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Neurourol Urodyn. 2014 Mar;33(3):307-11. doi: 10.1002/nau.22386. Epub 2013 Feb 22.

Comparison between transperineal ultrasound and digital detection of levator ani trauma. Can we improve the odds?

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Auckland Bioengineering Institute, University of Auckland, Level, Auckland, New Zealand.



To investigate the predictive ability of four digital assessment parameters to detect levator ani (LA) muscle defects (avulsion injury) and compare these to transperineal tomographic ultrasound images.


This was an observational study imbedded in a larger quasi-experimental cohort study for women with urinary incontinence. Seventy-two women, ≥ 60 years who had attended or were going to attend physiotherapy for treatment of urinary incontinence, were included in the study. Inclusion criteria from the parent study were symptoms of stress, urge or both types of urinary incontinence. The predictive ability of the following digital parameters: direct palpation of a discontinuity of the LA muscle from insertion on the pubic ramus; palpation of the distance between the muscle insertion sites; palpation of LA strength; palpation of LA tone, were analyzed against findings from tomographic transperineal ultrasound images. Correlation between methods was measured using Cohen's kappa for each of the individual parameters.


Seventeen women (24%) presented with a complete or partial avulsion of the puborectalis muscle as diagnosed with tomographic ultrasound imaging. Nine women (13%) had complete avulsions, one of which was bilateral. The predictive ability of the digital assessment parameters varied from poor (k = 0.187, 95% CI [0.02-0.36]) to moderate (k = 0.569, 95% CI [0.31-0.83]). The new parameter of 'width between insertion sites' performed best.


Adding the parameter of "width between insertion sites" appears to enhance our ability to detect avulsion of the levator ani (LA) muscle by digital examination however it does not distinguish between unilateral or bilateral avulsion.


3D ultrasound; digital assessment; levator ani muscle; trauma

[Indexed for MEDLINE]

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