Geburtsbedingtes Beckenbodentrauma

Zusammenfassung

Bei der Mehrheit aller Frauen kommt es während der Geburt zu einem Trauma am Beckenboden. Wir sind alle vertraut mit Damm- und Scheidenrissen und die Identifikation und Behandlung von dritt- und viertgradigen Dammrissen ist ein Schwerpunkt der geburtshilflichen Ausbildung. Innerhalb der letzten 10 Jahre ist allerdings klar geworden, dass der Begriff Beckenbodentrauma eine weitere Kategorie von Verletzungen umfasst, die meist okkult bleiben und nur selten unter der Geburt diagnostiziert werden. Fortschritte in der bildgebenden Diagnostik, insbesondere in der Kernspin- und 3-D-/4-D-Ultraschalldiagnostik, haben es uns ermöglicht, den M. levator ani, vor allem den M. puborectalis, routinemäßig darzustellen. Es ist inzwischen klar, dass das Puborectalis-Trauma („Avulsion“) recht häufig ist (15–40 % aller vaginalen Geburten) und dass es womöglich der numerisch wichtigste Faktor in der Pathogenese von Prolapsbeschwerden sein könnte. In der vorliegenden Übersichtsarbeit werde ich versuchen, den jetzigen Stand der klinischen Forschung auf diesem Gebiet zu umreißen. Ich werde mich auf Schäden am Levator ani beschränken, da zum Sphinktertrauma bereits ausreichend Literatur vorliegt. Ich werde auch versuchen, Perspektiven aufzuzeigen – nicht nur für die klinische oder bildgebende Diagnose von Levator-Rissen, sondern auch für die Prävention und chirurgische Behandlung dieser bisher vollständig vernachlässigten Form von Geburtstraumata.

Abstract

A majority of women delivering via the vaginal route suffer some form of trauma to the pelvic floor and perineum. Perineal and anal sphincter tears have been recognised as a major issue, requiring dedicated training of obstetric staff to ensure proper diagnosis and treatment. Over the last ten years, however, it has become evident that pelvic floor trauma comprises yet another category of trauma that usually remains occult and is virtually always overlooked in Labour Ward. Progress in the field of multiplanar and 3D/4D imaging, both in magnetic resonance and in ultrasound, has enabled us to assess the levator ani, in particular the puborectalis muscle, as a matter of routine. It has become clear that major damage in the form of an avulsion of the puborectalis muscle is common (15–40 % of vaginal deliveries), and that it may well be the most important aetiological factor in the development of female pelvic organ prolapse. In this review I'll try and summarize the current state of clinical research in this field. I'll limit myself to the levator ani, since anal sphincter trauma has been suffficiently covered in the literature. II'll also try to show up perspectives, not just for the diagnosis of such trauma by clinical examination and imaging, but also for prevention and surgical treatment of this hitherto ignored form of birth trauma.

Schlüsselwörter

3‐D - Beckenboden - Geburtstrauma - M. levator ani - Prolaps - Ultraschall

Key words

3D - birth trauma - female pelvic organ prolapse - levator ani - pelvic floor - ultrasound

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