COMPARISON OF LEVATOR ANI MUSCLEDAMAGE IN PATIENTS WITH CLINICALLY SIGNFICANT PREDOMINANT ANTERIORCOMPARTMENT PROLAPSE AND POSTERIOR COMPARTMENT PROLAPSE
A. HEGDE1, N.CHANDRASEKARAN 2, V. AGUILAR 3, G. DAVILA 2;
1CENTER FOR UROGYNECOLOGY AND PELVIC HEALTH (C.U.P),NEW DELHI, India, 2Cleveland Clinic Florida, Weston, FL,3UTSW at Austin, Austin, TX.
Introduction: Three dimensionalendovaginal ultrasound (3D EVUS) enables identification of thelevator ani (LA) muscle subdivisions reliably and obtains images thatdemonstrate good correlation to muscle parts in cadaveric studies. This lays the background for using the technology to understandthe association of levator ani muscle damage with prolapse. Recentlythe severity of levator ani muscle deficiency was found to beassociated with clinically significant prolapse (prolapse of stage 2or higher) .
Objective: To compare the prevalence of LAmuscle subdivision defect in patients with clinically significantpredominant anterior compartment prolapse and posterior compartmentprolapse.
Methods: This is a retrospective cohort study of90 women attending our center from August 2011 and July 2013. 45patients with stage II or higher cystocele on POP-Q assessmentconstituted Group A. 45 patients with stage II or higher rectocele onPOP-Q assessment constituted Group B. The study excluded patientswith clinically significant prolapse of any compartment other thananterior in group A and posterior in Group B. 360 degrees 3D EVUSwith the 2052 transducer (BK Medical Ultrafocus, Peabody, MA) wasperformed in the patients by a fellow who was blinded to the POP-Qexamination results and the group membership of the patient. The 3Dcubes obtained were analyzed to individually score each LA musclesubdivision (0: no defect, 1 = minimal defect with ≤ 50% muscleloss, 2 = major defect with > 50% muscle loss and 3: total absenceof the muscle)  on each side based on thickness of the muscle anddetachment from the pubic bone (figure 1). A cumulative score,categorized as 0 (no defect), mild (total score 1-6), moderate (7-12)and severe (≥ 13) was calculated for each patient. The prevalenceof levator ani subdivision defects was compared between the twogroups.
Results: The two groups matched with respect totheir demographic data of age, BMI, parity, smoking history andmenopausal status (p < 0.05). The stage of prolapse based on POP-Qassessment was similar in the two groups (table 1). The median scorefor each LA muscle subdivision and the total LA muscle defect scorewas similar between the two groups (table 2). The number of patientswith LA muscle defect was similar in the two groups (table 2). Theodds for significant LA muscle defect (moderate and severe LA muscledefect) was more in Group A when compared with Group B , but it didnot reach statistical significance [OR: 1.56 (95% CI: 0.68 - 3.59; p= 0.298).
Conclusions: The prevalence of levator ani musclesubdivision defect and its severity is similar in patients withclinically significant predominant anterior compartment prolapse andposterior compartment prolapse.
References: 1. ObstetGynecol 2009; 14: 66 -72. 2. 2. Obstet Gynecol 2013; 121(5):1017 -24.
Table1: Stage of prolapse
Stageof prolapse on POP-Q assessment
GroupA (n = 45)
GroupB (n = 45)
Stage2 n (%)
Stage3 n (%)
*pvalue: Chi-square test
Table2: Levator ani muscle subdivision defect score and severity oflevator ani muscle defect
Levatroani muscle subdivision score*
GroupA (n = 45) Patients with stage II and above cystocele
Patientswith stage II and above rectocele
Totalpubococcygeus/ iliococcygeus score
Totallevator ani muscle defect^
Patientswith no defect n (%)
Patientswith mild defect n (%)
Patientswith moderate defect n (%)
Patientswith severe defect n (%)
*Median(interquartile range); p value: Mann Whitney U test. ^Fisher Exacttest