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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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Heather is the best! I saw her today for terrible hip/groin pain. I was so impressed with the safety measures in place and felt completely safe . Thanks for the healing hands.

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Testimonial by R.S.

I wanted to thank you so much for helping me get through something I thought I may never be able to. We have achieved pain-free intercourse and this has really solidified our marriage. We are so grateful to you for all the work you do! Thank you!!

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Testimonial by R.H.

No one could tell me why I was having pain during sex--sharp pain, not just uncomfortable, pain. I was referred to Heather Jeffcoat after researching several different options. I had seen a specialist who told me physical therapy would not help and my only option was surgery. I really didn't want to go that route, so when we got a referral, I decided to try it--it can't hurt, I thought. I am so glad I did. She diagnosed the problem right away, which was a relief in itself.

To know why I was having pain eased my mind immensely. And to hear that she could fix it without surgery was another relief. She said she could fix the problem in 6 weeks. I think it was actually 4 for me. She was very methodical, and treated me as an intelligent human being capable of participating in my own recovery. I would absolutely recommend her to anyone. She did not try to prolong my session numbers, she worked hard to accommodate my schedule (and the fact that I had to bring a baby to sessions), and she was completely honest the entire time. It is so hard to find someone with these characteristics, much less a professional who is so good at what she does. She has my highest respect.

-- R.H.

Testimonial by M.M.

A personal journey and testimonial from one of my patients:

My husband and I were married for 5 years before we were able to have intercourse due to my vaginismus. There was nothing traumatic in my past but for some reason, even though I wanted sex, I mentally avoided "that area" of my body and didn't even admit to myself that there was a problem for a long time, even though I was never able to put tampons in. Once I finally opened my eyes up to the fact that I had a problem, I had a surgery that was supposed to fix the issue.

Read more: Testimonial by M.M.

Testimonial by Carolina J.

I had tried Pelvic Floor Physical Therapy before (with another PT) and I had a really bad (painful) experience. A friend of mine and fellow patient, told me about Heather, Laureen and Femina PT (née Fusion Wellness & Physical Therapy) and I decided to try again. I am so happy I did! Femina PT have, literally, changed my life. I was able to do again things I couldn't do for over 10 years!! Their bedside manners are impeccable, their knowledge and understanding make me feel comfortable to recommend this place to anyone in pain. Specially if you have Endometriosis. 100% recommended!!

-- Carolina J., 12/28/16 via Yelp!

Testimonial by Carolina J.

I had tried Pelvic Floor Physical Therapy before (with another PT) and I had a really bad (painful) experience. A friend of mine and fellow patient, told me about Heather, Laureen and Femina PT (née Fusion Wellness & Physical Therapy) and I decided to try again. I am so happy I did! Femina PT have, literally, changed my life. I was able to do again things I couldn't do for over 10 years!! Their bedside manners are impeccable, their knowledge and understanding make me feel comfortable to recommend this place to anyone in pain. Specially if you have Endometriosis. 100% recommended!!

-- Carolina J., 12/28/16 via Yelp!

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