Ultrasound Obstet Gynecol 2015; 46: 356362

Published online 28 July 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.14711

Status of the pelvic floor in young primiparous women

C. M. DURNEA*, B. A. OREILLY*, A. S. KHASHAN*, L. C. KENNY*, U. A. DURNEA*,
M. M. SMYTH and H. P. DIETZ
*The Irish Centre for Fetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University
College Cork, Cork, Ireland; Department of Urogynaecology, Cork University Maternity Hospital (CUMH), Cork, Ireland; Department
of Epidemiology and Public Health, University College Cork, Cork, Ireland; School of Medicine, University College Cork, Cork, Ireland;
Sydney Medical School Nepean, Nepean Hospital, Penrith, Australia

K E Y W O R D S: 3D transperineal scan; LAM avulsion; pelvic organ prolapse; POP; primiparous

ABSTRACT Partial or full levator avulsion was seen in 29% of

participants and was associated with POP and related
Objectives To investigate the postnatal prevalence of
symptoms. Congenital factors seem to play little role
sonographically diagnosed pelvic floor trauma, and
in the etiology of LAM trauma, and the main risk
the correlations with various antenatal/intrapartum
factor seems to be forceps delivery. Avoidance of difficult
predictors in primiparous women.
vaginal deliveries may prevent severe pelvic floor trauma.
Methods This was a prospective cohort study performed Copyright 2014 ISUOG. Published by John Wiley &
in a tertiary hospital with 9000 deliveries per annum. Sons Ltd.
Of those invited, 202 (23.2%) primiparous participants
were assessed clinically at least 1 year after delivery
INTRODUCTION
by Pelvic Organ Prolapse Quantification (POP-Q),
two/three-dimensional transperineal sonography and Pelvic floor dysfunction (PFD) is a common problem, with
quantification of serum collagen type III levels. childbearing recognized as one of the major risk factors1 .
Numerous epidemiological and clinical studies have been
Results There was a high prevalence of clinically
undertaken on various aspects of PFD, such as urinary
significant pelvic organ prolapse (POP) on POP-Q
and fecal incontinence, prolapse or sexual dysfunction.
staging: uterine prolapse, 63%; cystocele, 42%; and
There has been increasing interest over the last decade
rectocele, 23%. Ballooning of the levator ani muscle
in innovative methodologies investigating morphological
(LAM) hiatus was detected in 33% and LAM avulsion
changes of the pelvic floor, especially three-dimensional
in 29% of participants, with partial LAM avulsion
(3D) transperineal sonography (TPS). This technique
occurring in 15% and complete avulsion in 14%.
has good testretest and intraobserver repeatability and
Postnatal POP symptoms (odds ratios (ORs) given
is considerably cheaper than, and in some respects
here for presence of multiple prolapse symptoms)
superior to, magnetic resonance imaging, especially when
were positively associated with similar prepregnancy
assessing dynamic images, such as those for investigating
symptoms (OR, 7.2 (95% CI, 1.1944.33)), LAM
prolapse2 4 . Several groups have examined the role of
avulsion (OR, 4.8 (95% CI, 1.9911.34)) and forceps
trauma to the puborectalis aspect of the levator ani muscle
delivery (borderline significance; OR, 1.8 (95% CI,
(LAM) in the development of PFD5,6 . The appearance of
0.963.25)) and negatively associated with elective
LAM avulsion seems to be very uncommon in nulliparous
(OR, 0.2 (95% CI, 0.090.63)) and emergency (OR,
women, however it is present in 1236% of women after
0.3 (95% CI, 0.120.83)) Cesarean section. LAM
their first vaginal delivery7 . Additionally, TPS allows
abnormality was associated with forceps delivery (OR,
visualization of bladder neck mobility, urethral length,
4.9 (95% CI, 1.4416.97)) and prolapse (OR, 6.811.7
assessment and quantification of pelvic organ prolapse
(95% CI, 2.3478.51)), whereas collagen levels did not
(POP), measurement of the subpubic angle and assessment
play a role (OR, 1.001 (95% CI, 0.991.02)).
of the anal sphincter complex8 10 .
Conclusions Clinically significant POP was common in The present study is a part of the 4P Study (Prevalence
relatively young premenopausal primiparous women. and Predictors of Pelvic floor dysfunction in Primips),

Correspondence to: Dr C. M. Durnea, 5th floor, INFANT Research Centre, Department of Obstetrics and Gynaecology, Cork University
Maternity Hospital, Cork, Ireland (e-mail: costea.durnea@gmail.com)
Accepted: 21 October 2014

Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. ORIGINAL PAPER
Pelvic floor status in young primiparae 357

which is designed to assess comprehensively changes in Invited to participate in

the pelvic floor after first pregnancy and delivery. In this SCOPE, Ireland
study we aimed to investigate the postnatal prevalence (n = 2579)
of sonographically diagnosed morphological alterations
Declined to participate
in pelvic floor functional anatomy and their correlation (n = 793 (30.7%))
with various antenatal and intrapartum predictors in
primiparous women. Accepted
(n = 1786 (69.3%))

METHODS Excluded according to

exclusion criteria
The 4P Study is a prospective cohort study, nested within (n = 12 (0.5%))
the parent SCOPE (Screening for Pregnancy Endpoints, Recruited to SCOPE, Ireland
www.scopestudy.net) Ireland study, which has previously (n = 1774 (68.8%))
been described in detail11 . It was approved by the
Did not answer initial
Clinical Research Ethics Committee of the Cork Teaching questionnaire
Hospitals (CREC), Ireland, and performed in a tertiary (n = 290 (11.2%))
maternity hospital with 9000 deliveries per annum.
Recruited to 4P Study
All 4P Study participants, comprising 1484 nulliparous and answered first questionnaire
women (84% of those recruited for SCOPE), completed (n = 1484 (57.5%))
the validated Australian Pelvic Floor Questionnaire in
Did not answer second
early pregnancy at 1415 weeks gestation12 . The same questionnaire
questionnaire was answered 1 year after delivery by 1060 (n = 424 (16.4%))
(71.4%) of the women; however, only 872 (58.8%)
were included in the study analysis and constituted the Answered second questionnaire
(n = 1060 (41.1%))
core of the 4P Study, as 188 (12.7%) were excluded
owing to a second ongoing pregnancy. The recruitment Excluded owing to second
phase occurred between February 2008 and March ongoing pregnancy
(n = 188 (7.3%))
2011. All 872 participants included in the initial analysis
were invited for clinical follow-up examination between Invited for clinical follow-up
March and December 2012. We received answers from (n = 872 (33.8%))
530 (60.8%) participants, with the proposed follow-up Did not answer invitation
examination being accepted by 408 (46.8%). Participants letter
who had had more than one delivery or who were again (n = 342 (13.3%))
pregnant at the time of follow-up (n = 206; 23.6%) were
Answered invitation
excluded from the study (Figure 1). The clinical follow-up (n = 530 (20.6%))
was attended by 202 (23.2% of all invited) participants
between May and November 2012. All attendees under- Declined to participate in
follow-up
went the International Continence Society (ICS) Pelvic (n = 122 (4.7%))
Organ Prolapse Quantification (POP-Q) assessment,
two-dimensional (2D) and 3D-TPS examination for Accepted invitation
(n = 408 (15.8%))
quantification of pelvic organ prolapse (POP) and pelvic
morphology evaluation, a blood serum collection for pro- Excluded owing to second
ongoing pregnancy
collagen quantification and recording of personal and/or
(n = 206 (8.0%))
family history of connective tissue conditions, shown
previously to be associated with PFD and POP (Table S1). Attended clinical follow-up
(n = 202 (7.8%))
POP-Q measurements were obtained on maximal
Valsalva maneuver with a duration of effort of at least 6 s,
in order to achieve maximal pelvic organ descent13 . Per- Figure 1 STARD (Standards for the Reporting of Diagnostic
ineal body and genital hiatal lengths were measured at rest. accuracy studies) flowchart showing recruitment of study
The POP-Q classification does not specify which grade of population of primiparous women examined at least 1 year after
delivery. SCOPE, Screening for Pregnancy Endpoints study.
prolapse should be considered significant, however it has
been suggested that POP-Q Stage 1 may be considered to
be within the normal range14 . This may not be correct for Valsalva maneuver. To estimate the extent of prolapse,
the central compartment, in which Stage 1 prolapse seems we measured the distance from the most distal part of the
to be strongly associated with symptoms of prolapse14 . bladder or anorectal junction to a horizontal line placed
Hence, we defined clinically relevant prolapse as cysto- through the inferior margin of the pubic bone15 .
cele and rectocele Stage 2 or uterine prolapse Stage 1. There are no studies to date that correlate the degree
For POP investigation by 2D-TPS and 3D-TPS, two of prolapse diagnosed on POP-Q with that diagnosed
images were acquired, one at rest and one on maximal on ultrasound. However, previous studies have reported

Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
358 Durnea et al.

a better correlation between the presence of symptoms diseases, induction of labor, mode of delivery, oxytocin
and the grade of ultrasound prolapse16 . We used an augmentation, duration of labor, fetal head circumference
ultrasound POP classification, categorizing prolapse into and birth weight.
clinically significant or non-significant17 . A cut-off level
of 10 mm below the symphysis pubis was proposed
to define significant cystocele and 15 mm below the RESULTS
symphysis pubis to define significant rectocele. We used Clinical follow-up was attended by 202 primiparous
the reference line (cut-off of 0 mm) as the definition of women (30.3% of all 666 women eligible for follow-up,
significant uterine prolapse based on unpublished data after excluding 206 with a second ongoing pregnancy
provided by H.P.D., as there is currently no published from the cohort of 872 invited for follow-up). Among
cut-off for central compartment descent. the participants, 99.5% were Caucasian, with a mean
LAM integrity was assessed using 3D-TPS in tomo- age of 31.2 years, mean body mass index of 25.1 kg/m2
graphic ultrasound imaging mode, and the image acquired and mean weight of 68.0 kg. Demographic characteristics
on maximum pelvic floor muscle contraction. The plane of the women who participated in the 4P Study clinical
of minimal hiatal dimensions was selected as the reference follow-up and SCOPE Ireland were similar (Table 1).
plane. To cover the whole width of the LAM, five tomo- The SCOPE cohort has been shown previously to be
graphic slices cephalad to the reference plane, with a slice representative of the entire population11 .
thickness of 2.5 mm, were included in the analysis. LAM In order to avoid transitory postnatal pelvic floor
avulsion was diagnosed if the distance between the center changes, participants were invited for clinical follow-up
of the urethra and the LAM insertion (levatorurethra at least 1 year after delivery. The average interval between
gap) was 25 mm18 . Complete LAM avulsion was delivery and clinical assessment was 1 year and 9 months
diagnosed if a distance of more than 25 mm was observed (range, 1.14.1 years). Of all participants who answered
in the reference slice and in the two slices cephalad to it. the question concerned, 158 (80.2%) were asymptomatic,
Any other combination of abnormal slices was considered 19 (9.6%) complained of symptoms of a vaginal lump
as partial LAM avulsion19 . We also assessed ballooning or bulge, 30 (15.2%) of vaginal pressure or heaviness,
of the levator hiatus, which was defined as distension of four (2.2%) of prolapse reduction to void, 10 (5.6%) of
the hiatal area of > 25 cm2 , which has been shown to be prolapse reduction to defecate and 10 (5.6%) reported
associated with LAM trauma and symptoms and signs associated bother due to prolapse symptoms.
of prolapse20 . The subpubic arch angle was measured On clinical examination, the mean POP-Q values for
in the axial plane close to the plane of minimal hiatal various points on maximal Valsalva maneuver were
dimensions, where the pubic rami join. The image was as follows: Ba, 1.21 0.84 cm; Bp, 1.92 0.75 cm;
manipulated to obtain maximal pubic rami length8 . C, 5.23 1.03 cm. On 2D-TPS, maximal descent of
We measured the level of blood serum procollagen
Type III N-terminal propeptide (PIIINP) in 96 partici-
Table 1 Demographic characteristics of study population and
pants, using commercial enzyme-linked immunosorbent overall population of SCOPE Ireland study
assay (ELISA) tests (USCN Life Science Inc., Wuhan,
China). Participants with the highest and lowest values Present study SCOPE Ireland
for point C (leading edge of the cervix on POP-Q Characteristic (n = 202) (n = 1774)
assessment) were selected from the cohort for subsequent
Caucasian 201 (99.5) 1450 (81.7)
PIIINP quantification. The methodology used has been Age (years) 31.2 4.7 29.9 4.5
described in detail previously16 . Aged 1724 years 19 (9.4) 207 (11.7)
Aged 2529 years 49 (24.3) 545 (30.7)
Aged 3034 years 89 (44.1) 787 (44.4)
Statistical analysis Aged 3545 years 45 (22.3) 235 (13.2)
Weight (kg) 68.0 11.3 67.5 12.2
Statistical analysis was performed using IBM SPSS 19 Body mass index (kg/m2 ) 25.1 4.1 24.9 4.2
(IBM Corp., Armonk, NY, USA) and Stata Software 10.0 Underweight 4 (2.0) 22 (1.2)
(StataCorp, College Station, TX, USA). All statistical tests Normal weight 103 (51.0) 1036 (58.4)
were two-sided and P < 0.05 was considered statistically Overweight 70 (34.7) 495 (27.9)
significant. To investigate the effect of potential risk Obese 25 (12.4) 221 (12.5)
Education
factors on PFD, stepwise ordinal logistic regression
12 years 28 (13.9) 230 (13.0)
analysis was used to calculate the odds ratio (OR) and > 12 years 174 (86.1) 1544 (87.0)
95% CIs. In ordinal logistic regression, the outcome Smoking
measure is ordinal with more than two categories. Risk Non-smoker 148 (73.3) 1285 (72.4)
factors with borderline statistical significance (P < 0.1) Smoker 54 (26.7) 489 (27.6)
were used for multivariable logistic regression analysis. Alcohol consumption
No 39 (19.3) 339 (19.1)
Main outcome measures were rectocele, uterine prolapse,
Yes 163 (80.7) 1435 (80.9)
LAM trauma and LAM hiatal ballooning. The examined
risk factors were subpubic arch angle, collagen Type Data given as n (%) or mean SD. SCOPE, Screening for
III levels, personal or family history of collagen-related Pregnancy Endpoints.

Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
Pelvic floor status in young primiparae 359

Table 2 Prevalence of various types of pelvic organ prolapse on Pelvic Organ Prolapse Quantification (POP-Q) and three-dimensional
transperineal sonography (3D-TPS) assessment in 202 primiparous women at least 1 year after delivery

Cystocele Rectocele Uterine prolapse

Prolapse present POP-Q* 3D-TPS POP-Q* 3D-TPS POP-Q 3D-TPS

No 118 (58.4) 174 (86.1) 155 (76.7) 153 (75.7) 75 (37.1)

Yes 84 (41.6) 28 (13.9) 47 (23.3) 49 (24.3) 127 (62.9)

Data given as n (%). *Prolapse present if POP-Q Stage 2. Prolapse present if significant prolapse according to Dietz et al.17 . Prolapse
present if Grade 12 according to POP-Q according to Dietz et al.14 .

the bladder on Valsalva was 0.45 1.16 cm below the Table 3 Association between presence of prolapse symptoms and
symphyseal reference line. Maximal descent of the rectal various risk factors in 202 primiparous women examined at least
1 year after delivery by Pelvic Organ Prolapse Quantification and
ampulla was to 0.46 1.17 cm above the reference line. transperineal ultrasound on univariable logistic regression analysis
The prevalence of various types of POP assessed by
POP-Q and 3D-TPS is presented in Table 2. Clinically Outcome/risk factor OR (95% CI) P
significant uterine prolapse (Stage 1) on POP-Q mea-
Vaginal pressure or heaviness
surement (described in Methods section) was present in
Prepregnancy vaginal 4.4 (0.7724.8) 0.096
62.9% of participants. The prevalence of clinically sig- pressure/heaviness
nificant cystocele on POP-Q examination (Stage 2) was Prepregnancy total prolapse 4.4 (2.308.30) < 0.0001
three-fold higher compared with the finding of a signifi- score
cant cystocele on ultrasound (bladder 10 mm below the Forceps delivery 1.7 (0.962.94) 0.071
Emergency CS 0.4 (0.180.86) 0.019
symphysis pubis), with a prevalence of 41.6% vs 13.9%.
Elective CS 0.2 (0.090.52) 0.001
Significant posterior compartment descent (ICS-POP-Q Partial LAM avulsion 1.1 (0.353.70) 0.820
Stage 2, or descent of the ampulla 15 mm below the Complete LAM avulsion 5.3 (2.1413.3) < 0.0001
symphysis pubis) was similar for both diagnostic methods, Ballooning of LAM hiatus 3.9 (1.738.58) 0.001
with a prevalence of around 24%. Prolapse sensation
Examination by 3D-TPS revealed that nearly one-third Prepregnancy vaginal 3.5 (1.1310.66) 0.029
pressure/heaviness
(29.2%) of participants had some form of abnormal
Prepregnancy prolapse score 2.7 (1.106.85) 0.03
LAM morphology. Partial LAM avulsion was detected in Forceps delivery 0.3 (0.120.99) 0.048
15% of participants and complete avulsion in 14%, with Partial LAM avulsion 3.2 (0.8411.92) 0.089
right-sided avulsion being more common than left-sided Complete LAM avulsion 9.5 (3.0829.26) < 0.0001
(10.9% vs 2.5%), and bilateral avulsion being common Ballooning of LAM hiatus 3.2 (1.218.28) 0.019
at 15.8%. One-third (n = 67; 33.2%) of participants had Presence of multiple prolapse
symptoms
ballooning of the LAM hiatus, of whom 38 (56.7%) had
Prepregnancy vaginal 7.2 (1.1944.33) 0.032
associated LAM avulsion. pressure/heaviness
When analyzing factors associated with the presence Prepregnancy total prolapse 4.8 (2.379.55) < 0.0001
of prolapse symptoms (Table 3), we found statistically score
significant correlations with a prepregnancy presence Forceps delivery 1.8 (0.963.25) 0.069
Emergency CS 0.3 (0.120.83) 0.019
of prolapse symptoms (OR, 2.77.2), complete LAM
Elective CS 0.2 (0.090.63) 0.004
avulsion (OR, 4.89.5), LAM hiatal ballooning (OR, Partial LAM avulsion 1.6 (0.614.12) 0.340
2.55.2) and there was borderline significance for forceps Complete LAM avulsion 4.8 (1.9911.34) < 0.0001
delivery (OR, 1.8). Delivery by Cesarean section was Ballooning of LAM hiatus 2.5 (1.245.15) 0.011
found to be protective (OR, 0.20.4). Bother due to prolapse symptoms
Additionally, we analyzed the association of various Prepregnancy total prolapse 4.2 (1.5211.51) 0.006
score
antepartum and intrapartum factors with LAM trauma
Partial LAM avulsion 1.7 (0.329.40) 0.519
(Table 4) and ballooning of the LAM hiatus (Table 5). Complete LAM avulsion 7.4 (2.0726.21) 0.002
On univariable analysis we found statistically significant Ballooning of LAM hiatus 5.2 (1.5317.54) 0.008
or borderline significant correlation between any LAM
trauma and the use of oxytocin in labor (OR, 1.8), CS, Cesarean section; LAM, levator ani muscle; OR, odds ratio.
duration of the second stage of labor (OR, 1.01),
forceps delivery (OR, 4.5), episiotomy (OR, 4.2) and On multivariable analysis, LAM avulsion was found
postnatal presence of cystocele (OR, 4.2). Ballooning of to be statistically significantly associated with duration
the LAM hiatus was associated with forceps delivery of the second stage of labor (OR, 1.01), forceps delivery
(OR, 4.8), episiotomy (OR, 1.9), birth weight (OR, (OR, 4.9) and postnatal presence of cystocele (OR, 11.7)
1.01), postnatal presence of cystocele, rectocele or (Table 4). Multivariable analysis of risk factors for bal-
uterine prolapse (OR, 7.5, 2.6 and 7.6, respectively) and looning of the LAM hiatus found significant associations
partial or complete LAM avulsion (OR, 2.8 and 17.4, with uterine prolapse (OR, 6.8) and partial (OR, 3.2)
respectively). and complete (OR, 12.2) LAM avulsion. Forceps delivery

Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
360 Durnea et al.

Table 4 Association between diagnosis of levator ani muscle avulsion on transperineal sonography at least 1 year after childbirth and
various antenatal, intrapartum and postpartum factors in 202 primiparous women on univariable and multivariable ordinal logistic
regression analyses

Univariable analysis Multivariable analysis

Antenatal and intrapartum factors OR (95% CI) P OR (95% CI) P
Medical history
Family history of collagen diseases 1.5 (0.802.81) 0.209
Personal history of collagen diseases 0.9 (0.451.76) 0.743
Antenatal/intrapartum factors
Private maternity care 0.99 (0.472.09) 0.991
Induction of labor 1.4 (0.772.59) 0.265
Use of oxytocin in labor 1.8 (0.973.45) 0.063 0.7 (0.001.63) 0.435
Regional analgesia 0.9 (0.471.75) 0.779
Duration of first stage of labor 0.99 (0.911.10) 0.988
Duration of second stage of labor 1.01 (1.001.01) 0.003 1.01 (1.001.02) 0.019
Vacuum delivery 1.9 (0.874.23) 0.108 1.3 (0.483.52) 0.599
Forceps delivery 4.5 (1.9910.22) < 0.0001 4.9 (1.4416.97) 0.011
Emergency Cesarean section 0.6 (0.471.63) 0.352
Elective Cesarean section 0.7 (0.251.98) 0.507 0.4 (0.044.08) 0.450
Perineal tear 0.9 (0.651.25) 0.524
Episiotomy 4.2 (2.247.78) < 0.0001 1.8 (0.664.77) 0.251
Fetal birth weight 1.0 (0.991.01) 0.450
Fetal head circumference 1.1 (0.911.39) 0.296
Assessment >1 postnatal year
Delivery-to-assessment interval 0.99 (0.991.00) 0.342
Subpubic arch angle 0.98 (0.951.02) 0.290
High levels of collagen Type III 1.01 (0.991.02) 0.224
Cystocele 4.2 (0.9419.14) 0.061 11.7 (1.7378.51) 0.012
Rectocele 1.3 (0.582.71) 0.569
Uterine prolapse 1.6 (0.763.30) 0.218

OR, odds ratio.

Table 5 Association between diagnosis of ballooning of the levator ani muscle (LAM) hiatus on transperineal sonography at least 1 year
after childbirth and various antenatal, intrapartum and postpartum factors in 202 primiparous women on univariable and multivariable
logistic regression analyses

Univariable analysis Multivariable analysis

Antenatal and intrapartum factors OR (95% CI) P OR (95% CI) P
Medical history
Family history of collagen diseases 1.5 (0.792.73) 0.230
Personal history of collagen diseases 1.5 (0.772.83) 0.245
Antenatal/intrapartum factors
Private maternity care 1.1 (0.512.26) 0.860
Induction of labor 1.3 (0.702.38) 0.413
Use of oxytocin in labor 1.7 (0.893.21) 0.111
Regional analgesia 0.9 (0.451.69) 0.686
Duration of first stage of labor 1.1 (0.981.19) 0.102
Duration of second stage of labor 1.0 (1.001.01) 0.303
Vacuum delivery 1.5 (0.673.37) 0.326
Forceps delivery 4.8 (1.9111.82) 0.001 4.0 (0.8718.56) 0.074
Emergency Cesarean section 0.5 (0.121.77) 0.264 0.5 (0.072.98) 0.418
Elective Cesarean section 0.6 (0.241.64) 0.340 0.7 (0.133.33) 0.633
Perineal tear 0.9 (0.681.31) 0.725
Episiotomy 1.9 (1.053.52) 0.035 0.6 (0.171.88) 0.353
Fetal birth weight 1.01 (1.0011.03) 0.049 1.0 (0.991.00) 0.192
Fetal head circumference 1.2 (0.941.45) 0.169
Assessment >1 postnatal year
Delivery-to-assessment interval 0.73 (0.421.26) 0.263
Subpubic arch angle 1.01 (0.981.05) 0.459
High levels of collagen Type III 0.99 (0.981.01) 0.514
Cystocele 7.5 (1.6533.59) 0.009 2.1 (0.3512.03) 0.422
Rectocele 2.6 (1.155.79) 0.022 1.8 (0.576.59) 0.311
Uterine prolapse 7.6 (3.2117.93) < 0.0001 6.8 (2.3420.01) < 0.0001
Partial LAM avulsion 2.8 (1.256.24) 0.012 3.2 (1.208.69) 0.020
Complete LAM avulsion 17.4 (6.1149.87) < 0.0001 12.2 (3.2246.00) < 0.0001

OR, odds ratio.

Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 356362.
Pelvic floor status in young primiparae
showed only borderline significance for ballooning of the
LAM hiatus (OR, 4.0; P = 0.074) (Table 5).
We did not find any association between LAM
abnormality and head circumference, total duration of
labor, subpubic arch angle, collagen levels or history
of collagen disease. In addition, the time interval from
delivery to 3D-TPS examination did not significantly
influence the presence of LAM pathology. Delivery by
Cesarean section appeared to be protective, but this was
not statistically significant.
DISCUSSION
In the present study, we investigated the postnatal
prevalence of pelvic floor trauma in primiparous women
using 3D-TPS. Unlike previous studies, we intended to
describe the ultrasound appearance of the pelvic floor
in primiparous women at least 1 year after childbirth
and to investigate associations between these findings
and potential prepregnancy and intrapartum contributing
factors21 . We intentionally used a cut-off of 1 year to avoid
inclusion of transitory changes in the pelvic floor in our
study, which can persist for up to 6 months postnatally
or even longer22 .
We found that POP is very common in primiparous
women, with clinically significant cystocele being more
prevalent on POP-Q assessment, and rectocele having
similar detection rates on POP-Q and 3D-TPS investi-
gation. Around half of the participants had clinically
significant cystocele or uterine prolapse, and one quarter
had clinically significant posterior compartment descent,
although none had any form of prolapse greater than
Stage 2 (Table 2). It is known that the correlation
between POP findings on POP-Q assessment and TPS is
fair-to-good15 . However, it has also been shown that TPS
is more likely to avoid the potential confounding effect of
important factors such as levator coactivation, or a full
bladder or rectum (which can be visualized directly on
the screen and dealt with accordingly), whereas clinical
examination is able to displace one compartment to allow
other compartments to descend23 .
Prolapse symptoms were not uncommon (even though
80% of participants with objective prolapse were
asymptomatic) and were associated with LAM trauma
and forceps delivery, whereas delivery by Cesarean section
had a protective effect16 . At 14.4%, the prevalence of
complete LAM avulsion diagnosed by ultrasound in
this study is well within the range of values reported
previously, being similar to those reported recently in
studies using the same methodology24,25 . Our rate of
partial LAM avulsion is higher than rates found in
previous studies, however, similarly to previous reports,
we found that right-sided trauma is more common than
left-sided26 . This is probably owing to the fact that, in
Ireland, active management of labor is advocated, with a
high rate of forceps delivery. Slightly more than half the
cases with ballooning of the LAM hiatus were associated
with LAM trauma. The results of our univariable analysis
correspond well with those of previous studies, showing
Copyright 2014 ISUOG. Published by John Wiley & Sons Ltd.
361
an association between LAM trauma and duration of the
second stage of labor, mode of delivery and episiotomy,
in which the use of forceps was most predictive of
trauma5,24,25 . In contrast to other reports, we did not find
a significant association with fetal head circumference5 .
This could reflect different obstetric practices, or it could
be due to power issues. In addition, definitions of avulsion
vary in the published literature, which may explain some
of the differences in results.
The logistic regression analysis did not demonstrate
an association between congenital non-modifiable fac-
tors, such as subpubic arch angle, collagen levels or
collagen-related disease, with LAM pathology, which
most probably occurs because of the mechanical impact of
vaginal delivery, rather than because of pelvic weakness.
This conclusion confirms the results from previous studies
that used 3D-TPS intrapartum and in the early postnatal
period, which have shown that crowning of the head is
the immediate cause of avulsion of the LAM27 . Addi-
tionally, other research groups have shown that hiatal
dimensions, bladder neck descent, subpubic arch angle
and other anthropometric parameters are not associated
with avulsion. Our results are in keeping with these data,
and suggest that antenatal prediction of LAM trauma may
not be possible28 .
The main strength of our study is the fact that it
was nested within the SCOPE study, gaining access
to a detailed database containing information about
intrapartum risk factors and nulliparous women whose
phenotype has been well established. The present study is
likely to be representative of the entire study population,
which is homogeneous and has been shown to be repre-
sentative of the Irish population overall. All participants
were relatively young women who delivered in the
same hospital following similar obstetric management
principles and protocols. A potential congenital predictor
of pelvic organ support, procollagen III, was included
in the study design to investigate naturally occurring
confounders. All participants were assessed both clin-
ically by ICS-POP-Q and by TPS in order to describe
comprehensively the state of pelvic organ support.
The lack of baseline assessments remains a major
limitation, especially when interpreting clinical symp-
toms. Another drawback is the limited number of
observations performed owing to attrition, which may
limit the conclusions that can be drawn from our results,
although the participants demographic characteristics in
the present study were reasonably similar to those of the
Cork SCOPE population. The study had limited statistical
power owing to a small sample size, and this is reflected
in the wide 95% CIs for some ORs. For example, a
family history of collagen diseases, induction of labor
and oxytocin use during labor were not statistically
significant in the univariable models for LAM avulsion or
ballooning, despite the elevated OR. Further investigation
of these risk factors in larger cohorts is warranted.
In conclusion, more than half of relatively young
premenopausal primiparous women were shown to have
some form of clinically significant POP at 14 years
Ultrasound Obstet Gynecol 2015; 46: 356362.
362
after their first delivery. This is likely to contribute to
the development of PFD later in life. One-third showed
some degree of LAM trauma, which is associated with the
presence of POP and symptoms related to it in later life.
Congenital factors seem to play little role in the etiology of
LAM trauma, and the main risk factor seems to be forceps
delivery. Cesarean section was shown to be protective
against the presence of some symptoms. Avoidance of
difficult vaginal deliveries may prevent severe pelvic floor
trauma and associated symptoms.
ACKNOWLEDGMENTS
SCOPE Ireland is funded by Health Research Board of
Ireland (grant reference CSA 2007/2). The study was sup-
ported by Continence Foundation Ireland and INFANT
Centre, UCC. L.C.K. is a Science Foundation Ireland Prin-
cipal Investigator (08/IN.1/B2083) and the Director of the
SFI funded Centre, INFANT (12/RC/2272).
We would like to thank all SCOPE Ireland participants,
Continence Foundation Ireland and the Irish Centre for
Fetal and Neonatal Translational Research (INFANT) for
their input into this research project and Dr Lynne Kelly
(PhD), research bioscientist, for helping to perform ELISA
collagen analysis.
H.P.D. has received unrestricted educational grants
from GE Medical.
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The following supporting information may be found in the online version of this article:
Table S1 Medical conditions shown previously to be associated with pelvic floor dysfunction (PFD) and pelvic
organ prolapse (POP)
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