title: Agreement between palpation and transperineal and endovaginal ultrasound in the diagnosis of levator ani avulsion.
abstract: OBJECTIVE
  Our aim was to estimate agreement between transperineal and endovaginal ultrasound in assessing levator ani biometry and avulsion in nullipara and primipara women and determine agreement between levator avulsion palpation and ultrasound.
  
  
  METHODS
  This longitudinal cohort study assessed 269 nullipara women at 36 weeks gestation and 191 primipara women 13 weeks postpartum. Women underwent levator palpation, and avulsion was diagnosed if no attachment to the pubic bone was felt. Subsequently, 3/4D transperineal and 3D endovaginal ultrasound were performed. A standardized protocol was used to perform measurements at rest. Levator avulsion was diagnosed on endovaginal ultrasound at rest if >50 % was avulsed and on transperineal tomographic ultrasound imaging at maximum contraction if the central three slices were avulsed. Levator avulsion was analyzed by two independent, blinded investigators. A third investigator resolved discrepancies. Intraclass correlation coefficient and limits of agreement were calculated for each time point.
  
  
  RESULTS
  Intraclass correlation coefficient for levator urethra gap was 0.44-0.54, hiatus area 0.76-0.79, transverse diameter 0.51-0.59, anteroposterior diameter 0.70-0.72. Levator thickness correlated poorly. Endovaginal ultrasound measurements were generally smaller; however limits of agreement were acceptable for hiatus measurements. Overall agreement between both ultrasound techniques in diagnosing levator avulsion was 95 %; correlation 0.72 [95 % confidence interval (CI) 0.67-0.76]. Agreement between palpation and transperineal ultrasound was 92 % (kappa = 0.34), and between palpation and endovaginal ultrasound was 92 % (kappa = 0.37).
  
  
  CONCLUSIONS
  Transperineal and endovaginal ultrasound can both be used to analyze hiatus area and anteroposterior diameter with the patient at rest and to diagnose levator avulsion. Palpation correlates only fairly with both methods.
authors.affiliation: Department of Obstetrics and Gynaecology, Croydon University Hospital, Urogynaecology and Pelvic Floor Reconstruction Unit.530 London Road, Croydon, CR7 7YE, UK.
authors.forename: Kim W M
authors.initials: KW
authors.lastname: van Delft
authors.forename: Abdul H
authors.initials: AH
authors.lastname: Sultan
authors.forename: Ranee
authors.initials: R
authors.lastname: Thakar
authors.forename: S Abbas
authors.initials: SA
authors.lastname: Shobeiri
authors.forename: Kirsten B
authors.initials: KB
authors.lastname: Kluivers
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D010173:Palpation; D017773:Pelvic Floor / Q000293:injuries*; D059952:Pelvic Floor Disorders / Q000000981:diagnostic imaging*; D011247:Pregnancy; D011446:Prospective Studies; D014463:Ultrasonography / Q000379:methods; D055815:Young Adult