The impact of childbirth on pelvic floor morphology in primiparous Black South African women: a prospective longitudinal observational study.

INTRODUCTION AND HYPOTHESIS: There is a lack of prospective studies evaluating the impact of childbirth on the pelvic floor in non-white populations. We intended to study delivery-related changes in pelvic floor morphology in Black South African primiparae. We also intended to determine the impact of anatomical changes on symptoms in the postpartum period. METHODS: A total of 153 nulliparous women between 35 and 39 weeks gestation were recruited from a district antenatal clinic. All women had a standardized interview, completed the International Consultation on Incontinence Vaginal Symptoms questionnaire followed by three/four dimensional transperineal ultrasonography. This was repeated at 3-6 months postpartum. RESULTS: Of the 153 women, 84 (54.9%) returned at a mean of 4.8 months postpartum. Of these women, 60 (71.4%) had a vaginal delivery and the remainder a caesarean section (20 emergency and 4 elective). Overall, there were statistically significant increases in bladder neck descent (P = 0.003), pelvic organ descent and levator hiatal distensibility (all P < 0001) at the postpartum assessment. Levator avulsion was diagnosed in nine (15%) of those delivered vaginally. Postpartum vaginal laxity was the commonest bothersome vaginal symptom, reported by 51 women (60.7%). CONCLUSIONS: There is significant alteration in pelvic organ support and levator hiatal distensibility postpartum, with more marked effects in women after vaginal delivery. Of Black primiparous women, 15% sustained levator trauma after their first vaginal delivery.

Prospective evaluation of the safety and feasibility of a pelvic floor dilator during active labor.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the safety and feasibility of using a pelvic floor dilator during active labor to prevent injuries to the levator ani muscle (LAM) and perineum. METHODS: In a prospective pilot study, a pelvic floor dilator using soft pads was introduced into the vaginal canal to gradually expand the vagina, in 30 nulliparous women and in 10 controls. The primary outcomes were adverse events related to the device. Secondary outcomes were perineal lacerations after delivery, sonographically defined levator ani injury, hiatal area dimensions, and anal sphincter disruption, all at 12-20 weeks postpartum, and maximum pelvic floor dilation, time to achieve maximum dilation, and device retention rate. RESULTS: From October 2014 through November 2016, a total of 494 women were screened, and 61 consented to the study. Thirty women used the device and 27 returned for follow-up. No maternal or neonatal injuries were related to use of the dilator. The average maximum dilation of the vaginal canal was 7.4 cm (SD 0.7, range 5.5-8.0). Dilation time averaged 27 min (SD 13, range 5-60). Device insertion adjustment was needed in 13 out of 30 cases (43%). Similar rates of 3th-4th degree perineal lacerations were seen in both groups. Levator ani avulsion was diagnosed in 2 out of 27 (7%) in the device group and in 1 out of 9 (11%) in the control group (p = 0.2). The rate of partial injury in the device group was 2 out of 27 (7%) vs 2 out of 9 (22%) in the comparison group (p = 0.2). CONCLUSION: The use of the pelvic floor dilator during active labor is feasible. No safety issues were identified.

Can pelvic floor trauma be predicted antenatally?

INTRODUCTION: Levator trauma is a risk factor for the development of pelvic organ prolapse. We aimed to identify antenatal predictors for significant damage to the levator ani muscle during a first vaginal delivery. MATERIAL AND METHODS: A retrospective observational study utilizing data from two studies with identical inclusion criteria and assessment protocols between 2005 and 2014. A total of 1148 primiparae with an uncomplicated singleton pregnancy were recruited and assessed with translabial ultrasound at 36 weeks antepartum and 871 (76%) returned for reassessment 3-6 months postpartum. The ultrasound data of vaginally parous women were analyzed for levator avulsion and microtrauma. The former was diagnosed if the muscle insertion at the inferior pubic ramus in the plane of minimal hiatal dimensions and within 5 mm above were abnormal on tomographic ultrasound imaging. Microtrauma was diagnosed in women with an intact levator and if there was a postpartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2 . RESULTS: The complete datasets of 844 women were analyzed. Among them, 609 delivered vaginally: by normal vaginal delivery in 452 (54%), a vacuum birth in 102 (12%) and a forceps delivery in 55 (6%). Levator avulsion was diagnosed in 98 and microtrauma in 97. On multivariate analysis, increasing maternal age, lower body mass index and lower bladder neck descent were associated with avulsion. Increased bladder neck descent and a family history of cesarean section (CS) were associcated with microtrauma. CONCLUSIONS: Maternal age, body mass index, bladder neck descent and family history of CS are antenatal predictors for levator trauma.

Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units.

Vaginal birth may result in damage to the levator ani muscle (LAM) with subsequent pelvic floor dysfunction and there may be accompanying psychological problems. This study examines associations between these somatic injuries and psychological symptoms. A qualitative study using semi-structured interviews to examine the experiences of primiparous women (n = 40) with known LAM trauma was undertaken. Participants were identified from a population of 504 women retrospectively assessed by a perinatal imaging study at two obstetric units in Sydney, Australia. LAM avulsion was diagnosed by 3D/4D translabial ultrasound 3-6 months postpartum. The template consisted of open-ended questions. Main outcome measures were quality of information provided antenatally; intrapartum events; postpartum symptoms; and coping mechanisms. Thematic analysis of maternal experiences was employed to evaluate prevalence of themes. Ten statement categories were identified: (1) limited antenatal education (29/40); (2) no information provided on potential morbidities (36/40); (3) conflicting advice (35/40); (4) traumatized partners (21/40); (5) long-term sexual dysfunction/relationship issues (27/40); (6) no postnatal assessment of injuries (36/40); (7) multiple symptoms of pelvic floor dysfunction (35/40); (8) "putting up" with injuries (36/40); (9) symptoms of post-traumatic stress disorder (PTSD) (27/40); (10) dismissive staff responses (26/40). Women who sustain LAM damage after vaginal birth have reduced quality of life due to psychological and somatic morbidities. PTSD symptoms are common. Clinicians may be unaware of the severity of this damage. Women report they feel traumatized and abandoned because such morbidities were not discussed prior to birth or postpartum.

Levator Avulsion Is Associated With Pelvic Organ Prolapse 23 Years After the First Childbirth.

OBJECTIVES: This study aimed to ascertain the association between levator avulsion and pelvic organ prolapse (POP). METHODS: This was a cross-sectional study involving 195 women enrolled in a longitudinal cohort study and seen 20 years after an index birth. All had a standardized patient-administered questionnaire, the International Continence Society Pelvic Organ Prolapse Quantification assessment and 4D translabial ultrasound. Main outcome measures were objective POP clinically and on translabial ultrasound. Postimaging assessment of levator integrity and sonographically determined pelvic organ descent was done blinded against other data. RESULTS: Of 195 women who were seen a mean of 23 (range, 19.4-46.2) years after their first birth, one declined ultrasound assessment and was excluded, leaving 194. Mean age was 50.2 (range 36.9-66.5) years with a mean body mass index (BMI) of 27.6 (range, 18.3-54.3) kg/m2 . Median parity was 3 (range 1-14). Ninety-one percent (n = 176) had delivered vaginally. Eighteen percent (n = 34) were symptomatic of prolapse. Clinically, 36% (n = 69) had significant POP. Levator avulsion was diagnosed in 16% (n = 31). Mean levator avulsion defect score was 2.2 (range, 0-12). On univariate analysis, levator avulsion and levator avulsion defect score were associated with clinically and sonographically significant POP, that is, odds ratio 2.6 (1.2-5.7), P = .01; and odds ratio 3.3 (1.4-7.7); P = .003, respectively; Ba (P < .001); bladder (P < .001); uterine (P < .001) and rectal ampulla (P = .009) descent, but not POP symptoms, C, and Bp. Multivariate analysis controlling for potential confounders confirmed our findings. CONCLUSIONS: Levator avulsion is associated with female pelvic organ prolapse, especially of the anterior and central compartments. This association may become stronger with aging.

We need to treat pregnant women as adults: Women should be consented for an attempt at normal vaginal birth as for operative delivery, with risks and potential complications explained.

Since the mid-90s, Australian law has required doctors to disclose material risks of proposed treatment. Medical practitioners have had two decades to adapt, and, by and large, patient autonomy is acknowledged and respected by obtaining 'informed consent'. While problems with obtaining consent do surface in medico-legal litigation, practitioners are generally aware of the need to do so and usually comply with requirements. However, not in obstetrics. Here, even if material risk of a serious adverse event in an attempt at vaginal birth in a given case is over 50% (as it would be in the case of a 35-year-old primigravida at 41 + 3) obtaining informed consent is the exception rather than the rule. This degree of paternalism is not just unethical and immoral. It is illegal - and it needs to change.

Intrapartum predictors of maternal levator ani injury.

INTRODUCTION: Damage to the pelvic floor during vaginal childbirth is common, and may take the form of levator avulsion or irreversible overdistension of the levator hiatus (microtrauma). Such trauma is a major risk factor for pelvic organ prolapse later in life. In this study we aimed to identify intrapartum risk factors for levator trauma. MATERIAL AND METHODS: This is a retrospective analysis of data obtained in two perinatal studies on primiparous women. Between 2005 and 2014, 1148 women carrying an uncomplicated singleton pregnancy in the late third trimester were seen for 4D pelvic floor ultrasound and an interview. They were invited for a repeat assessment at three months postpartum. RESULTS: Of 1148 women, 871 (76%) returned for assessment at a mean of five months postpartum. The datasets of 844 women were analyzed due to missing data or concurrent pregnancy in 27. In all, 452 (54%) had a normal vaginal delivery, 102 (12%) a vacuum, 55 (6%) a forceps, and 235 (28%) a cesarean section. On multivariate analysis forceps, length of second stage and obstetric anal sphincter tears were significantly associated with levator avulsion. There were no significant predictors identified for irreversible overdistension. CONCLUSIONS: The use of forceps, a prolonged second stage, and obstetric anal sphincter tears were associated with levator avulsion. There were no associated intrapartum predictors for hiatal overdistension.

The association between maternal age at first delivery and risk of obstetric trauma.

BACKGROUND: There are a number of poor birth outcomes with advancing maternal age. Although there is some evidence of a higher risk of trauma to obstetric anal sphincter and the levator ani muscle with advancing age, findings to date are inconclusive. OBJECTIVE: The aim of this study was to assess the risk of pelvic floor injury using translabial 3- and 4-dimensional ultrasound relative to advancing maternal age in primiparous women after a singleton vaginal delivery at term and to determine any association between maternal age and obstetric trauma, including obstetric anal sphincter injuries, levator avulsion, and irreversible overdistension of the levator hiatus. STUDY DESIGN: This is a subanalysis of a perinatal intervention trial conducted in a specialist urogynecology referral unit at 2 tertiary units. All primiparous women with singleton birth at term underwent 3- and 4-dimensional translabial pelvic floor ultrasound both ante- and postnatally for the assessment of the obstetric trauma including levator ani muscle avulsion, hiatal overdistension to 25 cm(2) or more, and obstetric anal sphincter injuries. A multivariate logistic regression analysis was performed to examine the association between maternal age and obstetric trauma diagnosed on 3- and 4-dimensional translabial ultrasound. Multiple confounders were included, and the most significant (forceps and vacuum delivery) were used for probability modeling. RESULTS: Of 660 women recruited for the original study, a total of 375 women who had a vaginal delivery with complete data sets were analyzed. A total of 174 women (46.4%) showed evidence of at least 1 form of major pelvic floor trauma. Advancing maternal age at first delivery carries with it a significant incremental risk of major pelvic floor trauma with an odds ratio of 1.064 for overall risk of injury for each increasing year of age past age 18 years (P = .003). The probability of any type of trauma appears to be substantially higher for forceps delivery. Vacuum delivery appears to increase the risk of obstetric anal sphincter injuries but not of levator avulsion. CONCLUSION: There is a significant association between the risk of major pelvic floor injury and increasing maternal age at first delivery.

Maternal birth trauma: why should it matter to urogynaecologists?

PURPOSE OF REVIEW: There is increasing awareness of the importance of intrapartum events for future pelvic floor morbidity in women. In this review, we summarize recent evidence and potential consequences for clinical practice. RECENT FINDINGS: Both epidemiological evidence and data from perinatal imaging studies have greatly improved our understanding of the link between childbirth and later morbidity. The main consequences of traumatic childbirth are pelvic organ prolapse (POP) and anal incontinence. In both instances the primary etiological pathways have been identified: levator trauma in the case of POP and anal sphincter tears in the case of anal incontinence. As most such trauma is occult, imaging is required for diagnosis. SUMMARY: Childbirth-related major maternal trauma is much more common than generally assumed, and it is the primary etiological factor in POP and anal incontinence. Both sphincter and levator trauma can now be identified on imaging. This is crucial not only for clinical care and audit, but also for research. Postnatally diagnosed trauma can serve as intermediate outcome measure in intervention trials, opening up multiple opportunities for clinical research aimed at primary and secondary prevention.

Levator ani trauma and pelvic organ prolapse - a comparison of three translabial ultrasound scoring systems.

INTRODUCTION: The study aimed to analyze the relation between the degree of puborectalis muscle trauma and subjective symptoms and objective findings of pelvic organ prolapse (POP), comparing two continuous scoring systems with a discrete scoring system for translabial ultrasound imaging. MATERIAL AND METHODS: In this retrospective observational study the records of patients attending a tertiary urogynecological unit between January 2012 and December 2014 were analyzed. POP assessment included a standardized interview, clinical examination using Pelvic Organ Prolapse Quantification and four-dimensional translabial ultrasound. Puborectalis muscle trauma was assessed with tomographic ultrasound imaging using two continuous scoring systems and a previously established discrete system. Receiver operating characteristics and adjusted odds ratios were used for comparison of scoring systems in predicting symptoms and signs of POP. RESULTS: Of 1258 women analyzed, 52.6% complained of prolapse symptoms. On ultrasound imaging, 65.7% of women had sonographically significant POP. Complete avulsion was diagnosed in 25.3% of women, being unilateral in 13.9% and bilateral in 11.4%. A maximum score in the 6-point and the 12-point tomographic ultrasound imaging scale increased the odds for a diagnosis of any significant POP on ultrasound by 4.4 and 4.8 times, respectively, compared with 4.6 times for the discrete diagnosis of bilateral avulsion. For all avulsion scoring systems the relation was strongest for cystocele and uterine prolapse. CONCLUSIONS: A continuous avulsion scoring system based on tomographic findings does not provide superior performance for the prediction of subjective symptoms and objective findings of prolapse compared with a discrete diagnostic system of unilateral or bilateral avulsion.

Psychological and somatic sequelae of traumatic vaginal delivery: A literature review.

This literature review seeks to examine current knowledge of birth trauma associated with major pelvic floor dysfunction by interpreting and critically appraising existing published material. A search of the literature for peer reviewed journal articles was conducted between September and December 2013 of the following databases: PubMed; Wiley Online; MEDLINE; OvidSP; ScienceDirect; MD Consult Australia; Biomed Central; Sage; Cochrane Database of Systematic Reviews. Unpublished interviews from mothers who attended two tertiary teaching hospitals in Sydney, Australia and international Internet blogs/websites were also utilised. Maternal birth trauma seems to be a common cause of pelvic floor dysfunction. Women who have sustained birth trauma to the levator ani muscle or the anal sphincters are often injured more seriously than generally believed. There often is a substantial latency between trauma and the manifestation of symptoms. Urinary and faecal incontinence, prolapse and sexual dysfunction are commonly seen as too embarrassing to discuss with clinicians, and frequently, new mothers have inaccurate recollections of obstetric procedures that occurred without much explanation or explicit consent. Moreover, somatic trauma may contribute to psychological trauma and post-traumatic stress disorder. The link between somatic and psychological trauma is poorly understood.

The "bother" of urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Patient reported measures are important for the evaluation of symptom-specific bother and the distinction between different types of urinary incontinence. The aim of the study was to assess the validity of physician administered visual analogue scales (VAS) for the bother from stress urinary incontinence (SUI) and urge urinary incontinence (UUI). METHODS: In this prospective cohort study based at a tertiary urogynecological unit, women attending for investigation of lower urinary tract symptoms (n = 504) were asked to indicate their subjective bother from SUI and UUI on a 10-cm VAS. Clinical assessment, including multichannel urodynamic testing and 4D translabial ultrasound was performed for clinical diagnosis. Linear regression was used to model the average increase in VAS bother score of SUI and UUI for each explanatory variable. RESULTS: 74 % (n = 375) reported symptoms of SUI, with mean bother of 5.7 out of 10 (SD 2.8), and 73 % (n = 370) symptoms of UUI, with a mean bother of 6.5 out of 10 (SD 2.6). Bother from UUI was positively associated with the symptoms of nocturia (p < 0.0001) and frequency (p = 0.002), and the urodynamic findings of detrusor overactivity (p < 0.0001). Bother from SUI was positively related to the urodynamic diagnosis of USI (p < 0.0001) and a low abdominal leak point pressure (ALPP) (p = 0.002), as well as to the ultrasound findings of cystourethrocele (p < 0.0001) and funnelling (p = 0.04). All univariate associations remained highly significant on multivariate analysis, controlling for age, BMI, parity, previous incontinence/prolapse surgery and previous hysterectomy. CONCLUSIONS: Physician-administered VAS are a valid, reliable and practicable tool to measure bother related to SUI and UUI.

Postprocessing of pelvic floor ultrasound data: how repeatable is it?

AIMS: Translabial 3D/4D pelvic floor ultrasound (PFUS) is increasingly used in the evaluation of pelvic floor disorders. Commonly, this involves the analysis of stored volume data sets by postprocessing. In this study, we aimed to assess the time requirement to reaching acceptable repeatability for commonly employed outcome measures in PFUS. METHODS: Between 2010 and 2013, 20 individuals from 11 countries underwent training in postprocessing of PFUS volume data sets. They undertook test-retest series (n ≥ 20) between day 2 and day 15 of training. Outcome measures tested included levator hiatal area on Valsalva, descent of the bladder neck, bladder, uterus and rectal ampulla, and rectocele depth. After an initial training session of 10-20 cases, test-retest series were undertaken between the trainee and measurements obtained by the author or senior trainees. RESULTS: Trainees were obstetricians/gynaecologists in training (n = 4), obstetricians/gynaecologists or subspecialty trainees (n = 13), medical students (n = 1) and physiotherapists (n = 2). A total of 58 repeatability series were analysed, obtained between days 2 and 15 of training. When second or third retest series were necessary, there always was improvement in repeatability except for one series in one individual. Satisfactory repeatability (ICC > 0.7) was achieved by all trainees for all parameters required by them. Training lasted from 3 to 15 days, with means between 4 and 5.8 days. CONCLUSIONS: Postprocessing analysis of commonly used PFUS parameters can be taught to an acceptable standard within 1 week. Most commonly used ultrasound parameters obtained by postprocessing for prolapse assessment can be taught to an acceptable standard of repeatability within one week.

Enlargement of the levator hiatus in female pelvic organ prolapse: cause or effect?

AIM: This study was undertaken to investigate whether female pelvic organ prolapse repair changes levator hiatal biometry. METHODS: Retrospective analysis of clinical and translabial ultrasound volume data of women who underwent prolapse surgery at a tertiary urogynaecological unit between March 2005 and April 2009. Data sets of 81 women were analysed who had undergone an interview, clinical assessment using POP-Q staging and 3D translabial ultrasound before and after prolapse surgery. Imaging data were obtained preoperatively and 3-12 months postoperatively to determine potential changes in levator hiatal dimensions. Type of surgery, mesh use, symptoms of recurrent prolapse, age, significant recurrent prolapse and length of follow-up were tested in linear regression as potential confounders. RESULTS: The mean preoperative hiatal area on Valsalva was 31.9 cm(2) (range 13.5-58.1 cm(2), SD 10.0 cm(2)). Mean postoperative hiatal area on Valsalva was 28.9 cm(2) (range 13.9-47.4 cm(2); SD 7.3 cm(2)), which implies a significant reduction of 9% (P = 0.001). None of the tested potential confounders were found to be significantly associated with a perioperative change in hiatal area on Valsalva on linear regression analysis. CONCLUSIONS: Surgery for female pelvic organ prolapse is associated with a small but significant reduction in hiatal area, but abnormal hiatal distensibility persists in most cases. This suggests that excessive hiatal distensibility is more likely the cause rather than the effect of prolapse.

What's wrong with the debate on mesh surgery?

There is an increasingly acrimonious debate surrounding the use of anchored mesh in prolapse surgery. It is evident that clinicians and researchers working with this technology are under pressure from the public, from lawyers, regulators and colleagues. There is a risk that rapidly changing societal standards, championed by colleagues, lawyers and bureaucrats, will interfere with professional independence to such a degree that an entire new technology is lost before there has been time for clinical research to assess risks and benefits properly, before we learn which patients stand to benefit most, and before we get a chance to optimise implant design.

What's a proper push? The Valsalva manoeuvre revisited.

In daily practice, the Valsalva manoeuvre is used to assess pelvic organ prolapse, virtually always without standardisation of pressure. We undertook a study to determine maximum pressures reached and pressures required to obtain 80% of maximal pelvic organ descent, to investigate the need for such standardisation. Clinical data and ultrasound data sets of 75 women seen for urodynamic testing were reviewed retrospectively, with three Valsalva manoeuvres registered per patient. Maximum rectal pressures generated during Valsalva were 107 cm H (2) O on average (range, 45-190 cm H (2) O). Ninety-seven percent of all women managed to reach pressures ≥60 cm H (2) O. On average, 80% of maximal bladder neck descent was reached at 56 cm H (2) O, 80% of maximal pelvic organ descent at 38 cm H (2) O. Our results imply that virtually all patients were able to generate pressures resulting in ≥80% of maximal pelvic organ descent. This implies that standardisation of Valsalva pressures for prolapse assessment may be unnecessary.

Do women notice the effect of childbirth-related pelvic floor trauma?

INTRODUCTION: In 10-30% of women, vaginal birth results in levator ani tears ('avulsion') that are associated with pelvic floor dysfunction in later life. We hypothesised that women notice reduced pelvic floor muscle strength after childbirth, especially those with avulsion. METHODS: This is a secondary analysis of two perinatal studies. At 3-6 months postpartum, women were asked to estimate pelvic floor muscle strength relative to antepartum strength. Translabial ultrasound was performed to determine pelvic floor structure and function. RESULTS: Five hundred and thirteen primiparous women were seen at a median of 129 days after delivery of a singleton at a mean gestation of 40 weeks. At follow-up, 481 were able to rate pelvic floor strength (mean 89%). This reduction was associated with delivery mode (P < 0.001), episiotomy (P = 0.01), perineal tears (P = 0.025) and avulsion (n = 45, P = 0.04). CONCLUSION: After the birth of a first child, women notice a significant reduction in pelvic floor muscle strength, which is associated with delivery mode as well as perineal and pelvic floor muscle trauma. SUMMARY: Many women notice reduced pelvic floor function after childbirth, especially those who have suffered an avulsion of the puborectalis muscle.

A simplified method for determining hiatal biometry.

INTRODUCTION: The levator hiatus is the largest potential hernial portal in the human body. Its dimensions are measured in the axial plane and are strongly associated with female pelvic organ prolapse. We aimed to compare two commonly used methods for measuring hiatal dimensions. METHODS: We performed offline analysis of 100 consecutive 4D ultrasound volume datasets of women seen in a tertiary urogynecological clinic. Hiatal measurements were obtained in sectional planes (SP, Method A) and rendered volumes of 1-2 cm thickness (RV, Method B). RESULTS: A test-retest series in 20 women showed similar repeatability for both methods, with an intraclass correlation (ICC) of 0.85 (CI 0.81-0.88) for Method A (SP) and of 0.88 (CI 0.85-0.9) for Method B (RV). Measurements taken from rendered volumes were generally lower than those taken in axial plane slices, reaching significance for area on Valsalva (P=0.005), sagittal diameter and area on pelvic floor contraction (P=0.009 and 0.044). Method B seemed more strongly associated with symptoms of prolapse than Method A (P=0.008 vs P=0.027). CONCLUSIONS: We recommend that hiatal dimensions be measured in rendered volumes whenever possible because this method seems more valid and at least as repeatable. This is probably due to the fact that the plane of minimal hiatal dimensions is non-Euclidean, i.e., warped, which can be compensated for by measuring in a rendered volume of 1-2 cm thickness.

Sonographic detection of puborectalis muscle avulsion is not associated with anal incontinence.

BACKGROUND: The puborectalis muscle is believed to play an important role in anal continence. However, to date, there is very limited evidence to support this hypothesis. AIMS: This study was designed to test for an association between puborectalis trauma and ballooning of the levator hiatus on the one hand and anal incontinence on the other hand. METHODS: The records of 397 women who had attended a tertiary urogynaecological clinic were reviewed in a retrospective study. The history included questions on faecal urgency, soiling, faecal and flatus incontinence. Examination included puborectalis muscle assessment by palpation and 4D pelvic floor ultrasound. RESULTS: Mean age on presentation was 54 (19-89) years. Median vaginal parity was 2 (0-9). Of 397 women, 89 complained of faecal urgency, 65 of faecal incontinence (FI), 67 of soiling and 91 of flatus incontinence. Seventy-seven patients were diagnosed with puborectalis avulsion, of which 38 were bilateral. Puborectalis avulsion was not associated with FI (P = 0.801), faecal urgency (P = 0.894), soiling (P = 0.768) and flatus incontinence (P = 0.187). Hiatal dimensions at rest or on Valsalva were also found not to be associated with symptoms of anal incontinence. CONCLUSIONS: Surprisingly, we found no association between avulsion of the puborectalis muscle and hiatal biometry on the one hand and anal continence on the other hand. These findings argue against a major role of the puborectalis muscle in anal continence.