9 studies, 1,623 women: only 2 of 9 found a link between levator ani avulsion and postpartum sexual dysfunction
Journal: International Urogynecology Journal | Published: 2026-04-11 | Type: Systematic Review | PMID: 41964686 Authors: Samešová A, Kiebooms R, Cattani L, Williams H, Hympánová LH, Deprest J (KU Leuven, Department Development and Regeneration; Institute for the Care of Mother and Child, Prague) Funding/COI: Not listed; authors declare no conflicts of interest
Vaginal delivery can injure the levator ani muscle (LAM) — the main pelvic floor muscle — through avulsion (tearing from its bony attachment) or by widening the levator hiatus. This review asked whether those injuries predict sexual dysfunction in the first two years postpartum. Screening 7,621 publications down to 9 eligible studies (1,623 women), the authors found minimal evidence of an association: only 2 of 9 studies reported a statistically adverse relationship between LAM avulsion and sexual dysfunction. The authors planned a meta-analysis and could not run one — the studies were too methodologically inconsistent to combine.
A systematic review is the appropriate design for this question, and the team searched seven databases including CENTRAL and ClinicalTrials.gov, which is thorough. Risk of bias was assessed using the ROBINS-I tool (appropriate for non-randomized studies). Ending up with 9 usable studies from 7,621 initial hits signals either a highly specific research question or a near-total absence of literature — here, it's both.
The inability to run the planned meta-analysis is the central limitation and it's a real one. Eight different outcome questionnaires across nine studies is a methodological disaster: you cannot meaningfully compare a study using the FSFI with one using the ICIQ-VS or a bespoke instrument. This heterogeneity means "no association found" may reflect noise rather than biology — the studies were not designed to be pooled, and even their individual results may be measuring different constructs.
This review honestly reports that the field doesn't have enough standardized data to answer its own question. That's a legitimate finding — the literature is too thin and too heterogeneous to support conclusions about whether levator ani injury predicts postpartum sexual dysfunction. The 2-of-9 study split sounds like weak signal, but given that the 9 studies used 8 different outcome instruments, it's closer to noise. The review is methodologically sound for what it attempted; the problem is the literature it was reviewing. Worth reading as a gap map, not as a guide to clinical risk. Future research needs standardized outcome instruments — the ICIQ-VS or FSFI used consistently — before this question can be answered.