Title: Women’s experiences of life and healthcare after levator ani avulsion: a qualitative
interview study
Version: 2 Date: 09 Apr 2025
Reviewer:  Robyn Brennen
Reviewer's report:
Thank you for the opportunity to review this manuscript. The study reported provides important
and valuable information about the experiences and perspective of people who have been
diagnoses with levator avulsion. It is a very well designed and reported study, with a compelling
analysis of the results of the participant interviews.
Some minor revisions are recommended prior to publication of the article, as follows.
Congratulations on an excellent study and article, and a valuable contribution to the field of
knowledg.
Minor revisions recommended:
Abstract:
Excellent and clear.
One minor revision: Recommend changing ‘digital interviews’ to ‘online interviews’ or
‘videoconference interviews’.
Introduction
Para 1, sentence 4: Recommend removing the word ‘thus’ as this implies a causal process that
levator avulsion  causes decreased PFM support and increase gh size which combine to cause
prolapse, whereas the increased genital hiatus size and prolapse could both be symptoms of the
decreased PFM support and other factors that occurred at the time of levator avulsion, such
as stretching of connective tissues, rather then the genital hiatus size necessarily causing the
prolapse. This is addressed well in the discussion later, and this sentence just needs to made
consistent with this.
Para 2, sentence 4: Need to specific what the pelvic floor physiotherapy could be effective and
prolapse pessaries could be effective for, as based on the content of the paragraph this could be
muscle attachment, or sensation of looseness, or potentially general prolapse symptoms.
Para 3, sentence 1: The impact of LAM on quality of life has not been described, and so is not
a given. What is known on this topic should be summarised in a separate paragraph to the rest
of this paragraph, which addresses obstetric risk factors. The information in paragraph 5 could
be moved up.
Para 5: See the note on Para 3, sentence 1. Also, there needs to be a clear justification of the
current study, and identification of the gap that it addresses, considering that a previous study
on the topic is summarised here.
Methods
See minor comment on the abstract, recommend replacing the word ‘digital’ with ‘online’ or
‘videoconference’.
The questions from the semi-structured interview guide do not appear to be included. These
should be provided as supplementary material.
Results
Excellent presentation. Compelling narrative, well supported by quotes.
Discussion
P29, Para 3, Sentence 5: It is important to make it clear that assessment for tears post-birth is
not the same as assessment for levator ani muscle avulsion, and clinical assessment for levator
avulsion via vaginal examination immediately post-birth has not been validated.
Methodological discussion
Excellent
Conclusion and clinical implications
Para 1, sentence 1: Recommend changing ‘significantly impacts’ to ‘can substantially impact’
as there may be many women who have a diagnosis of LAM, or have LAM and have not been
diagnosed, who do not experience the same impacts on Quality of life as the participants in this
study. This is one of the limitations that the author’s have addressed and the conclusion needs to
reflect this limitation (p31). The change from ‘significantly’ to ‘substantially’ also avoids any
confusion with the idea of statistical significance, which is not relevant to this study.