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Management of levator ani avulsion: a systematic review and narrative synthesis

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Abstract

Purpose

Levator ani muscle (LAM) avulsion affects up to 35% of women. Unlike obstetric anal sphincter injury, LAM avulsion is not diagnosed immediately after vaginal delivery, however, has a profound impact on quality of life. The management of pelvic floor disorders is in growing demand yet the significance of LAM avulsion in the context of pelvic floor dysfunction (PFD) is poorly understood. This study collates information on success of treatment for LAM avulsion to establish the best options for management of women.

Methods

MEDLINE®, MEDLINE® In-Process, EMBASE, PubMed, CINAHL and The Cochrane Library were searched for articles that evaluated the management techniques used to treat LAM avulsion. The protocol was registered with PROSPERO (CRD42021206427).

Results

Natural healing of LAM avulsion occurs in 50% of women. Conservative measures, including pelvic floor exercises and pessary use are poorly studied. Pelvic floor muscle training for major LAM avulsions was of no benefit. Post-partum pessary use was only of benefit in the first three months for women. Surgeries for LAM avulsion are poorly researched but studies suggest they may provide benefit for 76–97% of patients.

Conclusions

Whilst some women with PFD secondary to LAM avulsion improve spontaneously, 50% continue to have pelvic floor symptoms 1 year following delivery. These symptoms result in a significant negative impact on quality of life, however, it is not clear whether conservative or surgical methods are helpful. There is a pressing need for research to find effective treatments and explore appropriate surgical repair techniques for women with LAM avulsion.

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Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Women’s and Children’s Division, Leeds Teaching Hospital Trust, Beckett Street, LS9 7TF, Leeds, United Kingdom

    Elizabeth A. Doxford-Hook & Fiona A. Marsh

  2. Airedale General Hospital, Skipton Road, Steeton, Keighley, BD20 6TD, United Kingdom

    Elizabeth Slemeck

  3. Clinical Sciences Building, Leeds Institute of Medical Research at St James’s, St. James’s University Hospital, University of Leeds, Leeds, LS9 7TF, United Kingdom

    Candice L. Downey

Authors
  1. Elizabeth A. Doxford-Hook
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  2. Elizabeth Slemeck
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  3. Candice L. Downey
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  4. Fiona A. Marsh
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Contributions

Contribution to manuscript: ED-H—protocol/project development, data collection and management, data analysis and manuscript writing. LS—data collection and management, data analysis and manuscript writing. CD—quality assessment, manuscript writing and editing: FM—manuscript writing and edited the article. All authors approved the final version.

Corresponding author

Correspondence to Elizabeth A. Doxford-Hook.

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Conflict of interest

There are no known conflicts of interest associated with this review and there has been no significant financial support for this work that could have influenced its outcome.

Ethical approval

This is a systematic review and no ethical approval is required.

Registration

This protocol has been published in the International Prospective Register of Systematic Reviews (PROSPERO) database (No. CRD42021206427. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID = CRD42021206427) .

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Doxford-Hook, E.A., Slemeck, E., Downey, C.L. et al. Management of levator ani avulsion: a systematic review and narrative synthesis. Arch Gynecol Obstet 308, 1399–1408 (2023). https://doi.org/10.1007/s00404-023-06955-4

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  • DOI: https://doi.org/10.1007/s00404-023-06955-4

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