The Appearance of Levator Ani Muscle Abnormalities

in Magnetic Resonance Images After Vaginal Delivery

John O. L. DeLancey, MD, Rohna Kearney, MRCOG, Queena Chou, MD, Steven Speights, MD,
and Shereen Binno, MD
OBJECTIVE: To describe the appearance and occurrence of
abnormalities in the levator ani muscle seen on magnetic
resonance imaging (MRI) in nulliparous women and in
women after their first vaginal birth.
METHODS: Multiplanar proton density magnetic resonance
images were obtained at 0.5-cm intervals from 80 nulliparous and 160 vaginally primiparous women. These had
been previously obtained in a study of stress incontinence,
and half the primiparas had stress incontinence. All scans
were reviewed independently by at least two examiners
blinded to parity and continence status.
RESULTS: No levator ani defects were identified in nulliparous women. Thirty-two primiparous women (20%) had a
visible defect in the levator ani muscle. Defects were identified in the pubovisceral portion of the levator ani in 29
women and in the iliococcygeal portion in three women.
Within the pubovisceral muscle, both unilateral and bilateral defects were found. The extent of abnormality varied
from one individual to the next. Of the 32 women with
defects, 23 (71%) were in the stress incontinent group.
CONCLUSION: Abnormalities in the levator ani muscle are
present on MRI after a vaginal delivery but are not found
in nulliparas. (Obstet Gynecol 2003;101:46 53. 2003
by The American College of Obstetricians and Gynecologists.)

During a study of the role of vaginal birth in causing

urinary incontinence we obtained magnetic resonance
images of women with stress incontinence after their first
vaginal birth and of normal continent nulliparous and
primiparous controls. On evaluating these scans we
found abnormalities in the levator ani muscles in both
the continent and incontinent women. The abnormalities seemed to occur only in women who delivered
vaginally, and not in nulliparas. These abnormalities
involved both the pubovisceral and iliococcygeal portions of the muscle and were sometimes unilateral and
From the University of Michigan, Ann Arbor, Michigan.
Supported by National Institutes of Health grants R01 DK51405 and R01
HD38665.

46

sometimes bilateral. Here we describe these defects and

evaluate whether or not they are associated with vaginal
delivery.

MATERIALS AND METHODS

Magnetic resonance images of the pelvis were obtained
from 240 women as part of an institutional review
boardapproved study concerning vaginal delivery and
stress urinary incontinence. Multiplanar two-dimensional fast spin (echo time 15 ms, repetition time 4000
ms) proton density magnetic resonance images of all
pelves were obtained by use of a 1.5-tesla superconducting magnet (Signa; General Electric Medical Systems,
Milwaukee, WI) with version 5.4 software as previously
described.1 Images 5 mm apart were obtained in axial,
coronal, and sagittal views.
At least two examiners blinded to the subjects parity
and continence reviewed all magnetic resonance scans
independently of one another. On initial review, scans
that appeared to have abnormalities were presumptively
identified based on comparison with normal anatomy of
the levator ani muscle previously described by our
group.13 Final classification of a muscle as abnormal
was made only when abnormal morphology was found
in both the axial and the coronal planes and agreed upon
by two examiners. In two instances two examiners disagreed as to the presence of an abnormality in the levator
ani. Re-examination of the scans disclosed that the one
abnormal classification in each pair arose because of an
asymmetry in the muscles appearance. Further examination revealed that the difference between the two sides
was related to the womans asymmetric placement in the
scanner, rather than a muscle abnormality on one side.
Both of these subjects were classified as normal. For
review and description we divided the muscle into its
two major components, the pubovisceral and the iliococcygeal.4 The pubovisceral portion includes those muscles arising from the pubic bonesnamely, the pubococcygeus, puborectalis, and puboperineus.

VOL. 101, NO. 1, JANUARY 2003

2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.

0029-7844/03/$30.00
PII S0029-7844(02)02465-1

Table 1. Study Population Demographics

Age (y)
Height (m)
Weight (kg)
BMI

Nullipara

Primiparous
continent

Primiparous
incontinent

29.2 (5.5)
1.66 (0.06)
66.4 (13.1)
24.3 (4.4)

29.8 (4.4)
1.66 (0.07)
63.4 (12.9)
23.4 (4.2)

30.0 (5.7)
1.66 (0.07)
71.2 (16.6)
26.2 (5.6)

Mean (standard deviation).

After this process, a new examiner (RK) viewed all

scans while blinded to parity, continence, and previous
evaluations and independently confirmed all defects.
The abnormal scans were then once more reviewed
independently by two individuals to finalize classification as abnormal.
These scans came from a study of 240 women that
included 80 nulliparas and 160 primiparas. Of the primiparous women 80 were continent and 80 had stress
incontinence that persisted at least 9 months after delivery. All groups were recruited to be similar in age (Table
1). There were no group differences in racial composition among the whites (89.4%), blacks (3.8%), and
women of other racial groups (6.8%). None of the continent women exhibited stress incontinence during urodynamic examination.
All 240 women were subjected to magnetic resonance
imaging (MRI) of the pelvic floor. The parous women
were examined 9 12 months after delivery. As part of
the overall study all women had a pelvic examination to
detect prolapse5 and urodynamic evaluation including
cystometrography, urethral function assessment, ultrasound examination of urethral support,6 and full bladder
stress testing.
RESULTS
There were 32 women (20%) with a visible defect in one
or both levator ani muscles among the 160 parous
women in the study. Of these, 29 (18%) involved the
pubovisceral portion of the muscle and three (2%) involved the iliococcygeal portion. Of the 80 women
who were incontinent, 23 (28%) had a defect in the
levator ani muscle, and of the 80 primiparous continent women, nine (11%) had a defect, making stress
incontinent primiparas twice as likely to have a muscle
abnormality. No defects were identified in nulliparous
women.
An example of normal magnetic resonance anatomy
seen in a 45-year-old nulliparous continent volunteer is
shown in Figure 1. In the axial scans the levator ani
muscle can be seen arising from the pubic bone lateral to
the urethra, vagina, and rectum. The coronal view demonstrates the same anatomy in a perpendicular plane.

VOL. 101, NO. 1, JANUARY 2003

Note in the axial scans the location of the pubovisceral

portion of the levator ani muscle between the urethra
and vagina and the obturator internus muscle where it
attaches to the pubic bone.
Figure 2 shows the appearance of a unilateral defect
in the left levator ani muscle of a 34-year-old primiparous woman. The asymmetry between the two
sides can be seen where the part of the muscle that
normally attaches to the pubic bone is lost. A small
portion of the muscle remains between the urethra,
vagina, and obturator internus muscle. The iliococcygeal
portion of the levator ani muscle remains normal. The
vagina protrudes laterally into the defect, so that the
vagina lies closer than normal to the obturator internus
muscle.
Figure 3 shows the appearance of complete loss of the
pubovisceral muscle bilaterally. Note the absence of
attachment to the pubic bones as well as the protrusion of
the vagina all the way to the obturator internus muscle.
In some women, the bulk of the levator ani muscle was
lost but the overall structural relationships were retained,
as shown in Figure 4. Note the normal location of the
vagina in contrast to the appearance in Figures 2 and 3,
where the vagina is no longer held in place by the fascial
envelope of the levator ani muscle.
In three women a portion of the iliococcygeus muscle
was smaller in both axial and coronal images. This defect
is shown in Figure 5.
DISCUSSION
Abnormalities have previously been demonstrated in the
levator ani muscles of women with stress urinary incontinence7 and pelvic organ prolapse,8 using magnetic resonance imaging (MRI). These abnormalities could be a
variant of normal anatomy, they could be a distortion
caused by abnormal pelvic organ positions, or they could
be damage that occurred during vaginal delivery. Our
study depicts levator ani muscle damage after vaginal
birth and provides the first scientific evidence that supports vaginal birth as a source of levator ani muscle
injuries. By comparing nulliparous women and women
after one vaginal delivery, we have documented the
presence of birth injury to the levator ani among vaginally parous individuals but not nulliparas.
Vaginal birth is the single most important risk
factor for the development of pelvic floor dysfunction.9 11 Although vaginal delivery has been well established as a significant risk for the subsequent development of pelvic floor dysfunction, the type of pelvic floor
injury that occurs during vaginal birth that results in
pelvic floor dysfunction has not been previously established.

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Levator Defects After Birth

47

Figure 1. Axial and coronal images from a 45-year-old nulliparous woman. The urethra (U), vagina (V), rectum (R), arcuate
pubic ligament (A), pubic bones (PB), and bladder (B) are shown. The arcuate pubic ligament is designated as zero for
reference, and the distance from this reference plane is indicated in the lower left corner. Note the attachment of the
levator muscle (arrows) to the pubic bone in axial 1.0, 1.5, and 2.0. Coronal images show the urethra, vagina, and
muscles of levator ani and obturator internus (OI). (Reprinted with permission. DeLancey 2002.)
DeLancey. Levator Defects After Birth. Obstet Gynecol 2003.

Our findings also show the extent of levator ani

abnormalities seen in these birth-related injuries and
provide a rough idea of how frequently they occur.
Further delineation of womens risk for levator injury
will require a population-based study of women recruited before delivery. To gain a better understanding of soft tissue injury during delivery, additional

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DeLancey et al

Levator Defects After Birth

research will be needed to identify induced connective

tissue rupture in the vaginal supports that also play a
role in pelvic floor dysfunction.12 Once this is done,
the interrelationship and interaction between these
muscular and fascial injuries can be more fully appreciated.
We have found that levator ani muscle injury most

OBSTETRICS & GYNECOLOGY

Figure 2. Axial and coronal images from a 34-year-old incontinent primiparous woman
showing a unilateral defect in
the left pubovisceral portion of
the levator ani muscle. The arcuate pubic ligament (A), urethra (U), vagina (V), rectum
(R), and bladder (B) are shown.
The location normally occupied by the pubovisceral muscle is indicated by the open
arrowhead in axial and coronal
images 1.0, 1.5, and
2.0. (Reprinted with permission. DeLancey 2002.)
DeLancey. Levator Defects After Birth.
Obstet Gynecol 2003.

frequently involves the pubovisceral portion of the levator ani muscle that arises from the inner surface of the
pubic bone just lateral to the vagina but also involves the
iliococcygeal muscle. In some of these women the vagina
protrudes laterally beyond the confines of its normal
location to reach the obturator internus muscle, whereas
in others it stays in its normal position (Figures 3 and 4).
The difference between these two types of injury needs

VOL. 101, NO. 1, JANUARY 2003

further clarification. These differences may arise because

some muscles are avulsed from their origin, whereas in
others they may be denervated, but the overall connections of the muscle to the bone might remain intact.
These speculations need further investigation. Documentation of the symptoms and physical findings associated with each of these injuries will also permit further
analysis.

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Levator Defects After Birth

49

Figure 3. Axial and coronal images of a 38-year-old incontinent primiparous woman are
shown. The area where the
pubovisceral portion of the levator ani muscle is missing
(open arrowhead) between the
urethra (U), vagina (V), rectum
(R), and obturator internus
muscle (OI) is shown. The vagina protrudes laterally into the
defects to lie close to the obturator internus muscle. A arcuate pubic ligament. (Reprinted with permission.
DeLancey 2002.)
DeLancey. Levator Defects After Birth.
Obstet Gynecol 2003.

The importance of the levator ani muscles providing

pelvic organ support has long been recognized.13 They
close the pelvic floor and support the pelvic organs14 in a
valve-like apparatus. Damage to these pelvic muscles
results in sagging and tipping of the levator plate.15
This decreased muscular support presumably increases
loads on the fascia and connective tissues of the pelvis.
Because the load carried by the pelvic floor is shared
between the muscles and connective tissues, a decrease

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DeLancey et al

Levator Defects After Birth

in muscle function would shift additional load to the

fibrous elements.
Previous studies have demonstrated that women with
pelvic organ prolapse have gross abnormalities in the
levator ani muscle.13 Histologic abnormalities in the
levator ani muscles of cadavers of women with vaginal
parity show significant muscle replacement by fibrosis.16
Studies have also demonstrated fibrosis in the muscles of
women with stress urinary incontinence and/or pelvic

OBSTETRICS & GYNECOLOGY

Figure 4. Levator ani defect in a 30-year-old incontinent primiparous woman with loss of muscle bulk but preservation of
pelvic architecture. The area where the levator is absent in this woman is shown (open arrowhead) in the axial images and
the coronal images 1.5 and 2.0. Note that in contrast to Figure 3, where the vagina lies close to the obturator internus
(OI), it has a normal shape. The normal appearance of the levator ani muscle is seen in coronal images 2.0 and 2.5
(arrows). A arcuate pubic ligament; U urethra; V vagina; R rectum. (Reprinted with permission. DeLancey
2002.)
DeLancey. Levator Defects After Birth. Obstet Gynecol 2003.

organ prolapse and further indicated that those with the

least muscle are more likely to have recurrence after
surgery.17,18
The ability of MRI to allow study of the entire muscle
in both two-dimensional and three-dimensional displays
in living women has obvious advantages for scientific
study.2,19,20 It also allows the ethical study of normal
volunteers with proven continence and pelvic organ
support. With the significant asymmetries of muscle
damage seen, MRI avoids the problems stemming from
taking a single biopsy from one side of an individual,
which might indicate a healthy muscle there but would
fail to pick up that the muscle on the other side is
abnormal.
It has been well established that pelvic nerve injury is
associated with pelvic floor dysfunction.2124 Nerve injury after vaginal delivery has also been shown.25 Further research should help define the relationship between

VOL. 101, NO. 1, JANUARY 2003

nerve injury and magnetic resonancevisible abnormalities. We believe MRI and electromyography will prove
to be complementary techniques. Because electromyography testing requires an innervated muscle, it is not
able to detect the complete absence of muscle documented in our magnetic resonance images because the
myographer must seek innervated muscle to study. On
the other hand, electromyography studies will probably
play a crucial role in determining the cause of muscle
abnormalities.
Now that we have defined the visibility of levator ani
muscle damage, it will be possible to study the obstetric
factors that lead to this injury. Once the factors associated with increased risk for this injury can be defined, it
will be possible to assess risk factors for developing
damage. Also needed is a more complete understanding
of the relationship between levator injury and pelvic
organ prolapse. Now that it can be documented, we can

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Levator Defects After Birth

51

Figure 5. Iliococcygeus muscle

defect. Thinning of the iliococcygeus muscle is demonstrated
(open arrowheads) on the patients left in axial images 3.0,
3.5, and 4.0 and coronal
images 1.0 and 1.5. The
urethra (U), vagina (V), bladder
(B), rectum (R), and arcuate pubic ligament (A) are shown. (Reprinted with permission. DeLancey 2002.)
DeLancey. Levator Defects After Birth.
Obstet Gynecol 2003.

observe these women to see what symptoms develop,

when they arise, and what other factors, such as connective tissue injury, influence the development of dysfunction and prolapse. A complete picture will depend on
adding other observations. The clear visibility of these
injuries and the fact that they can be permanently recorded with magnetic resonance scans add an important
investigative tool.

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Address reprint requests to: John O. L. DeLancey, MD, University of Michigan, Department of Obstetrics and Gynecology, 1500 East Medical Center Drive, Ann Arbor, MI 481090276; E-mail: delancey@med.umich.edu.
Received March 4, 2002. Received in revised form May 31, 2002.
Accepted July 11, 2002.

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