Top

International Urogynecology Journal

Published in:

01-08-2009 | Original Article

Does avulsion of the puborectalis muscle affect bladder function?

Authors: H. P. Dietz, A. Kirby, K. L. Shek, P. J. Bedwell

Published in: International Urogynecology Journal | Issue 8/2009

Abstract

Introduction and hypothesis

The levator ani muscle is generally thought to play a role in urinary continence, with incontinence assumed to be due to abnormal muscle function or morphology. This study examined whether avulsion of the puborectalis muscle is associated with symptoms or signs of bladder dysfunction.

Methods

In a retrospective observational study, we reviewed the records of 425 women who had attended a urogynecological unit for independent flowmetry, multichannel urodynamic testing, and 4D pelvic floor ultrasound.

Results

Mean age was 55 years (range, 17–87 years). Of 420 women with complete datasets, 104 (25%) were diagnosed with a puborectalis muscle avulsion. These women were less likely to suffer from stress urinary incontinence (SUI; P < 0.001) and urodynamic stress incontinence (USI; P = 0.065) and more likely to present with symptoms of prolapse (P < 0.001) and show signs of voiding dysfunction (P = 0.005). The negative association between avulsion and SUI persisted in multivariate models.

Conclusion

Puborectalis muscle trauma is not associated with an increased risk of SUI or USI in a urogynecological population, even when controlling for symptoms or signs of prolapse and previous surgery.

Kearney R, Miller J, Ashton-Miller J, Delancey J (2006) Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107(1):144–149PubMed

Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106:707–712PubMed

Dietz HP (2007) Quantification of major morphological abnormalities of the levator ani. Ultrasound Obstet Gynecol 29:329–334PubMedCrossRef

Hoyte L, Schierlitz L, Zou K, Flesh G, Fielding JR (2001) Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse. Am J Obstet Gynecol 185(1):11–19PubMedCrossRef

DeLancey JO (2002) Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 187(1):93–98PubMedCrossRef

Gainey HL (1943) Post-partum observation of pelvic tissue damage. Am J Obstet Gynecol 46:457–466

Kearney R, Miller JM, Delancey JO (2006) Interrater reliability and physical examination of the pubovisceral portion of the levator ani muscle, validity comparisons using MR imaging. Neurourol Urodyn 25(1):50–54PubMedCrossRef

Dietz HP, Shek KL (2008) Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J Pelvic Floor Dysfunct 19:1097–1101PubMedCrossRef

Dietz HP, Gillespie A, Phadke P (2007) Avulsion of the pubovisceral muscle associated with large vaginal tear after normal vaginal delivery at term. Aust N Z J Obstet Gynaecol 47:341–344PubMedCrossRef

10.

Lien KC, Mooney B, DeLancey JO, Ashton-Miller JA (2004) Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol 103(1):31–40PubMed

11.

DeLancey J, Morgan D, Fenner D, Kearney R, Guire K, Miller J et al (2007) Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol 109(2):295–302PubMed

12.

Dietz HP, Simpson J (2008) Levator trauma is associated with pelvic organ prolapse. Br J Obstet Gynaecol 115:979–984

13.

DeLancey J (2005) The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 192:1488–1495PubMedCrossRef

14.

Dietz HP, Steensma AB (2006) The prevalence of major abnormalities of the levator ani in urogynaecological patients. Br J Obstet Gynaecol 113(2):225–230

15.

Dietz HP (2004) Ultrasound imaging of the pelvic floor: 3D aspects. Ultrasound Obstet Gynecol 23(6):615–625PubMedCrossRef

16.

Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175(1):10–17PubMedCrossRef

17.

Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A (2002) The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 21(2):167–178PubMedCrossRef

18.

Dietz HP, Shek K, Clarke B (2005) Biometry of the pubovisceral muscle and levator hiatus by three-dimensional pelvic floor ultrasound. Ultrasound Obstet Gynecol 25:580–585PubMedCrossRef

19.

Dietz HP (2009) Tomographic ultrasound of the pelvic floor: which levels matter most? Ultrasound Obstet Gynecol (in press)

20.

Weinstein MM, Pretorius D, Nager CW, Mittal R (2007) Inter-rater reliability of pelvic floor muscle imaging abnormalities with 3D ultrasound. Ultrasound Obstet Gynecol 30(4):538CrossRef

21.

Laycock J (1994) Clinical evaluation of the pelvic floor. In: Schuessler B (ed) Pelvic floor re-education: principles and practice. Springer, London, pp 42–48

22.

Mant J, Painter R, Vessey M (1997) Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 104(5):579–585PubMed

23.

Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S (2003) Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med 348(10):900–907PubMedCrossRef

24.

Otcenasek M, Krofta L, Baca V, Grill R, Kucera E, Herman H et al (2007) 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 29:692–696PubMedCrossRef

25.

Dietz HP, Shek C (2008) Levator avulsion and grading of pelvic floor muscle strength. Int Urogynecol J Pelvic Floor Dysfunct 19:633–636PubMedCrossRef

26.

Abdool Z, Shek KL, Dietz HP (2009) The effect of levator avulsion on hiatal dimension and function. Am J Obstet Gynecol (in press)

27.

Dietz HP, Haylen BT, Vancaillie TG (2002) Female pelvic organ prolapse and voiding function. Int Urogynecol J 13(5):284–288CrossRef

28.

Wilson PD, Hay Smith EJ, Nygaard IE, Wyman JF, Yamanishi T, Berghmans B et al (2005) Adult conservative management. In: Abrams P, Cardozo L, Khoury S, Wein A (eds) Incontinence: third international consultation on incontinence. Health Publications Ltd, Paris, pp p855–p964

29.

Snooks SJ, Swash M, Mathers SE, Henry MM (1990) Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg 77(12):1358–1360PubMedCrossRef

30.

Allen RE, Hosker GL, Smith AR, Warrell DW (1990) Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 97(9):770–779PubMed

31.

DeLancey JO (2001) Anatomy. In: Cardozo L, Staskin D (eds) Textbook of female urology and urogynaecology. Isis Medical Media, London, UK, pp 112–124

Title: Does avulsion of the puborectalis muscle affect bladder function?
Authors: H. P. Dietz
A. Kirby
K. L. Shek
P. J. Bedwell
Publication date: 01-08-2009
Publisher: Springer-Verlag
Published in: International Urogynecology Journal / Issue 8/2009
Print ISSN: 0937-3462
Electronic ISSN: 1433-3023
DOI: https://doi.org/10.1007/s00192-009-0882-1

At a glance: The STEP trials

Springer Medicine

Does avulsion of the puborectalis muscle affect bladder function?

Abstract

Introduction and hypothesis

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction and hypothesis

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 8/2009

The association between diabetes mellitus and urinary incontinence in adult women

Caldesmon expression is decreased in women with anterior vaginal wall prolapse: a pilot study

Prophylactic antibiotics to prevent urinary tract infection during clean intermittent self-catheterization (CISC) for management of voiding dysfunction after prolapse and incontinence surgery: a decision analysis

How painful is multichannel urodynamic testing?

The great mesh debate

Female urethral diverticulum: a pathological insight