Levator defects are associated with prolapse after pelvic floor surgery

Objectives: Pelvic organ prolapse recurrence after pelvic floor surgery is a common problem. This study was designed to assess whether avulsion defects of the puborectalis muscle are associated with recurrent pelvic organ prolapse and its symptoms. Study design: We retrospectively evaluated 737 data sets of patients who had presented to a tertiary urogynaecology unit with symptoms of pelvic floor dysfunction. All underwent a standardised interview including a surgical history, a clinical examination and 4D pelvic floor ultrasound. Avulsion injury was diagnosed on tomographic ultrasound. The prevalence of pelvic organ prolapse and its symptoms was calculated for patients with previous hysterectomy and previous anti-incontinence and prolapse surgery, with and without confirmed avulsion injury. Results: Out of 737 patients, 248 (33.6%) reported a previous hysterectomy, 165 patients (22.4%) had undergone incontinence or prolapse procedures, 106 (14.4%) reported a previous anterior colporrhaphy, and 45 patients (6.1%) had undergone a colposuspension in the past. In all four groups avulsion injury was significantly associated with objective prolapse (relative risks between 2.3 and 3.3, odds ratios between 3.4 and 6). Symptoms of prolapse were significantly associated with avulsion injury post hysterectomy, incontinence or prolapse procedures and after anterior colporrhaphy. Conclusions: Avulsion injury of the puborectalis muscle is associated with prolapse in women with previous pelvic floor surgery.