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Introduction and Hypothesis: The anatomy of the skeletal muscles located between the vagina and anus is important during complex obstetric laceration reconstructions. We aimed to clarify the composition of skeletal muscles located between the vagina and anal canal and their three-dimensional configuration relevant to perineum repair. Methods: This observational study involved ten female cadavers. An anatomical dissection was performed to observe the muscles around the vagina and anal canal. Immunohistological analysis of the midsagittal section was performed to clarify the composition of the muscles, and dissection was performed to correspond to the cross-section. Wide-range serial sectioning and three-dimensional reconstruction were used to support these findings histologically and visualize the three-dimensional arrangement. Results: The region between the vagina and anal canal included the anterior part of the external anal sphincter, superficial transverse perineal muscle approaching from the lateral side, and levator ani, located cranially. They converge three-dimensionally in the median from each direction, forming a muscle complex between the vagina and anal canal. Conclusions: The medial region between the vagina and anal canal in those giving birth includes a skeletal muscle complex formed by the confluence of the external anal sphincter, anterior bundle of the levator ani, and superficial transverse perineal muscle. In cases of severe perineal lacerations, these muscles could be injured. The anatomical knowledge that a part of the levator ani forms a muscle sling anterior to the anal canal is particularly important for obstetricians and gynecologists repairing obstetric lacerations and treating pelvic floor disorders. [ABSTRACT FROM AUTHOR]

Introduction and Hypothesis: The objective of this feasibility study was to characterize the pelvic floor muscles (PFMs) in older women with urinary incontinence (UI) via clinical and magnetic resonance imaging (MRI) evaluation. Methods: This cross-sectional study included women aged ≥ 70 years with symptomatic UI confirmed by a 3-day bladder diary. Clinical evaluation of the PFMs included the Modified Oxford Scale strength assessment (grade 0–5). PFM defects were also characterized as none/normal, minor, and major based on MRI evaluation. Descriptive statistics were utilized. Spearman's correlation with 95% confidence intervals was calculated between PFMs strength, MRI defects, and age. Results: Participants (n = 20) were 76.6 ± 4.7 years. Clinical evaluation demonstrated poor PFM strength in 95% (n = 19) of participants with the following grades: 15% (n = 3) grade 0, 45% (n = 9) grade 1, and 35% (n = 7) grade 2. MRI evaluation demonstrated PFMs= defects in 100% of participants with 45% (n = 9) minor and 55% (n = 11) major defects. The correlation coefficients between PFM strength and MRI defects, MRI defects and age, and PFM strength and age were −0.29 (95% CI −0.64, 0.18; p = 0.22), −0.01 (95% CI = −0.44, 0.44; p = 0.99), and 0.04 (95% CI = −0.41, 0.47; p = 0.88) respectively. Conclusion: Clinical and MRI evaluation of PFMs in older women with UI is feasible. Clinical evaluation of PFMs demonstrated poor strength in 95% of women, and MRI revealed PFM defects in all participants. [ABSTRACT FROM AUTHOR]

Objective: Levator avulsion is a major etiological factor of pelvic organ prolapse (POP) and is primarily diagnosed on tomographic axial plane imaging. Two‐dimensional imaging can also image the levator. The objective was to test reproducibility and validity of coronal plane assessment for diagnosis of levator trauma by assessing the coronal plane obtained on tomographic ultrasound imaging. Methods: A retrospective study of women who had undergone an interview, POPQ and four‐dimensional translabial ultrasound at a tertiary urogynecological unit. Post‐processing of archived volume data was performed for assessment; and levator muscle area and estimate of remnant muscle mass in the coronal plane. Interobserver reproducibility of the latter two measures and associations between various measures of levator trauma and POP were tested. Results: Interobserver agreement was good for percentage estimates (ICC 0.743), but fair for area measurements (ICC 0.482). Six hundred and twenty four women were seen, 468 (75%) had significant clinical prolapse. Full levator avulsions were diagnosed in 137 (22%). Mean TTS was 2.7 (range 0–12). On coronal plane assessment average muscle area was 1.47 (SD 0.76) cm2 and 1.55 (SD 0.74) cm2 on the right and left, respectively (P =.005). It was 76% and 79% for average estimates of muscle mass (P =.021). Both measures were strongly associated with POP; however, they were not superior to TTS in predicting POP. Conclusion: Coronal plane assessment in volume data is reproducible and valid for evaluation of levator trauma. Muscle mass estimate may be a better measure than muscle area. Access the CME test here and search by article title. [ABSTRACT FROM AUTHOR]

The term "fistula in ano" refers to an aberrant track connecting the anal canal with the perineum and is one of the common anorectal disorders.[ 1 ] It is a common disorder that affects both men and women with male predominance and can cause substantial discomfort and pain. Therefore the effective management of a perianal fistula is crucial to avoid complications, including abscess development, incontinence, and recurrence. Identification of the fistula's internal opening, the primary source of cryptoglandular infection, the path of the primary track, and the location of any secondary tracks or abscesses are all crucial for effective fistula care.MRI(Magnetic resonance imaging) of the pelvis is the preferred imaging modality to detect and evaluate perianal fistulas due to its high spatial resolution and multiplanar capabilities, which provide exquisite details of the pelvis. [ABSTRACT FROM AUTHOR]

Background: The levator ani muscle (LAM) is crucial for pelvic floor stability, yet its quantitative MRI assessment is only a recent focus. Our study aims to standardize the quantitative analysis of the LAM morphology within the 3D Pelvic Inclination Correction System (3D-PICS). Methods: We analyzed 35 static MR datasets from nulliparous women examining the pubovisceral (PVM), iliococcygeal (ICM), coccygeal (COC), and puborectal muscle (PRM). The PVM consists of three origin-insertion pairs, namely the puboanal (PAM), puboperineal (PPM) and pubovaginal muscle (PVaM). The analysis included a quantitative examination of the morphology of LAM, focusing on the median location (x/y/z) (x: anterior–posterior, y: superior–inferior, z: left–right) of the origin and insertion points (a), angles (b) and lengths (c) of LAM. Inter-rater reliability was calculated. Results: Interindividual variations in 3D coordinates among muscle subdivisions were shown. In all, 93% of all origin and insertion points were found within an SD of <8 mm. Angles to the xz-plane range between −15.4° (right PRM) and 40.7° (left PAM). The PRM is the largest pelvic muscle in static MRI. The ICC indicated moderate-to-good agreement between raters. Conclusions: The accurate morphometry of the LAM and its subdivisions, along with reliable inter-rater agreement, was demonstrated, enhancing the understanding of normal pelvic anatomy in young nulliparous women. [ABSTRACT FROM AUTHOR]

Background and Objectives: Pelvic floor muscles (PFM) play a core role in defecation and micturition. Weakening of PFM underlies urogynecological disorders such as pelvic organ prolapse and stress urinary incontinence. Vaginal delivery damages PFM. Muscle trauma implies an inflammatory response mediated by myeloid cells, essential for subsequent recovery. Molecular signaling characterizing the pro-inflammatory phase shifts M1 macrophages to M2 macrophages, which modulate muscle repair. The present study aimed to evaluate histological characteristics and the presence of M1 and M2 macrophages in bulbospongiosus (Bsm) and pubococcygeus muscles (Pcm). Materials and Methods: Muscles from young nulliparous (N) and multiparous rabbits on postpartum days three (M3) and twenty (M20) were excised and histologically processed to measure the myofiber cross-sectional area (CSA) and count the centralized myonuclei in hematoxylin-eosinstained sections. Using immunohistochemistry, M1 and M2 macrophages were estimated in muscle sections. Kruskal–Wallis or one-way ANOVA testing, followed by post hoc tests, were conducted to identify significant differences (p < 0.05). Results: The myofiber CSA of both the Bsm and Pcm of the M3 group were more extensive than those of the N and M20 groups. Centralized myonuclei estimated in sections from both muscles of M20 rabbits were higher than those of N rabbits. Such histological outcomes matched significant increases in HLA-DR immunostaining in M3 rabbits with the CD206 immunostaining in muscle sections from M20 rabbits. Conclusions: A shift from the pro- to anti-inflammatory phase in the bulbospongiosus and pubococcygeus muscles of multiparous rabbits matches with centralized myonuclei, suggesting the ongoing regeneration of muscles. [ABSTRACT FROM AUTHOR]

This study presents a comprehensive investigation of the anatomical features of the levator ani muscle. The levator ani is a critical component of the pelvic floor; however, its intricate anatomy and functionality are poorly understood. Understanding the precise anatomy of the levator ani is crucial for the accurate diagnosis and effective treatment of pelvic floor disorders. Previous studies have been limited by the lack of comprehensive three‐dimensional analyses; to overcome this limitation, we analysed the levator ani muscle using a novel 3D digitised muscle‐mapping approach based on layer‐by‐layer dissection. From this examination, we determined that the levator ani consists of overlapping muscle bundles with varying orientations, particularly in the anteroinferior portion. Our findings revealed distinct muscle bundles directly attached to the rectum (LA‐re) and twisted muscle slings surrounding the anterior (LA‐a) and posterior (LA‐p) aspects of the rectum, which are considered functional parts of the levator ani. These results suggest that these specific muscle bundles of the levator ani are primarily responsible for functional performance. The levator ani plays a crucial role in rectal elevation, lifting the centre of the perineum and narrowing the levator hiatus. The comprehensive anatomical information provided by our study will enhance diagnosis accuracy and facilitate the development of targeted treatment strategies for pelvic floor disorders in clinical practice. [ABSTRACT FROM AUTHOR]

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information. [ABSTRACT FROM AUTHOR]

Introduction: Patients without concurrent baseline stress urinary incontinence (SUI) can develop de novo SUI after transvaginal mesh surgery (TVM) for cystocele repair. Surgeons should be aware of de novo SUI risk factors after TVM. Methods: A total of 1124 women who were underwent TVM surgeries were recruited and assessed for eligibility from January 1, 2012 to April 30, 2021. All data related to patients and surgeries was collected, which included general conditions, clinical examination, surgery records, and follow‐up results. Patients were divided into three groups according to follow‐up results and data were compared with each group. The relative risk (RR) of de novo SUI with levator avulsion was also calculated. Results: Three hundred thirty‐six patients were included in this study. They were divided into no complication group (n = 249), de novo SUI group (n = 68), and other complications group (n = 19). It seemed elder or obese women had a higher risk of de novo SUI after TVM (p < 0.05). In de novo SUI group, incidence of levator avulsion before surgery were higher than the other two groups (p = 0.001). TVM can significantly change a prolapse to point Aa and Ba on POP‐Q quantification system (p < 0.05). RR ratios of de novo SUI with unilateral avulsion group is 2.60 (95% confidence interval [CI] 1.39–4.87), and 2.58 (95%CI 0.82–8.15) for bilateral group. Conclusion: Unilateral levator avulsion, instead of bilateral levator avulsion, is a risk factor of de novo SUI after cystocele repair surgery. [ABSTRACT FROM AUTHOR]

Purpose: To review the findings of recent dynamic imaging of the levator ani muscle in order to explain its function during defecation. Historical anatomical studies have suggested that the levator ani initiates defecation by lifting the anal canal, with conventional dissections and static radiologic imagery having been equated with manometry and electromyography. Materials and methods: An analysis of the literature was made concerning the chronological development of imaging modalities specifically designed to assess pelvic floor dynamics. Comparisons are made between imaging and electromyographic data at rest and during provocative manoeuvres including squeeze and strain. Results: The puborectalis muscle is shown distinctly separate from the levator ani and the deep external anal sphincter. In contrast to conventional teaching that the levator ani initiates defecation by lifting the anus, dynamic illustration defecography (DID) has confirmed that the abdominal musculature and the diaphragm instigate defecation with the transverse and vertical component portions of the levator ani resulting in descent of the anus. Current imaging has shown a tendinous peripheral structure to the termination of the conjoint longitudinal muscle, clarifying the anatomy of the perianal spaces. Planar oXy defecography has established patterns of movement of the anorectal junction that separate controls from those presenting with descending perineum syndrome or with anismus (paradoxical puborectalis spasm). Conclusions: Dynamic imaging of the pelvic floor (now mostly with MR proctography) has clarified the integral role of the levator ani during defecation. Rather than lifting the rectum, the muscle ensures descent of the anal canal. [ABSTRACT FROM AUTHOR]

The Radical soft-tissue mobilisation (RSTM) described by J.H. Kelly for bladder exstrophy repair implies a detachment of levator ani muscle insertions from the pelvic wall. The aim of this controlled study was to evaluate the impact of this procedure on subsequent anorectal function. Monocentric controlled study of prospectively collected data of children who underwent RSTM for BEEC from 2010 to 2017. Patients born after 2017 were not included, as they were below the theoretical age of continence acquisition at the time of the study. Anorectal function was assessed using the Childhood Bladder and Bowel Dysfunction Questionnaire, and quality of life (QoL) related to fecal continence using the CINCY FIS questionnaire. The control group was paired on age and sex with a 1:3 patient/control ratio. Answers to questionnaires were collected from September 2021 to January 2022. Univariate statistical analysis comparing two groups and subgroup analysis following age were also performed. During the period of study, 55 children with BEEC underwent Kelly RSTM. Twenty-seven (49%) were included and paired with 81 healthy children on age and sex. Median age at surgery was 15 months [0.5–93] and median follow-up was 10 years [4–13]. Patient's group median age at evaluation was 11 years [5–19]. There was no difference between patients and control group in anorectal function for both incontinence and constipation items. No significant difference was found in QoL related to fecal incontinence assessment. Subgroup analysis did not show difference. This study suggests that the levator ani detachment during Kelly procedure, realised in a paediatric population under the age of 8, did not impact anorectal function with a mid-term follow-up. III. • What is currently known about this topic? The Kelly RSTM can be safely combined with delayed bladder closure in classic bladder exstrophy allowing successful urogenital reconstruction. • What new information is contained in this article? The pelvic floor muscles detachment involved in Kelly procedure does not have detectable consequences on anorectal function. [ABSTRACT FROM AUTHOR]

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Introduction: There is limited evidence about changes in the pelvic floor during active labor. We aimed to investigate changes in hiatal dimensions during the active first stage of labor and associations with fetal descent and head position. Material and methods: We conducted a longitudinal, prospective cohort study at the National University Hospital of Iceland, from 2016 to 2018. Nulliparous women with spontaneous onset of labor, a single fetus in cephalic presentation, and gestational age ≥37 weeks were eligible. Fetal position was assessed with transabdominal ultrasound and fetal descent was measured with transperineal ultrasound. Three‐dimensional volumes were acquired from transperineal scanning at the start of the active phase of labor and in late first stage or early second stage. The largest transverse hiatal diameter was measured in the plane of minimal hiatal dimensions. The levator urethral gap was measured as the distance between the center of the urethra and the levator insertion using tomographic ultrasound imaging. Measurements of the levator urethral gap were made in the plane of minimal hiatal dimensions and 2.5 and 5 mm cranial to this. Results: The final study population comprised 78 women. The mean transverse hiatal diameter increased 12.4% between the two examinations, from 39.4 ± 4.1 mm (±standard deviation) at the first examination to 44.3 ± 5.8 mm at the last examination (p < 0.01). We found a moderate correlation between the transverse hiatal diameter and fetal station at the last examination (r = 0.44, r2 = 0.19; p < 0.01; regression equation y = 2.71 + 0.014x), and a weak correlation between the change in transverse hiatal diameter and change in fetal station (r = 0.29; r2 = 0.08; p = 0.01; regression equation y = 0.24 + 0.012x). Levator urethral gap increased significantly in all three planes on both the left and right sides. Head position was not associated with hiatal measurements after adjusting for fetal station. Conclusions: We found a significant, but only modest, increase of the hiatal dimensions during the first stage of labor. The risk of levator ani trauma will therefore be low during this stage. The change in transverse hiatal diameter was associated with fetal descent but not with head position. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to analyze the sensory and muscle functions of the pelvic floor in women with endometriosis, trying to improve overall knowledge/findings regarding pelvic floor muscle functions in patients with endometriosis. Methods: Sample size calculated as 92 patients with endometriosis, aged between 18 and 45 years, not virgin, without other causes of pain and could not be pregnant. Patients underwent the Pelvic Floor Sensorial and Muscle Function Exam (EFSMAP). Descriptive data were recorded with mean and standard deviation, median (range), and absolute and relative frequency. The Kolmogorov–Smirnov test was used to observe the normality of quantitative variables. The significance level adopted for this study was 5%. Results: Of 92 women assessed, 93.3% had pain and 75% had increased tone in the levator ani muscle; 50.4% had impaired pelvic floor relaxation with median strength of 3 by the Oxford scale and endurance of 2 s. Conclusions: The patients had a high prevalence of pain and dysfunction of the pelvic floor muscles, such as low muscle endurance and difficulty to relax. It shows that these patients should be referred to a pelvic floor physiotherapist, as soon as they have the diagnosis of endometriosis, to be assessed to prevent and/or treat pelvic floor impairments. [ABSTRACT FROM AUTHOR]

Brief Summary : Maternal somatic birth trauma due to vaginal delivery is more common than generally assumed and an important cause of future morbidity. Maternal birth trauma may involve both psychological and somatic morbidity, some of it long-term and permanent. Somatic birth trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle, termed 'avulsion'. This review will focus on recent developments in the imaging diagnosis of maternal birth trauma, discuss the most important risk factors and strategies for primary and secondary prevention. Translabial and exo -anal ultrasound allow the assessment of maternal birth trauma in routine clinical practice and enable the use of levator avulsion and anal sphincter trauma as key performance indicators of maternity services. This is likely to lead to a greater awareness of maternal birth trauma amongst maternity caregivers and improved outcomes for patients, not the least due to an increasing emphasis on patient autonomy and informed consent in antenatal and intrapartum care. [ABSTRACT FROM AUTHOR]

Background and Objectives: Pelvic floor muscles (PFM) play a core role in defecation and micturition. Weakening of PFM underlies urogynecological disorders such as pelvic organ prolapse and stress urinary incontinence. Vaginal delivery damages PFM. Muscle trauma implies an inflammatory response mediated by myeloid cells, essential for subsequent recovery. Molecular signaling characterizing the pro-inflammatory phase shifts M1 macrophages to M2 macrophages, which modulate muscle repair. The present study aimed to evaluate histological characteristics and the presence of M1 and M2 macrophages in bulbospongiosus (Bsm) and pubococcygeus muscles (Pcm). Materials and Methods: Muscles from young nulliparous (N) and multiparous rabbits on postpartum days three (M3) and twenty (M20) were excised and histologically processed to measure the myofiber cross-sectional area (CSA) and count the centralized myonuclei in hematoxylin-eosinstained sections. Using immunohistochemistry, M1 and M2 macrophages were estimated in muscle sections. Kruskal–Wallis or one-way ANOVA testing, followed by post hoc tests, were conducted to identify significant differences (p < 0.05). Results: The myofiber CSA of both the Bsm and Pcm of the M3 group were more extensive than those of the N and M20 groups. Centralized myonuclei estimated in sections from both muscles of M20 rabbits were higher than those of N rabbits. Such histological outcomes matched significant increases in HLA-DR immunostaining in M3 rabbits with the CD206 immunostaining in muscle sections from M20 rabbits. Conclusions: A shift from the pro- to anti-inflammatory phase in the bulbospongiosus and pubococcygeus muscles of multiparous rabbits matches with centralized myonuclei, suggesting the ongoing regeneration of muscles.

Introduction and hypothesis: This study aimed to compare the difference in levator ani muscle (LAM) volumes between 'normal' and those with sonographically visualized LAM defects. We hypothesized that the 'muscle damage' group would have a significantly lower muscle volume. Methods: The study included patients who had undergone a 3D endovaginal ultrasound. The normal (NM) and damage (DM) muscle groups' architectural changes were evaluated based on anterior-posterior (AP), left-right (LR) diameter, and minimal levator hiatus (MLH) area. The puboanalis-puboperinealis (PA), puborectalis (PR), and pubococcygeus-iliococcygeus (PC) were manually segmented using 2.5 vs. 1.0 mm to find the optimal sequence and to compare the volumes between NM and DM groups. POPQs were compared between the NM and DM groups. Results: The 1.0-mm segmentation volumes created superior volume analysis. Comparing NM to the DM group showed no significant difference in LAM volume. Respectively, the mean total LAM volumes were 17.27 cm3 (SD = 3.97) and 17.04 cm3 (SD = 4.32), p = 0.79. The mean MLH measurements for both groups respectively were 10.06 cm2 (SD = 2.93) and 12.18 cm2 (SD = 2.93), indicating a significant difference (p = 0.01). POPQ analysis demonstrated statistically significant differences at Ba and Bp parameters suggesting that the DM group had worse prolapse (p = 0.05, 0.01, respectively). Conclusions: While LAM volumes are similar, there is a significant difference in the physical architecture of the LAM and the POPQ parameters in muscle-damaged patients compared to the normal group. [ABSTRACT FROM AUTHOR]

Objective: To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP).Methods: This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression.Results: Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva.Conclusion: Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: To assess the prevalence of pelvic floor and anal sphincter trauma in women after assisted vaginal delivery., Methods: Retrospective study on 201 primiparous women after assisted vaginal delivery, control group 43 women after normal vaginal delivery. 4D translabial ultrasound examination of the levator ani and the anal sphincter was performed according to standard methodology at least 3 months postpartum. Ultrasound classification of trauma was performed by two independent evaluators blinded to clinical data. A third evaluator was asked to confirm findings in case of discrepancy., Results: The LAM avulsion rate for normal delivery was 20.9%, for forceps 60%, for vacuum extraction 21.7% Odds ratio for forceps vs. NVD was 4.32 (1.69, 11.01), for vacuum vs. NVD 0.98 (0.409, 2.327). Ultrasound OASI rate was 33.3% for Forceps and 30.50% for Vacuum. This equated to an OR of 1.78 (0.85 - 3.10) for Forceps and 1.62 (0.85-3.10) for Vacuum relative to NVD., Conclusions: Our data confirm forceps as the major risk factor for levator avulsion. Forceps also implies a non-significantly higher risk of OASI compared to NVD., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction and hypothesis: The objective was to evaluate the agreement between 2D and 4D translabial ultrasound (TLUS) technique in showing levator ani muscle (LAM) states after vaginal birth. Methods: In a prospective observational cohort study between March 2017 and April 2019 we evaluated LAM states (intact, hematoma, partial, complete avulsion) of primiparous women having given birth vaginally with singletons in vertex presentation ≥ 36+0 gestational weeks by using 2D and 4D TLUS within 1–4 days postpartum (assessment A1) and again 6–10 weeks postpartum (assessment A2). Cohen's Kappa analysis was performed for each side separately to evaluate the test agreement between the two ultrasound techniques at every assessment period. Results: A total of 224 women participated at A1 and 213 at A2. The agreement between the two ultrasound techniques was good to very good at A1 (Cohen's kappa right-sided 0.78, left-sided 0.82) and very good at A2 (Cohen's kappa both sides 0.88). The agreement was best when assessing an intact LAM or a complete avulsion (Cohen's kappa between 0.78–0.92 for complete avulsions). Conclusions: The comparison between 2D and 4D TLUS showed a good to very good agreement in LAM trauma immediately after birth as well as 6–10 weeks postpartum. Therefore, 2D ultrasound could also be a valuable method for demonstrating a LAM abnormality and could be used in settings where 3D/4D ultrasound equipment is not available. [ABSTRACT FROM AUTHOR]

Aim: To identify the anatomical morphology of levator ani (LA) in primigravidae at term pregnancy and its natural process of changing after delivery. Methods: Forty‐one primigravidae (vaginal delivery: 29 women, cesarean delivery in the first stage of labor: 12 women) underwent magnetic resonance imaging (MRI) at full‐term pregnancy, 6 weeks and 10 months postpartum. Three‐dimensional (3‐D) model of LA created from MRI data using Mimics v.21.0 software and source images were assessed to determine the morphology. LA volume (LVOL) was calculated and used as indicator of muscle atrophy. Results: Decrease of levator hiatus length (LH‐L) was shown in both groups since 6 weeks postpartum. In the vaginal delivery group, the differences in LVOL between time points were significant (p < 0.05), showing a persistent decreasing tendency. Puborectalis attachment width (PAW) on the left was the smallest at 6 weeks postpartum (p < 0.05). LA avulsion and significant 2‐D morphological change after delivery were only observed in this group (p < 0.05); In the cesarean section group, smaller LVOL was found at 6 weeks postpartum comparing with full‐term pregnancy (p < 0.05); Larger levator‐symphysis gap (LSG) and levator hiatus width (LH‐W), smaller PAW were observed in vaginal delivery group comparing with cesarean section group at 6 weeks postpartum (p < 0.05), but none of the values exhibited between‐group differences (p > 0.05) at 10 months postpartum. No other comparisons were considered significant (p >0.05). Conclusions: Vaginal delivery, or even active labor itself may both lead to LA atrophy. And the morphology of LA is basically similar in different delivery modes at 10 months postpartum once the onset of labor has occurred, even though it changes more complicatedly after vaginal delivery. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The objective was to investigate the evolution of levator ani muscle (LAM) trauma over the first 9 months after birth and to evaluate their agreement between different assessment periods. Methods: From March 2017 to April 2019 we prospectively evaluated LAM states (intact, hematoma, partial or complete avulsion) of primiparous women after vaginal birth by using 4D translabial ultrasound (TLUS) at three different assessment periods. All women were examined 1–4 days (A1) and 6–10 weeks (A2) postpartum, and women with a trauma additionally 6–9 months postpartum (A3). Cohen's Kappa analysis was performed to evaluate the test agreement between the assessment periods. Results: Thirty-two percent of the women at A1 had a LAM trauma and 24% at A2. The higher number of LAM injuries at A1 can be explained by hematomas (14%), of which 51% spontaneously resolved at A2, 35% revealed themselves as partial, and 12% as complete avulsions. At A3, we observed anatomical improvement from complete to partial avulsions (23%) and few partial avulsions changed into an intact LAM (3%); none of the complete avulsions changed into an intact LAM. The agreement of 4D TLUS between A1 and A2 was moderate to good (0.64 for the right-sided LAM/0.60 for the left-sided LAM) and between A2 and A3 good to very good (0.76 right-sided/0.84 left-sided). Conclusions: Levator ani muscle trauma can reliably be diagnosed during all assessment periods. However, the agreement between A1 and A2 was only moderate to good. This can be explained by hematomas inside the LAM that were only observed early postpartum. We observed some anatomical improvement at A3, but no complete avulsion improved to an intact LAM. [ABSTRACT FROM AUTHOR]

Background: Urinary continence (UC) recovery dramatically affects quality of life after robot‐assisted radical prostatectomy (RARP). Membranous urethral length (MUL) has been the most studied anatomical variable associated with UC recovery. Objective: To investigate whether levator ani thickness (LAT), assessed with multi‐parametric magnetic resonance imaging (mpMRI), correlates with UC recovery after RARP. Design, Setting, and Participants: The study included 209 patients treated with RARP by expert surgeons with extensive robotic experience from 2017 to 2019. All patients had complete, clinical, mpMRI, pathological, and postoperative data including pelvic floor muscle training (PFMT) protocols. Intervention: After a radiologist‐specific training, two urologists independently examined the files, blinded to clinical and pathological findings as well as to postoperative continence status. Outcome Measurements and Statistical Analysis: On mpMRI, LAT, bladder neck (BN) shape, MUL, and apex overlapping (AO) were measured. UC recovery was defined as use of 0 or 1 safety pad at follow‐up. Multivariable models were used to assess the association between variables and UC recovery. Results and Limitations: Overall, 173 (82.8%) patients were continent after a median follow‐up of 23 months (interquartile range [IQR]: 17–28). Of these, 98 (46.9%) recovered within 3 months after surgery, 42 (20.1%) from 3 to 6 months, and 33 (15.8%) from 6 months onwards. A significant higher rate of patients with LAT > 10 mm (88.1 vs.75.8%; p = 0.03) experienced UC recovery, compared to those with LAT < 10 mm. This difference was observed in the first 3 months after surgery. At multivariable analysis, LAT (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02–1.37; p = 0.02), Preoperative ICIQ score (OR: 0.91, 95% CI: 0.82–0.98, p = 0.03) and PFMT (OR: 1.98, 95% CI: 1.01–3.93; p = 0.04) independently predict higher UC recovery within 3 months, after accounting for age, BMI, preoperative PSA, D'Amico risk group, MUL, BN shape and AO. Conclusions: LAT greater than 1 cm was associated with greater UC recovery. Specifically, LAT greater than 1 cm seems to be associated with higher UC rate at 3 months after RARP, compared to those with LAT < 1 cm. Patient Summary: Magnetic resonance features can help in predicting the risk of incontinence after robot‐assisted radical prostatectomy and should be taken into account when counseling patients before surgery. [ABSTRACT FROM AUTHOR]

Introduction: The levator ani (LA) complex in high-type imperforate anus (H-IA), low-type imperforate anus (L-IA), and Hirschsprung's disease (HD) patients as controls were documented using magnetic resonance imaging (MRI) and compared for symmetry. Materials and methods: Mean left:right LA thickness ratio (LA ratio), and deviation of the LA from the pubococcygeal line (PCL; LA angle) were calculated from thin-slice MRI images (axial 2 mm, coronal 2 mm, and sagittal 3 mm) of the puborectalis and pubococcygeus taken parallel to the PCL under sedation in H-IA (n=14), L-IA (n=16), and HD (n=9). Results: MRI scans were performed between January 2018 and June 2021. LA were significantly thinner in H-IA (1.78±0.46 mm) compared with L-IA (2.97±0.55 mm) and controls (2.87±0.32 mm), p<0.0001. LA ratio was significantly lower in H-IA (0.71±0.15) compared with L-IA (0.93±0.04), and controls (0.91±0.06), p<0.0001. Mean LA-angle was significantly different in H-IA, 10.8° (range 6°–19°), versus L-IA and controls, both zero degrees (range 0°–5°), p<0.0001, respectively. Conclusions: LA was confirmed to be significantly asymmetric in H-IA. Because outcome of surgical repair involving a midline incision, such as posterior sagittal anorectoplasty could be impaired, pediatric surgeons are advised to plan surgical intervention for H-IA carefully and appropriately. [ABSTRACT FROM AUTHOR]

Background and Aim: Ultrasonography (USG) is useful for non-invasively identifying changes that occur in soft tissue architecture. The objective of this research was to demonstrate postpartum (PP) uterine involution through the changes of perineal muscle intensity and thickness in Madura beef cow by ultrasonography. Materials and Methods: Madura's breed cows used in the research consist of eight non-pregnant (NP) cows and three PP cow. The transrectal and transperineal USG imaging of NP cows was performed on days 1, 33, and 65. USG imaging of PP cows was performed every day starting from day 1 (24 h after parturition) until day 21 PP. Transrectal USG of the reproductive tract was performed for the cervix, corpus uteri, and cornua uteri. USG was performed transcutaneously over the perineal area for coccygeus and levator ani muscles at the longitudinal and transverse angles. Reproductive tract diameter and perineal muscle intensity and thickness were measured with ultrasound imaging. Results: The analysis of the sonogram of PP cows showed that the diameter of the cervix, corpus uteri, and cornua uteri decreased within 21 days PP. The transverse view of the coccygeus muscle of PP cows showed decreased muscle intensity and thickness. On the other hand, the longitudinal view showed increased coccygeus muscle intensity and thickness. The transverse view of the coccygeus muscle of NP cows showed increased muscle intensity, while muscle thickness was reduced. Sonogram analysis of the levator ani muscle of PP cows showed decreased muscle intensity with increasing muscle thickness. However, imaging of the levator ani muscle of NP cows showed a decrease in both intensity and muscle thickness. There was a significant difference in the mean value intensity of the scanning view analysis results of the levator ani muscle of the PP cow (523.6 AU increased to 672.1 AU) and the NP cow (515.9 AU decreased to 465.4 AU). Furthermore, there was a significant difference (p

Pelvic Organ Prolapse (POP) is defined as the descent of the pelvic viscera (uterus, bladder, urethra, and rectum) from its normal position. There are different stages of POP starting from early asymptomatic until late obvious symptomatic stages. Levator Anal Muscle (LAM) which plays an important part in POP pathogenesis, showed that there was difference in Levator Hiatal (LH) area and anteroposterior length on every grade of POP. It is important to determine early diagnose of asymptomatic POP clinically by anteroposterior length measurement, and determined its relation with LH area measurement using Ultrasound (US) imaging. To compare LH area and anteroposterior length between POP subject with and without bulging symptom. A cross-sectional study was conducted among women diagnosed as POP with and without bulging symptom in a Urogynecology Clinic between November 2019 to March 2021. Patients were examined using the POP-Q system and 3D/4D imaging of the LH area using Voluson type systems. Data were analyzed to compare LH area and anteroposterior length between groups. A total of 109 subjects were included in this study. There was a significance difference in LH area (28.9+5.59 cm2 vs 19.6+4.63 cm2, p < 0.05 during valsalva maneuver, 15.2+4.08 cm2 vs 12.5+3.15 cm2, p

Dissection reveals elegant simplicity in pelvic floor structure. So, why are so many of us confused about the pelvic floor? The pelvic floor is in an invisible region between what we see from above and below, so our experience does not help. It is confusing because there is conflict between existing illustrations, so we do not know which are false and which are true. To resolve conflicts in pelvic anatomy we must: recognize the Vesalian principle that truth lies in the body, not necessarily in books; commit to focusing on structures rather than words; and overcome "theory-induced blindness," the psychological principle that discounts what is seen when it contradicts a theory we believe. We should revive century-old standards that require accuracy in anatomical illustration analogous to the p value in statistics. Committing to anatomical accuracy will ensure that we no longer navigate in surgery and research using a flawed map. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate and validate the safety and efficacy of modified laparoscopic sacrocolpopexy for advanced posterior vaginal wall prolapse at up to 3 years of follow-up., Material and Methods: As a prospective observational study, we collected 56 cases with advanced posterior vaginal wall prolapse and performed modified laparoscopic sacrocolpopexy (MLSC) with self-cut mesh. The main improvement is the cutting and fixing of the mesh. Patients were followed up at 6, 12, 24 and 36 months. The main indicators of follow-up were postoperative anatomic success rate and Pelvic organ prolapse quantitation (POP-Q) score, and secondary indicators were related to quality-of-life scales and postoperative complication rates., Results: All patients completed the operation through minimally invasive surgery, and there were no vital organs and blood vessel damage during the operation. The mean age was (58.32 ± 7.63) years. There was no recurrence of stage I or lower during the follow-up maximum of 36 months (median 24 months), and the anatomic success rate was 100%. The quality-of-life scores improved significantly (p < 0.001) and the quality of sexual life was not affected (p = 0.5). There was 1 case of continuous vaginal mesh exposure at 12 months (2.86%) and 1 case of severe infection with poor healing of vaginal stump within 6 months (1.79%). No one had urinary incontinence (UI) requiring reoperation., Conclusions: In patients with advanced posterior vaginal wall prolapse, MLSC can provide good and durable pelvic floor anatomical recovery and functional outcomes with no specific complications.

Pelvic Organ Prolapse (POP) is defined as the descent of the pelvic viscera (uterus, bladder, urethra, and rectum) from its normal position. There are different stages of POP starting from early asymptomatic until late obvious symptomatic stages. Levator Anal Muscle (LAM) which plays an important part in POP pathogenesis, showed that there was difference in Levator Hiatal (LH) area and anteroposterior length on every grade of POP. It is important to determine early diagnose of asymptomatic POP clinically by anteroposterior length measurement, and determined its relation with LH area measurement using Ultrasound (US) imaging. To compare LH area and anteroposterior length between POP subject with and without bulging symptom. A cross-sectional study was conducted among women diagnosed as POP with and without bulging symptom in a Urogynecology Clinic between November 2019 to March 2021. Patients were examined using the POP-Q system and 3D/4D imaging of the LH area using Voluson type systems. Data were analyzed to compare LH area and anteroposterior length between groups. A total of 109 subjects were included in this study. There was a significance difference in LH area (28.9+5.59 cm² vs 19.6+4.63 cm², p < 0.05 during valsalva maneuver, 15.2+4.08 cm² vs 12.5+3.15 cm², p <0.05 during contraction) and anteroposterior length (8.6+1.06 cm, vs 6.8+1.13 cm, p<0.05) between groups with and without bulge symptom. LH area and anteroposterior length cut-off to differentiate between subject with and without bulging symptom was respectively 25,1 cm² [sensitivity 84,6%, specificity 92,9%, AUC 0,925 (0,864-0,986)] and 7,75 cm [sensitivity 87,2%, specificity 77,1%, AUC 0,859 (0,787-0,932)]. In patient without bulging symptom there was a significant difference of anteroposterior length between prolapse stage 1, 2, and 3. Post hoc analysis with Tukey test showed a significant difference of anteroposterior length only between grade 0 and 2, and grade 1 and 2. There was a significant difference in LH area and anteroposterior length between groups with and without bulging symptom. LH area cut-off at 25,1 cm², anteroposterior length cut-off at 7.75 cm showed good sensitivity and specificity to differentiate between 2 groups. [ABSTRACT FROM AUTHOR]

Objective: To determine whether all three components of the levator ani muscle (pubovisceral [= pubococcygeal], puborectal and iliococcygeal) and the external anal sphincter are equally affected by oedema associated with muscle injury after vaginal birth. Design: Observational cross‐sectional study. Setting: Michigan Medicine, University of Michigan. Population: Primiparous women classified as high risk for levator ani muscle injury during childbirth. Method: MRI scans obtained 6–8 weeks postpartum were analysed. Muscle oedema was assessed on axial and coronal fluid‐sensitive magnetic resonance (MRI) scans. Presence of oedema was separately determined in each levator ani muscle component and in the external anal sphincter for all subjects. Descriptive statistics and correlation with obstetric variables were obtained. Main outcome measures: Oedema score on fluid‐sensitive MRI scans. Results: Of the 78 women included in this cohort, 51.3% (n = 40/78) showed muscle oedema in the pubovisceral (one bilateral avulsion excluded), 5.1% (n = 4/78) in the puborectal and 5.1% (n = 4/78) in the iliococcygeal muscle. No subject showed definite oedema on external anal sphincter. Incidence of oedema on the pubovisceral muscle was seven times higher than on any of the other analysed muscles (all paired comparisons, P < 0.001). Conclusions: Even in the absence of muscle tearing, the pubovisceral muscle shows by far the highest incidence of injury, establishing that levator components are not equally affected by childbirth. External anal sphincter did not show oedema—even in women with sphincter laceration— suggesting a different injury mechanism. Developing a databased map of injured areas helps understand injury mechanisms that can guide us in honing research on treatment and prevention. Injury‐associated levator ani muscle and anal sphincter oedema mapping on MRI reveals vulnerable muscle components after childbirth. Injury‐associated levator ani muscle and anal sphincter oedema mapping on MRI reveals vulnerable muscle components after childbirth. [ABSTRACT FROM AUTHOR]

Background: Puborectalis muscle rupture usually arises from peri-partum perineal trauma and may result in anterior, middle compartment prolapses, posterior compartment prolapse which includes rectocele and rectal prolapse, with or without associated anal sphincter damage. Patients with puborectalis muscle and levator ani rupture may present some form of incontinence or evacuation disorder, sexual dysfunction or pelvic organ descent. However, the literature on this subject is scarce. The aim of our study was to evaluate management and treatment of functional disorders associated with puborectalis and/or pubococcygei rupture at the level of the insertion in the pubis in a cohort of patients referred to a tertiary care coloproctology center. Methods: We conducted a prospective cohort study of patients with levator ani and puborectalis muscle avulsion in the Proctology and Pelvic Floor Unit, Division of Digestive Surgery of the University Hospitals of Geneva from January 2001 to November 2018. Clinical examination, anoscopy and ultrasound were performed on a routine basis. Rupture of the levator ani muscle was diagnosed by clinical examination and ultrasound. A Wexner incontinence score was completed before and 6 months after surgery. Levator ani muscle repair was performed using a transvaginal approach. Results: Fifty-two female patients (median age 56 ± 11.69 SD years, range 38–86 years) were included in the study. Thirty-one patients (59.6%) had anal incontinence, 25 (48.1%) urinary incontinence, 28 (53.9%) dyschezia (obstructive defecation or excessive straining to defecate), 20 (38.5%) dyspareunia, 17 (32.7%) colpophony, and 13 (25.0%) impaired sensation during sexual intercourse. Deviation of the anus on the side opposite the lesion was observed in 50 patients (96.2%), confirmed with clinical examination and both endoanal and perineal ultrasound. Out of these 52 patients, levator ani rupture (including puborectalis rupture) were categorized into right sided, 43 (82.69%), left sided, 7 (13.46%) and bilateral, 2 (3.85%). Levator ani muscle repair was performed in all patients, associated with posterior repair and levatorplasty in 26 patients (50%) and with sphincteroplasty in 34 patients (63.4%). Four patients (7.7%) experienced postoperative complications: significant postoperative pain (n = 3; 5.77%), urinary retention (n = 2; 3.85%), hematoma (n = 1; 1.92%), and perineal abscess (n = 1; 1.92%). Forty-one patients (78.8%) had full restoration of normal puborectalis muscle function (Wexner score: 0/20) after surgery, and overall, all patients had an improvement in the Wexner score and in sexual function. Dyschezia was reported by 28 patients (53.9%) preoperatively, resolved in 18 (64.3%) and improved by 50% or more in 10 (35.71%). Conclusions: Diagnosis of levator ani and puborectalis muscle rupture requires careful history taking, clinical examination, endoanal and perineal ultrasound. Surgical repair improved anal continence as well as sexual function in all patients. Transvaginal levator ani repair seems to be well tolerated with good short-term results. [ABSTRACT FROM AUTHOR]

Urinary incontinence is a bothersome situation to the ailing woman. Many times, the woman does not come to medicos due to shyness, and if she comes also she does not reveal all the information. Hence, a sympathetic and structured approach will help to provide judicious management to these women. When a woman with the complaint of urinary incontinence approaches us, we should collect maximum information with the help of structured questionnaire and protocol. Structured questionnaire provides most of the information pertinent to the urinary incontinence. Associated medical disorders are also looked for. Past obstetrical performance can have implication on this ailment. Pelvic organ prolapse, mass lower abdominal, etc., also can lead to urinary incontinence. Adverse effect of some medicines causes urinary incontinence. During general physical examination, attention has to be paid toward body mass index, joint hypermobility, spine, etc. During local examination, stress test, Bonney test, Q-tip test, etc., may help to some extent. The levator ani muscle is assessed of its strength. Neurological evaluation is to be done for all the patients with urinary incontinence. Urinary culture and sensitivity are routinely done. Once urinary infection is ruled out, then the woman is subjected to frequency/volume diary, ultrasonography, urodynamic study, cystoscopy, etc., depending on the necessity. A systematic approach to urinary incontinence will provide the best comfort to these ailing women.

Introduction and hypothesis: The term 'maternal birth trauma' has undergone substantial changes in meaning over the last 2 decades. Leaving aside psychological morbidity, somatic trauma is now understood to encompass not just episiotomy, perineal tears and obstetric anal sphincter injuries (OASI), but also trauma to the levator ani muscle. This review covers diagnosis of maternal birth trauma by translabial ultrasound imaging. Methods: Narrative review. Results: Tomographic imaging of pelvic structures with the help of 4D ultrasound, used since 2007, has allowed international standardization and seems to be highly reproducible and valid for the diagnosis of OASI and levator avulsion. Conclusions: Translabial and exo-anal ultrasound allows the assessment of maternal birth trauma in routine clinical practice and the utilization of avulsion and sphincter trauma as key performance indicators of maternity services. It is hoped that this will lead to a greater awareness of maternal birth trauma among maternity caregivers and improved outcomes for patients, both in the short term and in the decades to come. [ABSTRACT FROM AUTHOR]

Introduction: One of the functions of the pelvic floor muscles (PFM) is to support the pelvic organs and continence. This continence mechanism tends to change when PFM are exposed to high-impact exercises. Objetives: To describe the dynamic changes in the pelvic floor (PF) in elite nulliparous athletes. Methods: Translabial two and three-dimensional ultrasound was used to assess PF anatomy and function in athletes (n=8). This ultrasonography was performed after voiding and in the supine position, using a vaginal probe. The descent of the pelvic organs was assessed on a maximum Valsalva maneuver, whilst the volume datasets were acquired at rest, during maximum voluntary contraction (MVC) and during a Valsalva maneuver. The athletes performed each maneuver at least 3 times, with the most effective being used for evaluation. Results: The bladder neck descent was 14 mm for the javelin thrower, being the highest value when compared to the remaining participants. Three athletes featured the rectocele (swimming, gymnastics and javelin throw) and 4 participants presented a paravaginal defect (volleyball, horsemanship, javelin throw and printer). The volleyball athlete had the highest value of the levator hiatal area in MVC value. Conclusions: The athletes present minimal differences in the evaluated parameters. The sample is small to generalize the results, but there is a tendency for athletes of high-impact exercises to have a lower CMV value. Further studies are needed to corroborate these results.

Introduction and hypothesis: Vaginal flatus is an embarrassing condition that can impair women's quality of life. The underlying pathophysiology is unclear. We aimed to evaluate the association between vaginal flatus and pelvic floor anatomy. Methods: Retrospective observational study on women seen in a tertiary urogynaecological service. All had undergone a standardised interview, clinical examination and four-dimensional transperineal ultrasound. Offline analysis of volume data was performed blinded against clinical data. Results: Datasets of 570 women were analysed. Five hundred twelve (90%) were vaginally parous. Vaginal flatus was reported by 190 (33%). Mean bother score was 4.2 (SD 3.4, range 0–10). One hundred eighty-five reported frequency of vaginal flatus: it occurred < once a month in 25 (14%), once a month in 70 (38%), once a week in 47 (25%), once daily in 28 (15%) and > once daily in 15 (8%). One hundred two women identified the following precipitating factors: intercourse in 72 (71%), postural change in 22 (22%) and physical activities in 9 (9%). Vaginal birth, central and posterior compartment prolapse, anal incontinence, higher levator resting tone and younger age were associated with vaginal flatus. The latter was moderately correlated with symptom bother (correlation coefficient − 0.21). Conclusions: Vaginal flatus is a prevalent and bothersome condition affecting one-third of our study population. The condition is associated with pelvic floor functional anatomy. A higher resting tone may confer a higher resistance against which trapped air is expelled during physical activities. Younger age was moderately correlated with symptom bother. [ABSTRACT FROM AUTHOR]

Introduction: Visible birth tears and levator ani muscle (LAM) trauma are common after birth. For the diagnosis of LAM trauma ultrasound evaluation is advisable. As ultrasound equipment and trained personnel are not available everywhere at all times, we aimed to evaluate whether specific overt birth tears are an indicator for LAM trauma. Methods: In a prospective cohort study at our center from March 2017–April 2019, we evaluated vaginal births of nulliparous women with singletons in vertex presentation ≥ 36 + 0 gestational weeks for LAM trauma by translabial ultrasound and for overt birth tears by inspection. We then calculated the association of overt birth tears with complete LAM avulsion. Results: Of 213 women, 23.9% had any kind of LAM trauma, with 14.1% being complete avulsions. In univariate analysis, solely high-grade perineal tears (OASIS) were significantly associated with complete LAM avulsions. Conclusions: Fourteen percent of women suffered a complete LAM avulsion after vaginal birth, with OASIS being the only associated parameter of significance. The occurrence of such trauma might be an indicator for a mismatch between the size of the fetus and the structures of the birth canal, leading to birth trauma. Assessing for LAM trauma by translabial ultrasound in women with OASIS might be worthwhile. [ABSTRACT FROM AUTHOR]