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Int Urogynecol J. 2017 Jun;28(6):907-911. doi: 10.1007/s00192-016-3214-2. Epub 2016 Dec 6.

Predicting levator avulsion from ICS POP-Q findings.

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Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, 2750, Australia.
División de Obstetricia y Ginecología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
Unidad de Piso Pélvico, Servicio de la Mujer, Complejo Asistencial Dr. Sótero Del Río, Santiago, Chile.
Unidad de Piso Pélvico, Clínica Puerto Varas, Otto Bader 810, Puerto Varas, Chile.
Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, 2750, Australia.
Departamento de Ginecología y Obstetricia, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile.
Departamento de Ginecología y Obstetricia, Unidad de Piso Pélvico, Hospital Clínico Universidad de Chile, Santiago, Chile.
Department of Obstetrics and Gynaecology, Liverpool Clinical School, Western Sydney University, Sydney, Australia.



Levator avulsion is a common consequence of vaginal childbirth. It is associated with symptomatic female pelvic organ prolapse and is also a predictor of recurrence after surgical correction. Skills and hardware necessary for diagnosis by imaging are, however, not universally available. Diagnosis of avulsion may benefit from an elevated index of suspicion. The aim of this study was to examine the predictive value of the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) for the diagnosis of levator avulsion by tomographic 4D translabial ultrasound.


This is a retrospective analysis of data obtained in a tertiary urogynaecological unit. Subjects underwent a standardised interview, POP-Q examination and 4D translabial pelvic floor ultrasound. Avulsion of the puborectalis muscle was diagnosed by tomographic ultrasound imaging. We tested components of the ICS POP-Q associated with symptomatic prolapse and other known predictors of avulsion, including previous prolapse repair and forceps delivery with uni- and multivariate logistic regression. A risk score was constructed for clinical use.


The ICS POP-Q components Ba, C, gh and pb were all significantly associated with avulsion on multivariate analysis, along with previous prolapse repair and forceps delivery. A score was assigned for each of these variables and patients were classified as low, moderate or high risk according to total score. The odds of finding an avulsion on ultrasound in patients in the "high risk" group were 12.8 times higher than in the "low risk" group.


Levator avulsion is associated with ICS POP-Q measures. Together with simple clinical data, it is possible to predict the risk of avulsion using a scoring system. This may be useful in clinical practice by modifying the index of suspicion for the condition.


Avulsion; Levator ani; POP-Q; Prolapse; Tomographic imaging; Transperineal ultrasound

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