What is to blame for postnatal pelvic floor dysfunction in primiparous women—Pre-pregnancy or intrapartum risk factors?

Pelvic floor dysfunction in postpartum women: A cross-sectional study

BACKGROUND

Pelvic floor dysfunction (PFD) is a disease of weakened pelvic floor support tissues, leading to changes in the pelvic organ position and function of pelvic organs, with long-term effects on women. This study aimed to assess pelvic floor function using electrophysiology and clinical symptoms, exploring the risk factors for PFD one month postpartum.

METHODS

This cross-sectional study included 845 women from postpartum outpatient clinic of Nantong Affiliated Hospital from August 2019 to October 2021. Pelvic floor muscle strength was evaluated via pelvic floor surface electromyography. Clinical symptoms (urinary incontinence (UI) and pelvic organ prolapse) were diagnosed by gynecologists. Sociodemographic, pregnancy, and obstetrical data were obtained from self-reported questionnaires and electronic records.

RESULTS

The study identified maternal age, parity, immigrant status, and economic income as factors were related to PFD. Gestational constipation increased the risk of abnormal resting muscle strength (OR:1.553, 95%CI: 1.022-2.359). Cesarean delivery was associated with higher rates of abnormal resting muscle strength than vaginal delivery (post-resting stage: OR, 2.712; 95% CI, 1.189-6.185), but a decreased incidence of UI (OR: 0.302; 95% CI, 0.117-0.782). Increased gestational weight gain was correlated with a greater risk of developing UI (OR:1.030, 95%CI: 1.002-1.058). Women with vaginal inflammation faced a higher risk of abnormal fast-twitch muscle (OR: 2.311, 95%CI: 1.125-4.748).

CONCLUSIONS

In addition to uncontrollable factors like mode of delivery, age, and parity, interventions targeting weight gain and constipation during pregnancy and vaginal flora could mitigate the risks of PFD. Educational programs for pregnant women should emphasize a proper diet and lifestyle. For women with vaginal inflammation, clinical treatment should be carried out as soon as possible to avoid further aggravating the damage to the pelvic floor muscles.

Acupuncture combined with pelvic floor rehabilitation training for postpartum stress urinary incontinence: protocol for a systematic review and meta-analysis

Introduction

The purpose of this study is to systematically evaluate the efficacy and safety of acupuncture combined with pelvic floor rehabilitation training in the treatment of postpartum stress urinary incontinence, and to promote the further promotion and application of acupuncture in the field of rehabilitation.

Methods and analysis

Randomized controlled trials (RCTs) of acupuncture combined with pelvic floor rehabilitation in the treatment of postpartum stress urinary incontinence will be searched in PubMed, Web of Science (WOS), Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang (WF), and VIP databases. The clinical trial Registry (ClinicalTrials.gov and Chinese clinical trial Registry) will also be searched. The search period is limited to July 1, 2023, and the language limit of this systematic review is Chinese and English. The primary outcome is clinical effective rate. International Consultation on Incontinence Questionnaire-Short Form (ICI-Q-SF), 1-h pad test, pelvic floor muscle potential value, incidence of adverse events are secondary outcomes. A meta-analysis will be performed using RevMan 5.4 statistical software. If feasible, subgroup analysis and sensitivity analysis will be performed to address potential causes of inconsistency and heterogeneity. The risk of bias will be assessed using the approach recommended by Cochrane Handbook for Systematic Reviews of Interventions, and the quality of evidence will be assessed using GRADE. This Protocol has been developed in accordance with the guideline of Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015.

Discussion

Acupuncture combined with pelvic floor rehabilitation training can effectively promote the rehabilitation of postpartum stress urinary incontinence patients, and provide a reference for the clinical application of integrated Chinese and Western medicine treatment in the field of rehabilitation.

Systematic review registration

PROSPERO CRD42023455801.

Assessment of defecation disorders using high-resolution MRI-defecography

AIMS

The aim of this retrospective study was to try to find correlations between different diagnoses established by clinical examination, anorectal manometry and MRI-defecography and, the association with psychiatric disorders.

METHODS

44 patients (median age 53.81 years) presenting with intestinal motility disorders and who underwent clinical, biological and psychiatric examination, dynamic defecographic-MRI (resting, squeezing, straining, defecation and evacuation phases), anorectal manometry, colonoscopy. MRI was performed using the 1,5 T.

RESULTS

MRI-defecography revealed the following changes: anismus (16), rectocele (12), pelvic floor dysfunction (6), peritoneocele (2), cervical-cystic-ptosis (1), rectal prolapse (6), and in 1 case the examination was normal. Hypertonic anal sphincter (16) and lack of defecation reflex (12) at anorectal manometry correlated with anismus in all patients at MRI-defecography. Lack of inhibitor anal reflex (6) was associated with rectocele (4), cervix-cysto-ptosis (1) and peritoneocele (2). Anxiety (11), depression (6) and anxiety-depressive disorders (10) were found in 27/44, somatization disorders in 9/44 and no psychiatric changes in 8/44 cases.

CONCLUSION

As multiparous women are at risk for outlet obstruction constipation, MRI-defecography is suggested in this category. There is good correlation between diagnosis using anorectal manometry and MRI-defecography in patients with terminal constipation and anismus. Lower defecation dysfunction is often associated with psychiatric disorders.

Educating Women About Pelvic Floor Disorders During Pregnancy From the First to the "Fourth Trimester": A Randomized Clinical Trial

IMPORTANCE

Pregnancy and childbirth are risk factors for developing pelvic floor disorders (PFDs), and this continues postpartum ("fourth trimester"). Knowledge of PFDs among women of childbearing age is lacking and presents an opportunity for education.

OBJECTIVES

The aim of this study was to compare the increase in knowledge of PFDs in patients who received written handouts versus interactive workshops as measured by the Prolapse and Incontinence Knowledge Questionnaire (PIKQ).

STUDY DESIGN

This was a randomized clinical trial of pregnant patients 18 years or older. Patients either received written handouts only or received handouts and attended an interactive workshop. Handouts were created in collaboration with communication specialists focusing on risk factors and prevention strategies. The primary outcome was the change in PIKQ score. Secondary outcomes were Pelvic Floor Distress Inventory score and postpartum phone interviews of workshop group participants. Questionnaires were assessed at recruitment and 6 weeks postpartum. The nonparametric Wilcoxon test compared continuous variables, and the Fisher exact test compared categorical variables.

RESULTS

One hundred twenty patients were randomized. Demographics were similar between groups. Median PIKQ score change showed no difference between groups (P = 0.37). Pelvic Floor Distress Inventory-20 scores were similar between groups at baseline (P = 0.78) and postpartum (P = 0.82). Quantile regression showed posteducation PIKQ scores were significantly higher in the workshop (21.00 vs 17.00; P = 0.011) and written (21.00 vs 17.00; P < 0.001) groups. Phone interviews showed consistent themes: (1) greater awareness of PFDs, (2) more likely to discuss PFDs, and (3) relief that PFDs are treatable. Fifty-nine percent of patients preferred learning through workshops compared with the handouts.

CONCLUSIONS

Both groups showed improvement in knowledge of PFDs. Well-written, illustrated handouts were effective in increasing patient knowledge of PFDs.

Comparison of High Uterosacral and Sacrospinous Ligament Suspension Surgeries for the Treatment of Pelvic Organ Prolapse in Women

Background

Pelvic floor disorders include urinary incontinence, fecal incontinence, and pelvic floor prolapse, which are common complaints in women. Patients that suffer from uterine prolapse could benefit from surgical procedures that stabilize pelvic ligaments. Here, we aimed to compare the high uterosacral and sacrospinous ligament suspension surgeries.

Materials and Methods

This clinical trial was performed in 2019-2021 on 64 women with uterine prolapse. Demographic data of the patients, including age, body mass index (BMI), past medical diseases, history of delivery, type of delivery, and duration of hospitalization, were collected. We assessed their urinary symptoms, prolapse degree, and sexual symptoms using the Female Sexual Function Index (FSFI) and Pelvic Floor Disability Index (PFDI-20) questionnaires before surgical interventions. Patients were divided into two groups undergoing high uterosacral and sacrospinous ligament suspension. They were followed up 6 and 12 months after surgeries.

Results

Patients treated with sacrospinous ligament suspension had higher frequencies of surgical complications (P = 0.039), and the most common complication was low back pain (15.6%). The uterine prolapse andC point degree improved significantly in all cases after 6 and 12 months (P < 0.001). The Pelvic Organ Prolapse Quantifications System (POP-Q) scores improved significantly in both groups 6 and 12 months after surgery (P < 0.001), and patients who underwent sacrospinous ligament suspension had significantly lower pain intensity compared to the other group (P = 0.003). FSFI scores improved significantly in patients treated in both groups (P < 0.001).

Conclusion

Both high uterosacral and sacrospinous ligament suspension techniques significantly improved pain, uterine prolapse, and C point degree.

Prevalence and Severity of Pelvic Floor Disorders during Pregnancy: Does the Trimester Make a Difference?

(1) Background: Women experience pelvic floor dysfunction symptoms during pregnancy. This study is the first to investigate and compare variances in the prevalence and severity of pelvic floor symptoms between trimesters using a valid pregnancy-targeted questionnaire. (2) Methods: A retrospective cohort study was conducted between August 2020 to January 2021 at two university-affiliated tertiary medical centers. Pregnant women (n = 306) anonymously completed the Pelvic Floor Questionnaire for Pregnancy and Postpartum with its four domains (bladder, bowel, prolapse, and sexual). (3) Results: Thirty-six women (11.7%) were in the 1st trimester, eighty-three (27.1%) were in the 2nd trimester, and one hundred and eighty-seven (61.1%) were in the 3rd trimester. The groups were similar in age, pregestational weight, and smoking habits. A total of 104 (34%) had bladder dysfunction, 112 (36.3%) had bowel dysfunction, and 132 (40.4%) reported sexual inactivity and/or sexual dysfunction. Least prevalent (33/306; 10.8%) were prolapse symptoms. Increased awareness of prolapse and significantly higher rates of nocturia and the need to use pads due to incontinence were recorded in the 3rd trimester. Sexual dysfunction or abstinence were equally distributed in all three trimesters. (4) Conclusions: Bladder and prolapse symptoms, equally frequent throughout pregnancy, significantly intensified in the 3rd trimester. Bowel and sexual symptoms, equally frequent throughout pregnancy, did not intensify in the third trimester.

Postpartum pelvic organ prolapse and pelvic floor muscle training: secondary analysis of a randomized controlled trial of primiparous women

INTRODUCTION AND HYPOTHESIS

Pelvic floor dysfunction is common after childbirth. We hypothesize that physiotherapist-guided pelvic floor muscle training (PFMT) is effective regarding pelvic organ prolapse (POP) symptoms during the first postpartum year.

METHODS

This was a secondary analysis from a randomized controlled trial (RCT), carried out at a physiotherapy clinic, Reykjavik. Participants were eighty-four primiparous women with a singleton delivery. They were screened for eligibility 6-13 weeks postpartum. Women in a training group conducted 12 weekly individual sessions with a physiotherapist within an RCT, starting on average 9 weeks postpartum. Outcomes were assessed after the last session (short term) and at approximately 12 months postpartum (long term). The control group received no instructions after the initial assessment. Main outcome measures were self-evaluated POP symptoms by the Australian Pelvic Floor Questionnaire.

RESULTS

Forty-one and 43 women were in the training and control groups, respectively. At recruitment, 17 (42.5%) of the training group and 15 (37%) of the control group reported prolapse symptoms (p = 0.6). Five (13%) from the training group and nine (21%) controls were bothered by the symptoms (p = 0.3). There was a gradual decrease in the number of women with symptoms and no significant short-term (p = 0.08) or long-term (p = 0.6) differences between the groups regarding rates of women with POP symptoms. The difference between groups regarding bother in the short (p = 0.3) or longer term (p = 0.4) was not significant. Repeated-measures analyses using Proc Genmod in SAS did not indicate a significant effect of the intervention over time (p > 0.05).

CONCLUSIONS

There was an overall decrease in postpartum symptoms of POP and bother during the first year. Physiotherapist-led PFMT did not change the outcomes.

CLINICAL TRIAL REGISTRATION

The trial was registered 30 March 2015 at https://register.

CLINICALTRIALS

gov (NCT02682212). Initial participant enrollment was on 16 March 2016 and reported following CONSORT guidelines for randomized controlled trials.

Pelvic floor dysfunction and its influencing factors during radiotherapy in cervical cancer survivors: A cross-sectional study

PURPOSE

Radiotherapy can negatively affect the pelvic floor function of patients with cervical cancer; however, the impact of different radiotherapy times and other related factors on pelvic floor function in cervical cancer survivors during radiotherapy remains unclear. We aimed to investigate the status of pelvic floor dysfunction (PFD) in cervical cancer survivors during radiotherapy and to analyze the factors influencing PFD.

METHODS

In this cross-sectional study, a convenience sampling method was used to recruit cervical cancer survivors undergoing radiotherapy from January 2022 to July 2022 at a tertiary first-class hospital located in northeastern China. The Pelvic Floor Distress Inventory-Short Form 20 was used for participants' self-report of their PFD during radiotherapy.

RESULTS

Data from 120 cervical cancer survivors were included in this study. The results showed that the mean PFDI-20 total score was 32.69 ± 7.76. Multiple stepwise linear regression analysis showed that 56.9% of the variance in PFD was explained by age (β = 0.25, p < 0.001), body mass index (β = 0.32, p < 0.001), recurrence (β = 0.29, p < 0.001), number of radiotherapy sessions (β = 0.39, p < 0.001), and number of deliveries (β = 0.35, p < 0.001).

CONCLUSION

It is important to pay more attention to the PFD status of cervical cancer survivors receiving radiotherapy. Future therapeutic approaches should involve early identification of relevant risk factors early to provide patients with personalized care at different stages of radiotherapy for reducing their discomfort and improving their health-related quality of life.

The "Mother Load" and Return to Sport: A Case Report of Returning to Professional Netball Following Cesarean Section

Background

Increasing numbers of elite female athletes are competing in professional sport, and many wish to become pregnant and return to competitive sport after childbirth. Athletes have a higher risk of pelvic floor dysfunction (PFD) than non-athletes (54% versus 7%) and there is also an increased prevalence in post-partum women compared to nulliparous women (35% versus 2.8-7.9%). Additionally, PFD has been shown to influence athletic performance. High quality evidence for elite athletes is lacking, and there are no exercise guidelines specifically for these women to prepare or effectively guide their safe return to sport (RTS). The purpose of this case report is to detail the management of an elite athlete who presented following cesarean section (CS) with the goal of RTS within 16 weeks.

Case Description

A 27-year-old primiparous Caucasian professional netballer presented at four weeks post- caesarean section (CS) for RTS screening and assessment of pelvic floor muscle (PFM) function. Assessment included readiness and fear of movement screening, dynamic pelvic floor muscle function, structural integrity of the CS wound, levator hiatal dimensions, bladder neck descent, and early global neuromuscular screening. Measures were collected at four weeks, eight weeks, and six months post-partum. The post-partum athlete demonstrated alterations in pelvic floor muscle function, reduced lower limb power and psychological readiness. A functionally staged dynamic and sport specific pelvic floor muscle training program was implemented and adapted to the patient for her early post-partum timeline.

Results

Rehabilitation strategies were effective in achieving the primary outcome of RTS at 16 weeks post-partum with no adverse events reported at 6 months follow-up.

Discussion

This case highlights the need for a holistic and individualised RTS management approach that includes women's and pelvic health risk factors in a professional athlete.

Level of Evidence

5.

Effects of the Oxytocin Hormone on Pelvic Floor Muscles in Pregnant Rats

Background and Objectives: Oxytocin induction is a known risk factor for pelvic floor disorders (PFDs). The aim of the study was to investigate the effects of oxytocin induction on pelvic floor muscles in pregnant rats. Methods: Thirty-two female Wistar rats were included and divided into four groups (n = 8). The groups were as follows: virgin group (group I)-from which muscles were dissected at the beginning of the experiment; spontaneous vaginal delivery (group II) which has delivery spontaneously; saline control group (group III) and oxytocin group (group IV). In groups III and IV, pregnancy was induced on d 21 of pregnancy, with 2.5 mU saline solution or iv oxytocin, respectively, delivered by the intravenous (iv) route in pulses at 10-min intervals for 8 h. Then, the rats were euthanized, the m. coccygeus, m. iliocaudalis and m. pubocaudalis muscles were excised and tissue samples were taken. After histological processing, the vertical and horizontal dimensions of the muscles were analyzed under a light microscope. Results: In group IV; the measurement of the horizontal dimension of the m. pubocaudalis muscles was 50.1 ± 5.4 µm and it was significantly higher than other groups (p < 0.001). In group III; the mean value of the horizontal dimension of m. coccygeus muscle was found to be 49.5 ± 10.9 µm and it was significantly higher than other groups (p < 0.009). Between-group comparisons revealed no difference in mean m. iliocaudalis muscle dimension (p > 0.05). Conclusions: As a result of our study it can say that whether oxytocin induced or not, vaginal birth is a process that affects the pelvic muscles.

Prevention and treatment of peripartum urinary incontinence-a survey of hospital-based maternity services in Ireland

INTRODUCTION AND HYPOTHESIS

Considerable proportions of pregnant and postpartum women experience urinary incontinence, but to our knowledge, there are no national data on the preventative and treatment services available in Ireland's 19 maternity hospitals.

METHODS

Ethical approval was granted. A national benchmarking survey on the range and type of services on prevention and treatment of urinary incontinence during pregnancy and postpartum was developed. Directors of Midwifery and Nursing in each hospital identified midwives and women's health physiotherapists to complete the survey. Data were analysed descriptively, and results presented as proportions.

RESULTS

Responses were received from 17 hospitals. Women were asked about urinary incontinence during their first booking visit in 6 hospitals, during all antenatal visits in 2 and the onus was on women self-reporting symptoms in 9. Pelvic floor muscle exercises were taught in antenatal classes in 14 hospitals and management of urinary incontinence in 9. In hospital postpartum, midwives in 13 hospitals asked women about urinary incontinence. All women were seen by a physiotherapist in 7 hospitals and only those who were referred in 6. Women could access the hospital's physiotherapy services up to 6 weeks postpartum in 3 hospitals, up to 6 months or 1 year in 5 and beyond 1 year in 6.

CONCLUSIONS

Geographical inequity exists in the services offered to pregnant and postpartum women nationally. This indicates that many pregnant and postpartum women, both continent and incontinent, cannot avail themselves of preventative and treatment services within the maternity hospital system and points to the need to review, reconfigure and resource services.

Reducing pelvic floor injury by induction of labor

INTRODUCTION AND HYPOTHESIS

We hypothesized that elective induction of labor (eIOL) at 39 weeks is protective of levator ani muscle injury (LAMI) and is associated with decreased pelvic symptoms at 6 weeks postpartum compared to expectant management of labor.

METHODS

Prospective cohort pilot study of uncomplicated, primiparous women with a singleton, vertex gestation enrolled immediately post-vaginal delivery (VD). Subjects were dichotomized into two groups based on labor management: eIOL without complication defined by the ARRIVE trial versus spontaneous VD between 39 weeks0/7 and 42 weeks5/7 or no indication for IOL prior to 40 weeks5/7. The primary outcome was LAMI at 6 weeks postpartum as evidenced by any of the following ultrasound measures: (1) increased levator hiatal area (LHA) > 2500 mm2, (2) increased elasticity index (EI, > 75th quartile) or (3) levator enthesis avulsion.

RESULTS

Analysis represents 45/102 consented women from July 2019-October 2020 (eIOL n = 22 and spontaneous VD, n = 23). Neither maternal, clinical, sociodemographic characteristics nor pelvic symptoms differed between groups. Fewer women had LAMI as defined by the primary outcome with eIOL (n = 5, 23.8%) compared to spontaneous VD (n = 15, 65.2%), p = 0.008. Levator enthesis was more deformable (increased EI) with spontaneous VD as compared to the eIOL [10.66 (8.99) vs. 5.68 (2.93), p = 0.046]. On univariate logistic regression women undergoing spontaneous VD had unadjusted OR of 6.0 (1.6-22.5, p = 0.008) of sustaining LAMI compared to those undergoing eIOL.

CONCLUSIONS

Composite measures of LAMI though not pelvic floor symptoms were markedly increased in women undergoing spontaneous VD compared to those undergoing eIOL at 39 weeks.

Three-dimensional ultrasound assessment of risk factors for cystocele and Green classification in primipara

BACKGROUND AND AIMS

The present study aimed to analyze the effects of factors on cystocele and the Green classification.

MATERIALS AND METHODS

We conducted a cross-sectional study on 357 primiparous women examined at our hospital from January 2019 to May 2021. The following data were recorded: maternal characteristics, neonatal characteristics, and factors of childbirth. It was added to the multivariate logistic regression model to determine the independent predictors of the cystocele and the Green classification.

RESULTS

A total of 242 women had cystocele, including 71 women with Green type I cystocele, 134 women with Green type II cystocele, and 37 women with Green type III cystocele. In multivariate logistic regression analysis, body mass index (BMI) at delivery was associated with cystocele, while BMI at delivery and the second stage of labor (SSL) > 1 h were independently with the distance from the symphysis pubis to the bladder neck (SPBN) abnormal (P < 0.05). BMI at examination was associated with the large retrovesical angle (RVA) (P < 0.05). BMI at delivery and the fetal right occiput anterior position (ROA) were independently associated with the distance from the symphysis pubis to the posterior wall of the bladder (SPBP) abnormal (P < 0.05), while epidural anesthesia (EDA) was the protective factor (P < 0.05).

CONCLUSION

Primipara women should strive to avoid exposure to modifiable risk factors such as controlling weight during pregnancy, reducing weight after delivery, and shortening SSL to reduce the occurrence of cystocele.

Planned mode of birth after previous cesarean section and risk of undergoing pelvic floor surgery: A Scottish population-based record linkage cohort study

BACKGROUND

The global rise in cesarean sections has led to increasing numbers of pregnant women with a history of previous cesarean section. Policy in many high-income settings supports offering these women a choice between planned elective repeat cesarean section (ERCS) or planned vaginal birth after previous cesarean (VBAC), in the absence of contraindications to VBAC. Despite the potential for this choice to affect women's subsequent risk of experiencing pelvic floor disorders, evidence on the associated effects to fully counsel women is lacking. This study investigated the association between planned mode of birth after previous cesarean section and the woman's subsequent risk of undergoing pelvic floor surgery.

METHODS AND FINDINGS

A population-based cohort study of 47,414 singleton term births in Scotland between 1983 to 1996 to women with 1 or more previous cesarean sections was conducted using linked Scottish national routine datasets. Cox regression was used to investigate the association between planned as well as actual mode of birth and women's subsequent risk of having any pelvic floor surgery and specific types of pelvic floor surgery adjusted for sociodemographic, maternal medical, and obstetric-related factors. Over a median of 22.1 years of follow-up, 1,159 (2.44%) of the study population had pelvic floor surgery. The crude incidence rate of any pelvic floor surgery per 1,000 person-years was 1.35, 95% confidence interval (CI) 1.27 to 1.43 in the overall study population, 1.75, 95% CI 1.64 to 1.86 in the planned VBAC group and 0.66, 95% CI 0.57 to 0.75 in the ERCS group. Planned VBAC compared to ERCS was associated with a greater than 2-fold increased risk of the woman undergoing any pelvic floor surgery (adjusted hazard ratio [aHR] 2.38, 95% CI 2.03 to 2.80, p < 0.001) and a 2- to 3-fold increased risk of the woman having surgery for pelvic organ prolapse or urinary incontinence (aHR 3.17, 95% CI 2.47 to 4.09, p < 0.001 and aHR 2.26, 95% CI 1.79 to 2.84, p < 0.001, respectively). Analysis by actual mode of birth showed these increased risks were only apparent in the women who actually had a VBAC, with the women who needed an in-labor non-elective repeat cesarean section having a comparable risk of pelvic floor surgery to those who had an ERCS. The main limitation of this study is the potential for misclassification bias.

CONCLUSIONS

This study suggests that among women with previous cesarean section giving birth to a singleton at term, planned VBAC compared to ERCS is associated with an increased risk of the woman subsequently undergoing pelvic floor surgery including surgery for pelvic organ prolapse and urinary incontinence. However, these risks appear to be only apparent in women who actually give birth vaginally as planned, highlighting the role of vaginal birth rather than labor in pelvic floor dysfunction requiring surgery. The findings provide useful additional information to counsel women with previous cesarean section about the risks and benefits associated with their future birth choices.

Urinary and anal incontinence among female gymnasts and cheerleaders-bother and associated factors. A cross-sectional study

INTRODUCTION AND HYPOTHESIS

Artistic gymnastics, team gymnastics and cheerleading are sports including high-impact activities. It is presumed that the athletes' pelvic floor must be functioning well to prevent urinary (UI) and anal incontinence (AI) during sports. The aim of this study was to investigate the prevalence and risk factors for UI and AI in female artistic gymnasts, team gymnasts and cheerleaders; the influence of UI and AI on daily living and sport performance; and the athletes' knowledge about the pelvic floor muscles (PFM).

METHODS

All female athletes ≥ 12 years of age competing in ≥ 1 National Championship in artistic gymnastics, team gymnastics or cheerleading in 2018/2019 were invited. International Consensus on Incontinence Questionnaires were used to assess the prevalence/bother of UI and AI.

RESULTS

Among the 319 gymnasts and cheerleaders who participated, the prevalence of UI and AI was 67% and 84%, respectively. Age, training ≥ 4 days/week and straining to void were significantly associated with stress urinary incontinence (SUI) and years of training with AI. Eighty-three percent of athletes with SUI reported a negative effect on sports performance, 22% would occasionally avoid training or specific exercises because of leakage, and 28% used pads for protection. Forty-one percent of the athletes had never heard about the PFM, and 74% reported an interest in PFM training to prevent/treat UI or AI.

CONCLUSIONS

UI and AI were prevalent in female gymnasts and cheerleaders, and SUI negatively influenced sport performance. The athletes' knowledge about the PFM was limited.

Risk factors for postoperative pelvic floor dysfunction in patients with cervical cancer: evidences for management strategies

Background

It’s necessary to evaluate the potential risk factors for postoperative pelvic floor dysfunction (PFD) in patients with cervical cancer, to provide insights into the treatment and nursing care of cervical cancer.

Methods

Our study was a case-control study design. Patients who underwent radical cervical cancer surgery in our hospital from January 2018 to January 2020 were included. We selected the patients with benign uterine lesions after hysterectomy at the same time as the control group. The patient characteristics of two groups were retrospectively compared and analyzed. Multiple logistic regression analyses were conducted to identify the potential risk factors.

Results

A total of 247 patients were included. The duration of surgery, estimated blood loss, duration of urinary catheter, and length of hospital stay in cervical cancer group were significantly more than that of control group (all P<0.05). The incidence of postoperative PFD was 63.93%. There were significant differences in the age, postoperative constipation, number of deliveries, duration of urinary catheter between PFD and no PFD patients (all P<0.05). Age ≥45y (OR 4.39, 1.05–9.83), duration of urinary catheter ≥7d (OR 4.31, 1.22–8.05), postoperative constipation (OR 3.17, 1.07–5.89) and number of deliveries ≥2 (OR 2.75, 1.22–5.43) were the risk factors for postoperative PFD in patients with cervical cancer.

Conclusions

Early measures targeted on those risk factors should be implemented for the prophylaxis of PFD.

Pelvic floor dysfunction after vaginal delivery: MOODS-a prospective study

INTRODUCTION AND HYPOTHESIS

Labor is a known risk factor for pelvic floor dysfunction (PFD); however, the impact of operative vaginal delivery (OVD), particularly spatulas, remains unclear. The aim of this study was to compare postpartum PFD symptoms in women undergoing spontaneous vaginal delivery (SVD) and those undergoing OVD.

METHODS

An observational prospective study (MOODS: Maternal-neonatal Outcomes in Operative Vaginal Delivery) was enrolled at Hospital de Braga from February to October 2018. All singleton term OVD (Thierry spatulas and vacuum extractor) and a convenience SVD sample were recruited, in a 2:1 ratio. To assess PFD symptoms Pelvic Floor Distress Inventory-20 (PFDI-20) was applied at 3, 6, and 12 months postpartum. The questionnaire is divided into three subscales: Urinary (UDI), Colorectal-Anal (CRADI), and Pelvic Organ Prolapse Distress Inventory (POPDI).

RESULTS

Of the 304 women recruited, 207 were included, 34.3% with SVD and 65.7% with OVD. Thierry spatulas were used in 53.7% of women undergoing OVD. Frequency of nulliparous (p < 0.001), episiotomy (p < 0.001), neuraxial anesthesia (p < 0.001), postpartum pain (p = 0.001) and occiput-posterior fetal position (p < 0.001) were significantly higher in OVD. Second phase of labor duration was longer in OVD (p = 0.001). At 3 months postpartum, women undergoing OVD and spatula-assisted delivery had higher UDI score, POPDI score, and global score, with no differences at 6 months and 1 year. After controlling for confounding variables, OVD and spatulas were still associated with greater POPDI scores at 3 months postpartum.

CONCLUSIONS

Operative vaginal delivery, particularly with spatulas, seems to be associated with a higher prevalence of early PFD symptoms, mainly regarding pelvic organ prolapse.

Effect of Epidural Analgesia on Pelvic Floor Dysfunction at 6 Months Postpartum in Primiparous Women: A Prospective Cohort Study

INTRODUCTION

Epidural analgesia has become a universal intervention for relieving labor pain, and its effect on the pelvic floor is controversial.

AIM

To investigate the effect of epidural analgesia on pelvic floor dysfunction (PFD) in primiparous women at 6 months postpartum.

METHODS

We performed a prospective cohort study involving 150 primiparous women in preparation for vaginal delivery, with 74 (49.3%) receiving epidural analgesia. Baseline demographic and intrapartum data were collected. At 6 months postpartum, PFD symptoms, including stress urinary incontinence, overactive bladder, defecation disorder, pelvic organ prolapse, and 4 kinds of sexual dysfunction (arousal disorder, low sexual desire, dyspareunia, and orgasm disorder), were evaluated. Pelvic floor muscle (PFM) function and postpartum depression were also assessed. Multivariate logistic regression was applied to identify factors associated with the PFD symptoms affected by epidural analgesia.

MAIN OUTCOME MEASURE

PFD symptoms and sexual dysfunction were evaluated through Pelvic Floor Distress Inventory-20 (PFDI-20) and Female Sexual Function Index (FSFI-12). PFM function was examined with palpation and surface electromyography (sEMG). Postpartum depression was assessed using Self-Rating Depression Scale (SDS).

RESULTS

At 6 months postpartum, women who delivered with epidural analgesia had a higher incidence of dyspareunia (43.2% vs 26.3%, P <0.05) and longer first, second, and total stage of labor durations (P <0.01) than those who without. No significant difference in other PFD symptoms or PFM function was found between the 2 groups (P >0.05). Multivariate logistic regression revealed that epidural analgesia (OR = 3.056, 95% CI = 1.217-7.671) and SDS scores (OR = 1.066, 95% CI = 1.009-1.127) were independent risk factors for dyspareunia.

CONCLUSION

At 6 months postpartum in primiparous women, epidural analgesia was associated with an increased risk of postpartum dyspareunia and longer labor durations, which deserves attention for rehabilitation after delivery. Future studies with a larger sample size are needed to evaluate the impact of epidural analgesia on other PFD symptoms. Du J, Ye J, Fei H, et al. Effect of Epidural Analgesia on Pelvic Floor Dysfunction at 6 Months Postpartum in Primiparous Women: A Prospective Cohort Study. Sex Med 2021;9:100417.

Habitus and Pelvic Floor Symptoms and Support 1 Year Postpartum

OBJECTIVE

To estimate the association between habitus measures and pelvic floor support and symptoms in primiparous women 1 year after term vaginal delivery.

METHODS

In this cross-sectional study including women enrolled at seven academic and community sites, we assessed pelvic floor support, weight, height, waist circumference, and percent fat using air displacement plethysmography and participants completed questionnaires, all at one year postpartum. We tested the association of quintiles of habitus measure, including body mass index (BMI), waist circumference, percent body fat, and waist/height ratio, with the primary outcomes: anatomic support, dichotomized as maximal vaginal descent less than 0 cm (better support) compared with 0 cm or more (worse support) per the pelvic organ prolapse quantification examination and symptom burden (positive with bothersome symptoms in two or more of six symptom domains), and on five secondary outcomes. The sample size provides 90% power to detect odds ratios (ORs) of 1.78 or greater between women at mean compared with mean+1 SD of habitus measure.

RESULTS

Of 592 participants, 55 (9.3%) demonstrated worse support and 321 (54.2%) symptom burden. In multivariable analyses, habitus measures were not significantly associated with anatomic support or, except for the highest waist/height ratio quintile, with symptom burden. Compared with women in the first quintile of each habitus measure, those in most higher quintiles demonstrated elevated odds of moderate to severe urinary incontinence (UI); increased odds for stress urinary incontinence (SUI) were mainly limited to the highest quintile. After adjusting for percent body fat, the increased odds for BMI on SUI (OR 2.47, 95% CI 1.43-4.28) were no longer significant (OR 1.38, 95% CI 0.54, 3.51).

CONCLUSION

Habitus in primiparous patients at 1 year postpartum was not associated with anatomic support or symptom burden. Habitus was more associated with moderate to severe UI than mild UI. The association of higher BMI with SUI was attenuated by fitness, reflected by fat percentage.

Trajectories of Pelvic Floor Symptoms and Support After Vaginal Delivery in Primiparous Women Between Third Trimester and 1 Year Postpartum

OBJECTIVES

The objectives of this study were to describe trajectories of pelvic floor symptoms and support from the third trimester to 1 year postpartum in primiparous women after vaginal delivery and to explore factors associated with their resolution between 8 weeks postpartum and 1 year postpartum.

METHODS

Five hundred ninety-seven nulliparous women 18 years or older who gave birth vaginally at term completed the Epidemiology of Prolapse and Incontinence Questionnaire and the Pelvic Organ Prolapse Quantification examination at the third trimester, 8 weeks postpartum, and 1 year postpartum.

RESULTS

At 1 year postpartum, 41%, 32%, and 23% of participants reported stress urinary incontinence, nocturia, and flatus incontinence, respectively, and 9% demonstrated maximal vaginal descent (MVD) ≥ 0 cm. For more common symptoms, incidence rates between the third trimester and 8 weeks postpartum ranged from 6% for urinary frequency to 22% for difficult bowel movements, and resolution rates between 8 weeks postpartum and 1 year postpartum ranged from 23% for stress urinary incontinence to 73% for pain. Between the third trimester and 8 weeks postpartum, 13% demonstrated de novo MVD ≥ 0 cm. For most symptoms, the presence of the same symptom before delivery decreased the probability of resolution between 8 weeks postpartum and 1 year. However, the sensitivities of predelivery vaginal bulge and MVD of 0 cm or greater for those outcomes at 1 year postpartum was overall low (10-12%).

CONCLUSIONS

One year postpartum, urinary and bowel symptoms are common in primiparous women who gave birth vaginally. A substantial portion of this burden is represented by symptoms present before delivery, while most of the prevalence of worse anatomic support is accounted for by de novo changes after delivery.

Postpartum voiding dysfunction following vaginal versus caesarean delivery

In this prospective study, we evaluated postpartum voiding dysfunction stratified by mode of delivery - vaginal delivery versus elective caesarean delivery (CD). We recruited nulliparous women carrying singleton gestation at term admitted to delivery room or elective CD. Pre-labour voiding function was assessed by recording the post-voiding residual volume (PVRV) using a bladder scan. PVRV evaluation was repeated at least 12 hours following delivery and before discharge. PVRVs were considered abnormal if ≥150 mL. PVRVs were compared between vaginal and CD. Overall, 54 women were included. Of them, 34 (63%) delivered vaginally and 20 (37%) had an elective CD. Postpartum mean PVRVs were significantly higher compared to pre-labour PVRVs (215 vs. 133 mL, p<.001). Abnormal postpartum PVRV was significantly higher in vaginal delivery compared to CD (73.5% vs. 45%, p<.05). In conclusion, delivery adversely affects voiding function. Vaginal delivery is associated with more severe voiding dysfunction compared to elective CD.Impact StatementWhat is already known on this subject? Delivery is associated with voiding dysfunction. While most studies on postpartum voiding dysfunction were related to vaginal delivery, little is known on the effect of mode of delivery (vaginal versus caesarean delivery (CD)) on voiding dysfunction.What the results of this study add? In this study, we found that postpartum post-voiding residual volume is significantly higher than the pre-labour PVRV in women delivered vaginally. In addition, postpartum PVRV was significantly higher in women delivered vaginally compared to elective CD.What the implications are of these findings for clinical practice and/or further research? This study implicates that women with vaginal delivery are more prone to voiding dysfunction compared to elective CD. However, larger observational studies are warranted to confirm these results and evaluate whether this difference still exists beyond the post-partum period.

Effects of Oxytocin for Induction and Augmentation of Labor on Pelvic Floor Symptoms and Support in the Postpartum Period

OBJECTIVE

The aim of the study was to determine whether oxytocin for induction or augmentation of labor impacts the incidence or persistence of pelvic floor symptoms and support 5 to 10 weeks after first vaginal delivery.

METHODS

Participants in this prospective cohort study were nulliparous women 18 years or older that delivered vaginally at 37 weeks gestation or more and completed the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Pelvic Organ Prolapse Quantification examination in third trimester and 5 to 10 weeks postpartum. We compared the incidence and persistence of symptomatic EPIQ domains and worse vaginal support (maximal vaginal descent ≥0 cm) between women who received oxytocin with those that did not (with or without prostaglandin or mechanical methods in both groups). We performed modified binomial regression to calculate adjusted relative risks of each outcome with 95% confidence intervals.

RESULTS

The mean (SD) age of the 722 participants was 28.3 (5.2) years; 20% were Hispanic. There were no significant differences according to oxytocin exposure in either incidence or persistence of symptomatic EPIQ domains or worse vaginal support. We found similar results in sensitivity analyses comparing women who received oxytocin as the sole pharmacologic agent to women who received no pharmacologic agent. After adjusting for demographic and obstetric factors associated with incidence and persistence of symptoms and support, oxytocin exposure continued to have no effect.

CONCLUSIONS

Oxytocin during labor does not significantly increase the risks for the incidence or persistence of pelvic floor symptoms or worse vaginal support in the early postpartum period, although power for less frequent outcomes was limited.

What Does Your Pelvic Floor Do for You? Knowledge of the Pelvic Floor in Female University Students: A Cross-sectional Study

OBJECTIVES

To assess the knowledge of the pelvic floor in female university students, including knowledge of pelvic floor structure, function, pelvic floor dysfunction, and pelvic floor muscle exercises (PFMEs).

METHODS

The study design is a cross-sectional study via online questionnaire with convenience sampling of female students registered at University College Cork, Ireland for the academic year 2018 to 2019. An online questionnaire was distributed to students at their registered email addresses. Overall knowledge was assessed through 15 questions, looking at pelvic floor structure, function, pelvic floor dysfunction and PFMEs. A score of 1 was allocated to each correct question, with a maximum possible score of 15. Only respondents who answered all 15 questions were included in the analysis. Ethical approval was granted by the Clinical Research and Ethics Committee, Cork, Ireland, on January 4, 2019.

RESULTS

Nine hundred thirty-eight responses were received. There were 72.6% (n = 640) students who had never received information on the pelvic floor. There were 83.9% (n = 691) students who reported that they thought it was important to exercise the pelvic floor. The mean overall knowledge score of 792 respondents was 9.57 (SD, ± 2.72). There was a statistically significant difference (P < 0.001) in the overall knowledge between the students in the school of medicine and health (n = 307, mean = 11.8, SD = 2.35) and the students of other schools (n = 529, mean = 9.39, SD = 2.88).

CONCLUSIONS

Knowledge of the pelvic floor in female university students is poor. Further interventions should aim to improve knowledge of the pelvic floor and encourage correct performance of PFMEs in college students.

Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum

BACKGROUND

Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, women may be particularly vulnerable to greater pelvic floor loading.

OBJECTIVE

This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth.

STUDY DESIGN

We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression.

RESULTS

Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively. The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31-1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35-1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02-1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11-1.61) demonstrated higher prevalence of symptom burden. Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes.

CONCLUSION

Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.

Association Between Measures of Trunk Recovery 5 to 10 Weeks Postpartum and Pelvic Floor Support and Symptoms 1 Year Postpartum in Primiparas Delivered Vaginally

OBJECTIVE

To determine whether 2 aspects of trunk recovery after childbirth, intraabdominal pressure (IAP) generation and trunk flexor endurance (TFE), predict measures of pelvic floor health 1 year postpartum.

METHODS

In this prospective cohort study, we enrolled nulliparas in their third trimester and followed up those delivered vaginally for 1 year. We measured IAP while lifting a weighted car seat (IAPLIFT), IAP during TFE testing (IAPTFE), and TFE duration 5 to 10 weeks postpartum and assessed pelvic floor support and symptoms 1 year postpartum.

RESULTS

Mean age of the 624 participants was 28.7 years. At 5 to 10 weeks postpartum, mean (SD) maximal IAPLIFT and IAPTFE were 47.67 (11.13) and 51.57 (12.34) cm H2O, respectively. Median TFE duration was 126 seconds (Interquartile range, 74-211). At 1 year postpartum, 9.3% demonstrated worse support (maximal vaginal descent at or below hymen) and 54% met criteria for symptom burden (bothersome symptoms in ≥2 domains of Epidemiology of Prolapse and Incontinence Questionnaire). In multivariable models, neither IAPLIFT nor IAPTFE were associated with worse support or symptom burden (P = 0.54-1.00). Trunk flexor endurance duration increased prevalence of worse support (prevalence ratio, 1.05; 95% confidence interval, 1.01-1.08) per 60-second increase, P = 0.005) but not symptom burden (prevalence ratio, 1.00; 95% confidence interval, 0.98-1.03; P = 0.92).

CONCLUSIONS

These results provide some reassurance to early postpartum women, who are unlikely to perform routine activities that generate IAP far outside the range tested. Further research is needed to understand why women with long TFE durations have increased prevalence of worse support.

Economic evaluation of elective cesarean versus vaginal delivery on cost of future pelvic floor disorders in the United States

AIM

To analyze the cost impact of cesarean versus vaginal delivery in the United States on the development of stress urinary incontinence (SUI) and pelvic organ prolapse (POP).

METHODS

We compared average cost of delivery method to the lifetime risk and cost of pelvic floor disorders (PFDs) in women < 65 years. Costs of maternal care, obtained from the MarketScan® database, included those incurred at delivery and 3 months post-partum. Future costs of PFDs included those incurred after delivery up to 65 years. Previously reported data on the prevalence of POP and SUI following cesarean and vaginal delivery was used to calculate attributable risk. An incremental cost of illness model was used to estimate costs for SUI. Direct surgical and ambulatory care costs were used to determine cost of POP.

RESULTS

Average estimated cost was $7089 for vaginal delivery and $9905 for cesarean delivery. The absolute risks for SUI and POP were estimated as 7% and 5%, respectively, following cesarean delivery, and 13% and 14%, respectively, following vaginal delivery. For SUI, average direct cost was $5642, indirect cost was $4208, and personal cost was $750. Average direct cost of POP surgery was $4658, and nonsurgical cost was $2220. The potential savings for reduced prevalence of SUI and POP in women who underwent cesarean delivery is estimated at $1255, but they incur an additional $2816 maternal care cost over vaginal delivery.

CONCLUSIONS

Although elective cesarean is associated with reduced prevalence of PFDs, the increased initial cost of cesarean delivery does not offset future cost savings.

The Influence of Early Exercise Postpartum on Pelvic Floor Muscle Function and Prevalence of Pelvic Floor Dysfunction 12 Months Postpartum

OBJECTIVE

There is limited knowledge on how exercise impacts the pelvic floor muscles (PFM) and prevalence of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) postpartum. The purpose of this study was to investigate whether early onset of general exercise postpartum negatively affects the PFM and/or increases the risk of SUI and POP 12 months postpartum.

METHODS

This study used a prospective cohort design. At 6 weeks postpartum, 57 women classified as exercisers (exercising ≥3 times at ≥30 min/wk) were compared with 120 nonexercisers (mean age = 29 years, SD = 4.3). Manometry was used to measure vaginal resting pressure, PFM strength, and PFM endurance, and symptoms of SUI and POP were assessed using questionnaires. Data were presented as standardized beta coefficients (B) and odds ratios (OR).

RESULTS

No differences were found between exercisers (n = 57) and non-exercisers (n = 120) at 6 weeks postpartum on vaginal resting pressure (B = -0.04 [95% CI = -3.4 to 2.1]), PFM strength (B = 0.03 [95% CI = -4.7 to 7.4]), PFM endurance (B = -0.02 [95% CI = -59 to 46]), or symptoms of SUI (OR = 0.51 [95% CI = 0.25 to 1.1]) or POP (OR = 0.62 [95% CI = 0.26 to 1.5]) measured at 12 months postpartum. Adjusting for covariates, women with body mass index between 25 and 29.9 and >30 were more likely to report SUI 12 months postpartum (OR = 2.2 [95% CI = 1.0 to 4.7] and OR = 3.3 [95% CI = 1.2 to 9.4], respectively). Women with physically strenuous occupations were more likely to report POP 12 months postpartum (OR = 3.0 [95% CI = 1.2 to 7.3]).

CONCLUSIONS

This study suggests that regular exercise 6 weeks postpartum has no negative effect on PFM function or on SUI or POP. Being overweight, however, was associated with more SUI, and women with physically strenuous occupations reported more POP.

IMPACT

Results from this study suggest that first-time mothers should be encouraged to start general exercise within the first 6 weeks after giving birth. Women at risk for PFD should be advised accordingly and potentially modifiable risk factors should be addressed prior to delivery.

LAY SUMMARY

First-time mothers are encouraged to talk with a physical therapist about starting regular general exercise in the early postpartum weeks. Health care providers should advise patients on possible preventive measures for women at risk for PFD.

Risk Factors for Postpartum Stress Urinary Incontinence: a Systematic Review and Meta-analysis

Stress urinary incontinence (SUI) is a distressing symptom affecting females globally and is one of the most common complications of delivery. The etiology of female SUI is multifactorial, and the trauma caused by delivery is one of the most important risk factors for SUI. We performed a meta-analysis to determine the relationship between these various factors and postpartum SUI. We searched PubMed, Embase, Web of Science, and the Cochrane Library until January 2019 using appropriate keywords and extracted 46 eligible studies that included 73,010 participants. The study protocol was registered with PROSPERO (No. CRD42020150094). The pooled results indicated that 12 risk factors, including vaginal delivery (OR 2.08, 95% CI 1.72-2.52), advanced age at gestation (OR 1.06, 95% CI 1.04-1.08), advanced maternal BMI (OR 1.04, 95% CI 1.03-1.06), excess weight gain during pregnancy (OR 1.13, 95% CI 1.00-1.26), advanced current BMI (OR 1.32, 95% CI 1.02-1.70), diabetes (OR 1.91, 95% CI 1.53-2.38), episiotomy (OR 1.76, 95% CI 1.06-2.94), forceps delivery (OR 2.69, 95% CI 1.25-5.76), gestational UI (OR 5.04, 95% CI 2.07-12.28), gestational SUI (OR 4.28, 95% CI 2.61-7.01), prenatal UI (OR 8.54, 95% CI 3.52-20.70), and early postpartum UI (OR 3.52, 95% CI 1.61-7.69), were associated with postpartum SUI. The findings of this analysis could serve to generate risk prediction models and provide a basis for developing treatment strategies for patients with postpartum SUI.

Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence (UI) and up to one-tenth have faecal incontinence (FI) after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both preventing and treating incontinence. This is an update of a Cochrane Review previously published in 2017.

OBJECTIVES

To assess the effects of PFMT for preventing or treating urinary and faecal incontinence in pregnant or postnatal women, and summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearched journals and conference proceedings (searched 7 August 2019), and the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised or quasi-randomised trials in which one arm included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention. Populations included women who, at randomisation, were continent (PFMT for prevention) or incontinent (PFMT for treatment), and a mixed population of women who were one or the other (PFMT for prevention or treatment).

DATA COLLECTION AND ANALYSIS

We independently assessed trials for inclusion and risk of bias. We extracted data and assessed the quality of evidence using GRADE.

MAIN RESULTS

We included 46 trials involving 10,832 women from 21 countries. Overall, trials were small to moderately-sized. The PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Two participants in a study of 43 pregnant women performing PFMT for prevention of incontinence withdrew due to pelvic floor pain. No other trials reported any adverse effects of PFMT. Prevention of UI: compared with usual care, continent pregnant women performing antenatal PFMT probably have a lower risk of reporting UI in late pregnancy (62% less; risk ratio (RR) 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; moderate-quality evidence). Antenatal PFMT slightly decreased the risk of UI in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; high-quality evidence). There was insufficient information available for the late postnatal period (more than six to 12 months) to determine effects at this time point (RR 1.20, 95% CI 0.65 to 2.21; 1 trial, 44 women; low-quality evidence). Treatment of UI: compared with usual care, there is no evidence that antenatal PFMT in incontinent women decreases incontinence in late pregnancy (very low-quality evidence), or in the mid-(RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; low-quality evidence), or late postnatal periods (very low-quality evidence). Similarly, in postnatal women with persistent UI, there is no evidence that PFMT results in a difference in UI at more than six to 12 months postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; low-quality evidence). Mixed prevention and treatment approach to UI: antenatal PFMT in women with or without UI probably decreases UI risk in late pregnancy (22% less; RR 0.78, 95% CI 0.64 to 0.94; 11 trials, 3307 women; moderate-quality evidence), and may reduce the risk slightly in the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; low-quality evidence). There was no evidence that antenatal PFMT reduces the risk of UI at late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; moderate-quality evidence). For PFMT started after delivery, there was uncertainty about the effect on UI risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; moderate-quality evidence). Faecal incontinence: eight trials reported FI outcomes. In postnatal women with persistent FI, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (very low-quality evidence). In women with or without FI, there was no evidence that antenatal PFMT led to a difference in the prevalence of FI in late pregnancy (RR 0.64, 95% CI 0.36 to 1.14; 3 trials, 910 women; moderate-quality evidence). Similarly, for postnatal PFMT in a mixed population, there was no evidence that PFMT reduces the risk of FI in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, low-quality evidence). There was little evidence about effects on UI or FI beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it.

AUTHORS' CONCLUSIONS

This review provides evidence that early, structured PFMT in early pregnancy for continent women may prevent the onset of UI in late pregnancy and postpartum. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on UI, although the reasons for this are unclear. A population-based approach for delivering postnatal PFMT is not likely to reduce UI. Uncertainty surrounds the effects of PFMT as a treatment for UI in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women. It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches, and in certain groups of women. Hypothetically, for instance, women with a high body mass index (BMI) are at risk of UI. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups, and how much PFMT women in both groups do, to increase understanding of what works and for whom. Few data exist on FI and it is important that this is included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence. In addition to further clinical studies, economic evaluations assessing the cost-effectiveness of different management strategies for FI and UI are needed.

Prenatal high-low impact exercise program supported by pelvic floor muscle education and training decreases the life impact of postnatal urinary incontinence: A quasiexperimental trial

BACKGROUND

Pregnancy and high impact exercise may cause postnatal urinary incontinence. We aimed to evaluate the life impact of postnatal urinary incontinence in women attending prenatal, high-low impact exercise program, supported by pelvic floor muscle education and training, in comparison to controls.

METHODS

It was a quasiexperimental trial among 260 postpartum Caucasian women (age 29 ± 4 years; mean ± standard deviation). The training group (n = 133) attended a high-low impact exercise and educational program from the 2nd trimester of pregnancy until birth, 3 times a week. We educated this group to contract and relax pelvic floor muscles with surface electromyography biofeedback and instructed how to exercise postpartum. Control women (n = 127) did not get any intervention. All women reported on the life impact of urinary incontinence 2 months and 1 year postpartum using the Incontinence Impact Questionnaire (IIQ).

RESULTS

Training group started regular pelvic floor muscle exercises substantially earlier postpartum than controls (P < .001). Significantly less training women reported the life impact of urinary incontinence both 2 months (P = .03) and 1 year postpartum (P = .005). Two months after birth, for the symptomatic women the IIQ scores were significantly lower in the training than in the control women (median [Me] = 9.4 vs Me = 18.9; P = .002). Between the 1st and 2nd assessments the number of women affected by incontinence symptoms decreased by 38% in the training group and by 20% in the controls.

CONCLUSION

High-low impact activities supported by pelvic floor muscle exercises and education should be promoted among pregnant, physically active women. Such activities may help women to continue high-intensity exercise with the simultaneous prevention of postnatal urinary incontinence.Thy study was registered at ISRCTN under the title "Pelvic floor muscle training with surface electromyography" (DOI 10.1186/ISRCTN92265528).

Urinary incontinence after uncomplicated spontaneous vaginal birth in primiparous women during the first year after birth

Introduction and hypothesis

Urinary incontinence (UI) is associated with pregnancy and parity and can cause health problems for women. Our objective was to explore risk factors for UI and its effect on women’s daily activities, psychological health and wellbeing 9–12 months postpartum in a low-risk primiparous population.

Methods

In this prospective cohort study, first-time mothers in a low-risk population with a spontaneous vaginal birth reported the occurrence of UI and its effect on daily activities and on their psychological health and wellbeing in a questionnaire completed 1 year after birth. Descriptive and comparative statistics were employed for the analysis.

Results

A total of 410 women (75.7%) completed the questionnaire. The self-reported rates of stress urinary incontinence, urge urinary incontinence and mixed urinary incontinence were 45.4%, 38.0% and 27.0% respectively. Neither the duration of the second stage of labour, the baby’s head circumference or its birth weight were associated with the incidence of UI. There was an association between reported negative impact on daily activities and more negative psychological wellbeing (p < 0.001).

Conclusions

Urinary incontinence was common among primiparous women at 9–12 months postpartum. Women whose symptoms had a negative impact on their daily activities reported more psychological suffering.

[Cesarean section and perineal protection: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The endpoint was to assess the interest of planned cesarean section in primary and secondary obstetrical perineal prevention.

METHODS

This is a review of the literature about the impact of the mode of delivery in urinary incontinence (UI), anal incontinence (AI), pelvic organ prolapse (POP), sexual disorders de novo or prior to delivery and history of obstetric anal sphincter injuries (OASI).

RESULTS

The studies about UI, AI and sexual disorders report a potential protective impact of cesarean section but with a possible selection bias and an inadequate comparability of the groups. Randomized trials do not report any protective effect of planned cesarean section for these 3 disorders. The literature about POP reports a higher risk for the women who delivered vaginally but still with a possible selection bias et there is no randomized trial for this outcome. About the secondary prevention of OASI, there is no evidence in the literature for a benefit of a systematic planned cesarean section for all women. For symptomatic women, the mode of delivery has to be discussed individually. In secondary prevention of UI, AI, POP and sexual disorders, there is no evidence in the literature for a benefit of planned cesarean section even if there is a history of surgical procedure for the disorder.

CONCLUSION

Planned cesarean section is not recommended in order to prevent primary or secondary obstetrical perineal disorders except for symptomatic OASI for whom an individual discussion about the mode of delivery is recommended.

Questionnaires to evaluate pelvic floor dysfunction in the postpartum period: a systematic review

Background

Pelvic floor dysfunctions (PFDs) affect the female population, and the postpartum period can be related to the onset or aggravation of the disease. Early identification of the symptoms and the impact on quality of life can be achieved through assessment instruments.

Objective

The purpose of this systematic review is to evaluate questionnaires used to assess PFD in the postpartum period.

Methods

A systematic review study was conducted, following Preferred Reporting Items for the Systematic Reviews and Meta-Analyses (PRISMA) criteria, using the databases: PubMed, Biblioteca Virtual de Saúde (BVS), Web of Science, and Scopus, and the keywords PFD or pelvic floor disorders, postpartum or puerperium, and questionnaire. Articles published up till May 2018 were included, searching for articles using validated questionnaires for the evaluation of PFDs in postpartum women. The articles included were evaluated according to a checklist, and the validation studies and translated versions of the questionnaires were identified.

Results

The search of the databases resulted in 359 papers, and 33 were selected to compose this systematic review, using nine validated questionnaires to assess PFDs in the postpartum period: International Consultation on Incontinence Questionnaire – Vaginal Symptoms (ICIQ-VS), Pelvic Floor Distress Inventory 20 (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), PFDI-46, Pelvic Floor Impact Questionnaire (PFIQ-31), Pelvic Floor Bother Questionnaire (PFBQ), Female Pelvic Floor Questionnaire, electronic Personal Assessment Questionnaire – Pelvic Floor, and PFD questionnaire specific for pregnancy and postpartum. The most frequently reported questionnaires included PFDI-20, PFIQ-7, and ICIQ-VS and are recommended by ICI. In addition, the review identified a specific questionnaire, recently developed, to access PFD during pregnancy and postpartum.

Conclusion

The questionnaires used to evaluate PFD during postpartum period are developed for general population or urology/gynecology patients with incontinence and reinforce the paucity of highly recommended questionnaires designed for postpartum, in order to improve early and specific approach for this period of life.

Pelvic Floor Physical Therapy and Women's Health Promotion

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on a woman's quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction, diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women's health care providers can screen for, identify, and treat pelvic floor dysfunction. This article examines the case of a woman with multiple pelvic-floor-related problems and presents the evidence for the use of pelvic floor physical therapy (PFPT) for pregnancy-related pelvic floor dysfunction. PFPT is an evidence-based, low-risk, and minimally invasive intervention, and women's health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or management of pelvic floor dysfunction.

Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women

BACKGROUND

About one-third of women have urinary incontinence and up to one-tenth have faecal incontinence after childbirth. Pelvic floor muscle training (PFMT) is commonly recommended during pregnancy and after birth for both prevention and treatment of incontinence.This is an update of a review previously published in 2012.

OBJECTIVES

To determine the effectiveness of pelvic floor muscle training (PFMT) in the prevention or treatment of urinary and faecal incontinence in pregnant or postnatal women.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (16 February 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials in pregnant or postnatal women. One arm of the trial included PFMT. Another arm was no PFMT, usual antenatal or postnatal care, another control condition, or an alternative PFMT intervention.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trials for inclusion and risk of bias. We extracted data and checked them for accuracy. Populations included: women who were continent (PFMT for prevention), women who were incontinent (PFMT for treatment) at randomisation and a mixed population of women who were one or the other (PFMT for prevention or treatment). We assessed quality of evidence using the GRADE approach.

MAIN RESULTS

The review included 38 trials (17 of which were new for this update) involving 9892 women from 20 countries. Overall, trials were small to moderate sized, and the PFMT programmes and control conditions varied considerably and were often poorly described. Many trials were at moderate to high risk of bias. Other than two reports of pelvic floor pain, trials reported no harmful effects of PFMT.Prevention of urinary incontinence: compared with usual care, continent pregnant women performing antenatal PFMT may have had a lower risk of reporting urinary incontinence in late pregnancy (62% less; risk ratio (RR) for incontinence 0.38, 95% confidence interval (CI) 0.20 to 0.72; 6 trials, 624 women; low-quality evidence). Similarly, antenatal PFMT decreased the risk of urinary incontinence in the mid-postnatal period (more than three to six months' postpartum) (29% less; RR 0.71, 95% CI 0.54 to 0.95; 5 trials, 673 women; moderate-quality evidence). There was insufficient information available for the late (more than six to 12 months') postnatal period to determine effects at this time point.Treatment of urinary incontinence: it is uncertain whether antenatal PFMT in incontinent women decreases incontinence in late pregnancy compared to usual care (RR 0.70, 95% CI 0.44 to 1.13; 3 trials, 345 women; very low-quality evidence). This uncertainty extends into the mid- (RR 0.94, 95% CI 0.70 to 1.24; 1 trial, 187 women; very low-quality evidence) and late (RR 0.50, 95% CI 0.13 to 1.93; 2 trials, 869 women; very low-quality evidence) postnatal periods. In postnatal women with persistent urinary incontinence, it was unclear whether PFMT reduced urinary incontinence at more than six to 12 months' postpartum (RR 0.55, 95% CI 0.29 to 1.07; 3 trials; 696 women; very low-quality evidence).Mixed prevention and treatment approach to urinary incontinence: antenatal PFMT in women with or without urinary incontinence (mixed population) may decrease urinary incontinence risk in late pregnancy (26% less; RR 0.74, 95% CI 0.61 to 0.90; 9 trials, 3164 women; low-quality evidence) and the mid-postnatal period (RR 0.73, 95% CI 0.55 to 0.97; 5 trials, 1921 women; very low-quality evidence). It is uncertain if antenatal PFMT reduces urinary incontinence risk late postpartum (RR 0.85, 95% CI 0.63 to 1.14; 2 trials, 244 women; low-quality evidence). For PFMT begun after delivery, there was considerable uncertainty about the effect on urinary incontinence risk in the late postnatal period (RR 0.88, 95% CI 0.71 to 1.09; 3 trials, 826 women; very low-quality evidence).Faecal incontinence: six trials reported faecal incontinence outcomes. In postnatal women with persistent faecal incontinence, it was uncertain whether PFMT reduced incontinence in the late postnatal period compared to usual care (RR 0.68, 95% CI 0.24 to 1.94; 2 trials; 620 women; very low-quality evidence). In women with or without faecal incontinence (mixed population), antenatal PFMT led to little or no difference in the prevalence of faecal incontinence in late pregnancy (RR 0.61, 95% CI 0.30 to 1.25; 2 trials, 867 women; moderate-quality evidence). For postnatal PFMT in a mixed population, there was considerable uncertainty about the effect on faecal incontinence in the late postnatal period (RR 0.73, 95% CI 0.13 to 4.21; 1 trial, 107 women, very low-quality evidence).There was little evidence about effects on urinary or faecal incontinence beyond 12 months' postpartum. There were few incontinence-specific quality of life data and little consensus on how to measure it. We found no data on health economics outcomes.

AUTHORS' CONCLUSIONS

Targeting continent antenatal women early in pregnancy and offering a structured PFMT programme may prevent the onset of urinary incontinence in late pregnancy and postpartum. However, the cost-effectiveness of this is unknown. Population approaches (recruiting antenatal women regardless of continence status) may have a smaller effect on urinary incontinence, although the reasons for this are unclear. It is uncertain whether a population-based approach for delivering postnatal PFMT is effective in reducing urinary incontinence. Uncertainty surrounds the effects of PFMT as a treatment for urinary incontinence in antenatal and postnatal women, which contrasts with the more established effectiveness in mid-life women.It is possible that the effects of PFMT might be greater with targeted rather than mixed prevention and treatment approaches and in certain groups of women. Hypothetically, for instance, women with a high body mass index are at risk factor for urinary incontinence. Such uncertainties require further testing and data on duration of effect are also needed. The physiological and behavioural aspects of exercise programmes must be described for both PFMT and control groups and how much PFMT women in both groups do, to increase understanding of what works and for whom.Few data exist on faecal incontinence or costs and it is important that both are included in any future trials. It is essential that future trials use valid measures of incontinence-specific quality of life for both urinary and faecal incontinence.