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Hiatus Levatorius – Anatomy and Clinical Relevance

The hiatus levatorius is an anatomical opening in the pelvic floor through which the urethra, vagina, and rectum pass. It plays a key role in pelvic floor health.

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Things worth knowing about "Hiatus levatorius"

The hiatus levatorius is an anatomical opening in the pelvic floor through which the urethra, vagina, and rectum pass. It plays a key role in pelvic floor health.

Definition and Anatomy

The hiatus levatorius (also referred to as the levator hiatus or urogenital hiatus) is a midline gap within the levator ani muscle, the principal muscular component of the pelvic floor. In women, this opening allows the passage of the urethra, vagina, and rectum; in men, the urethra and rectum pass through it. The hiatus is bordered anteriorly by the medial portions of the pubococcygeus muscle and represents the critical gateway for the pelvic viscera.

The dimensions of the hiatus levatorius are of significant clinical relevance: an enlarged or functionally insufficient hiatus is associated with pelvic floor disorders such as pelvic organ prolapse and urinary incontinence.

Clinical Significance

The hiatus levatorius is a key focus in pelvic floor diagnostics and treatment planning. Its dimensions are routinely assessed using transperineal ultrasound (TPUS) and magnetic resonance imaging (MRI). An increased cross-sectional area of the hiatus is considered a risk factor for several urogynecological conditions.

Normal Values and Changes

During transperineal ultrasound, the area of the hiatus levatorius is measured at rest and during maximum Valsalva maneuver. An area exceeding 25 cm² is considered enlarged (termed ballooning) and has been associated with a higher risk of pelvic organ prolapse in the scientific literature.

Causes of Enlargement

Vaginal delivery: Traumatic births, particularly those involving forceps or vacuum extraction, can cause overstretching or tearing of the levator ani muscle.
Aging: With increasing age, pelvic floor structures lose elasticity and muscular tone.
Chronically elevated intra-abdominal pressure: Obesity, chronic constipation, or persistent coughing can place ongoing strain on the pelvic floor.
Genetic predisposition: Congenital connective tissue weakness may affect the structural integrity of the hiatus levatorius.

Associated Conditions and Symptoms

Pelvic organ prolapse (POP): Descent of the bladder, uterus, or rectum through an enlarged hiatus levatorius.
Urinary incontinence: Stress incontinence resulting from inadequate pelvic floor support.
Fecal incontinence: Weakness of the sphincter complex due to altered pelvic anatomy.
Chronic pelvic pain: Muscle tension or avulsion injuries in the region of the levator ani.

Diagnosis

Assessment of the hiatus levatorius is primarily performed through imaging techniques:

Transperineal ultrasound (TPUS): The standard method for measuring the hiatal area at rest and under Valsalva. It is non-invasive, widely available, and cost-effective.
Magnetic resonance imaging (MRI): Provides detailed visualization of pelvic floor structures, especially for detecting levator ani muscle avulsions.
Clinical examination: Palpation and functional pelvic floor assessment by specialists in urogynecology or proctology.

Treatment and Management

Treatment depends on the underlying condition and the degree of pelvic floor dysfunction:

Conservative Treatment

Pelvic floor exercises (Kegel exercises): Targeted strengthening of the levator ani and surrounding pelvic floor musculature.
Physiotherapy: Specialized pelvic floor rehabilitation by trained physiotherapists, potentially including biofeedback techniques.
Pessary therapy: Use of pessary devices for mechanical support in cases of pelvic organ prolapse.

Surgical Treatment

Reconstructive pelvic floor surgery: In cases of significant pelvic organ prolapse, surgical procedures such as colporrhaphy or sacrospinous fixation may be required.
Levatorplasty: Surgical repair and reconstruction of the levator ani muscle in cases of severe avulsion tears.

References

Dietz HP. Pelvic floor ultrasound: a review. Am J Obstet Gynecol. 2010;202(4):321-334.
Ashton-Miller JA, DeLancey JO. Functional anatomy of the female pelvic floor. Ann N Y Acad Sci. 2007;1101:266-296.
Bump RC, Mattiasson A, Bo K et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175(1):10-17.

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