title: Longitudinal follow-up of levator ani muscle avulsion: does a second delivery affect it?
abstract: OBJECTIVE
  To evaluate the morphological outcome of levator ani muscle (LAM) avulsion 3-5 years after a first delivery and to assess the effect of a second delivery on this condition. The impact of LAM avulsion on pelvic floor disorders was also studied.
  
  
  METHODS
  Six hundred and sixty-six women who had been assessed for LAM avulsion 8 weeks after their first delivery were invited for a follow-up examination 3-5 years later. Women completed the Pelvic Floor Distress Inventory including the Urinary Distress Inventory (UDI) and Pelvic Organ Prolapse Distress Inventory (POPDI) questionnaires to explore symptoms of pelvic floor disorders, and the pelvic floor was examined using three-dimensional translabial ultrasound and assessed using the pelvic organ prolapse quantification system.
  
  
  RESULTS
  Three hundred and ninety-nine women completed the study, of whom 151 were multiparous. Mean interval between first delivery and follow-up was 42.3 ± 7.6 months. Among 69 women who had LAM avulsion 8 weeks after their first delivery, nine (13.0%) had no LAM avulsion at follow-up. One (0.9%) woman had a new LAM avulsion after her second vaginal delivery. A greater proportion of women with LAM avulsion reported symptoms of stress urinary incontinence (SUI) (adjusted odds ratio, 2.09 (95% CI, 1.18-3.70); P = 0.01) and symptoms of prolapse than did women without avulsion; however, this difference did not reach statistical significance (P = 0.61). Women with LAM avulsion had higher UDI and POPDI scores than did women without avulsion (median UDI score, 17.7 (interquartile range (IQR), 5.0-32.4) vs 9.2 (IQR, 0.0-22.1); P = 0.045 and median POPDI score, 20.8 (IQR, 8.8-40.5) vs 10.7 (IQR, 0.0-32.8); P = 0.021).
  
  
  CONCLUSIONS
  The risk of developing new LAM avulsion after a second vaginal delivery is low (0.9%). Healing of LAM avulsion was observed in 13% of women who had at least one vaginal delivery. At 3-5 years after delivery, women with LAM avulsion reported symptoms of SUI more often than did those without, and had higher UDI and POPDI scores, implying more bothersome symptoms. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
authors.affiliation: Department of Obstetrics & Gynaecology, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR.
authors.forename: S S C
authors.initials: SSC
authors.lastname: Chan
authors.affiliation: Department of Obstetrics & Gynaecology, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR.
authors.forename: R Y K
authors.initials: RYK
authors.lastname: Cheung
authors.affiliation: Department of Obstetrics & Gynaecology, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR.
authors.forename: L L
authors.initials: LL
authors.lastname: Lee
authors.affiliation: Department of Obstetrics & Gynaecology, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR.
authors.forename: R K W
authors.initials: RKW
authors.lastname: Choy
authors.affiliation: Department of Obstetrics & Gynaecology, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, SAR.
authors.forename: T K H
authors.initials: TKH
authors.lastname: Chung
mesh_terms: D000328:Adult; D001003:Anal Canal / Q000000981:diagnostic imaging / Q000293:injuries*; D005260:Female; D005500:Follow-Up Studies; D006723:Hong Kong / Q000453:epidemiology; D006801:Humans; D015601:Injury Severity Score; D008137:Longitudinal Studies; D018482:Muscle, Skeletal / Q000000981:diagnostic imaging / Q000293:injuries*; D007744:Obstetric Labor Complications / Q000000981:diagnostic imaging / Q000453:epidemiology*; D059952:Pelvic Floor Disorders / Q000000981:diagnostic imaging / Q000453:epidemiology*; D011247:Pregnancy; D015995:Prevalence; D012307:Risk Factors; D016216:Ultrasonography, Prenatal
keywords: levator ani muscle avulsion; levator ani muscle injury; pelvic floor disorders; second delivery; second pregnancy