolapsebut commonly these may well be the most difcult forms of prolapse to treat surgically.

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Urinary incontinence Many laypeople and medical practitioners as well as physiotherapists and continence nurse practitioners assume that urinary incontinence is a sign of a weak pelvic oor. This may not be true. We have recently shown that levator avulsion is negatively associated with stress urinary incontinence (SI) and urodynamic stress incontinence (USI), and this association remained negative even after controlling for eight potential confounders, including all forms of female pelvic organ prolapse (unpublished data). These ndings are highly counterintuitive. Why is it that there should be no major effect of puborectalis muscle trauma on SI or USI, considering that pelvic oor muscle (PFM) training is a recognized and proven therapeutic intervention in women with stress urinary incontinence?38 If the puborectalis muscle is part of the urinary continence mechanism, shouldnt it matter if one or both insertions of this muscle are disconnected from the inferior pubic ramus, rendering it badly dysfunctional? Firstly, one should point out that the therapeutic success of PFM training does not prove a role of the puborectalis muscle in stress urinary continence. After all, PFM training affects not just the puborectalis muscle but likely trains all muscular structures innervated by the sacral segments. Secondly, there are several other potential mechanisms by which childbirth might affect urinary continence. Denervation is the most obvious candidate since we have good evidence on the deleterious effect of vaginal birth on the pudendal nerve and its branches.10 Damage to the urethral rhabdosphincter or the longitudinal smooth muscle of the urethra may also be mediated through other factors such as devascularization. There is also the issue of pressure transmission, likely mediated through the pubourethral ligaments and/ or suburethral tissues. Clearly, much research will be needed before we can claim to understand the pathophysiological basis for stress urinary incontinence.

Faecal incontinence The second major clinical symptom that has been attributed to an abnormal puborectalis muscle (via an opening of the anorectal angle) is faecal incontinence. However, we have found no signicant association between this symptom and levator trauma (unpublished data). It therefore appears unlikely that any intervention targeting levator dimensions or function would have a major impact on faecal continence. Any improvement in symptoms is more likely to be due to other associated therapeutic effects.

Sexual function The puborectalis muscle has been billed as the love muscle by sections of the popular press. It is likely that avulsion, especially if bilateral, would have some effect on

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sexual function. To date, however, we have only anecdotal information on this issue. Considering the popularity of cosmetic genitoplasty procedures aiming to tighten the vagina, this may become an important consideration in the future. In some women the site of the avulsion remains tender, even after decades, and some women and their partners notice a marked difference in sexual relations after the birth of their rst child. Other couples however dont notice any change. For obvious reasons this is not an issue that is easy to investigate.

Clinical repercussions Major morphological abnormalities of the levator ani probably affect surgical outcomes. A study using MR imaging demonstrated that recurrence after anterior colporrhaphy was much more likely in women with an abnormal pelvic oor.39 The authors unit has recently shown that avulsion is associated with prolapse after hysterectomy, anti-incontinence and prolapse operations, especially after anterior repair (unpublished data). In view of the current, often acrimonious discussion regarding the use of mesh implants in reconstructive surgery, this association may turn out to be of major clinical importance. In the opinion of the author it makes little sense to perform a traditional anterior repair in women with bilateral avulsion since such a procedure is very likely to fail.

FUTURE DEVELOPMENTS Prediction One approach to reducing the incidence of levator trauma in childbirth would be to target preventative intervention at high risk groups. This will require individual pre- delivery risk assessment. It is currently not clear whether such risk assessment is feasible, but the potential benets of such an approach should make this a high priority for research. The only currently known pre-labor risk factor is maternal age at rst delivery.1,2,31 Others are currently being investigated, such as body mass index, ethnicity and pelvic oor biomechanical properties. It is evident that many women at least 3040% of all those delivering vaginally- suffer no appreciable pelvic oor trauma. In view of the necessary distension to allow passage of a term fetal head this is what is truly astounding not the fact that some births result in trauma. Clearly, we need to investigate what it is that allows so many women to experience a non-traumatic vaginal delivery. Recently, computer modeling has been used by a number of units to try and investigate pelvic organ support and pelvic oor dysfunction. While computer modeling has enabled important insights into mechanisms of trauma,4 signicant progress is unlikely until input variables are properly dened. There is really no

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information on boundary conditions and the material properties of bone, muscle and their interface at present, and any imaging data used for modeling will be just a snapshot of the static anatomical situation in one person. We have recently shown how much static and dynamic dimensions of the levator hiatus can vary between individuals.5 On the basis of this information it seems that computer modeling is unlikely to be relevant for clinical practice or even for research until the biomechanical properties of the levator hiatus are better dened. In consequence, modeling is unlikely to play a role in the prediction of trauma for the foreseeable future.

Prevention The ultimate preventative intervention is of course elective caesarean section. In view of the ever-increasing caesarean section rate it is quite possible that pelvic oor trauma will cease to be much of an issue within a generation. However, as mentioned above, many women clearly do not need an operation to deliver their baby and preserve an intact pelvic oor, and it would be an enormous waste of resources to institute a policy of universal caesarean section. Quite apart from resource issues, caesarean section has very substantial disadvantages, both for the mother and her infant, the nature and magnitude of which are beyond the scope of this review. Clearly, caesarean section would only be a potential option in women shown to be at high risk of trauma. Other forms of prevention may potentially be more practicable, such as attempts to change the biomechanical properties of the muscle-bone interface or the muscle and connective tissue of the pelvic oor in general. This may not be as far- fetched as it sounds. There is a commercially available device, the Epi-NoTM , that is used to dilate the perineum and vagina in the last few weeks of pregnancy, and this device has been shown to reduce perineal trauma.40 The Epi-No is currently under investigation regarding a potential role in pelvic oor protection.

Treatment Is there anything we can do to repair avulsion injury, either immediately after childbirth, or at a later date? From a plastic surgery point of view, surgical failure due to suture dislodgment seems very likely in the postpartum setting, given the quality of the tissues and the fact that there is no opportunity for splinting or immobilisation. I know of four failed attempts at repairing avulsion by direct suturing after childbirth. Direct repair may have to wait several months and may have to utilize autologous fascia or mesh. A rst attempt using fascia lata has been reported by Abbas Shobeiri, a Urogynaecologist from Oklahoma City (personal communication). In a different approach, the author has developed a minimally invasive concept that should at least compensate for (if not actually close) an avulsion defect. However, it will very likely

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be many years before any reconstructive surgical approach can be regarded as proven and appropriate for general use.

References
1 2 3 4 5 6 7 8 9 10 11 12 Dietz H, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol 2005; 106: 707712. Kearney R, Miller J, Ashton-Miller J, Delancey J. Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 2006; 107: 14449. Dietz HP, Steensma AB. The prevalence of major abnormalities of the levator ani in urogynaecological patients. BJOG 113: 22530. Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol 2004; 103: 3140. Svabik K, Shek KL, Dietz HP. How much does the puborectalis muscle have to stretch in childbirth? Int Urogynecol J 1951; S76. Lanzarone V, Dietz H. 3Dimensional ultrasound imaging of the levator hiatus in late pregnancy and associations with delivery outcomes. Aust NZ J Obstet Gynaecol 2007; 47: 17680. Balmforth J, Toosz- Hobson P, Cardozo L. Ask not what childbirth can do to your pelvic oor but what your pelvic oor can do in childbirth. Neurourol Urodyn 2003; 22: 54042. Dietz H, Gillespie A, Phadke P. Avulsion of the pubovisceral muscle associated with large vaginal tear after normal vaginal delivery at term. Aust NZ J Obstet Gynaecol 2007; 47: 34144. Swash M, Snooks SJ, Henry MM. Unifying concept of pelvic oor disorders and incontinence. J R Soc Med 1985; 78: 90611. Allen RE, Hosker GL, Smith AR, Warrell DW. Pelvic oor damage and childbirth: a neurophysiological study. BJOG 1990; 97: 77079. Dietz HP, Hyland G, Hay-Smith J. The assessment of levator trauma: A comparison between palpation and 4D pelvic oor ultrasound. Neurourol Urodyn 2006; 25: 42427. Kearney R, Miller JM, Delancey JO. Interrater reliability and physical examination of the pubovisceral portion of the levator ani muscle, validity comparisons using MR imaging. Neurourol Urodyn 2006; 25: 5054. Dietz HP, Shek KL. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J 2008; 19: 10971101. Dietz HP, Shek C. Levator avulsion and grading of pelvic oor muscle strength. Int Urogynecol J 2008; 19: 63336. Laycock J. Assessment and treatment of pelvic oor dysfunction [PhD]. University of Bradford, 1992. Devreese AM, Staes F, De Weerdt W, Feys H, Van Assche A, Penninckx F et al. Clinical evaluation of pelvic oor muscle function in continent and incontinent women. Neurourol Urodyn 2004; 23: 19097. Mantle J. Urinary function and dysfunction. In: Mantle J, Haslam J, Barton S, (eds). Physiotherapy in Obstetrics and Gynaecology. Edinburgh: Butterworth Heinemann, 2004. Gainey HL. Post-partum observation of pelvic tissue damage. Am J Obstet Gynecol 1943; 46: 45766. 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. Debus-Thiede G. Magnetic Resonance Imaging (MRI) of the Pelvic Floor. In: Schuessler B, Laycock J, Norton P, Stanton SL, (eds). Pelvic Floor Reeducation- Principles and Practice. London: Springer, 1994: 7882.

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Toozs- Hobson P, Athanasiou S, Khullar V, Boos K, Anders K, Cardozo LD. Does vaginal delivery damage the pelvic oor? Neurourol Urodyn 1997; 16: 38586. Athanasiou S, Chaliha C, Toozs-Hobson P, Salvatore S, Khullar V, Cardozo L. Direct imaging of the pelvic oor muscles using two-dimensional ultrasound: a comparison of women with urogenital prolapse versus controls. Br J Obstet Gynaecol 2007; 114: 88288. Dietz H. Ultrasound Imaging of the Pelvic Floor: 3D aspects. Ultrasound Obstet Gynecol 2004; 23: 61525. Dietz H. Quantication of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 2007; 29: 32934. Dietz H, Shek K. Tomographic ultrasound of the pelvic oor: which levels matter most? Neurourol Urodyn 2008; 27: 63940. Dietz H, Shek K. Levator trauma can be diagnosed by 2D translabial ultrasound (In Press) Int Urogynecol J; 2009. DeLancey J, Morgan D, Fenner D, Kearney R, Guire K, Miller J, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol 2007; 109: 295302. Dietz H. Levator trauma in labour: a challenge for obstetricians, surgeons and sonologists. Ultrasound Obstet Gynecol 2007; 29: 36871. Abdool Z, Shek K, Dietz H. The effect of levator avulsion on hiatal dimensions and function. Am J Obstet Gynecol 2008; in press. Krofta L, Kasikova E, Otcenasek M, Feyereisl J. Pubococcygeus- puborectalis trauma after instrumental delivery: the use of 4D ultrasound in the evaluation of levator ani muscle. Ultrasound Obstet Gynecol 2007; 30: 446. Dietz H, Simpson J. Does delayed childbearing increase the risk of levator injury in labour? Aust NZ J Obstet Gynaecol 2007; 47: 49195. 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: 69296. Dietz H, Simpson J. Levator trauma is associated with pelvic organ prolapse. Br J Obstet Gynaecol 2008; 115: 97984. Dietz H, De Leon J, Shek K. Ballooning of the levator hiatus. Ultrasound Obstet Gynecol 2008; 31: 67680. DeLancey JO. Anatomy. In: Cardozo L, Staskin D, editors. Textbook of Female Urology and Urogynaecology. London, UK: Isis Medical Media, 2001: 11224. Shek K, Dietz H. The effect of vaginal childbirth on levator hiatal dimensions. Int Urogynecol J 2008; 19: S130. Dietz H, Shek K, Clarke B. Biometry of the pubovisceral muscle and levator hiatus by threedimensional pelvic oor ultrasound. Ultrasound Obstet Gynecol 2005; 25: 58085. Wilson PD, Hay Smith EJ, Nygaard IE, Wyman JF, Yamanishi T, Berghmans B, et al. Adult conservative management. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence: Third International Consultation on Incontinence. Paris: Health Publications Ltd, 2005: 855964. Adekanmi OA, Freeman R, Puckett M, Jackson S. Cystocele: Does anterior repair fail because we fail to correct the fascial defects? A clinical and radiological study. Int Urogynecol J 2005; 16: S73. Kovacs G, Heath P, Heather C. First Australian trial of the pirth- training device Epi-No: A highly signicantly increased chance of an intact perineum. Aust NZ J Obstet Gynaecol 2004; 44: 34748.

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