However, there is another type of pelvic muscle tear that can occur deeper in the pelvis and often goes undiagnosed and untreated. They get called levator nor injuries, tears or avulsions (where the muscles separate from the bone). Research shows that these injuries occur in approximately 10-30% of vaginal births, yet most people have never heard of them!
Levator ani injuries can cause problems immediately after birth or years later. If you are preparing for childbirth, understanding this injury can help you make informed decisions about your delivery and postpartum care. If you are postpartum and suffer from symptoms such as a heavy pelvis, urine leakage or pain during sex after childbirth, this may be the reason. The good news is that these symptoms can improve with the right treatment!
What are the levator ani muscles?
The levator ani is a group of muscles at the base of the pelvis. They support your pelvic organs (including your bladder, rectum and uterus) and help with bladder and bowel control, sexual function and core stability. These muscles form a funnel shape that extends from your pubic bone in the front to your tailbone in the back, connecting to your sit bones on either side. The rectum, vagina and urethra all pass through it. When you contract these muscles (such as when you try to stop the flow of urine), they lift the pelvic floor – which is actually where the name comes from (‘levator’ means ‘to lift’).
How is the levator ani affected during labor?
During the ‘pushing’ phase of labor (also called the second stage), your levator ani muscles stretch significantly as your baby moves through the birth canal. We’re talking about stretching up to 3.3 times their resting length; that’s way more than most muscles in your body can handle! While this extreme stretching exercise is quite amazing, it also puts these muscles at risk. Unlike perineal tears that occur on the surface where you and your healthcare provider can see them, levator ani injuries occur deeper in your pelvis. In more severe cases, the muscle may completely detach from the bone in some places (this is called “levator ani muscle avulsion”).
Here’s some hopeful news: research suggests that about half of people who experience these types of tears will recover within a year of giving birth. However, if you’re in the other half and your symptoms don’t go away on their own, they can significantly impact your quality of life. That’s where treatment comes in, and pelvic floor therapy is an excellent place to start.
How common is levator ani injury and what are the risk factors?
There are a wide range of estimates of how common levator ani injuries occur, with studies reporting anywhere from 10-30% of all vaginal deliveries. Certain birth interventions can do that increase your risk, especially the use of tweezers and vacuum aid. Other factors that may increase your risk include a longer pushing phase, delivering a baby with a larger head or birth weight, a lower BMI, a posterior birth position of the occiput (when your baby is face up, also known as ‘sunny side up’) and older maternal age. On the other hand, having an epidural and an increased BMI of the birthing person appear to be protective factors for levator ani injuries. It’s also important to know that if you have a C-section after you’ve already pushed, you can still have this injury.
Additional factors that may increase risk, but are usually only measured in a research setting, include the initial length of the muscles, the extensibility of the tissues involved, the shape of the pubic bones at the front of the pelvis, as well as the degree to which the baby’s head “forms” into a cone shape. But even with some of these known risk factors, it can still be unpredictable whether or not someone will develop this injury. That’s why it’s important to get tested if you’re concerned!
Can you prevent a levator ani injury?
This is a difficult question because levator ani injury during birth cannot always be avoided. However, there are some steps you might consider that may help:
- To get pelvic floor therapy before birth: Working with a pelvic floor physical therapist during pregnancy can ensure that you know how to contract and relax these muscles properly. If you push but tense your levator ani muscles in the opposite direction, that’s counterproductive! A PT can teach you how to use your breathing, pelvic floor, and abdomen together to push effectively.
- Communicate your birth preferences: Consider whether you are comfortable using forceps or vacuum assistance during labor, given the higher risk. Make your preferences clear in your birth plan and make sure your birth partner knows your wishes so he or she can advocate for you if necessary.
How can you tell if you have a levator ani injury?
If you have had this type of injury, you may experience symptoms such as:
- Pelvic pain or pressure
- Difficulty with bowel movements
- Bowel or bladder leakage
- Pain during sex or reduced sensation during penetration
- A feeling of heaviness or as if something is “falling out”
- In some cases, your anus may visibly shift to one side
You can have some of these symptoms without a levator ani injury, and you can also have an injury without experiencing all of these symptoms.
Some physical therapists and obstetricians/gynecologists with special training can detect a levator ani avulsion during a vaginal exam, but the most definitive way to diagnose diagnose it is with an echo. If you’re wondering if you have this injury, talk to your doctor about an examination.
What happens if you have this injury?
Like many injuries, the impact of a levator ani injury can range from causing no symptoms at all to problems that affect your daily life. The most common complication is pelvic organ prolapse (POP), when one of your pelvic organs (bladder, uterus, or rectum) pushes into your vaginal canal. In some cases it may protrude from the vaginal opening.
Mild prolapse is actually very common and often causes no symptoms. However, if you experience a visible or palpable bulge that makes it difficult to urinate or defecate, or if you experience uncomfortable pressure or pain, it is worth addressing. If you are considering surgery for prolapse, it is important that your doctor first rule out a levator ani avulsion. If the underlying muscle injury is not addressed, you may experience a recurrence of the prolapse after repair.
What are the treatment options for a levator ani injury?
Pelvic floor physiotherapy: If you have symptoms that are bothering you, this is an excellent first step. A pelvic floor therapist can help you strengthen your pelvic floor muscles, reduce painful tension, and improve coordination of surrounding muscles to compensate for the injury. They can also help you resolve problems with bowel movements, bladder function, or sexual activity. Book your virtual or in-person evaluation Today!
Other options if PT isn’t enough: If your symptoms don’t improve with physical therapy alone, there are additional options. If you have symptoms of prolapse, you can try a pessary (a supporting device inserted into your vagina). There are also surgical options that can repair or reattach the levator ani muscles or address prolapse. The best surgical approach for you depends on how severe your prolapse is, what type of avulsion you have, and the expertise of your surgeon.
You’re not alone
If you have suffered a levator ani injury or other birth injury or trauma, know that you are not alone. The first step is recognizing what is happening so you can get the right treatment and support. It can be difficult to talk about these issues, but by being informed and advocating for yourself, you can access the care you deserve.
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