UOG Journal Club: December 2012Diagnosis of levator avulsion injury:

a comparison of three methods

HP Dietz, F Moegni, KL ShekVolume 40, Issue 6, Date: December 2012, pages 693–698

Journal Club slides prepared by Dr Tommaso Bignardi(UOG Editor for Trainees)

• Levator avulsion is common after vaginal delivery and is strongly associated with prolapse and prolapse recurrence after reconstructive surgery

• Levator avulsion can be diagnosed by vaginal palpation, 3D/4D translabial ultrasound or magnetic resonance imaging (MRI)

• With the 3D ultrasound technique, data can be analysed as rendered volumes or else tomographic multislice imaging

Background

The aim of this study was to compare assessment by digital palpation and two ultrasound methods, one using rendered volumes and the other multislice imaging, for

the diagnosis of levator avulsion

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

Patients and Methods

• 266 women seen at a tertiary urogynecological unit

• Each woman underwent an interview, vaginal examination and 3D/ 4D translabial ultrasound

retrospective offline analysis of ultrasound volumes, blinded against clinical data, using two techniques

rendered volumes tomographic ultrasound imaging (TUI)

Agreement was evaluated between the ultrasound techniques and findings on digital palpation

The results were finally related to symptoms and signs of pelvic organ prolapse

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

Vaginal palpation

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

The index finger is placed parallel to the urethra, with fingertip at the bladder neck.

The fingertip is turned towards the inferior pubic ramus, whilst the patient is asked to contract the pelvic floor.

The gap between urethra and muscle should be about one fingerbreadth.

If no contractile tissue is palpated there will be room for two or more fingers between urethra and pelvic sidewall, and a diagnosis of avulsion is made.

Rendered volumes

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

• Obtained on maximal pelvic floor contraction• Slice thickness of between 1.5 and 2.5 cm• Plane of minimal hiatal dimensions included in the ‘region of interest’

Tomographic ultrasound imaging (TUI)

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

• Obtained during maximum pelvic floor contraction• Set of 8 slices in the axial plane at intervals of 2.5mm• Taken from 5mm caudad to 2.5mm cephalad of the plane of minimal hiatal dimensions

Methods compared Agreement(%)

Cohen’s kappa (95% CI)

Palpation versus rendered volume

86 0.43 (0.32–0.53)

Rendered volume versus TUI

80 0.35 (0.26–0.44)

Palpation versus TUI

87 0.56 (0.48–0.62)

Results: Agreement between methods

CI, confidence interval

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

TUI, tomographic ultrasound imaging.

Method Symptomsofprolapse

Significantprolapse (POPQ stage 2+)

Maximumbladderdescent onultrasound

Maximumhiatal areaon Valsalva

Palpation χ2 = 39.8P< 0.001†

χ2 = 91.1P< 0.001†

t = 4.22P< 0.001

t = -6.92P< 0.001*

Renderedvolume

χ2 = 25.8P< 0.001*

χ2 = 64.3P< 0.001*

t = 2.73P= 0.007*

t = -3.46P< 0.001**

Tomographicultrasound

χ2 = 13.8P< 0.001

χ2 = 58.3P< 0.001

t = 3.78P< 0.001

t = -7.04P< 0.001*

n=266 except for *n=259 and **n=252. All findings were blinded against each other, except for those marked with †.

Results: Association with symptoms and signs of prolapse

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

Key findings

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

• Vaginal palpation, rendered ultrasound volumes and multislice imaging all seem to be moderately repeatable and they correlate moderately well with each other

• Findings for all three methods are significantly associated with symptoms, signs and ultrasound findings of female pelvic organ prolapse

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

Limitations

• Retrospective analysis

• Women with previous pelvic surgery not excluded • Palpation data obtained by senior author not consistently blinded to history and other clinical findings

• These three methods need validation in other populations

Discussion points

Diagnosis of levator avulsion injury: a comparison of three methodsDietz et al., UOG 2012

• Should the study of levator avulsion form part of routine investigations for women presenting with symptoms and/or signs of pelvic prolapse?

• What are the clinical implications of diagnosing avulsion, especially prior to prolapse surgery?

• Do the data presented in the study demonstrate the superiority of ultrasound techniques over digital palpation for diagnosing levator avulsion?

• How do the techniques investigated compare against MRI assessment?

• How can we identify and counsel women at higher risk of recurrence after pelvic reconstructive surgery?