Reliability of a novel technique for three-dimensional pelvic floor ultrasound imaging for the diagnosis of levator muscle avulsion

Aly Youssef*, Elisa Montaguti*, Ginevra Salsi*, Olimpia Sanlorenzo*, Tullio Ghi*, Gianluigi Pilu*, Nicola Rizzo*
* Department of Obstetrics and Gynecology, Sant’Orsola-Malpighi Hospital, University of Bologna, Italy

Objectives: The aim of this study was to compare a new technique for 3D ultrasound (3DUS) pelvic floor imaging, the Omniview-Volume contrast imaging (Omniview-VCI, GE Healthcare) with the standard previously suggested 3D method in diagnosing levator ani muscle (LAM) avulsion.
Methods: We acquired a 3DUS transperineal volume from 106 symptomatic women referred to our center with urinary or prolapse symptoms. Each 3D dataset was saved anonymously and later randomly analyzed by means of the Omniview-VCI technique and of the rendering method (ROI) in order to asses if there was any LAM avulsion and if this damage was in bilateral, in the left or right side. Analysis of the stored volumes was performed offline by an operator who was blinded to all clinical data.
Results: The agreement in the diagnosis of levator avulsion between Omniview-VCI technique and rendered methods was 87,7%. In table 1 are reported the contingency table of volumes analyzed. In particular 32 volumes were judged to be without LAM avulsion, 8 with right, 7 with left and 45 with bilateral LAM avulsion by both methods used. On the contrary, 14 volumes reported conflicting results. The agreement yielded a Cohen’s kappa of 0.80 (95% CI, 0.71 to 0.89) with a P value <0.001.
Conclusions: Omniview-VCI is a reliable tool for the diagnosis of levator ani lesions.


  1. Dietz HP, Simpson JM. Levator trauma is associated with pelvic organ prolapse. BJOG 2008; 115: 979-984.
  2. Dietz HP. Clinical consequences of levator trauma. Ultrasound Obstet Gynecol 2012; 39: 367-371.
  3. Dietz HP, Gillespie AV, Phadke P. Avulsion of the pubovisceral muscle associated with large vaginal tear after normal vaginal delivery at term. Aust N Z J Obstet Gynaecol 2007; 47: 341-344.
  4. Volloyhaug I, Wong V, Shek KL, Dietz HP. Does levator avulsion cause distension of the genital hiatus and perineal body? Int Urogynecol J 2013; 24: 1161-1165.
  5. Dietz HP. Pelvic floor trauma following vaginal delivery. Curr Opin Obstet Gynecol 2006; 18: 528-537.
  6. Dietz HP, Hyland G, Hay-Smith J. The assessment of levator trauma: a comparison between palpation and 4D pelvic floor ultrasound. Neurourol Urodyn 2006; 25: 424-427.
  7. Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol; 202: 321-334.
  8. Dietz HP, Moegni F, Shek KL. Diagnosis of levator avulsion injury: a comparison of three methods. Ultrasound Obstet Gynecol 2012; 40: 693-698.