title: The natural history of levator avulsion one year following childbirth: a prospective study.
abstract: OBJECTIVE
  To explore the natural history of levator avulsion in primipara 1 year postpartum and correlate this to pelvic floor dysfunction (PFD).
  
  
  METHODS
  Observational longitudinal cohort study.
  
  
  METHODS
  District General University Hospital.
  
  
  METHODS
  Nullipara at 36 weeks of gestation, 3 months and 1 year postpartum.
  
  
  METHODS
  Validated methods assessed muscle strength, prolapse, ultrasound measurements of levator hiatus and avulsion, and questionnaires for sexual function, and urinary and anal incontinence. Pattern differences over time were evaluated using linear mixed models.
  
  
  METHODS
  Natural history of levator avulsion and relationship with PFD.
  
  
  RESULTS
  Of the 269 nullipara, 191 returned at 3 months and 147 (55%) at 1 year postpartum; 109 had a vaginal delivery and 38 had a caesarean delivery. Sixty-two percent (n = 13/21; 95% CI 41-79%) of levator avulsions diagnosed 3 months postpartum were no longer evident at 1 year. Following vaginal delivery, nine women (8%, 95% CI 4.2-15.1%) had persistent levator avulsion. Most changes in PFD occurred between the antenatal and first postnatal visit, without improvement at 1 year. Women with persistent levator avulsion had significantly worse deterioration patterns of muscle strength, hiatus measurements and vaginal symptoms (loose vagina/lump sensation). However, evidence of PFD was also related to no longer evident levator avulsion.
  
  
  CONCLUSIONS
  Sixty-two percent of levator avulsions were no longer evident 1 year postpartum. Partial avulsion has a tendency to improve over time, which seems to be less common for complete levator avulsions. Women with no longer evident and persistent levator avulsion had PFD, with worse patterns in presence of persistent avulsion.
authors.affiliation: Department of Obstetrics and Gynaecology, Urogynaecology, Croydon University Hospital, Croydon, UK.
authors.forename: K W M
authors.initials: KW
authors.lastname: van Delft
authors.affiliation: Department of Obstetrics and Gynaecology, Urogynaecology, Croydon University Hospital, Croydon, UK.
authors.forename: R
authors.initials: R
authors.lastname: Thakar
authors.affiliation: Department of Obstetrics and Gynaecology, Urogynaecology, Croydon University Hospital, Croydon, UK.
authors.forename: A H
authors.initials: AH
authors.lastname: Sultan
authors.affiliation: Radboud University Medical Centre, Department for Health Evidence, Section Biostatistics, Nijmegen, the Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: IntHout
authors.affiliation: Radboud University Medical Centre, Department of Obstetrics and Gynaecology, Nijmegen, the Netherlands.
authors.forename: K B
authors.initials: KB
authors.lastname: Kluivers
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000293:injuries*; D005242:Fecal Incontinence / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D053580:Muscle Strength; D007744:Obstetric Labor Complications / Q000503:physiopathology*; D036801:Parturition; D017773:Pelvic Floor / Q000503:physiopathology*; D059952:Pelvic Floor Disorders / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology*; D049590:Postpartum Period; D011247:Pregnancy; D011446:Prospective Studies; D011788:Quality of Life; D012735:Sexual Dysfunction, Physiological / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology*; D011795:Surveys and Questionnaires; D014549:Urinary Incontinence / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology*
keywords: Childbirth; hiatus distension; levator ani avulsion; pelvic floor dysfunction; pelvic organ prolapse; transperineal ultrasound