Comparison of pelvic floor muscle strength in nulliparous women and those with normal vaginal delivery and cesarean section

Pelvic floor muscle strength and influencing factors based on vaginal manometry among healthy women at different life stages: A multicentre cross-sectional study

OBJECTIVE

To assess pelvic floor muscle (PFM) strength and influencing factors among healthy women at different life stages.

DESIGN

Multicentre cross-sectional study.

SETTING

Fourteen hospitals in China.

POPULATION

A total of 5040 healthy women allocated to the following groups (with 1680 women per group): premenopausal nulliparous, premenopausal parous and postmenopausal.

METHODS

The PFM strength was evaluated by vaginal manometry. Multivariate logistic regression was used to determine the influencing factors for low PFM strength.

MAIN OUTCOME MEASURES

Maximum voluntary contraction pressure (MVCP).

RESULTS

The median MVCP values were 36, 35 and 35 cmH2 O in premenopausal nulliparous (aged 19-51 years), premenopausal parous (aged 22-61 years), and postmenopausal (aged 40-86 years) women, respectively. In the premenopausal nulliparous group, physical work (odds ratio, OR 2.05) was the risk factor for low PFM strength, which may be related to the chronic increased abdominal pressure caused by physical work. In the premenopausal parous group, the number of vaginal deliveries (OR 1.28) and diabetes (OR 2.70) were risk factors for low PFM strength, whereas sexual intercourse (<2 times per week vs. none, OR 0.55; ≥2 times per week vs. none, OR 0.56) and PFM exercise (OR 0.50) may have protective effects. In the postmenopausal group, the number of vaginal deliveries (OR 1.32) and family history of pelvic organ prolapse (POP) (OR 1.83) were risk factors for low PFM strength.

CONCLUSIONS

Physical work, vaginal delivery, diabetes and a family history of POP are all risk factors for low PFM strength, whereas PFM exercises and sexual life can have a protective effect. The importance of these factors varies at different stages of a woman's life.

Development and evaluation of the psychometric properties of a digital questionnaire for the self-management of health and well-being in the postpartum period

BACKGROUND

Despite the fact that the Global Strategy for Women's, Children's and Adolescents' Health (2016-2030) recognises the special importance of care for women during the postpartum period, thus highlighting the need to identify and measure any condition that may affect the welfare of pregnant women in any way, this is one of the most neglected stages in the health system. Given the absence in our area of global, efficient instruments, the objective of this study was to design a complete, specific measurement tool with good metric qualities in digital format for the evaluation of self-reported health and well-being during the puerperium, to conform to what was proposed by the ICHOM.

METHODS

A cross-sectional study was carried out to evaluate the psychometric characteristics of a digital measurement tool. The development of the tool was carried out in 4 steps, following the recommendations of the International Test Commission. It was tested on 280 puerperas attending primary healthcare appointments in the Basque Healthcare System (Osakidetza), and they did the newly created survey, answering all the questions that had been selected as the gold standard. The average age of the women was 34.93 (SD = 4.80). The analysis of the psychometric characteristics was based on mixed procedures of expert judgment (a focus group of healthcare professionals, an item evaluation questionnaire and interviews with users) and quantitative evaluations (EFA, CFA, and correlation with gold standard, ordinal alpha and McDonald's omega).

RESULTS

The final version of the tool comprised 99 items that evaluate functional state, incontinence, sexuality, breastfeeding, adaptation to the role of mother and mental health, and all of these questions can be used globally or partially. It was found that the scores were valid and reliable, which gives metric guarantees for using the tool in our area.

CONCLUSIONS

The use of this comprehensive concise tool with good psychometric properties will allow women to take stock of their situation, assess if they have the necessary resources, in psychological and social terms, and work together with midwives and other healthcare professionals on the most deficient areas.

A randomized controlled pilot trial to assess the effectiveness of a specially formulated food supplement and pelvic floor muscle training in women with stress-predominant urinary incontinence

BACKGROUND

Pelvic floor muscle training (PFMT) is the first-line treatment approach for stress urinary incontinence. Creatine and leucine have been shown to improve muscle function. Our aim was to assess the effectiveness of a food supplement and PFMT in women with stress-predominant urinary incontinence.

METHODS

Women with stress-predominant urinary incontinence were randomized in 1:1 ratio to receive daily oral supplementation for six weeks with either a food supplement (treatment group) or placebo (control group). Both groups were instructed to perform standardized daily PFMT. The primary outcome was the Urogenital Distress Inventory Short Form (UDI-6) score. Secondary outcomes were the Incontinence Impact Questionnaire (IIQ-7) score, Patient's Global Impression of Severity (PGI-S), and Biomechanical Integrity score (BI-score) measured by Vaginal Tactile Imager. To have a power of 80% and a significance level of 5% to detect a decrease of 16 points in the UDI-6 score, a sample size of 32 was needed, with 16 patients in each arm of our trial.

RESULTS

Sixteen women in the control group and sixteen in the treatment group completed the trial. Between-group analysis revealed no significant differences between the control and treatment group except for mean change (delta) in vaginal squeeze pressure [(cmH2O, mean ± SD), 5 ± 12 vs. 15 ± 15, P = 0.04] and mean change (delta) in PGI-S score [(mean ± SD), -0.2 ± 0.9 vs. -0.8 ± 0.8, P = 0.04]. Within-group analysis showed that UDI-6 and IIQ-7 scores improved significantly from baseline to six weeks in the treatment group but not in the control group [UDI-6 score (mean ± SD) 45 ± 21 vs. 29 ± 21, P = 0.02; 43 ± 18 vs. 33 ± 26, P = 0.22] [IIQ-7 score (mean ± SD) 50 ± 30 vs. 30 ± 21, P = 0.01; 48 ± 23 vs.40 ± 28, P = 0.36]. PGI-S scores only improved in the treatment group from baseline to six weeks after treatment [PGI-S score (mean ± SD) 3.1 ± 0.8 vs. 2.3 ± 0.8, P = 0.0001]. BI-score, on average, improved significantly in the treatment and control group as well [SD unit, mean, from - 1.06 to -0.58, P = 0.001; from - 0.66 to -0.42, P = 0.04].

CONCLUSIONS

Women with stress-predominant urinary incontinence receiving a specially formulated supplement in addition to daily PFMT for six weeks had significantly improved urinary symptoms (decrease in UDI-6 score and IIQ-7) and BI-score compared to their baseline.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05358769. 27/04/2022.

Evaluation of Pelvic Floor Muscle Strength in Nulliparous, Parous and Postmenopausal Women and its Association with Various Factors

Objective

To evaluate pelvic floor muscle strength (PFMS) in nulliparous, parous and postmenopausal women using vaginal digital palpation and perineometer.

Material and Methods

It was a cross-sectional study, conducted in department of Obstetrics and Gynecology, VMMC & Safdarjung hospital. A total of 300 women were recruited from Gynaecology and Family welfare outpatient departments and divided into 3 equal groups-nulliparous women, premenopausal parous women and postmenopausal women. PFMS was measured by modified Oxford Scale with vaginal digital palpation and by perineometer. Linear regression analysis was performed to evaluate and compare mean PFMS and identify its associated factors.

Results

Median age was 21 years in nulliparous, 27 years in parous and 58 years in postmenopausal group. The average body mass index was 27.45, 28.01 and 34.63 kg/m2 in nulliparous, parous and postmenopausal group. The mean MOS by digital vaginal palpation was 4.66 in nulliparous, 3.9 in parous and 2.54 in postmenopausal women. The difference was statistically significant. The mean PFMS by perineometer was 40.04 cm H2O, 37.69 cm H2O and 34.93 cm H2O in nulliparous, parous and postmenopausal group, respectively. The difference was statistically significant (p < 0.001). Majority (50%) of nulliparous women had PFMs between 41 and 50 cm H2O and parous (81%) had PFMS between 21 and 30 cm H2O. There was a statistical significance between the groups.

Conclusions

The PFMS of nulliparous women was significantly higher than multiparous women, and difference was statically significant (p < 0.001). Age had an important influence on pelvic floor muscle before menopause, but after menopause, it is years of menopause which has significant negative impact on PFMS and not age.

Risk factors of pelvic floor muscle strength in south Chinese women: a retrospective study

Objectives

To evaluate pelvic floor muscle strength using surface electromyography and risk factors for pelvic floor muscle strength in the early postpartum period.

Methods

This retrospective study included 21,302 participants who visited Fujian Maternity and Child Health Hospital from September 2019 to February 2022. All participants were assessed by medical professionals for general information and surface electromyography.

Results

Univariate analysis indicated that age was inversely related to tonic and endurance contractions. In contrast, all the other variables, including education level, body mass index, neonatal weight, and number of fetuses, had a positive impact on rapid, tonic, and endurance contractions. Likewise, parity was also positively associated with rapid contractions. In addition, compared with vaginal delivery, cesarean section delivery had a protective effect on the amplitude of the three types of contractions. Stepwise regression analysis showed that both age and neonatal weight had a negative linear relationship with the amplitude of rapid, tonic and endurance contractions. In contrast, the amplitude of rapid, tonic and endurance contractions significantly increased as body mass index, parity (≤ 3), education level and gestational weight gain (endurance contractions only) increased. Participants with cesarean section delivery showed positive effects on rapid, tonic, and endurance contractions compared to participants with vaginal delivery.

Conclusions

We found that age, neonatal weight, vaginal delivery, episiotomy, and forceps delivery were risk factors for pelvic floor muscle strength; in contrast, body mass index, parity (≤ 3) and gestational weight gain had a positive relationship with pelvic floor muscle strength.

Investigating Pelvic Floor Muscle Strength in Women of Reproductive Age and Factors Affecting It

This descriptive study was designed to investigate the pelvic floor muscle strength (PFMS) of women aged 18 to 49 years and to examine the factors that may have an effect on PFMS. The study was conducted on 258 women who visited a gynecology outpatient clinic between January 2019 and January 2020, who met the research criteria, and who agreed to participate in the study. The data were collected using the Sociodemographic Characteristics Information Form. The Modified Oxford Scale (MOS) and a perineometer were used to evaluate the PFMS of the women. The mean PFMS value measured using the perineometer was 31.56 ± 12.17 cmH₂O (moderate pressure). The PFMS values were 20.00 to 29.9 cmH₂O (weak pressure) and 30.00 to 39.9 cmH₂O (moderate pressure) in 23.6% of the women, respectively. The PFMS values measured with MOS were of grade 3 strength (moderate pressure) in 23.6% of the women and grade 2 strength (weak pressure) in 23.3%. A statistically significant strong correlation was found between the perineometer measurement and the women's MOS values. Moreover, a statistically significant difference was found between the PFMS values measured with the perineometer, MOS scores, and women's age groups, educational status, marital status, employment status, income status, persistent cough, use of nicotine, alcohol and coffee consumptions, chronic constipation, history of frequent urinary tract infections, regular exercise, body mass index, history of pregnancy, mode of delivery, use of episiotomy at birth, perineal rupture at birth, use of forceps vacuum at birth, multiple pregnancies, delivery of a baby weighing ≥4,000 g, treatment during pregnancy, hysterectomy, menopause, frequency of sexual intercourse, and pain during sexual intercourse (p < .05). We conclude that most of the women in the study had weak to moderate PFMS, that the evaluation of PFMS with the MOS positively overlapped with the perineometric measurements, and that a number of sociodemographic and obstetric variables act as risk factors that affect PFMS. The PFMS of all women should be assessed as part of their routine gynecological examinations.

Sphincter muscle activity before and after delivery: Does it depend on the type of birth?

AIM

There are ongoing discussions whether cesarean section is the safest mode of childbirth to prevent pelvic floor disorders. Pelvic floor electromyography (EMG) allows the analysis of external anal sphincter (EAS) function during voluntary contractions. The primary objective of this study was the evaluation of EMG amplitude of external anal sphincter in women who had vaginal delivery, compared to women who had cesarean section. The secondary objective was to evaluate the anal incontinence score changes before and after delivery between the groups, and to look for any relationship between the clinical and EMG findings.

METHODS

Multichannel surface EMG was detected during maximal contractions in three sessions: (i) during pregnancy, (ii) 6 weeks after delivery and (iii) 1 year after delivery. Women were divided into two groups: cesarean section and vaginal delivery.

RESULTS

External anal sphincter EMG amplitude decreases 6 weeks after vaginal deliveries from 10.1 to 8.6 μV with effect size of 0.4, but returns to baseline after 1 year. No differences were observed between groups in all other variables.

CONCLUSION

No differences were observed after 1 year in EMG activity between the two groups; however, a slight decrease of sphincter muscle amplitude was noted 6 weeks after vaginal delivery. The delivery mode does not have effect on the EAS amplitude 1 year after delivery. Incontinence score slightly increased in both groups after delivery, with no significant differences between the two groups. No association was observed between the increase of incontinence score and the decrease of EMG signal amplitude.

The prevalence of urinary incontinence symptoms among multiparous women: a survey of Saudi health-care centers

OBJECTIVE

To determine the distribution of urinary incontinence (UI) symptoms and their relation to childbirth events.

METHODS

This cross-sectional study used a structured self-administered questionnaire that included the Questionnaire for Female Urinary Incontinence Diagnosis and the Urogenital Distress Inventory Short Form. The study included 802 women sampled from four primary health care centers in Dammam, KSA. A chi-square test and adjusted logistic regression models were used to examine the relation between UI symptoms and obstetric events.

RESULTS

Of the participants, 56.6% (n = 454) had at least one UI symptom. Symptoms were most commonly associated with grand multiparity (80.47%), a history of abortion (72%), assisted vaginal delivery (70%), an age of ≤ 18 years at first birth (66.67%) and ≥ 35 years at last birth (75.48%), and a history of macrosomia (84.62%) and episiotomy (67.89%). Unlike the risk of urgency UI, the risk of stress UI was statistically significantly linked to obstetric events. Grand multiparity was associated with a higher risk of both stress UI (odds ratio [OR]: 3.75, confidence interval [95% CI]: 1.68-8.40) and urgency UI (OR: 2.87, 95% CI: 1.07-7.73).

CONCLUSION

UI symptoms are common among grand multiparas. Unlike urgency UI, stress UI is associated with previous obstetric events.

Does size matter? Perineometer and digital examination of a model levator hiatus

INTRODUCTION

Evaluation of the female pelvic floor muscles is commonly carried out with digital examination and assigning a modified Oxford scale score or vaginal manometry. Racial differences can influence the size of the levator hiatus (LH) with "black" or African nulliparous women having a significantly larger LH compared to Caucasian women. The aim of this study was to assess the impact of LH size on manometry readings of simulated pelvic floor muscle contractions (PFMCs) using a small and large model LH.

METHODS

Small and large LH models were created using published data for size. Inflation of a pressure cuff placed circumferentially in the LH model represented a simulated PFMC. The models were examined in a supine position by three examiners and a perineometer twice each at varying simulated PFMC strength.

RESULTS

Positive correlation was found between increasing simulated PFMC strength with a higher Oxford score following digital examination and manometry readings for both the small (r_s  = .87, r_s  = .98) and large (r_s  = .95, r_s  = .87) models. There was good to excellent inter and intraobserver correlation for digital assessment of both models. The manometry measurements showed a much larger incremental rise from baseline in the small model compared with the large model (P < .05).

CONCLUSION

This study demonstrates that perineometer readings are affected by natural variations in LH size and PFMC strength. Therefore improvement to pelvic floor strength cannot be interpreted and measurements cannot be compared with others unless the LH size is known or digital examination is carried out.

Randomized controlled trial for improved recovery of the pelvic floor after vaginal delivery with a specially formulated postpartum supplement

Objective

To improve pelvic floor recovery after vaginal delivery with daily supplementation of a specially formulated postpartum recovery supplement.

Methods

Within 48 hours of vaginal delivery, primipara women were randomized in a 1:1 ratio to receive daily oral supplementation for 6 weeks with either a combination of regular prenatal vitamin (PNV), leucine (4 g/day), zinc (30 mg/day) and omega-3 fatty acid (900 mg/day) (treatment group), or only a PNV daily (control group). Co-primary outcomes were vaginal squeeze pressure as measured by perineometer and levator muscle injury as measured by transperineal 3-dimensional tomographic ultrasound at 6 weeks postpartum.

Results

Twenty-six women in the control group and 27 in the treatment group completed the trial. Weak pelvic floor muscle strength was significantly less frequent in the treatment group compared to the control group at 6 weeks after delivery (28% vs. 58%, P=0.03). Both right and left-sided levator-urethra gap was significantly larger in the control group compared to the treatment group indicating more levator injury being present in the control group at 6 weeks after delivery. Anterior vaginal wall prolapse at or beyond the hymenal ring was significantly more common in the control group compared to the treatment group (19% vs. 0%, P=0.02). Significantly more women reported bothersome bulge symptoms in the control group compared to the treatment group at 6 weeks postpartum (19% vs. 0%, P=0.02).

Conclusion

Postpartum women who received a specially formulated postpartum recovery supplement had improved recovery of the pelvic floor after vaginal delivery.

Are there differences in short-term pelvic floor muscle function after cesarean section or vaginal delivery in primiparous women? A systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

The literature presents controversial results regarding the role of delivery mode in pelvic floor muscle (PFM) function after birth. Some studies showed a greater impairment of PFM function after vaginal delivery compared with cesarean section, while others have not identified a significant difference between these two modes of delivery. This study aimed to investigate whether there was a difference in short-term PFM function after childbirth in primiparous women who underwent cesarean section compared with those who underwent vaginal delivery.

METHODS

Up to December 2018, the PubMed-MEDLINE, CINAHL, Embase, Bireme, Scopus, Web of Science, and Science Direct databases were searched. Two independent reviewers performed the selection process based on titles, abstracts, and full-text reading. Observational studies comparing PFM function after cesarean section versus vaginal delivery in primiparous women were included. PRISMA guidelines and Cochrane recommendations were followed. Methodological quality of the primary studies was assessed through the checklist proposed by the Joanna Briggs Institute for cross-sectional studies. Random effects meta-analysis was performed to synthesize evidence regarding PFM strength in primiparous woman after vaginal delivery compared with cesarean section. The GRADE approach was applied to classify the quality of the evidence.

RESULTS

Eleven studies met the inclusion criteria and were included in this review. A total of 1726 primiparous women were analyzed after childbirth. Five studies were included in the meta-analysis. No difference in PFM strength after childbirth was identified when cesarean section was compared with vaginal delivery [standardized mean difference (SMD): -0.15, 95% confidence interval (CI): -0.85 to 0.56]. Differences in PFM strength were identified when patients who underwent cesarean section were compared with those with an episiotomy or instrumented vaginal delivery (SMD: -12.51, CI 95%: -24.57 to -0.44), favoring the cesarean section group. In both cases, the quality of evidence was classified as very low because of the observational design of the included studies and population heterogeneity.

CONCLUSION

There was no difference in short-term PFM strength after childbirth between primiparous women who underwent cesarean section or vaginal delivery, as assessed through vaginal manometry. However, we identified reduced PFM strength in women who underwent an episiotomy or instrumented vaginal delivery compared with those who underwent cesarean section. Nevertheless, this conclusion should be cautiously considered as the observational design of the primary studies and possible heterogeneity among the primiparous women included in the studies contributed to reducing the quality of the evidence synthesized. Future primary studies with longitudinal designs and long-term follow-up periods are needed to strengthen the quality of evidence and provide more conclusive evidence to guide clinical practice.

Pelvic floor dysfunction in the immediate puerperium, and 1 and 3 months after vaginal or cesarean delivery

OBJECTIVE

To identify and assess postpartum pelvic floor dysfunction (PFD) between vaginal delivery, elective cesarean delivery (ECD), and intrapartum cesarean delivery (ICD).

METHODS

The present prospective observational study included women aged at least 18 years with no history of pelvic surgery or lower urinary tract malformation, and who had not undergone pelvic floor muscle (PFM) training in the preceding 12 months, who underwent delivery at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil between August 1, 2016, and May 31, 2017. Participants were assessed at 48 hours (phase 1), 1 month (phase 2), and 3 months (phase 3) after delivery. Assessments included the International Consultation on Incontinence Questionnaire, Short Form (ICIQ-SF); the Jorge-Wexner anal incontinence scale; a self-rated visual analog scale for pelvic pain; the pelvic organ prolapse quantification (POP-Q) system; and a PFM perineometer.

RESULTS

A total of 227 women were assessed in phase 1 (141 vaginal deliveries; 28 ICDs; and 58 ECDs), 79 in phase 2, and 41 in phase 3. The ICIQ-SF, Jorge-Wexner scale, visual analog scale, and perineometer measurements did not identify significant differences in relation to the type of delivery (P>0.05).

CONCLUSION

The type of delivery was not associated with differences in the short-term development of postpartum PFD.