title: Does levator ani injury affect cystocele type?
abstract: OBJECTIVE
  To determine the prevalence of levator ani injury in patients with different types of cystocele, as defined by translabial ultrasound, in order to shed light on potential pathophysiological mechanisms.
  
  
  METHODS
  The datasets of 222 women who had undergone a physical examination, urodynamic testing and four-dimensional (4D) pelvic floor ultrasound were evaluated offline for prolapse, levator ani hiatal dimensions and levator ani trauma using tomographic ultrasound imaging (TUI), blinded against all clinical and urodynamic data. Cystoceles reaching below the symphysis pubis on ultrasound examination were classified based on bladder neck position, retrovesical angle (RVA) and urethral rotation as Green II (cystourethrocele) or Green III (cystocele with intact RVA).
  
  
  RESULTS
  Of 102 women who had a cystocele reaching below the symphysis pubis, 63 were classified as a Green type II cystocele and 39 as a Green type III cystocele. Women with Green type III cystoceles were older (59.4 vs. 48.7 years, P < 0.001), and had more severe prolapse (71 vs. 43%, P = 0.004) and objective voiding dysfunction (39 vs. 18%, P = 0.018). Women with Green III cystoceles also had larger hiatal dimensions and were more often diagnosed with an avulsion of the levator ani muscle (69 vs. 35%, P = 0.001).
  
  
  CONCLUSIONS
  A cystocele with an intact RVA is more likely to be associated with avulsion injury of the levator ani muscle and thus more likely to be caused by birth-related trauma. This contradicts the commonly held belief that such cystoceles are caused by central rather than by lateral fascial defects.
authors.affiliation: Department of Obstetrics and Gynecology, Sheba Medical Centre, Tel Hashomer, Israel. veredeis@bezeqint.net
authors.forename: V H
authors.initials: VH
authors.lastname: Eisenberg
authors.forename: V
authors.initials: V
authors.lastname: Chantarasorn
authors.forename: K L
authors.initials: KL
authors.lastname: Shek
authors.forename: H P
authors.initials: HP
authors.lastname: Dietz
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001003:Anal Canal / Q000000981:diagnostic imaging / Q000293:injuries*; D052858:Cystocele / Q000000981:diagnostic imaging* / Q000209:etiology; D005260:Female; D006801:Humans; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000000981:diagnostic imaging / Q000293:injuries; D007744:Obstetric Labor Complications / Q000000981:diagnostic imaging*; D011247:Pregnancy; D014463:Ultrasonography; D014549:Urinary Incontinence / Q000000981:diagnostic imaging* / Q000209:etiology; D014596:Uterine Prolapse / Q000000981:diagnostic imaging* / Q000209:etiology; D055815:Young Adult