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Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors

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Abstract

Introduction and hypothesis

The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders.

Methods

This narrative review was conducted by applying the keywords “levator hiatus” OR “genital hiatus” OR “urogenital hiatus” in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation.

Results

Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2–3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation—the rest can be explained by pelvic muscle function and possibly injury to other level III structures.

Conclusions

Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.

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Notes

  1. In discussing levator injury some authors in the ultrasound literature refer to the pubovisceral muscle as the puborectal muscle.

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Acknowledgments

The authors thank Sarah Block for assistance with manuscript preparation.

Funding

Drs. Ashton-Miller and DeLancey were supported by NIH Grant RC2 DK122379. Dr. Chen was supported by NIH Grant R01 HD094954.

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Author notes

  1. Wen** Cheng

    Present address: Beaumont Hospital Dearborn, Department of Obstetrics and Gynecology, 18101 Oakwood Blvd, Dearborn, MI, 48124, USA

  2. Emily English

    Present address: Michigan Medicine, University of Michigan Health-West, Grand Rapids, MI, USA

  3. Carolyn W. Swenson

    Present address: Division of Urogynecology and Pelvic Reconstructive, University of Utah, Salt Lake City, UT, USA

  4. Fernanda Pipitone

    Present address: Hospital das Clínicas, University of São Paulo, São Paulo, Brazil

Authors and Affiliations

  1. Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA

    Wen** Cheng, Emily English, Whitney Horner, Carolyn W. Swenson, Luyun Chen, Fernanda Pipitone & John O. L. DeLancey

  2. Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA

    Luyun Chen & James A. Ashton-Miller

  3. Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA

    James A. Ashton-Miller

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  1. Wen** Cheng
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Contributions

W. Cheng: literature review, data collecting, data analysis, manuscript writing and editing; E. English: literature review, data collecting, manuscript writing and editing; W. Horner: literature review, manuscript writing and editing; C.W. Swenson: literature review, manuscript writing and editing; L. Chen: literature review, manuscript editing; F. Pipitone: literature review, manuscript editing; J.A. Ashton-Miller: literature review, manuscript editing; J.O. DeLancey: literature review, data analysis, manuscript writing and editing.

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Correspondence to Wen** Cheng.

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Cheng, W., English, E., Horner, W. et al. Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors. Int Urogynecol J 34, 327–343 (2023). https://doi.org/10.1007/s00192-022-05354-8

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