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Levator Avulsion: Simply Explained

02 March, 2013

In 2007, quite a few years ago now, I had an ‘Oh My God’  moment in a lecture at one of our National Conferences. Professor Peter Dietz, a Sydney Urogynaecologist, was revealing to the attentive audience of doctors, physiotherapists and nurses that, what had been always attributed to nerve damage in the pelvic floor muscles, was in fact sometimes due to a concept called Levator Avulsion– where part or all of the pelvic floor muscles were pulled off the pubic bone on one or both sides. Peter used 3D/4 D ultrasound to confirm his findings and similarly Professor John DeLancey, a world-renowned anatomist and urogynaecologist from the USA, discovered the same concept through MRI technology.

 

levator avulsion

In fact, this had first been mentioned in 1907 by Halban and Tandler and again in 1943 by Howard Gainey, a general obstetrician from Kansas City, but was seemingly ignored by the medical fraternity until 2005. (Prof Hans Peter Dietz)

The levator ani muscles (particularly pubo-rectalis) forms the levator hiatus and is of central importance in pelvic organ support and the maintenance of urinary and faecal continence. Avulsion injuries– are a disconnection of the muscle from its insertion on the inferior pubic ramus and the pelvic side wall associated with vaginal delivery.(1) Avulsion of the levator ani muscle from the pubic bone is known to occur in up to 36% of parous women.

The levator hiatus represents the largest hernial portal in the human body- what this means is if the muscles have pulled off the pubic bones, the gap is wider and there is a clear opportunity for the internal organs to relax or prolapse down with increases in intra-abdominal pressure such as with coughing, lifting, bending, squatting etc.

An analogy to make it easier to understand is if half of your deltoid muscle (shoulder) was cut through then it would be pretty hard to lift your arm if that muscle is not attached across the joint. But whilst that helps you understand why the muscles don’t work, the process of damage is much more like a rope that is gradually fraying, as the mountain climber gets closer to the top of the mountain because it is slung over a sharp rock- one fibre pings, then a few more and for some birth injuries, the rope completely gives way (the fibres completely avulse).

Now women are pretty shocked when they hear that they have avulsed their muscles off the pubic bone because it sounds pretty final- but often there is a moment of clarity as well-because the good devoted exercisers have been furiously working away at their pelvic floor exercises and are frustrated when there is no improvement in strength. So understanding about the process is very useful.

What to do about this?

I find if there is a partial avulsion it helps for patients to visualize the deficient right/left side on my model of the pelvis and I get them to take a photo of this model with their phone and view the muscles they are trying to recruit as they do the exercises. That allows them to use the brain to help recruit every fibre.

photo of model of pelvis

Then once they know there has been significant, and for now, permanent damage of their pelvic floor muscles what is paramount is early prevention of prolapse. This involves the things we have talked about continually on this blog:

  • pelvic floor muscle training (for those muscles still attached),
  • bracing with increased intra-abdominal pressure (especially bending),
  • correct positioning and coordination for defaecation and particularly pelvic floor-friendlyexercising– avoiding those manoeuvres which will push pelvic organs down that hernia portal!
  • early use of a pessary- a silicone device to help support the internal structures to prevent future prolapse

So in summary from Peter’s website: All we can say right now is that pelvic floor muscle trauma (‘avulsion’)

  • weakens the muscle by about 1/3 on average
  • makes the muscle more stretchy by about 50%
  • enlarges the opening of the pelvic floor (the ‘hiatus’) by about 1/4
  • more than doubles the risk of bladder prolapse
  • triples the risk of prolapse of the uterus (the womb).
  • triples the risk of a prolapse returning after pelvic floor surgery

The next Oh Yes moment will be when stem cell research has perfected the implantation of stem cells which will help re-grow the muscles. Did I ever tell you that I scoffed loudly when the movie Face Off was released…….

(1)¨Pelvic floor trauma following vaginal delivery. Best Pract Res Clin Obstet Gynaecol. 2005 Dec;19(6):913-24. Epub 2005 Sep 22  Dietz HP. ¨Pelvic floor trauma in childbirth – myth or reality? Aust N Z J Obstet Gynaecol. 2005 Feb;45(1):3-11 Dietz HP, Schierlitz L.¨Aust and NZ Journal of Obstets and Gynae2007 Aug;47(4):341-4¨International Urogynaecology Journal 2007 Nov 13
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16 Comments
  1. Dee permalink

    Sue, thanks for the post. Very informative! It’s very frustrating that muscle damage to the LA is a new concept or at least being looked at again and not by everyone the pelvic floor. Seems pretty obvious. I would think that many patients would assume their PF muscles are being checked for integrity, but it seems like this isn’t always the case. How can one palpate their own LA to check for problems? If one isn’t looking out for themselves, then damage might go undetected. That’s a big problem for anyone contemplating surgical repair. I’m reading that surgical is more likely to fail with a LAA and that current surgical practices aren’t effectively addressing LAA. Big deal if you aren’t wanting repeat PF repair failures.

  2. Dee permalink

    Sue, thanks for the post. Very informative! It’s very frustrating that muscle damage to the LA is a new concept or at least being looked at again and not by everyone treating the pelvic floor. Seems pretty obvious. I would think that many patients would assume their PF muscles are being checked for integrity, but it seems like this isn’t always the case. How can one palpate their own LA to check for problems? If one isn’t looking out for themselves, then damage might go undetected. That’s a big problem for anyone contemplating surgical repair. I’m reading that surgical is more likely to fail with a LAA and that current surgical practices aren’t effectively addressing LAA. Big deal if you aren’t wanting repeat PF repair failures.

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    I will bookmark your blog and check again here regularly.
    I’m quite sure I’ll learn lots of new stuff right here!

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  4. Hmm it seems like your blog ate my first comment (it was extremely long)
    so I guess I’ll just sum it up what I submitted and say,
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  5. Reblogged this on sue croft physiotherapist blog and commented:

    We’ve been having a discussion on Facebook in our Women’s Health group about the use of the Epi-No as a preventative strategy for Levator Avulsion and so I decided to re-blog my Levator Avulsion blog.

  6. Reblogged this on Healthy Solutions and commented:
    One of the best explanations I have seen on Levator Avulsion

  7. Judi permalink

    Is there a doctor anywhere in the US who can repair a levator ani partial avulsion that has been repaired in the past, was stable and held for 15 years but became detached. When it was initially repaired, the doctor did not say “avulsed” in the operative report but rather outlined how he pulled it together and said it was the puborectalis muscle. Have had a pelvic floor ultrasound that shows the defect as a “partially avulsed levator muscle” but also says partial avulsion are not felt to be clinically significant. When it became detached, fecal incontinence began and has continually gotten worse over time. Is there any doctor in the US who does this repair as a means to control fecal incontinence?

    • Hi Judi, Professor Peter Dietz has been working on this for years, but not with great success- he has a trial underway I understand – I will write about the results in another blog. There are strategies you can use for the faecal incontinence. Here is a blog with some advice in it. https://suecroftphysiotherapistblog.wordpress.com/2012/12/09/i-cant-feel-anything-anymore/ Let me know if you can track an American surgeon- I am a physio in Brisbane Australia

      • Judi permalink

        Thank you. I am aware of Prof Dietz, a genius in his time. I can’t afford to go to Australia. I wish. I definitely would want him to try to repair it. I know what an improvement I felt after my repair. Big difference! And the doctor who repaired it said he had never seen this entity before but he knew anatomy and fixed it. I don’t know why it can’t be fixed. I have seen it repaired with mesh which would make sense since mine was repaired with permanent sutures but still didn’t hold under extreme stress. As far as controlling the incontinence, I have no sensation that it’s about to occur (pudendal nerve damage been discovered). I’ve done the bulking agents, fiber diet, fiber foods, still all day, all night, every day, every night… besides the nerve damage, there’s about 30% scar tissue on external sphincter. Do the exercises all the time-no success. Hopeless…

      • What about biofeedback or sacral nerve stimulation – the latter is very expensive- covered by Medicare here but Im not sure what would be the case in the US.

  8. Jan permalink

    Hi Sue.
    Have your book pelvic floor recovery just a question. I have had a pos and ant vaginal repair So kegels exercises are they worth doing if you have levator avulsion.

    • Hi Jan pelvic floor exercises are always worth doing because there may be some muscle left to work and be able to activate with increased intra-abdominal pressure. Have you had a 3D/4D Ultrasound to confirm the diagnosis? If you try drawing in with your low tummy and then attempt activation of the pelvic floor and then try a cough, and assess the amount of descent into the chair you are sitting on and then repeat the cough without attempting that activation- you will almost always feel more supported with the activation. Check with your surgeon if you are not yet 6 weeks post-op as they may want you to wait before commencing them again. Be sure there is no sense of bearing down when you do them.

  9. Jan permalink

    Hi Sue thank you so much for your prompt reply. I am 4 weeks post op will def run the ultrasound idea past my Dr in 2 weeks. No diagnosis just that my Dr said on PV examination and delivery history of a OPP with forcepts and episiotomy in 1983. That the damage to my muscles would make pelvic exercises ineffective. Thank you for your book. I love it. Its been a life changer. Like The Bible it has shown up my errors of a lifetime and shown the direction I need to go forever. I have learnt so much and been able to successfully impliment most of it. Jan

Trackbacks & Pingbacks

  1. Injury to the Pelvic Floor Muscles during Childbirth, and how Pelvic Floor Physiotherapy Can Help | Squamish Physiotherapy
  2. What They Don’t Tell You!: A Patient’s Story | sue croft physiotherapist blog
  3. Roundup: What Top Pelvic Health Bloggers are Talking About - Pelvic Health and Rehabilitation Center

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