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Kubotani J1, Elito Junior J1, Passos J1, Araujo Junior E1, Campos A2, Zanetti M3
1Federal University of São Paulo, São Paulo, Brazil, 2Casa Moara, São Paulo, Brazil, 3Federal University of São Paulo, Santos, Brazil
Background: The levator ani avulsion is defined when there is interruption of the insertion of this muscle to the pubic bone. It is currently recognized as an important triggering factor for genital prolapse, since 36% of women with prolapse present this anatomical alteration (Dietz e Simpson, 2008). Its incidence after vaginal delivery varies from 13 to 22% by ultrasonographic diagnosis (Shek e Dietz, 2009; Valsky e col, 2009; Shek e Dietz, 2010; Chan e col, 2012).
Although conservative treatment, involving physical therapy should be considered as the first referral for women with pelvic floor dysfunction, there was no indication for the levator ani avulsion to date. Thus, the report of this case, as the first to be described on the topic, may give rise to further investigation into this possibility of treatment.
Purpose: The purpose of this study is to describe a case report about a physical therapy treatment applied in a patient with levator avulsion.
Methods: Patient C.S.B, female, white, 40 years old, was referred by the gynecologist after diagnosis of urinary incontinence. She presents as obstetric history of one pregnancy, with vaginal delivery, and newborn weighed 3020 gr. Vacuum extractor was used in her deliver that occured in 2017 and the patient presented second degree laceration, which has been sutured. Two months after delivery, she sought medical attention with complaints of moderate urinary incontinece during coughing, sneezing and with urgency. The gynecological examination revealed discontinuity of the insertion of the levator anus muscle, when the ultrasound examination (Transperineal 3D sonography-GEHealthcare, Zipf, Austria) was performed to confirm the diagnosis.
In the functional evaluation of the pelvic floor, the patient presented incorrect contraction of the pelvic floor musculature and degree 1, according to the OXFORD scale. The patient completed the ICIQ-SF (16) and the voiding diary during the first week of treatment had daily urinary frequency (DF) of eigth, nocturia (N) were two and three urinary losses.
The physiotherapeutic treatment consisted of 13 sessions twice a week, lasting one hour each, with intravaginal electrotherapy (10 Hz of frequency, 500 Ms of Pulse width during 20 minutes) followed by pelvic floor muscles exercises in different positions.
Results: At the end of 13 physiotherapy sessions, another ultrasound examination was performed by the same examiner and reinsertion of the levator ani muscle was observed (will be presented in figure). In addition, in the physical examination, the patient presented correct contraction of the pelvic floor musculature and degree two on the OXFORD scale. The ICIQ-SF questionnaire presented symptoms improvement (11) as well in the voiding diary (DF: 8; N: 1) with rarer urinary incontinence episodes, only during substancial efforts, like jumping.
Conclusion(s): In this case, the results show that levator ani muscle can be reinserted with physiotherapeutic treatment, specially with combination of electrotherapy and pelvic floor muscles exercises.
Implications: More studies should be done about conservative treatments possibilities of the levator ani avulsion. But this first case report could highlight a new perspective for this pelvic floor dysfunction after childbirth.
Keywords: pelvic floor, levator ani avulsion, electrotherapy
Funding acknowledgements: Not Funded
Although conservative treatment, involving physical therapy should be considered as the first referral for women with pelvic floor dysfunction, there was no indication for the levator ani avulsion to date. Thus, the report of this case, as the first to be described on the topic, may give rise to further investigation into this possibility of treatment.
Purpose: The purpose of this study is to describe a case report about a physical therapy treatment applied in a patient with levator avulsion.
Methods: Patient C.S.B, female, white, 40 years old, was referred by the gynecologist after diagnosis of urinary incontinence. She presents as obstetric history of one pregnancy, with vaginal delivery, and newborn weighed 3020 gr. Vacuum extractor was used in her deliver that occured in 2017 and the patient presented second degree laceration, which has been sutured. Two months after delivery, she sought medical attention with complaints of moderate urinary incontinece during coughing, sneezing and with urgency. The gynecological examination revealed discontinuity of the insertion of the levator anus muscle, when the ultrasound examination (Transperineal 3D sonography-GEHealthcare, Zipf, Austria) was performed to confirm the diagnosis.
In the functional evaluation of the pelvic floor, the patient presented incorrect contraction of the pelvic floor musculature and degree 1, according to the OXFORD scale. The patient completed the ICIQ-SF (16) and the voiding diary during the first week of treatment had daily urinary frequency (DF) of eigth, nocturia (N) were two and three urinary losses.
The physiotherapeutic treatment consisted of 13 sessions twice a week, lasting one hour each, with intravaginal electrotherapy (10 Hz of frequency, 500 Ms of Pulse width during 20 minutes) followed by pelvic floor muscles exercises in different positions.
Results: At the end of 13 physiotherapy sessions, another ultrasound examination was performed by the same examiner and reinsertion of the levator ani muscle was observed (will be presented in figure). In addition, in the physical examination, the patient presented correct contraction of the pelvic floor musculature and degree two on the OXFORD scale. The ICIQ-SF questionnaire presented symptoms improvement (11) as well in the voiding diary (DF: 8; N: 1) with rarer urinary incontinence episodes, only during substancial efforts, like jumping.
Conclusion(s): In this case, the results show that levator ani muscle can be reinserted with physiotherapeutic treatment, specially with combination of electrotherapy and pelvic floor muscles exercises.
Implications: More studies should be done about conservative treatments possibilities of the levator ani avulsion. But this first case report could highlight a new perspective for this pelvic floor dysfunction after childbirth.
Keywords: pelvic floor, levator ani avulsion, electrotherapy
Funding acknowledgements: Not Funded
Topic: Women's & men's pelvic health
Ethics approval required: No
Institution: UNIFESP
Ethics committee: CEP-UNIFESP
Reason not required: CASE REPORT IS NOT A RESEARCH. TREATMENT WAS DONE AND THE RESULTS MUST BE DISCLOSED BECAUSE OF ITS RELEVANCY
All authors, affiliations and abstracts have been published as submitted.
