Anatomic and functional evaluation of the levator ani muscle after an obstetric anal sphincter injury

  • Eva Martínez FrancoEmail author
  • José Luís López Negre
  • David Parés
  • Cristina Ros Cerro
  • Lluís Amat Tardiu
  • Daniel Cuadras
  • Montserrat Espuña Pons
General Gynecology



To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI).


This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients.


72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, with an average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02).


The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.


Anal sphincter obstetric injury Anal incontinence Levator ani 



We thank Sra Emma Herrero for her contribution in patient recruitment and schedule.

Author contributions

EMF: project development and data collection; JLLN: data collection; DP: manuscript editing; CRC: project development; LlAT: manuscript editing; DC: data analysis; MEP: project development.


Study was awarded with a local Research Grant of the Parc Sanitari Sant Joan de Déu and the Sant Joan de Déu Foundation.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Sultan AH (1999) Obstetric perineal injury and anal incontinence. Clinical Risk 5:193–196Google Scholar
  2. 2.
    Abramowitz L, Sobhani I, Ganansia R, Vuagnat A, Benifla JL, Darai E, Madelenat P, Mognon M (2000) Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum 43:590–598CrossRefGoogle Scholar
  3. 3.
    Borello-France D, Burgio KL, Richter HE, Zyczynski H, FitzGerald MP, Whitehead W, Fine P, Nygaard I, Handa VL, Visco AG, Weber AM, Brown MB, for the Pelvic Floor Disorders Network (2006) Fecal and urinary incontinence in primiparous women. Obstet Gynecol 108(4):863–872CrossRefGoogle Scholar
  4. 4.
    Gurol-Urganci I, Cromwell D, Edozien L, Mahmood T, Adams E, Richmond D, Templeton A, van der Meulen J (2013) Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 120:1516–1525CrossRefGoogle Scholar
  5. 5.
    Ampt AJ, Patterson JA, Roberts CL, Ford JB (2015) Obstetric anal sphincter injury rates among primiparous women with different modes of vaginal delivery. Int J Gynaecol Obstet. 131(3):260–264CrossRefGoogle Scholar
  6. 6.
    Sakse A, Secher NJ, Ottesen M, Starck M (2009) Defects on endoanal ultrasound and anal incontinence after primary repair of fourth-degree anal sphincter rupture: a study of the anal sphincter complex and puborectal muscle. Ultrasound Obstet Gynecol 34:693–698CrossRefGoogle Scholar
  7. 7.
    Starck M, Bohe M, Valentin L (2006) The extent of endosonographic anal sphincter defects after primary repair of obstetric sphincter tears increases over time and is related to anal incontinence. Ultrasound Obstet Gynecol 27:188–197CrossRefGoogle Scholar
  8. 8.
    Guedea MA, Alcázar Zambrano JL, Baixauli Fons J, Juez Viana L, Olartecoechea Linaje B, Mínguez Milio JA (2015) Alteration of anal sphincter function in patients with levator avulsion: observational study. Int Urogynecol J 26:985–990CrossRefGoogle Scholar
  9. 9.
    Lewicky-Gaupp C, Brincat C, Yousuf A, Patel DA, Delancey JO, Fenner DE (2010) Fecal incontinence in older women: are levator ani defects a factor? Am J Obstet Gynecol. 202:491.e1–6CrossRefGoogle Scholar
  10. 10.
    Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum. 36:77–97CrossRefGoogle Scholar
  11. 11.
    Laycock J, Jerwood D (2001) Pelvic floor muscle assessment: the PERFECT scheme. Physiotherapy. 87:631–642CrossRefGoogle Scholar
  12. 12.
    Salvans S, Parés Pera M, Pascual M, Alonso S, Courtier R, Gil MJ, Maestre Ibañez-Zafón I, Delgado-Aros S, Grande L (2009) Endoanal ultrasound findings in patients with faecal incontinence using a scoring system. Cir Esp. 86(5):290–295CrossRefGoogle Scholar
  13. 13.
    Dietz HP, Bernardo MJ, Kirby A, Shek KL (2011) Minimal criteria for the diagnosis of avulsion of the puborectalis muscle by tomographic ultrasound. Int Urogynecol J. 22:699–704CrossRefGoogle Scholar
  14. 14.
    Simó González M, Cassadó Garriga J, Dosouto Capel C, Porta Roda O, Perelló Capó J, Gich Saladich I (2017) Is obstetric anal sphincter injury a risk factor for levator ani muscle avulsion in vaginal delivery? Ultrasound Obstet Gynecol 49:257–262CrossRefGoogle Scholar
  15. 15.
    Cassadó Garriga J, Pessarrodona Isern A, Espuña Pons M, Durán Retamal M, Felgueroso Fabregas A, Rodriguez-Carballeira M (2011) Tridimensional sonographic anatomical changes on pelvic floor muscle according to the type of delivery. Int Urogynecol J 22:1011–1018CrossRefGoogle Scholar
  16. 16.
    Green-top Guideline (2015) The management of third- and fourth-degree perineal tears. No. 29. Royal College of Obstetrics and GynaecologistsGoogle Scholar
  17. 17.
    Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A (2016) Functional anorectal disorders. Gastroenterology 150:1430–1442CrossRefGoogle Scholar
  18. 18.
    Dietz HP, Shek C (2008) Levator avulsion and grading of pelvic floor muscle strength. Int Urogynecol J 19:633–636CrossRefGoogle Scholar
  19. 19.
    DeLancey JO, Morgan DM, Fnenner DE, Kearney R, Guire K, Miller JM, Hussain H, Umek W, Hsu Y, Ashton-Miller JA (2007) Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol. 109:295–302CrossRefGoogle Scholar
  20. 20.
    Kim S, Wong V, Moore KH (2013) Why are some women with pelvic floor dysfunction unable to contract their pelvic floor muscles? Aust NZJ Obstet Gynaecol 53:574–579CrossRefGoogle Scholar
  21. 21.
    Ferreira CH, Barbosa PB, de Oliveira Souza F, Antônio FI, Franco MM, Bø K (2011) Inter-rater reliability study of the modified Oxford Grading Scale and the Peritron manometer. Physiotherapy 97(2):132–138CrossRefGoogle Scholar
  22. 22.
    Ros Cerro C, Martínez Franco E, Santoro GA, Palau MJ, Wieczorek P, Espuña-Pons M (2017) Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms Int Urogynecol J 28:455–460Google Scholar
  23. 23.
    Johannessen H, Wibe A, Stordahl A, Sandvik L, Mørkved S (2017) Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial. BJOG 124:686–694CrossRefGoogle Scholar
  24. 24.
    Nazir M, Carlsen E, Jacobsen AF, Nesheim BI (2002) Is there any correlation between objective anal testing, rupture grade, and bowel symptoms after primary repair of obstetric anal sphincter rupture? Dis Colon Rectum 45:1325–1331CrossRefGoogle Scholar
  25. 25.
    Broens PMA, Jonker JE, Trzpis M (2018) The puborectal continence reflex: a new regulatory mechanism controlling fecal continence. Int J Colorectal Dis. 33:627–633CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Eva Martínez Franco
    • 1
    Email author
  • José Luís López Negre
    • 2
  • David Parés
    • 3
  • Cristina Ros Cerro
    • 4
  • Lluís Amat Tardiu
    • 5
  • Daniel Cuadras
    • 6
  • Montserrat Espuña Pons
    • 4
  1. 1.Obstetrics and Gynecology Department, Parc Sanitari Sant Joan de DéuUniversitat de BarcelonaSant Boi de LlobregatSpain
  2. 2.General and Digestive Surgery Department, Parc Sanitari Sant Joan de DéuUniversitat de BarcelonaSant Boi de LlobregatSpain
  3. 3.Colorectal Surgery Unit, General and Digestive Surgery Department, Hospital Germans Trias I PujolUniversitat Autónoma de BarcelonaBadalonaSpain
  4. 4.Obstetrics and Gynecology Department, Hospital ClínicUniversitat de BarcelonaBarcelonaSpain
  5. 5.Obstetrics and Gynecology Department, Hospital Sant Joan de DéuUniversitat de BarcelonaEsplugues de LlobregatSpain
  6. 6.Statistical and Methodological DepartmentSant Joan de Déu Research FoundationEsplugues de LlobregatSpain

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