What is Levator Avulsion and How Does it Occur?

What is Levator Avulsion and How Does it Occur?

Levator avulsion is a significant pelvic floor injury that often goes undiagnosed, yet it can profoundly impact a person’s quality of life. Understanding what levator avulsion is, how it occurs, and its implications is vital for those experiencing pelvic floor issues. This blog explores the anatomy, causes, and initial recognition of levator avulsion.

What is Levator Avulsion?

Levator avulsion refers to the partial or complete detachment of the levator ani muscle—specifically, the puborectalis or pubococcygeus—from its attachment to the pubic bone. This detachment disrupts the structural integrity of the pelvic floor, increasing the risk of prolapse, incontinence, and chronic pelvic pain. Research indicates that levator avulsion occurs in up to 36% of women who have given birth vaginally (Dietz, 2005).

 

How Does it Happen?

Levator avulsion is typically associated with vaginal childbirth. During labor, the pelvic floor muscles endure immense strain as they stretch to accommodate the passage of the baby. Factors that increase the likelihood of avulsion include:

• Instrumental Delivery: Forceps use has been strongly linked to a higher risk of avulsion.
• Prolonged Second Stage of Labor: Extended pushing can cause excessive stress on the levator ani.
• Large Baby: A baby’s larger size can place additional pressure on the pelvic floor.
• Perineal Trauma: Severe tearing or episiotomy during childbirth can contribute to muscle detachment.

Signs and Symptoms

Many women are unaware they have experienced levator avulsion until they face symptoms such as:

• Persistent weakness in pelvic floor muscles despite consistent exercises.
• Pelvic organ prolapse.
• Urinary or fecal incontinence.
• Pelvic pain or discomfort, especially during physical activity or intercourse.

How is Levator Avulsion Diagnosed?

• 3D/4D Ultrasound: This is a non-invasive and effective way to visualize the detachment of the levator ani.
• MRI Scans: Magnetic resonance imaging provides detailed views of pelvic floor anatomy.
• Clinical Examination: Skilled physiotherapists and gynecologists may detect avulsion through palpation and functional assessments.

Treatment Options

1. Pelvic Floor Muscle Training (PFMT)
• Although the detached muscles cannot be reattached, strengthening the remaining fibers can improve function and reduce symptoms.
• A physiotherapist can guide you through tailored exercises.
2. Pessary Use
• Pessaries are silicone devices inserted into the vagina to support pelvic organs and prevent prolapse progression.
• They are especially beneficial for those not ready or eligible for surgical intervention.
3. Surgical Repair
• In severe cases, surgical options like pelvic organ prolapse repair may be considered. However, the risk of recurrence is higher in individuals with levator avulsion.
4. Pain Management
• Manual therapy, acupuncture, or medication can help manage chronic pelvic pain associated with the condition.

Lifestyle Adjustments

• Bracing Techniques: Engaging the pelvic floor before lifting or bending can minimize intra-abdominal pressure. Learning how to do this effective can be paramount to protecting the pelvic organs and support network. 
• Pelvic Floor Strengthening and Strength Based Exercises: Ensuring your pelvic floor muscles as well as glutes, adductors, calf and core stay strong can help to support and protect the pelvic floor. Getting individual advice from a Pelvic Floor Physio is highly recommended. 
• Proper Defecation Posture: Using a footstool to elevate the knees can reduce strain during bowel movements.

Preventive Strategies

1. Education During Pregnancy
• Ensuring the pelvic floor can relax and lengthen well can help to reduce the risk of instrumental deliveries and a prolonged pushing stage. 
• Keeping the pelvic floor strong and ensuring regular pelvic floor strengthening AND relaxation
2. Early Postnatal Care
• Regular check-ups with a pelvic health physiotherapist can aid in early detection and management of avulsion injuries.
3. Ongoing Support
• Ensuring yearly progress checks with a Pelvic Floor Physio where required. We know that monitoring the pelvic floor on a yearly basis can allow for early detection and prevention if things like prolpase are worsening.