Levator muscle division
What are the levator muscles?
The levator group of muscles are actually composed of 3 different muscle groups
- Pubococcygeus muscle
- Puborectalis muscle
- Iliococcygeus muscle
These muscles are fundamental for pelvic organ support and when they contract do so in a valve like action compressing around the three main ‘defects’ in the muscle group. These ‘defects’ in the levators are (from front to back), the:
The main nerve supply of the elevator muscle and other pelvic floor structures is the Pudendal nerve via its branches
- Inferior rectal
Levator muscle contraction requires an intact, normally functioning Pudendal nerve. This is known as ‘motor’ innervation. Sensory nerves are also transmitted via the Pudendal nerve, and these are responsible for sensation (touch, heat, pressure, pain) within the pelvic floor.
Indications for division of the levator muscle
Women are often told that successful treatment does not require drugs, surgery, Botox injections, hypnosis or any complex invasive techniques. In fact many women do need a variety of therapies to achieve resolution of this problem. No single treatment or regimen will suit all. Focussed levator muscle division is an end stage procedure, suitable for women who have failed more conservative management. It is highly effective when performed by trained specialists.
There are numerous causes of pain during intercourse towards the lower or outer part of the vagina. Levator muscle division is suitable not only for women suffering from vaginismus resulting from the pain but those who cannot enjoy sexual intercourse because of an abnormally tight introital area unrelated to muscle spasm. This is commonly observed in women who have had a large tear or episiotomy during childbirth where the subsequent healing has not been optimal.
The basic principles of Levator muscle division
Pre surgery identification of the position of the Levator muscles going into spasm. The patient will need to be awake for this to be effective so pre-assessment counselling about the technique and indication needs to be effectively communicated to ensure maximum cooperation.
Admission to hospital. Surgery can be done under a spinal or general anaesthetic. Local + sedation will not be effective. A pudendal nerve block can facilitate reduction of post surgery pain. A lithotomy position is used with good lighting to visualise the field of surgery.
The vaginal epithelium over the muscle to be divided is dissected open. With good surgical technique, the vaginal epithelium incision can remain small and still allow for subepithelial dissection to access the Levator muscle.
I use sharp dissection with a coagulation device to divide the Levator muscle. Discrete, limited incisions are made in a lateral superio-medial to inferio-lateral direction reducing the risk of injury to branches of the pudendal nerve . The Levator muscles have a well supplied vascular bed and incision into the muscle will result in some bleeding. The coagulation device reduces bleeding by cauterising at the same time as cutting.
No heroic attempt is made to use coagulation to stop venous bleeding as it is very difficult to identify and isolate the responsible vessels. The vaginal walls are sutured closed and then a pessary device is inserted into the vagina. The aim of this pessary is to keep the Levator muscle distended during the healing period.
Small sutures are used to attach the vaginal support pessary to the distal part of the posterior vaginal wall so that it is not displaced. This support pessary is routinely removed in the office at 4 weeks after surgery. In some cases it will need to be removed earlier if the patient struggles to tolerate its’ presence.
A catheter is sited in the bladder at the conclusion of surgery. This is removed about 4 hours after surgery and a trial of void carried out before the patient is discharged home on appropriate analgesia.
Followup is organised so that the vaginal support pessary can be removed. This is usually very straightforward as the sutures will usually have dissolved and fallen away. Any that remain are cut and removed. The pessary is removed and a brief inspection of the vaginal walls made with a speculum.
Vaginal dilators should then be used. The largest size tolerated will be the appropriate size to use. Liberal use of either a water-based lubricant or a vaginal oestrogen cream on the dilator will make the application of the dilator more easily tolerated.
Ultimate success of surgery may depend on regular and persistent use of a vaginal dilator 2-3 times a day for up to 2 months after surgery. Vaginal intercourse can begin 6 weeks after surgery.
The first attempt at vaginal intercourse should take place not less than 6 weeks after surgery. Lubricant should be applied to the entrance to the vagina and to the full length of the penis. You should chose a position that gives you the most control of both speed and depth of penetration.
Persistence is essential for success.