Pelvic Floor Dysfunction after Levator Trauma 1 Year after Vaginal Delivery: A Prospective Case-Control Study

Fragestellung: aim of our prospective case-control study was to evaluate urinary, anal, prolapse and sexual symptoms in patients with levator ani muscle (LAM) trauma in comparison with patients with intact LAM 1-year after vaginal delivery.

Methode: primiparous women who delivered vaginally in our department between January-June 2009 and with 3D ultrasound diagnosis of LAM trauma on 2^nd- 3^rd day postpartum confirmed one year later, were included in the case group. The controls were represented by primiparae after vaginal delivery recruited in the same period with intact LAM in the early postpartum and 1-year later. Women presenting urinary, anal, prolapse and sexual symptoms or submitted to previous pelvic surgery prior to delivery or during pregnancy were excluded.

LAM trauma was defined as a defect present in at least 3 consecutive tomographic slices at and above the plane of minimal hiatal dimension obtained with 3D perineal ultrasound. All women were investigated on urinary, anal, prolapse and sexual symptoms with the validated German language of the Australian Pelvic Floor Questionnaire 1-year postpartum.

Ergebnisse: Forty patients were included in our trial, 20 with (Fig.1) and 20 without levator trauma. Patients', obstetrics' and fetal characteristics were comparable between the two groups (Tab.1,2). Urinary symptoms were significantly increased in women with levator defect compared with controls (p=0.01). Anal and sexual symptoms worsened in the case group without reaching statistical significance (p=0.24, p=0.60, respectively). The two groups were comparable regarding prolapse symptoms (p=0.99). The Total Pelvic Floor Dysfunction Score was not statistically different between the two groups (p=0.214) (Tab.3).

Schlussfolgerung: this is the first case-control study evaluating pelvic floor dysfunction after levator trauma with a validated pelvic floor questionnaire in women 1-year after vaginal delivery. Except for urinary symptoms, our data suggest that levator trauma does not significantly affect pelvic floor function as soon as one year postpartum.

Tab.1: Patients' characteristics

	Women with LAM defect (n=20)	Women without LAM defect (n=20)	Pv
Age (y)	30 (±5.0)	31.5 (±4.8)	0.75
BMI	22 (18–32)	25.5 (16–44)	0.14
Caucasian, n (%)	20	17 (85%)	0.23
Sexually active	20	20	1

Data expressed as median (range), mean±standard deviation or number (%).

Tab.2: Obstetrics and fetal data

	Women with LAM defect (n=20)	Women without LAM defect (n=20)	Pv
Gestational age at delivery (d)	279 (247–290)	269 (183–292)	0.06
Fetal Weight (g)	3458 (±449)	3309 (±481)	0.37
Fetal Circumference (cm)	35.45 (±1.3)	34.68 (±1.2)	0.06
Operative delivery (vacuum, forceps)	2 (10%)	2 (10%)	1

Tab.3: Comparison of urinary, anal, prolapse and sexual symptoms between case and control groups.

	Women with LAM defect (n=20)	Women without LAM defect (n=20)	Pv
Urinary symptoms (score __/45)	3 (0–9)	1 (0–6)	0.01*
Anal symptoms (score__/34)	2 (0–8)	2 (0–6)	0.24*
Prolapse symptoms (score __/15)	0 (0–1)	0 (0–9)	0.99*
Sexual symptoms (score __/21)	1.5 (0–6)	0 (0–9)	0.6*
Total Pelvic floor dysfunction Score (score__/40)	2.4 (±2.0)	1.6 (±1.66)	0.21°

Data are expressed as median (range), mean±standard deviation.

° t-test Student;

*Mann-Withney test

Figure 1. Levator ani trauma 1-year after spontaneous delivery Levator ani defect 1-year after spontaneous vaginal delivery (acquisition screen GE Voluson-e® System).A In the multiplanar mode, the axial plane (lower left) and the rendered image (lower right) show a monolateral levator discontinuity (**) on the left side of pubococcigeal-puborectalis muscle.B Eight slices obtained with TUI in coronal-C plane in the same patients: the discontinuity (arrow) is demonstrated in at least three consecutive slices at and above the plane of minimal hiatal dimension (frames *,-1,-2,-3).