The diagnostic assessment of pelvic floor function and anatomy is moving from the fringes to the mainstream of Obstetrics and Gynaecology. Modern imaging methods such as magnetic resonance and 3D ultrasound have enabled us to diagnose major abnormalities of pelvic floor structure and function reliably and accurately. These most commonly take the form of an avulsion of the puborectalis muscle off its insertion on the os pubis. Such trauma can also be palpated- a skill that is available to every clinician, requiring neither investment nor specialised equipment.

In this presentation I will try to summarize the methodologies of pelvic floor assessment by palpation and ultrasound, and to describe the commonest abnormalities and their consequences. Levator avulsion occurs in about 20% of all women delivering vaginally, with vaginal operative delivery and maternal age the main predictors. Avulsion is associated with anterior and central compartment prolapse and with prolapse recurrence after reconstructive surgery. It is the only useful predictor of surgical failure and potentially useful in selecting patients for modern mesh techniques of prolapse repair. This seems particularly likely for cystocele repair since recurrence after routine anterior colporrhaphy is common.

On the other hand, recent developments open up possibilities for prevention of trauma (and thereby later prolapse), either by identifying high-risk patients and offering them elective Caesarean Section, via intervention trials designed to alter the biomechanical properties of the muscle and its insertion, or by changing obstetric management. The area certainly promises to be a fertile field for future clinical research.