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Treatment for Levator Ani Avulsion after childbirth | Image Courtesy of Aditya Romansa via Unsplash
Treatment for Levator Ani Avulsion after childbirth | Image Courtesy of Aditya Romansa via Unsplash

Learn About Pelvic Floor Physical Therapy as Treatment for Levator Ani Avulsion

The pelvic floor is a group of muscles positioned like a hammock along our saddle region. The group of muscles attach from our pubic bone on the inside and then to our lateral walls with a bundle of collagen fibers called the levator arch, and attach to the ischial spines and tailbone on the back side.

During vaginal childbirth, the pubococcygeus muscle, a group of pelvic floor muscles, stretches 3.26 times more than its normal length to make room for the coming baby in the vaginal canal! As you can imagine, this can result in some perineal tearing and/or levator ani avulsion. Levator ani avulsion occurs when muscle fibers of the puborectalis (the most innermost muscle of the pubococcygeus group) are detached from its insertion on the pubic bone. About 20% of women experience an avulsion during their first vaginal childbirth. Risk factors include instrumental-assisted delivery (forceps higher risk than vacuum), older age at vaginal birth, second stage lasting longer than 2 hours, baby weighing over 8 pounds and 13 ounces, and those who underwent a grade 4 perineal tear. 

What does this mean for us to have an avulsion?

As bad as it sounds to have an avulsion, research has shown that it does not necessarily increase perineal pain in postpartum or beyond. However, it does put women at risk for pelvic organ prolapse either early in postpartum or in their later years. Pelvic organ prolapse is a weakening of the pelvic support system (fascia, ligaments, muscles) that leads to a descent or shift of organs bulging onto the vaginal wall. Women with prolapse often complain of a vaginal bulge, heaviness in vagina, or like an old/dry tampon “hanging” out. Symptoms often increase with standing, lifting, after having a bowel movement and often improve in a restful lying down position.

Researchers have found that women with avulsion tend to have a larger levator hiatus size (vaginal canal opening) and decreased strength in pelvic floor muscles compared to those without. These two factors are likely contributors to a decreased support system leading to prolapse. Another common complaint is decreased vaginal sensation, which can lead to decreased pleasure during sexual activity. One study found that at six months postpartum, those with levator ani avulsion following a forceps-assisted delivery reported a decrease in these categories: arousal, natural vaginal lubricant, orgasm, and sexual satisfaction compared to their counterparts. 

What can we do for Levator Ani Avulsions?

Knowing what we know about levator ani avulsions, we can be proactive. Regardless of type of pregnancy or complicated v. uncomplicated childbirth (regardless of severity of tearing or avulsion, or even type of delivery-yes cesarean section too!), it is a great idea to know and assess the health of your pelvic floor before and/or after childbirth. This way, we can improve any early symptoms you may be experiencing, educate early on to prevent symptoms from occurring, and overall empower the body physically and sexually. Pelvic floor physical therapists can help improve the strength and coordination of the pelvic floor muscles and improve the integrity of the other tissues that assist in organ support. They also help with many different types of sexual dysfunction through education, manual therapy, therapeutic exercises, and neuromuscular re-education.

Pelvic floor physical therapists also assess and treat other common postpartum conditions such as: 

There is help and specialized pelvic floor physical therapists are here for you!       

References:           

Cassadó J, Simó M, Rodríguez N et al. Prevalence of levator ani avulsion in a multicenter study (PAMELA study). Archives of Gynecology and Obstetrics. 2020; 302:273–280 https://doi.org/10.1007/s00404-020-05585-4.

Lien K, Mooney B, DeLancey JOL, and Ashton-Miller JA. Levator Ani Muscle Stretch Induced by Simulated Vaginal Birth. Obstet Gynecol. 2004; 103(1): 31-40.

Handa VL, Roem J, Boaquist JL, et al. Pelvic organ prolapse as a function of levator ani avulsion, hiatus size, and strength. Am J Obstet Gynecol. 2019; 221(1): 41.e1–41.e7. doi:10.1016/j.ajog.2019.03.004. 

Handa VL, Blomquist JL, Roem J, et al. Levator morphology and strength after obstetrical avulsion of the levator ani muscle. Female Pelvic Med Reconstr Surg. 2020; 26(1): 56-60. doi:10.1097/SPV.    0000000000000641 

García-Mejido JA, Idoia-Valero I, Aguilar-Gálvez IM, et al. Association between sexual dysfunction and avulsion of the levator ani muscle after instrumental vaginal delivery. Acta Obstet Gynecol Scand. 2020;99:1246–1252. doi: 10.1111/aogs.13852 

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Testimonial by A.B.

Before I was referred to Heather Jeffcoat I was living in a nightmare. I had been married to my husband for three years and I was suffering from Vaginismus. That all changed when I visited my OBGYN and she said she knew of someone with a great success rate. To be honest I was hesitant at first because my first doctor had already told me that all I needed to do was order dilators from the internet and I should overcome my problem. She was wrong because I had followed the book on how to use the dilators with absolutely no advancements in my condition. However, that all changed when I went in for my first visit and Heather took the time to explain my condition and how we were going to work together to overcome it.

I remember leaving her office with a glimmer of hope that I could live a normal life. As my sessions continued I began to see immediate results. With only four sessions and a strict dedication to my home programs I was cured of Vaginismus. In the beginning of this process I was made aware that my health insurance company might not cover the costs, which was disappointing but today I can say one hundred percent that it was the best money I ever spent. Now thanks to Heather I am finally enjoying my life to the fullest with my husband. Thank you Heather, I can’t begin to tell you how much I appreciate all that you have done for me. I will never forget it. Those who are suffering from these types of conditions don’t be afraid because she makes you feel so comfortable and the end result is worth it. Good luck to you all and I hope you experience the success I have.
-- A.B.

Testimonial by Y.L. (mom of 2)

After having my second baby via C-section I searched for months to try to find help for my lower back pain and separated abdominal muscles. I finally came across Heather Jeffcoat via a mommy blog. I reached out to her via email and set my first appointment. My first appointment went amazing … she listened to what my symptoms, check my separation and explained to me in detail what the next steps would be. Not only did my abdominal separation go from 3 to about 1 -1/2 but my back has pain has significantly reduced. I’m personally recommending all my mommy friends to Heather!

Y.L. (mom of 2)

Testimonial by M.M.

My husband and I were married for 5 years and unable to have intercourse, but I never knew why. After numerous awful experiences at doctor’s offices (where many doctors told me I “just needed to relax”), a surgery that didn’t fix the problem, and a year of owning dilators that didn’t get me anywhere, someone finally referred me to Heather for Physical Therapy. I finally had answers and information from someone who knew exactly what I was dealing with!

Read more: Testimonial by M.M.

Testimonial by Lauren B.

Femina PT (née Fusion Wellness & Physical Therapy) has been such an answer to prayer, i'm so glad I found them! I've been struggling with vaginismus my whole life, but didn't have a name for it until about 6 or 7 months ago. Even once I did have a name for it though, I didn't know where to begin in getting help. My OB/GYN had me get a set of dilators, but I couldn't even insert the smallest one by myself. Most times I tried I just ended up frustrated and in tears. I felt really alone, like I was broken and didn't have the energy to keep trying. When I got engaged a few months ago though, I realized I needed to get answers so i wasn't dreading my honeymoon.

Read more: Testimonial by Lauren B.

Testimonial by Y.L. (mom of 2)

After having my second baby via C-section I searched for months to try to find help for my lower back pain and separated abdominal muscles. I finally came across Heather Jeffcoat via a mommy blog. I reached out to her via email and set my first appointment. My first appointment went amazing … she listened to what my symptoms, check my separation and explained to me in detail what the next steps would be. Not only did my abdominal separation go from 3 to about 1 -1/2 but my back has pain has significantly reduced. I’m personally recommending all my mommy friends to Heather!

Y.L. (mom of 2)

Testimonial by Jackie W.

I was in multiple car accidents a decade ago, and I have been to many physical therapists through the years without success. They found the root of my lower back pain problems and after nearly a decade of barely being able to walk I finally can again without pain. They are also the best pelvic floor pts and the only ones who found the connection between my pelvic floor and lower back problems. If you need help with physical pain, they are your answer.

-- Jackie W., 1/19/17 via Yelp!

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