201 9 Levator ani muscle morphology and function in women with obstetric anal sphincter injury Journal Club slides prepared by Dr Erkan Kalafat UOG Editor for Trainees I Volløyhaug ID: 774608
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Slide1
UOG Journal Club:
March
201
9
Levator ani muscle morphology and function in women with obstetric anal sphincter injury
Journal Club slides prepared by Dr
Erkan Kalafat(UOG Editor for Trainees)
I.
Volløyhaug
, A. Taithongchai, I. Van Gruting, A. Sultan
and
R
.
Thakar
Volume
53
,
Issue
3
,
pages
410–416
Slide2Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
Approximately, one out of five women will undergo surgical repair for pelvic organ prolapse during their lifetime.
Levator
ani avulsion is a significant risk factor for pelvic organ prolapse which can be detected by palpation, ultrasound or MRI. However, it is controversial whether levator ani avulsion is also a risk factor for urinary or anal incontinence.
INTRODUCTION
~%20
Slide3Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
Obstetric anal sphincter injury (OASI) can be diagnosed after delivery via palpation whereas most levator ani avulsions are occult.
INTRODUCTION
Levator
ani muscle (LAM) avulsion
Anal sphincter injury
The
primary aim
of this study was to estimate
the
prevalence
of major LAM injury
in
women with
clinically diagnosed
OASI
and to explore the risk factors
associated with
LAM injury.
The
secondary aim
was to assess
the
association
between LAM injury and pelvic floor
muscle contraction
,
anal incontinence (AI)
and
urinary incontinence (UI)
in women with
OASI.
Slide4Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
(
n = 250)
Women referred to Croydon University Hospital between 2013 and 2015 with a clinical diagnosis of OASI were included in the study. Included women were evaluated via:
Clinical history
Anal
incontinence- St
. Mark’s incontinence score
Urinary incontinence - ICIQ-UI-SF
Pelvic muscle strength - Modified Oxford ScaleLAM integrity – transperineal 4D ultrasound
METHODS
Slide5Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
At the time of
evaluation,
88 (35.2%) women were pregnant again.
The median time interval between last pregnancy and evaluation was 5 months.
Two
women were excluded from analysis due to artifacts in the saved image
volumes (
levator muscle was assessed in 248 ultrasound volumes).
RESULTS
Slide6Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
Major LAM avulsion
(73/248, 29.4%)
Intact LAM
(177/248, 70.6%)
Evaluated with 4D
transperineal
ultrasonography
Unilateral
(49/248, 19.8%)
Bilateral
(24/248, 9.7%)
RESULTS
Slide7Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
RESULTS
Factors associated with major LAM avulsion (univariate analysis)
Previous operative delivery
increased
significantly the
odds of major LAM
avulsion along with obesity in the univariate analysis
P
< 0.05
Slide8Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
RESULTS
Factors associated with major LAM avulsion (multivariable analysis)
Previous operative delivery (forceps) and lower BMI
remained
as significant risk factors for major LAM
avulsion.
Women
with previous operative delivery had 4.1 times increased odds of major LAM avulsion
.
One-point
increase in BMI was associated with a 10% reduced risk of major LAM avulsion
.
Slide9Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
RESULTS
Women with major LAM avulsion had weaker pelvic muscle contraction in both digital and ultrasound examination.However, major LAM avulsion was not associated with an increased severity of anal or urinary incontinence symptoms.
Slide10Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
DISCUSSION
In this
study,
operative
vaginal delivery was associated with
a four-fold
higher risk of LAM injury than was normal
vaginal
delivery.
Women
with major LAM injury had
weaker pelvic
floor muscle contraction as assessed by
palpation and
on
ultrasound.
No association between LAM
injury and AI or UI, and no association
between
muscle
contraction and
incontinence
were
demonstrated.
Slide11Levator ani muscle morphology and function in women with obstetric anal sphincter
injury
Voll
øyhaug et al., UOG 2019
POINTS FOR DISCUSSION
The effect of major LAM avulsions on incontinence symptoms in elderly women.
Possible implications of universally screening postpartum women with
transperineal
ultrasonography for the detection of pelvic muscle
trauma.
Importance of pelvic rehabilitation for women with pelvic muscle
trauma.
Slide12