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Clinical and Experimental Obstetrics & Gynecology  2020, Vol. 47 Issue (3): 341-347    DOI: 10.31083/j.ceog.2020.03.5252
Original Research Previous articles | Next articles
Pelvic floor rehabilitation in patients with levator ani muscle avulsion
J.A. García-Mejido1, 2, *(), C. Suarez-Serrano3, E.M. Medrano-Sanchez3, M.J. Bonomi Barby1, A. Armijo Sánchez1, J.A. Sainz1, 2
1Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
2Department of Obstetrics and Gynecology, University of Seville, Spain
3Department of Physiotherapy, University of Seville, Spain
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Abstract  

Objective: To determine if physiotherapy treatment applied to patients with levator ani muscle (LAM) avulsion identified after a vaginal delivery, reduces the LAM hiatus area. Material and Methods: A prospective observational study of 52 nulliparous (26 in the experimental and 26 in the control group). We included patients with LAM avulsion, diagnosed by 3-4D/transperineal ultrasound performed 3 months after delivery. Patients in the experimental group underwent a program of pelvic floor exercises, assisted by biofeedback and lumbopelvic stabilization exercises. Assessment of LAM was carried out at 6 and 9 months postpartum, using 3-4D/transperineal ultrasound, and taking the following measurements: levator hiatus area at rest, during Valsalva and at maximum contraction; LAM area, and thickness of right and left LAM. Results: Patients in the experimental group presented a reduction in the levator hiatus area at rest (17.0, 15.7, 15.9 cm2), during Valsalva (23.0, 20.8, 19.9 cm2) and at maximum contraction (15.6, 14.4 and 13.5 cm2), in comparison with patients in the control group, who presented a levator hiatus area at rest of 17.4, 17.2 and 16.8 cm2, during Valsalva of 21.0, 20.8 and 20.3 cm2, and at maximum contraction of 16.6, 16.1 and 15.6 cm2, at 1, 6 and 9 months postpartum respectively (P < 0.05). However, no changes were appreciated in the successive examinations regarding LAM area between study groups: experimental 9.5, 8.9, 9.6 cm2 versus 8.9, 9.0, 9.2 cm2 in the control group. Conclusions: Physiotherapy treatment based on pelvic floor exercises with lumbopelvic stabilization exercises in patients with LAM avulsion reduces the levator hiatus area at rest, during Valsalva and at maximum contraction.

Key words:  Pelvic floor muscle training      Levator ani muscle avulsion      Postpartum physiotherapy     
Submitted:  12 May 2019      Accepted:  22 July 2019      Published:  15 June 2020     
Fund: 
PI16/01387/Instituto de Salud Carlos III
ERDF/ESF, "Investing in your future"/European Union
*Corresponding Author(s):  JOSÉ ANTONIO GARCÍA MEJIDO     E-mail:  jagmejido@hotmail.com

Cite this article: 

J.A. García-Mejido, C. Suarez-Serrano, E.M. Medrano-Sanchez, M.J. Bonomi Barby, A. Armijo Sánchez, J.A. Sainz. Pelvic floor rehabilitation in patients with levator ani muscle avulsion. Clinical and Experimental Obstetrics & Gynecology, 2020, 47(3): 341-347.

URL: 

https://ceog.imrpress.com/EN/10.31083/j.ceog.2020.03.5252     OR     https://ceog.imrpress.com/EN/Y2020/V47/I3/341

Figure 1. —  Recruitment process (flow diagram).

Table 1. —  Obstetric data of study population
Mean (± DT) or %
Experimental (n = 9) Control (n = 26) P
Maternal Age 30.4 (± 4.2) 30.0 (± 4.6 ) NS
Gestational age 40.3 (± 1.2) 40.1 (± 1.3 ) NS
Epidural 9/9 (100 %) 26/26 (100 %)
2nd stage of labour (min) 97.5 (± 67.3 ) 79.4 (± 35.1 ) NS
Episiotomy 7/9 (77.8%) 20/26 (76.9%) NS
Perineal tear
No 0/9 (0.0%) 17/26 (65.4%) <0.0005
Grade I 0/9 (0.0%) 3/26 (11.5%)
Grade II 8/9 (88.9%) 1/26 (3.8%)
Grade III 1/9 (11.1%) 5/26 (19.2%)
Grade IV 0/9 (0.0%) 0/26 (0.0%)
Type of delivery
Vacuum 7/9 (77.8%) 12/26 (46.2%) 0.019
Forceps 1/9 (11.1%) 14/26 (53.8%)
Spatulas 1/9 (11.1%) 0/26 (0.0%)
Birth weight 3335.9 (± 489.7 ) 3588.3 (± 401.5 ) NS
Type of avulsion
Unilateral 5/9 (55.6%) 14/26 (53.8%) NS
Bilateral 4/9 (44.4%) 12/26 (46.2%)
Table 2. —  Levator hiatus area and LAM measurements in the experimental group (n = 9)
Mean (± SD) or % P
3 month postpartum 6 months postpartum 9 months postpartum
Levator hiatus area at rest (cm2) 17.0 (± 2.1) 15.7 (± 2.9) 15.9 (± 2.4) NS
Levator hiatus area during Valsalva (cm2) 23.0 (± 3.8) 20.8 (± 5.9) 19.9 (± 3.2) 0.032
Levator hiatus area at maximum contraction (cm2) 15.6 (± 3.7) 14.4 (± 2.9) 13.5 (± 2.4 ) NS
LAM area (cm2) 9.5 (± 1.6) 8.9 (± 1.7) 9.6 (± 2.3) NS
Right puborectal muscle thickness (mm) 10.6 (± 1.7) 10.9 (± 1.7) 12.2 (± 0.8 ) 0.01
Left puborectal muscle thickness (mm) 9.2 (± 1.4) 9.6 (± 1.6) 11.0 (± 1.1) 0.003
Table 3. —  Levator hiatus area and LAM measurements in the control group (n:26).
Media (± DT) or % P
3 month postpartum 6 months postpartum 9 months postpartum
Levator hiatus area at rest (cm2) 17,4 (±4,5 ) 17,2 (±4,3) 16,8 (±4,2) NS
Levator hiatus area during Valsalva (cm2) 21,0 (± 5,2) 20,8 (± 5,2) 20,3 (±4,9) < 0,0005
Levator hiatus area at maximum contraction (cm2) 16,6 (± 4,9) 16,1 (± 4,8) 15,6 (±4,7) < 0,0005
LAM area (cm2) 8,9 (±2,8 ) 9,0 (±2,7) 9,2 (±2,7) < 0,0005
Right puborectal muscle thickness (mm) 11,1 (± 2,2) 11,2 (±2,2) 11,3 (±2,2) 0,004
Left puborectal muscle thickness (mm) 9,3 (±2,4 ) 9,6 (±2,3) 9,9 (±2,1) < 0,0005
Figure 2. —  The continuous lines represent the non-rehabilitated patients while the discontinuous lines represent the rehabilitated patients. The figure shows the levator hiatus area at rest (cm2) (A), levator hiatus area during Valsalva (cm2) (B), levator hiatus area at maximum contraction (cm2) (C) and LAM area (cm2) (D).

Figure 3. —  The levator ani muscle area. (A). The levator ani muscle area of the non-rehabilitated patients. (B). The levator ani muscle area of the rehabilitated patients.

[1] Shek K.L., Dietz H.P.: “The effect of childbirth on hiatal dimensions”. Obstet. Gynecol., 2009, 113, 1272.
doi: 10.1097/AOG.0b013e3181a5ef23 pmid: 19461422
[2] Dietz H.P., Shek K.L.: “Levator defects can be detected by 2Dtranslabial ultrasound”. Int. Urogynecol. J. Pelvic Floor Dysfunct., 2009, 20, 807.
pmid: 19495542
[3] García Mejido J.A., Suárez Serrano C.M., Fernández Palacín A., Aquise Pino A., Bonomi Barby M.J., Sainz Bueno J.A.: “Evaluationof levator ani muscle throughout the different stages of labor bytransperineal 3D ultrasound”. Neurourol. Urodyn., 2017, 36, 1776.
doi: 10.1002/nau.23175 pmid: 27868224
[4] Schwertner-Tiepelmann N., Thakar Sultan A.H., Tunn R.: “Obstetriclevator ani muscle injuries: current status”. Ultrasound Obstet.Gynecol., 2012, 39, 372.
[5] Garcia-Mejido J.A., Gutierrez-Palomino L., Borrero C., Valdivieso P., Fernandez-Palacin A., Sainz-Bueno J.A.: “Factors that influencethe development of avulsion of the levator ani muscle in eutocic deliveries:3-4D transperineal ultrasound study”. J. Matern. FetalNeonatal. Med., 2016, 29, 3183.
[6] Shek K., Dietz H.P.: “Intrapartum risk factors for levator trauma”. BJOG, 2010, 117, 1485.
doi: 10.1111/j.1471-0528.2010.02704.x pmid: 20735379
[7] Dietz H.P.: “Forceps: towards obsolescence or revival?” Acta Obstet.Gynecol. Scand., 2015, 94, 347.
[8] García-Mejido J.A., Gutiérrez L., Fernández-Palacín A., Aquise A., Sainz J.A.: “Levator ani muscle injuries associated with vaginal vacuumassisted delivery determined by 3/4D transperineal ultrasound”. J. Matern. Fetal Neonatal Med., 2016, 21, 1.
doi: 10.1080/14767050802375039 pmid: 18785069
[9] Dietz H.P., Franco A.V., Shek K.L., Kirby A.: “Avulsion injury andlevator hiatal ballooning: two independent risk factors for prolapse?An observational study”. Acta Obstet. Gynecol. Scand., 2012, 91, 211.
doi: 10.1111/j.1600-0412.2011.01315.x pmid: 22050558
[10] DeLancey J.O., Morgan D.M., Fenner D.E., Kaerney R., Guire K., Miller J.M., et al.: “Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse”. Obstet.Gynecol., 2007, 109, 295.
[11] Dietz H.P., Shek C.: “Levator Avulsion and Grading of Pelvic Floor-Muscle Strength”. Int. Urogynecol. J., 2008, 19, 633.
[12] Dietz H., Bernardo M., Kirby A., Shek K.: “Minimal criteria for thediagnosis of avulsion of the puborectalis muscle by tomographic ultrasound”. Int. Urogynecol. J., 2010, 22, 699.
doi: 10.1007/s00192-010-1329-4 pmid: 21107811
[13] García Mejido J.A., Valdivieso Mejías P., Fernández Palacín A., Bonomi Barby M.J., De la Fuente Vaqueros P., Sainz Bueno J.A.: “Evaluation of isolated urinary stress incontinence according to thetype of levator ani muscle lesion using 3/4D transperineal ultrasound36 months post-partum”. Int. Urogynecol. J., 2017, 28, 1019
doi: 10.1007/s00192-016-3208-0 pmid: 27872979
[14] Kamisan Atan I., Shek K.L., Langer S., Guzman Rojas R., Caudwell-Hall J., Daly J.O., et al.: “Does the EPI-No prevent pelvic floortrauma? A multicentre randomised controlled trial”. BJOG, 2016, 123, 995.
doi: 10.1111/1471-0528.13924 pmid: 26924418
[15] Dietz H.P., Gillespie A., Phadke P.: “Avulsion of the pubovisceralmuscle associated with large vaginal tear after normal vaginal deliveryat term”. Aust. N. Z. J. Obstet. Gynaecol., 2007, 47, 341.
doi: 10.1111/j.1479-828X.2007.00748.x pmid: 17627693
[16] Shek K.L., Dietz H.P.: “Can levator avulsion be predicted antenatally?” Am. J. Obstet. Gynecol., 2010, 202, 586.e1.
[17] Falkert A., Endress E., Weigl M., Seelbach-Göbel B.: “Three-dimensionalultrasound of the pelvic floor 2 days after first delivery: influence of constitutional andobstetric factors”. Ultrasound Obstet. Gynecol., 2010, 35, 583.
doi: 10.1002/uog.7563 pmid: 20084643
[18] Cyr M.P., Kruger J., Wong V., Dumoulin C., Girard I., Morin M.: “Pelvic floor morphometry and function in women with and without puborectalis avulsion in the early postpartum period”. Am. J. Obstet. Gynecol., 2017, 216, 274.e1.
[19] Braekken I.H., Majida M., Ellstrom Engh M., Holme I.M., Bo K.: “Pelvic floor function is independently associated with pelvic organprolapse”. BJOG, 2009, 116, 1706.
doi: 10.1111/j.1471-0528.2009.02379.x pmid: 19906017
[20] Diez-Itza I., Arrue M., Ibanez L., Paredes J., Murgiondo A., Sarasqueta C.: “Postpartum impairment of pelvic floor muscle function: factors involved and association with prolapse”. Int. Urogynecol. J., 2011, 22, 1505.
doi: 10.1007/s00192-011-1484-2
[21] Morin M., Bourbonnais D., Gravel D., Dumoulin C., Lemieux M.C.: “Pelvic floor muscle function in continent and stress urinary incontinentwomen using dynamometric measurements”. Neurourol. Urodyn., 2004, 23, 668.
doi: 10.1002/nau.20069 pmid: 15382183
[22] Marques J., Botelho S., Pereira L.C., Lanza A.H., Amorim C.F., Palma P., Riccetto C.: “Pelvic floor muscle training program increasesmuscular contractility during first pregnancy and postpartum: electromyographic study”. Neurourol. Urodyn., 2013, 32, 998.
doi: 10.1002/nau.22346 pmid: 23129397
[23] Gagnon L.H., Boucher J., Robert M.: “Impact of pelvic floor muscletraining in the postpartum period”. Int. J. Urogynecol., 2016, 27, 255.
doi: 10.1007/s00192-015-2822-6
[24] Mosalanejad F., Afrasiabifar A., Zoladl M.: “Investigating the combinedeffect of pelvic floor muscle exercise and mindfulness on sexualfunction in women with multiple sclerosis: a randomizedcontrolled trial”. Clin. Rehab., 2018, 32, 1340.
doi: 10.1177/0269215518777877
[25] Braekken I.H., Majida M., Ellstrom Engh M., Holme I.M., Bo K.: “Morphological changes after pelvic floor muscle training measuredby 3-Dimensional ultrasonography”. Obstet. Gynecol., 2010, 115, 317.
doi: 10.1097/AOG.0b013e3181cbd35f pmid: 20093905
[26] Folland J.P., Williams A.G.: “The adaptations to strength training: morphological and neurological contributions to increased strength”. Sports Med., 2007, 37, 145.
doi: 10.2165/00007256-200737020-00004 pmid: 17241104
[27] Bø K., Hilde G., Stær-Jensen J., Brækken I.H.: “Can the Paulamethod facilitate co-contraction of the pelvic floor muscles? A 4D ultrasoundstudy”. Int. Urogynecol. J., 2011, 22, 671.
doi: 10.1007/s00192-010-1317-8
[28] Bø K., Hilde G., Staer-Jensen J., Siafarikas F., Tennfjord M.K., Engh M.E.: “Postpartum pelvic floor muscle training and pelvic organ prolapse—a randomized trial of primiparous women”. Am. J. Obstet. Gynecol., 2015, 212, 38.e1.
doi: 10.1016/j.ajog.2014.06.049
[29] Hagen S., Stark D., Clazener C., Dickson S., Barry S., Elders A., et al.: “Individualised pelvic floor muscle training in womenwith pelvic organ prolapse (POPPY): a multicentre randomised controlledtrial”. Lancet, 2014, 383, 796.
doi: 10.1016/S0140-6736(13)61977-7
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