title: Does the prevalence of levator ani muscle avulsion differ when assessed using tomographic ultrasound imaging at rest vs on maximum pelvic floor muscle contraction?
abstract: OBJECTIVE
  It has been suggested that transperineal ultrasound images obtained during maximum pelvic floor muscle contraction improve the diagnosis of levator ani muscle (LAM) avulsion by comparison with those obtained at rest. The objective of this study was to establish, using transperineal tomographic ultrasound imaging (TUI), the correlation between LAM avulsion diagnosed at rest and that on contraction.
  
  
  METHODS
  Primiparous women were examined 3 months postpartum by Pelvic Organ Prolapse Quantification (POP-Q) assessment and for LAM avulsion clinically by digital palpation and by transperineal TUI performed at rest and on pelvic floor muscle contraction. LAM avulsion was diagnosed on TUI when the three central slices were abnormal. A comparison was made between LAM avulsion diagnosed at rest and on maximum contraction. Two independent blinded investigators performed the analyses and a third investigator resolved discrepancies.
  
  
  RESULTS
  One hundred and ninety primiparae were analyzed providing 380 results for comparison, as right and left LAM were analyzed independently. LAM avulsion was found in 36 (9.5%) images obtained at rest and in 35 (9.2%) on contraction, revealing moderate correlation between the two (ICC, 0.58 (95% CI, 0.51-0.64)). Twenty-two cases of LAM avulsion were identified both at rest and on contraction. One woman had LAM avulsion on palpation, which was seen on TUI as LAM avulsion on contraction, but not at rest. More cases of anterior and posterior compartment prolapse were found in women with LAM avulsion diagnosed on contraction only compared to LAM avulsion observed at rest only (POP-Q assessment point Ba, -1.8 vs -2.5 (P = 0.075) and point Bp, -2.5 vs -2.8 (P = 0.072)).
  
  
  CONCLUSIONS
  Findings on transperineal TUI performed in women at rest and on contraction correlate reasonably well. However, given the trend towards an association with signs of pelvic floor dysfunction, diagnosis of LAM avulsion on contraction seems to be more reliable. Consistency in technique and interpretation should be maintained.
authors.affiliation: Departments of Obstetrics and Gynaecology and Urogynaecology, Croydon University Hospital, Croydon, UK.
authors.forename: K
authors.initials: K
authors.lastname: van Delft
authors.affiliation: Departments of Obstetrics and Gynaecology and Urogynaecology, Croydon University Hospital, Croydon, UK.
authors.forename: R
authors.initials: R
authors.lastname: Thakar
authors.affiliation: Departments of Obstetrics and Gynaecology and Urogynaecology, Croydon University Hospital, Croydon, UK.
authors.forename: A H
authors.initials: AH
authors.lastname: Sultan
authors.affiliation: Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: K B
authors.initials: KB
authors.lastname: Kluivers
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D009119:Muscle Contraction / Q000502:physiology*; D010173:Palpation; D017773:Pelvic Floor / Q000000981:diagnostic imaging*; D056887:Pelvic Organ Prolapse / Q000000981:diagnostic imaging* / Q000503:physiopathology; D049590:Postpartum Period / Q000502:physiology; D011247:Pregnancy; D015995:Prevalence; D014463:Ultrasonography; D055815:Young Adult
keywords: correlation; levator ani avulsion; maximum pelvic floor muscle contraction; tomographic ultrasound imaging; transperineal ultrasound