Does levator ani hiatal area configuration affect pelvic organ prolapse?
Abstract
Objective: Levator ani trauma and hiatal overdistension have been shown to be associated with female pelvic organ prolapse (POP); however, the role of the shape of the levator hiatus in POP has not been examined to date. The aim of this study was to investigate the association between the configuration of the levator ani hiatus and POP. Methods: This was a retrospective study of 547 women who attended a tertiary urogynecological center for symptoms of pelvic floor and lower urinary tract dysfunction between October 2014 and August 2016. All women underwent a standardized interview and prolapse assessment using the International Continence Society (ICS) Pelvic Organ Prolapse Quantification (POP‐Q) method and four‐dimensional translabial ultrasound (TLUS). Measurements of the hiatal anteroposterior diameter (APD), coronal diameter (CD) and hiatal area (HA), at rest and on maximal Valsalva maneuver, and those of organ descent were performed offline at a later date by an investigator blinded to all other data. Hiatal configuration was defined as the ratio APD/CD. Associations between HA and HA adjusted by APD/CD at rest and on maximal Valsalva and symptoms and signs of prolapse were analyzed statistically using logistic regression modelling. Results: The mean age of the women was 54 ± 13.6 (range, 16–89) years. Of the 547 women included, 241 (44%) presented with prolapse symptoms. Clinically significant POP was detected in 406 (74%) patients and significant prolapse on TLUS was detected in 331 (61%). Hiatal ballooning was observed in 310 (57%) women and this was strongly associated with signs and symptoms of POP. HA at rest and on Valsalva was associated with significant POP both on clinical examination and on TLUS. Adjusted odds ratios for hiatal shape showed no effect of the hiatal configuration on the association between HA and POP. Conclusion: Hiatal shape does not seem to influence the association between HA and symptoms and signs of prolapse. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Women with POP have pelvic floor muscle impairment.
“Women with POP have shown to have PFM impairment [4, 6, 8–16]”
From International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training (2022) · cites this paper as [13]
The association between a decrease in levator plate angle, an increase in levator hiatus area and presence of POP has been confirmed in several studies.
“The association between a decrease in levator plate angle, increase in levator hiatus area and presence of POP has been confirmed in several studies [5–13].”
From International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training (2022) · cites this paper as [13]
Cites
The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction
Bump, R. C., Mattiasson, A., Bø, K., Brubaker, L. P., DeLancey, J. O. L., Klarskov, P., Shull, B. L., & Smith, A. R. B. (1996) · American Journal of Obstetrics and Gynecology · doi:10.1016/s0002-9378(96)70243-0 · Cited by 4,275 · see citing works
Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery
Wu, J. M., Matthews, C. A., Conover, M. M., Pate, V., & Jonsson Funk, M. (2014) · Obstetrics & Gynecology · doi:10.1097/aog.0000000000000286 · Cited by 1,111 · see citing works
Lifetime Risk of Undergoing Surgery for Pelvic Organ Prolapse
Smith, F. J., Holman, C. D. J., Moorin, R. E., & Tsokos, N. (2010) · Obstetrics & Gynecology · doi:10.1097/aog.0b013e3181f73729 · Cited by 822 · see citing works
Risk factors for pelvic organ prolapse and its recurrence: a systematic review
Vergeldt, T. F. M., Weemhoff, M., IntHout, J., & Kluivers, K. B. (2015) · International Urogynecology Journal · doi:10.1007/s00192-015-2695-8 · Cited by 572 · see citing works
Biometry of the pubovisceral muscle and levator hiatus by three‐dimensional pelvic floor ultrasound
Dietz, H. P., Shek, C., & CLARKE, B. (2005) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.1899 · Cited by 506 · see citing works
Self-citationBallooning of the levator hiatus
Dietz, H. P., Shek, C., León-Luis, J. A. D., & Steensma, A. B. (2008) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.5355 · Cited by 318 · see citing works
Self-citationRisk factors for prolapse recurrence: systematic review and meta-analysis
Friedman, T., Eslick, G. D., & Dietz, H. P. (2018) · International Urogynecology Journal · doi:10.1007/s00192-017-3475-4 · Cited by 222 · see citing works
Self-citationLevator co‐activation is a significant confounder of pelvic organ descent on Valsalva maneuver
Örnö, A. K., & Dietz, H. P. (2007) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.4082 · Cited by 170 · see citing works
Self-citationDIETZ, H. P., FRANCO, A. V. M., SHEK, K. L., & KIRBY, A. (2012) · Acta Obstetricia et Gynecologica Scandinavica · doi:10.1111/j.1600-0412.2011.01315.x · Cited by 158 · see citing works
Self-citationDietz, H. P., & Lekskulchai, O. (2007) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.4024 · Cited by 127 · see citing works
Self-citationDietz, H. P., & Mann, K. P. (2014) · International Urogynecology Journal · doi:10.1007/s00192-013-2307-4 · Cited by 98 · see citing works
Self-citationRodrigo, N., Wong, V., Shek, K. L., Martin, A. J., & Dietz, H. P. (2014) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/ajo.12171 · Cited by 84 · see citing works
Self-citationWhat is abnormal uterine descent on translabial ultrasound?
Shek, K. L., & Dietz, H. P. (2015) · International Urogynecology Journal · doi:10.1007/s00192-015-2792-8 · Cited by 73 · see citing works
Self-citationDietz, H. P., Atan, I. K., & Salita, A. (2015) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.14872 · Cited by 61 · see citing works
Self-citationEnlargement of the levator hiatus in female pelvic organ prolapse: Cause or effect?
Andrew, B., Shek, K. L., Chantarasorn, V., & Dietz, H. P. (2012) · Australian and New Zealand Journal of Obstetrics and Gynaecology · doi:10.1111/ajo.12026 · Cited by 52 · see citing works
Self-citationThree-dimensional shape differences in the bony pelvis of women with pelvic floor disorders
Brown, K., Handa, V. L., Macura, K. J., & DeLeon, V. B. (2012) · International Urogynecology Journal · doi:10.1007/s00192-012-1876-y · Cited by 37 · see citing works
Practice Bulletin No. 176 Summary: Pelvic Organ Prolapse
(2017) · Obstetrics and Gynecology · doi:10.1097/aog.0000000000002008 · Cited by 6 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Bø, K., Anglès-Acedo, S., Batra, A., Brækken, I. H., Chan, Y. L., Jorge, C. H., Kruger, J., Yadav, M., & Dumoulin, C. (2022) · International Urogynecology Journal · doi:10.1007/s00192-022-05324-0 · Cited by 64 · see citing works
Up for the tackle? The pelvic floor and rugby. A review
Donnelly, G., Bø, K., Forner, L. B., Rankin, A. T., & Moore, I. S. (2024) · European Journal of Sport Science · doi:10.1002/ejsc.12121 · Cited by 33 · see citing works
Sainz‐Bueno, J. A., Bonomi, M. J., Suárez-Serrano, C., Medrano-Sánchez, E. M., Sánchez, A. A., Fernández-Palacín, A., & García‐Mejido, J. A. (2022) · Quantitative Imaging in Medicine and Surgery · doi:10.21037/qims-21-877 · Cited by 24 · see citing works
Transperineal ultrasound assessment of maternal pelvic floor at term and fetal head engagement
Youssef, A., Brunelli, E., Montaguti, E., Donna, G. D., Dodaro, M. G., Bianchini, L., & Pilu, G. (2020) · Ultrasound in Obstetrics and Gynecology · doi:10.1002/uog.21982 · Cited by 23 · see citing works
Type of levator ani muscle avulsion as predictor for the disappearance of avulsion
García‐Mejido, J. A., & Sainz‐Bueno, J. A. (2020) · Neurourology and Urodynamics · doi:10.1002/nau.24484 · Cited by 13 · see citing works
Lipetskaia, L., Gupta, A., Cheung, R. Y. K., Khullar, V., Ismail, S. I. M. F., Bradley, M. S., Karmakar, R., Clifton, S. C., Doo, J., & Quiroz, L. H. (2025) · International Urogynecology Journal · doi:10.1007/s00192-024-05948-4 · Cited by 10 · see citing works
Effect of exercise on female pelvic floor morphology and muscle function: a systematic review
Menezes, E. C., Pereira, F. D. S., Porto, R. M., Fank, F., & Mazo, G. Z. (2022) · International Urogynecology Journal · doi:10.1007/s00192-022-05375-3 · Cited by 9 · see citing works
Automatic C-Plane Detection in Pelvic Floor Transperineal Volumetric Ultrasound
Williams, H., Cattani, L., Yaqub, M. K., Sudre, C. H., Vercauteren, T. K., Deprest, J. A., & D’hooge, J. (2020) · Lecture notes in computer science · doi:10.1007/978-3-030-60334-2_14 · Cited by 7 · see citing works
Özgül, S., Gürşen, C., Celenay, S. T., Baran, E., Üzelpasacı, E., Nakip, G., Çınar, G. N., Beksaç, M. S., & Akbayrak, T. (2022) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2022.2127137 · Cited by 6 · see citing works
Li, D., & Lu, R. (2023) · PubMed Central · doi:10.11817/j.issn.1672-7347.2023.220577 · Cited by 4 · see citing works
He, X., Du, Q., Chang, L., Jiang, Y. L., Dou, W., Pylypenko, D., Yu, D., Wang, Q., Guo, Y., & Wang, F. (2023) · Archives of Gynecology and Obstetrics · doi:10.1007/s00404-023-07253-9 · Cited by 2 · see citing works
Elsersy, M. A. (2022) · Italian Journal of Gynaecology and Obstetrics · doi:10.36129/jog.2022.19 · Cited by 1 · see citing works
Chen, Y., Qian, C., Yin, Y., Zhou, Y., Xu, Z., & Fang, X. (2025) · Research Square · doi:10.21203/rs.3.rs-6182348/v1
Shou, J., Wang, K., Xu, W., Yang, H., & He, Y. (2025) · Journal of Clinical Ultrasound · doi:10.1002/jcu.70088
Lin, Y., Pan, H., Chen, Y., Dong, C., & Luo, Y. (2025) · Acta Obstetricia Et Gynecologica Scandinavica · doi:10.1111/aogs.70065
Packet, B., Severen, R. V., Cattani, L., Samešová, A., Florian, R., Williams, H., Richter, J., & Deprest, J. A. (2025) · European Journal of Obstetrics & Gynecology and Reproductive Biology · doi:10.1016/j.ejogrb.2025.114867
Chen, Y., Qian, C., Yin, Y., Zhou, Y., Xu, Z., & Fang, X. (2026) · Medicine · doi:10.1097/md.0000000000045922
Assessment and measurement of the female pelvic floor
Vesting, S., & McLean, L. (2026) · Elsevier eBooks · doi:10.1016/b978-0-443-32986-9.00016-3
An evolutionary perspective on human pelvic floor function and disorders
Warrener, A. G., & Donnelly, G. (2026) · Elsevier eBooks · doi:10.1016/b978-0-443-32986-9.00011-4
Dong, C., Liu, X., Wang, J., Lin, Y., Pan, H., & Luo, Y. (2026) · Ultrasound in Medicine & Biology · doi:10.1016/j.ultrasmedbio.2026.05.024
- Authors
- Xuan, Y., Friedman, T., & Dietz, H. P.
- Affiliations
- The University of Sydney (AU)
- Corresponding author
- Dietz, H. P.
- Venue
- Ultrasound in Obstetrics & Gynecology
- Publisher
- Wiley
- Published
- 2019-06-12
- Volume
- 54
- Issue
- 1
- Pages
- 124-127
- ISSN
- 0960-7692 (ISSN-L)
- 1469-0705
- OpenAlex
- W2906342356
- Cited by
- 20
- References
- 17
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 1 · 2023: 2 · 2022: 5 · 2020: 3
- FWCI
- 0.64
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Ultrasound in Obstetrics and Gynecology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Rheumatology › Pelvic floor disorders treatments
- Health Sciences › Medicine › Urology › Urinary Bladder and Prostate Research
- Health Sciences › Medicine › Obstetrics and Gynecology › Uterine Myomas and Treatments
- Keywords
- pelvic organ prolapse, anteroposterior diameter, Valsalva maneuver, POP-Q, female pelvic floor dysfunction
- MeSH terms
- Adult, Aged, Female, Humans, Middle Aged, Perineum, Retrospective Studies, Ultrasonography, Urologic Diseases, Valsalva Maneuver, Pelvic Floor, Imaging, Three-Dimensional, Pelvic Organ Prolapse
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
