Adding Insult to Injury: Levator Ani Avulsion in Women with Obstetric Anal Sphincter Injuries

Bhumy Davé Heliker*, Kimberly Kenton, Alix Leader-Cramer, Oluwateniola Brown, Katarzyna Bochenska, Julia Geynisman-Tan, Margaret Mueller, Christina Lewicky-Gaupp

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Objective In women with obstetric anal sphincter injuries, we compared the rate of major levator ani avulsion after forceps-assisted delivery versus spontaneous vaginal delivery. Methods Prospective cohort of primiparous women with obstetric anal sphincter injuries. The primary outcome was the rate of major levator ani avulsion as measured by 3-dimensional transvaginal ultrasonography performed between 1 and 2 weeks postpartum. Secondary outcomes included ultrasonographic anteroposterior hiatal diameter, levator hiatal area, and levator-urethra gap, and differences in validated pelvic disorder questionnaires scores at 1 to 2 and 13 weeks postpartum. Results Sixty-two women (30 spontaneous deliveries, 32 forceps deliveries) were included in the final analysis. After controlling for delivery variables, women who underwent forceps-assisted delivery were more likely to experience a major avulsion as compared with those who underwent spontaneous delivery (21/32, [65.6%] vs 8/30 [26.7%]; odds ratio, 5.9; 95% confidence interval, 1.5-24.5; P = 0.014). They were also more likely to have larger levator-urethra gaps bilaterally (P = 0.012, 0.016). After controlling for potential confounders, levator ani avulsion was independently associated with persistent anal incontinence symptoms at 13 weeks postpartum (P = 0.02). Conclusions In women with obstetric anal sphincter injuries, the risk of levator ani avulsion is almost 6 times higher after forceps-assisted vaginal delivery as compared with spontaneous vaginal delivery. In those with avulsion, recovery of anal continence is compromised, suggesting that adding insult (avulsion) to injury (obstetric anal sphincter injury) may have negative functional consequences.

Original languageEnglish (US)
Pages (from-to)462-467
Number of pages6
JournalFemale Pelvic Medicine and Reconstructive Surgery
Issue number7
StatePublished - 2021


  • anal incontinence
  • levator ani avulsion
  • obstetric anal sphincter injuries

ASJC Scopus subject areas

  • Urology
  • Obstetrics and Gynecology
  • Surgery


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