Accuracy of MRI, ultrasound and vaginal assessment for the diagnosis of levator ani muscle avulsion in women

Gruting, Isabelle Ma van; Delft, K.W. van; Thakar, Ranee; IntHout, Joanna; Sultan, Abdul H.

doi:10.1002/14651858.cd011900

Cited by 3 publications

(10 citation statements)

References 94 publications

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“…This may suggest stretch injury has occurred within the “avulsion” cohort. This would support the link between this imaging finding and vaginal delivery, where the PVM is thought to stretch more than three times its original length and double the maximum stretch capacity expected to cause injury in muscle of a non‐gravid individual …”

Section: Discussionsupporting

confidence: 60%

Levator Ani avulsion: The histological composition of this site. A cadaveric study

Silva

Asfour

Digesu

et al. 2018

Neurourology and Urodynamics

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Introduction The sonographic appearance of a levator muscle “avulsion” representing the literal detachment of the pubovisceral muscle (PVM) enthesis has been contested. The nature of the levator ani “avulsion” is still not fully understood. It is known, that the tensile strength of a tendon is dependent on collagen with increased synthesis of collagen occurring in tissue with increased mechanical load levels. This study aims to perform a quantitative histological evaluation of the PVM enthesis with or without the imaging finding of levator ani “avulsion” to determine if there is a difference in the proportion of muscle and collagen. Method Three‐dimensional translabial ultrasound for PVM “avulsion” was performed on cadavers using a GE Voluson I with a 5‐9 MHz electronic probe. Cadavers were meticulously dissected to identify the presence or absence of an anatomical avulsion. The PVM enthesis was excised for further histopathological processing and treated with three different colorations. Quantitative analysis using ImageJ software was conducted to compare tissue composition in samples with or without sonographic “avulsion.” All stages were performed by two separate investigators blinded to each other's results. The results were analyzed using SPSS v24, IBM. Results Twenty‐three PVM enthesis with histological staining were procured. Ultrasonographic “avulsions” were seen in 5/23 PVM enthesis. No anatomical avulsions were seen. There was no difference in the overall muscle or collagen content (Kruskal‐Wallis, P = 0.864). The mean organized skeletal muscle content was 23% in the sonographic “avulsion” group versus 62% in the no “avulsion” group (Kruskall‐Walis, P = 0.02). “Avulsions” were associated with a disorganized appearance at histology. Conclusion The tissue composition relating to the proportion of muscle and collagen was not significantly different in specimens with or without sonographic “avulsions.” However, morphological differences were observed in the organization of the muscle fibres, which requires further evaluation.

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Section: Discussionsupporting

confidence: 60%

Levator Ani avulsion: The histological composition of this site. A cadaveric study

Silva

Asfour

Digesu

et al. 2018

Neurourology and Urodynamics

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“…A pelvic MRI scan was subsequently conducted within 2 weeks of the assessment on 14 consenting symptomatic (n = 8) and non-symptomatic (n = 6) women, as the "gold standard" for defining pelvic floor muscle damage by showing LA muscle defects [18]. The images were acquired on a 3.0-Tesla MRI scanner (Ingenia; Philips Medical Systems, Best, The Netherlands).…”

Section: Vaginal Elastometrymentioning

confidence: 99%

Postnatal pelvic floor muscle stiffness measured by vaginal elastometry in women with obstetric anal sphincter injury: a pilot study

et al. 2019

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Introduction and hypothesis Vaginal childbirth is associated with pelvic floor muscle (PFM) damage in a third of women. The biomechanics prediction, detection and management of PFM damage remain poorly understood. We sought in this pilot study to determine whether quantifying PFM stiffness postnatally by vaginal elastometry, in women attending a perineal trauma clinic (PTC) within 6 months of obstetric anal sphincter injury, correlates with their antecedent labour characteristics, pelvic floor muscle damage, or urinary/bowel/sexual symptoms, to inform future definitive prospective studies. Methods In this pilot study, we measured postnatal PFM stiffness by vaginal elastometry in 54 women. A subset of participants (n = 14) underwent magnetic resonance imaging (MRI) to define any levator ani (LA) muscle defects from vaginal childbirth. We investigated the association of PFM stiffness with demographics, labour and delivery characteristics, clinical features and MRI evidence of LA damage. Results Raised maternal BMI was associated with reduced pelvic floor stiffness (r = −0.4; p < 0.01). Higher stiffness values were associated with forceps delivery for delayed second stage of labour (n = 14) vs non-forceps vaginal delivery (n = 40; 630 ± 40 N/ m vs 500 ± 30 N/m; p < 0.05), and a non-significant trend towards longer duration of the second stage of labour. Women with urinary, bowel or sexual symptoms (n = 37) demonstrated higher pelvic floor stiffness values than those without (570 ± 30 N/m vs 450 ± 40 N/m; p < 0.05). Conclusions A history of delayed second stage of labour and forceps delivery was associated with higher PFM stiffness values in the postnatal period. Whether high pelvic muscle stiffness antenatally is a risk factor for instrumental vaginal delivery and LA avulsion is unknown.

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“…Besides MRI, there are currently two imaging techniques available for detecting LAM avulsion: three-dimensional (3D) or four-dimensional (4D) transperineal ultrasound and 3D endovaginal ultrasound. 9 With transperineal ultrasound rendered volumes or tomographic ultrasound imaging can be used to detect LAM avulsion. It has been suggested that the diagnosis of LAM avulsion should be made using tomographic ultrasound imaging.…”

mentioning

confidence: 99%

“…It has been suggested that the diagnosis of LAM avulsion should be made using tomographic ultrasound imaging. 9 However, the 3D transducer is not universally available, and many gynecologists are not familiar with 3D ultrasound.…”

mentioning

confidence: 99%

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Transvaginal Two‐Dimensional Ultrasound Evaluation as a Screening Tool for Levator ani Muscle Avulsion in Postpartum Women

Wang

2022

J of Ultrasound Medicine

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Objectives-To evaluate the agreement between two-dimensional transvaginal ultrasound (2D-TVUS) and transperineal tomographic ultrasound imaging on three-dimensional (3D) volume in diagnosing levator ani muscle (LAM) avulsion of postpartum women. Furthermore, we tested the repeatability of the 2D-TVUS in measuring the LAM thickness.Methods-A retrospective study was performed using the data sets from postpartum women. One doctor measured the thickness of the LAM on the images at the attachment to the arcus tendinous levator ani and the middle part using the 2D-TVUS ultrasound data sets of postpartum women. These women were examined twice, at 42-56 days and 3-6 months postpartum. Intra-observer repeatability was expressed using intraclass correlation coefficients (ICCs). The other doctor judged whether there was avulsion in the LAM on the 2D-TVUS and transperineal tomography imaging on the 3D volume. The inter-method agreement was determined using Cohen's kappa coefficient (k).Results-Thickness measurements of the middle part and attachment of the LAM by 2D-TVUS showed excellent and good intra-observer repeatability (ICC 0.84; 95% CI, 0.76-0.88, and ICC 0.74; 95% CI, 0.67-0.84, respectively). The overall agreement was 92% (Cohen's kappa was 0.79) between 2D-TVUS and transperineal tomographic imaging. Compared to transperineal tomographic imaging in the diagnosis of LAM avulsion, the diagnostic sensitivity of 2D-TVUS was 91.7%, the specificity was 92.1%.Conclusions-The 2D-TVUS technique, a simple and reproducible method for assessing LAM avulsion, may be helpful as a screening tool for LAM avulsion of postpartum women.

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Accuracy of MRI, ultrasound and vaginal assessment for the diagnosis of levator ani muscle avulsion in women

Cited by 3 publications

References 94 publications

Levator Ani avulsion: The histological composition of this site. A cadaveric study

Levator Ani avulsion: The histological composition of this site. A cadaveric study

Postnatal pelvic floor muscle stiffness measured by vaginal elastometry in women with obstetric anal sphincter injury: a pilot study

Transvaginal Two‐Dimensional Ultrasound Evaluation as a Screening Tool for Levator ani Muscle Avulsion in Postpartum Women

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