Levator hiatal area associated with recurrent prolapse

1. Women with larger levator hiatal area and stage 3-4 pelvic organ prolapse at baseline were more likely to develop post-operative cystocele recurrence.

2. Levator hiatal area was a poor predictor of cystocele recurrence.

Evidence Rating Level: 2 (Good)    

Study Rundown: Pelvic organ prolapse (POP), defined as herniation of the pelvic organs, is a condition that affects many women worldwide. Normally, pelvic organs are supported by pelvic floor muscles, especially the levator ani muscle complex, and ligaments attached to the pelvic bones. Risk factors for pelvic organ prolapse include increasing parity, older age, obesity and hysterectomy. While some women with POP are asymptomatic, others experience bulging or vaginal pressure that may be associated with urinary, bowel or sexual dysfunction. Treatment options for symptomatic women include pessaries, pelvic floor physical therapy and surgical procedures. Prior studies employing translabial 3D ultrasound demonstrated an association between increased levator hiatal area during Valsalva and POP. Given the high incidence of repeat operations for POP, study authors sought to evaluate levator hiatal area as a predictor of POP recurrence following surgical correction. They found that while levator hiatal area was associated with cystocele recurrence, it was a poor positive predictor.

Strengths of this study included prospective design and multicenter study. Limitations include small sample size and inclusion of only patients treated at teaching hospitals, which may limit power and generalizability, respectively. Additional studies are needed to develop a useful predictive tool for POP recurrence.

Click to read the study in BJOG

Relevant Reading: Primary and repeat surgical treatment for female pelvic organ prolapse and incontinence in parous women in the UK- a register linkage study

In-Depth [prospective cohort]: This study assessed the predictive value of levator hiatal area in recurrence of cystocele among 139 women undergoing anterior colporrhaphy. Levator ani area was defined as the area bordered by the levator ani muscle, pubic symphysis and inferior pubic rami; it was measured at rest, during contraction of the pelvic floor and during Valsalva. The primary outcome of interest was cystocele recurrence.

Women with stage 3 or 4 POP preoperatively were more likely to develop recurrent pelvic organ prolapse post-operatively (OR 3.47, CI 1.66-7.28). Increased levator hiatal area was associated with increased odds of recurrence (OR 1.06, CI 1.01-1.11). However, the area under ROC curve for hiatal area during Valsalva was only 0.76 (CI 0.72-0.80), with a specificity of 83% and sensitivity of 52%.

Image: PD

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