Figure: Unilateral right-sided avulsion injury of the pubovisceral muscle in 52 year old patient with 2^nd degree cystocele and uterine prolapse (rendered volume, axial plane, caudocranial direction, 80/20 mix of surface rendering and transparency mode).

Results Of 490 patients, 480 could be examined for defects. Two were virginal, seven could not be assessed due to vaginal stenosis or atrophy, and in one case the examination was omitted for unknown reasons. Avulsion injuries were detected in 104 women (24.1% of parous women). Mean age was 55.6 years (range 17-90), with 387 (79%) complaining of stress urinary incontinence, and 106 (22.5%) of symptoms of prolapse. Mean vaginal parity was 2.6 (range 0-12), and mean age at first vaginal delivery was 24 (range 14-38). 49 were nulliparous or had only delivered by Caesarean Section. Defects were found only in vaginally parous women. They were unilateral on the right in 59, unilateral on the left in 18, and bilateral in 27 women which implies a higher likelihood of trauma on the right (P< 0.001). There was a significant association with maternal age (P=0.004), with patients showing defects having delivered their first child on average 1.6 years later than those without. There was no association between defects and urodynamics findings except for the diagnosis of voiding dysfunction (residual >= 100 ml and/ or maximum flow rate centile below 5, P= 0.003 on Fisher’s exact test), or between bladder symptoms and levator defects, but women with defects were more likely to complain of symptoms of prolapse (P= 0.009), and they showed higher grades of anterior and central compartment prolapse, both clinically (Cystocele and uterine prolapse, P< 0.001) and on ultrasound (Cystocele, P< 0.001, uterine prolapse, P= 0.01).

Interpretation of results Defects of the pubovisceral muscle are common and seem to occur more often on the right. They seem to be associated with symptoms of prolapse, clinical and ultrasound measures of prolapse, and urodynamically diagnosed voiding dysfunction, but no other symptoms or signs of bladder dysfunction. We have recently been able to show that increased maternal age may be a risk factor for intrapartum pelvic floor trauma[3] in women delivering today. This has recently been confirmed in another imaging study using magnetic resonance, and there is some epidemiological support for this hypothesis. The patients examined for this study had been much younger on average when they delivered their first child (24.0 vs. 31.6 years in [3]), but we again found a relationship, albeit weaker, between maternal age at first vaginal delivery and levator trauma.

Concluding message
Major morphological abnormalities of the levator ani muscle seem associated with age at first vaginal delivery. The
current worldwide trend towards delayed childbearing may well result in an increased prevalence of related disorders,
in particular pelvic organ prolapse, in coming decades.

References

1. Obstet Gynecol, 2003. 101(1): p. 46-53.

2. Br J Obstet Gynaecol, 2005. 113: p. 1-5.

3. Obstet Gynecol, 2005. 106: p. 707-712.

FUNDING: Betty Byrne Henderson Foundation, University of Queensland DISCLOSURES: NONE HUMAN SUBJECTS: This study was approved by the Wentworth Area Human Research Ethics Committee and followed the Declaration of Helsinki Informed consent was not obtained from the patients.

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