I say they're wrong. Not about the accuracy of what they referenced. I've read the ancient literature, the modern literature, and everything in between. I've been performing levatorplasties for over two decades. My patients aren't experiencing the painful sex that my contemporaries have referenced and the Ancients have described. What's going on here?
A review of the history of levatorplasty indicates clearly that their levatorplasty and my levatorplasty are not the same. A review of the ancient "proof" of levatorplasty-induced sexual pain (dyspareunia) reveals that these procedures were overaggressive in certain respects and incomplete in others.
For the uninitiated, levatorplasty or more accurately, anterior levatorplasty is the practice of suturing the medial-most portion of the levator ani fibers (a section of the muscle called the puborectalis) immediately proximal to the anal sphincters across the midline and advancing this plication proximally, This is usually done through a perineal incision extended to the posterior vaginal wall.
The practice of levatorplasty was introduced by Robert Ziegenspeck of Germany in 1900. To understand the problem with the "wrong" techniques of levatorplasty, we need to go back one hundred years ago and examine the work of Arnold Sturmdorf:
It is clear that the levator plication sutures are extremely broad and deep. The complete "encirclement" of these muscles and ligation places extreme tension on a large mass of tissue. This will undoubtedly cause ischemia and ischemia will cause significant discomfort in the short term. In the long term, chronic tension on the muscle tissue will predispose to myalgia and traction pain on nerve fibers.
The absence of an independent repair of the rectocele bulge creates two problems. First, it places all of the tension of subsequent bowel movements directly onto a single plane of tissue placing additional stress centrally. It would surprise no one that this type of levatorplasty would create pain with sex or any activity that stresses the muscle tissue. Second, it leaves the low-pressure tissue of the rectocele hernia floating, in essence, and free to float cephalad beyond the plication zone and recur later.
First, we see that taking huge bites of the levator ani muscle and forcing them together under high tension creates problems.
Second, we see that using a single layer of muscle tissue as the only repair for a rectocele creates problems.
Third, we see that quoting articles that quote articles doesn't provide data directly and that opinions in the discussion section of published articles aren't exactly the same thing as evidence and might distort the impression of the literature for those who fail to dig a little deeper.
It doesn't require huge bites of muscle tissue. It doesn't involve high tension. And it doesn't take place withouit the support of a sturdy rectocele repair underneath to take the tension and stress off the sensitive muscle tissue.
Two decades. No problems. No kidding.
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