Related Experiment Video
Updated: Jun 23, 2026
Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse POP Quantification System
Published on: September 20, 2018
Impact of levator ani muscle avulsions on Manchester procedure outcomes: A 5-year follow-up study
Sissel Hegdahl Oversand1,2, Anne Cathrine Staff1,2, Ingrid Volløyhaug3
1Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway.
Introduction:
Levator ani muscle avulsion is a risk factor for inferior outcomes after native tissue pelvic organ prolapse repair. In a previously published study, we found no such association 1 year after the Manchester procedure (anterior repair combined with cardinal and uterosacral ligament suspension and perineal repair). The aim of the present study was to compare women with and without levator ani muscle avulsions in terms of patient-reported and anatomical outcomes, and failure rates in the same cohort after 5 years.
Material And Methods:
Five-year prospective cohort study of 143 women operated on for anterior and/or mid-compartment pelvic organ prolapse with the Manchester procedure between October 2014 and January 2017, Clinical Trial study number NCT02246387. Levator ani muscle avulsions (uni- or bilateral) were diagnosed at inclusion by transperineal ultrasound. Primary outcome at 5-year follow-up was subjective bulge symptoms (question 3, Pelvic Floor Distress Inventory-20). Secondary outcomes were total score from the same questionnaire, sexual distress (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12), subjective cure, Pelvic Organ Prolapse Quantification scale measurements, defining optimal outcomes as anterior compartment stage <0-1 and mid-compartment point C ≤-5, and new surgical or conservative prolapse treatment.
Results:
Among 143 women followed up after 5 years, the avulsion rate was 52.4%. Both groups showed similar reductions in bulge symptoms, pelvic floor symptoms, and anatomical anterior- and mid-compartment measurements. Sexual distress improvement was significantly greater for women with avulsion (Mean change difference: -3.4 (-6.4 to -0.5)). Multivariate regression revealed no significant effect of avulsion on symptom scores, cure rates, or need for new prolapse treatment. Women with avulsion had half the odds of obtaining an optimal anterior compartment outcome compared to those without avulsion (adjusted odds ratio: 0.5 (0.2-0.9)).
Conclusions:
Although women with levator ani muscle avulsion had lower odds of achieving an optimal anterior compartment outcome, the overall anatomical changes from preoperative to 5 years were similar in both groups. Importantly, avulsion did not impact symptom improvement, patient-reported outcomes, or the need for further treatment. These findings support the Manchester procedure as an effective and durable surgical option for women with POP, regardless of avulsion status.
Insights
Levator ani muscle avulsion did not negatively impact outcomes 5 years after the Manchester procedure for pelvic organ prolapse (POP). The Manchester procedure remains effective for POP, regardless of avulsion status.
Area of Science:
- Urogynecology
- Pelvic Floor Surgery
- Female Pelvic Medicine
Background:
- Levator ani muscle avulsion is a known risk factor for poor outcomes in native tissue pelvic organ prolapse (POP) repair.
- Previous studies showed no association between avulsion and outcomes 1 year after the Manchester procedure.
- This study aimed to compare outcomes at 5 years in women with and without levator ani muscle avulsions.
Purpose of the Study:
- To compare patient-reported and anatomical outcomes, and failure rates at 5 years in women who underwent the Manchester procedure for POP, stratified by the presence or absence of levator ani muscle avulsion.
- To assess the long-term impact of levator ani muscle avulsion on the efficacy of the Manchester procedure.
Main Methods:
- A 5-year prospective cohort study of 143 women who underwent the Manchester procedure for anterior and/or mid-compartment POP.
- Levator ani muscle avulsions were diagnosed via transperineal ultrasound at inclusion.
- Outcomes assessed at 5 years included subjective bulge symptoms, overall pelvic floor symptoms, sexual distress, subjective cure rates, Pelvic Organ Prolapse Quantification (POP-Q) measurements, and need for further prolapse treatment.
Main Results:
- The avulsion rate was 52.4% among the 143 women followed for 5 years.
- Both avulsion and non-avulsion groups demonstrated similar improvements in bulge symptoms, pelvic floor symptoms, and anatomical measurements.
- Women with avulsion experienced significantly greater improvement in sexual distress, but had half the odds of achieving an optimal anterior compartment outcome.
Conclusions:
- Despite a lower likelihood of optimal anterior compartment outcome, levator ani muscle avulsion did not compromise overall anatomical changes or symptom improvement 5 years after the Manchester procedure.
- The Manchester procedure is an effective and durable surgical option for women with POP, irrespective of levator ani muscle avulsion status.
- Avulsion status did not influence patient-reported outcomes or the need for subsequent prolapse treatments.
