Avulsion injury and levator hiatal ballooning: two independent risk factors for prolapse? An observational study
Open accessAbstract
Objective. To study whether avulsion and ballooning are independent risk factors for symptoms and/or signs of pelvic organ prolapse. Design. Retrospective analysis of data obtained in clinical practice. Setting. Tertiary urogynecology unit. Population. Seven hundred and sixty‐one consecutive women with symptoms of pelvic floor dysfunction. Methods. Evaluation included history, vaginal examination and four‐dimensional translabial ultrasound. Ultrasound analysis was performed off‐line, blinded against clinical data. Hiatal dimensions were measured at the plane of minimal hiatal dimensions. Puborectalis avulsion was identified using tomographic imaging. Main outcome measures. Symptoms and objective signs of prolapse (ICS POP‐Q stage 2+). Results. Owing to previous surgery 156 women were excluded, leaving 605, of whom 258 (43%) had prolapse symptoms. Significant prolapse (International Continence Society Prolapse Quantification System grade 2+) was identified as follows: cystocele in 222 (37%) women, rectocele in 159 (27%) and apical in 40 (8%), while 110 (18%) had an avulsion. There was a strong association between avulsion, hiatal ballooning and symptoms/signs of prolapse ( p < 0.001). On multivariable backwards stepwise logistic regression, puborectalis avulsion was associated with an increased risk of symptoms and signs of prolapse, even after allowing for the degree of levator ballooning. The presence of avulsion did not modify the relation between hiatal area and symptoms of prolapse. Conclusions. Puborectalis avulsion injury and levator hiatal ballooning are independent risk factors for symptoms and signs of prolapse. The role of avulsion in the pathogenesis of prolapse is not fully explained by its effect on hiatal dimensions. It is likely that avulsion implies not only muscular trauma but also damage to structures impossible to assess clinically or by imaging, i.e. myofascial and connective tissue.
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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 [6]
The Introduction and Results report an association between larger levator hiatal dimensions and symptoms and clinical signs of pelvic organ prolapse. The paper does not report a decrease in levator plate angle or test its association with prolapse, so it supports only the hiatal-area part of the claim. Page numbers are unavailable in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredWomen with POP have pelvic floor muscle impairment.
“Women with POP have shown to have PFM impairment [4, 6, 8–16]”
Increased levator hiatal area on Valsalva was a statistically significant risk factor for primary pelvic organ prolapse in 2 out of 2 studies; results could not be pooled, but it was identified as a confirmed risk factor.
“An increased levator hiatal area on Valsalva was a statistically significant risk factor for primary POP in 2 out of 2 studies.23,27 The results could not be pooled because of differences in definitions, but it can be identified as a confirmed risk factor”
From Risk factors for primary pelvic organ prolapse and prolapse recurrence: an updated systematic review and meta-analysis (2022) · cites this paper as [23]
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References 29 · Cited by 158
Research works printed but not linked: 2
- [2]2. Ghetti C, Gregory T, Edwards R, Clark A. Severity of pelvic organ prolapse is associated with measurements of genital hiatus. Neurourol Urodyn. 2003;22:513-4.
- [18]18. Wong V, Shek KL, Goh J, Rane A, Dietz HP. Is levator avulsion a predictor of recurrence after anterior compartment mesh? Neurourol Urodyn 2011;30:879-80.
- Authors
- DIETZ, H. P., FRANCO, A. V. M., SHEK, K. L., & KIRBY, A.
- Affiliations
- St George's Hospital (GB)
- Corresponding author
- DIETZ, HANS PETER
- Venue
- Acta Obstetricia et Gynecologica Scandinavica
- Publisher
- Wiley
- Published
- 2012-01-09
- Volume
- 91
- Issue
- 2
- Pages
- 211-214
- ISSN
- 0001-6349 (ISSN-L)
- 1600-0412
- OpenAlex
- W1493923267
- Cited by
- 158
- References
- 29
- Citations by year
- 2026: 6 · 2025: 7 · 2024: 7 · 2023: 7 · 2022: 11 · 2021: 11 · 2020: 7 · 2019: 13 · 2018: 9 · 2017: 11 · 2016: 11 · 2015: 19 · 2014: 11 · 2013: 16 · 2012: 9
- FWCI
- 9.12
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Acta Obstetricia Et Gynecologica Scandinavica (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, risk factors, pelvic floor dysfunction, cystocele, rectocele, apical prolapse
- MeSH terms
- Adolescent, Adult, Aged, Aged, 80 and over, Female, Humans, Middle Aged, Retrospective Studies, Risk Factors, Ultrasonography, Logistic Models, Pelvic Floor, Parturition, Young Adult, Pelvic Organ Prolapse, Pelvic Floor Disorders
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