This Journal Club presentation provides a summary and discussion of the following free access article published in UOG: Diagnosis of levator avulsion injury: a comparison of three methods H.P Dietz, F. Moegni, K.L. Shek Volume 40, Issue 6, Date: December 2012, pages 693-698 It can be accessed here: http://onlinelibrary.wiley.com/doi/10.1002/uog.11190/abstract

1. UOG Journal Club: December 2012
Diagnosis of levator avulsion injury:
a comparison of three methods
HP Dietz, F Moegni, KL Shek
Volume 40, Issue 6, Date: December 2012, pages 693–698
Journal Club slides prepared by Dr Tommaso
Bignardi
(UOG Editor for Trainees)

2. Background
• 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

3. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz et al., UOG 2012
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

4. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz 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

5. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz et al., UOG 2012
Vaginal palpation
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.

6. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz et al., UOG 2012
Rendered volumes
• 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’

7. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz et al., UOG 2012
Tomographic ultrasound imaging (TUI)
• 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

8. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz et al., UOG 2012
Results: Agreement between methods
Methods compared Agreement Cohen’s kappa
(%) (95% CI)
Palpation versus 86 0.43 (0.32–0.53)
rendered volume
Rendered volume 80 0.35 (0.26–0.44)
versus TUI
Palpation 87 0.56 (0.48–0.62)
versus TUI
TUI, tomographic ultrasound imaging.
CI, confidence interval

9. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz et al., UOG 2012
Results: Association with symptoms and signs of prolapse
Method Symptoms Significant Maximum Maximum
of prolapse bladder hiatal area
prolapse (POPQ stage 2+) descent on on Valsalva
ultrasound
Palpation χ2 = 39.8 χ2 = 91.1 t = 4.22 t = -6.92
P< 0.001† P< 0.001† P< 0.001 P< 0.001*
Rendered χ2 = 25.8 χ2 = 64.3 t = 2.73 t = -3.46
volume P< 0.001* P< 0.001* P= 0.007* P< 0.001**
Tomographic χ2 = 13.8 χ2 = 58.3 t = 3.78 t = -7.04
ultrasound P< 0.001 P< 0.001 P< 0.001 P< 0.001*
n=266 except for *n=259 and **n=252. All findings were blinded against each other,
except for those marked with †.

10. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz et al., UOG 2012
Key findings
• 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

11. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz 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

12. Diagnosis of levator avulsion injury: a comparison of three methods
Dietz et al., UOG 2012
Discussion points
• 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?