Urogynecology in obstetrics: impact of pregnancy and delivery on pelvic floor disorders, a prospective longitudinal observational pilot study

Purpose

To assess changes in the pelvic floor anatomy that cause pelvic floor disorders (PFDs) in primigravidae during and after pregnancy and to evaluate their impact on women’s quality of life (QoL).

Methods

POP-Q and translabial ultrasound examination was performed in the third trimester and 3 months after delivery in a cohort of primigravidae with singleton pregnancy delivering in a tertiary center. Results were analyzed regarding mode of delivery and other pre- and peripartal factors. Two individualized detailed questionnaires were distributed at 3 months and at 12 months after childbirth to determinate QoL.

Results

We recruited 45 women, of whom 17 delivered vaginally (VD), 11 received a vacuum extraction delivery (VE) and 17 a Cesarean section in labor (CS). When comparing third-trimester sonography to 3 months after delivery, bladder neck mobility increased significantly in each delivery group and hiatal area increased significantly in the VD group. A LAM avulsion was found in two women after VE. Connective tissue weakness (p = 0.0483) and fetal weight at birth (p = 0.0384) were identified as significant risk factors for the occurrence of PFDs in a multivariant regression analysis. Urinary incontinence was most common with 15% and 11% of cases at 3, respectively, 12 months after delivery. 42% of women reported discomfort during sexual intercourse, 3 months after delivery and 24% 12 months postpartum. Although 93% of women engage a midwife after delivery, only 56% participated in pelvic floor muscle training.

Conclusion

Connective tissue weakness and high fetal weight at birth are important risk factors for the occurrence of PFDs. Nevertheless, more parturients should participate in postpartal care services to prevent future PFDs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06022-w.

Pelvic floor ultrasound finds after episiotomy and severe perineal tear: systematic review and meta-analysis

AIM

Vaginal delivery is a well-known risk factor for pelvic floor muscle (PFM) injuries, mainly when associated to prolonged labor, instrumental birth and perineal trauma such as episiotomy and perineal tears. The purpose of this meta-analysis was to test the hypothesis that episiotomy and severe perineal tear may increase the risk of pelvic floor damage.

METHODS

We performed a systematic literature search through electronic databases including MEDLINE via PubMed, LILACS via BVS, Embase via Elsevier and Cochrane Library up to January 2019. We included articles that reported as outcome one or more morphological aspects of the PFM evaluated by ultrasonography in primiparous women three to 24 months postpartum. This review is registered in the PROSPERO database (registration number: CRD42017075750).

RESULTS

the final selection was composed of 18 articles for the systematic review, and 10 for the meta-analysis. Women with levator ani muscle (LAM) avulsion were 1.77 times more likely to have undergone episiotomy (OR = 1.77, CI 95% 1.25-2.51, five trials), 4.31 times more likely to have severe perineal tear (OR = 4.31, CI 95% 2.34-7.91, two trials). Women with defects in the anal sphincters were 2.82 times more likely to have suffered severe perineal tear (OR = 2.82, 95% CI 1.71-4.67, three trials).

CONCLUSIONS

Both episiotomy and severe perineal tear are risk factors for LAM avulsion and anal sphincter injury, and this can be useful for identifying women who are at greater risk of developing PFM dysfunctions.

Predicting stress urinary incontinence during pregnancy: combination of pelvic floor ultrasound parameters and clinical factors

INTRODUCTION

The aim of this study was to develop and validate a predictive tool that combines pelvic floor ultrasound parameters and clinical factors for stress urinary incontinence during pregnancy.

MATERIAL AND METHODS

A total of 535 women in the first or second trimester of pregnancy were included for an interview and transperineal ultrasound assessment from two hospitals. Imaging data sets were analyzed offline to assess for bladder neck vertical position, urethra angles (α, β and γ angles), hiatal area and bladder neck funneling. All significant continuous variables at univariable analysis were analyzed by receiver operating characteristics. Three multivariable logistic models were built on clinical factors, and combined with ultrasound parameters. The final predictive model with best performance and fewest variables was selected to establish a nomogram. Internal and external validation of the nomogram was performed by both discrimination represented by C-index and calibration measured by Hosmer-Lemeshow test. A decision curve analysis was conducted to determine the clinical utility of the nomogram.

RESULTS

After excluding 14 women with invalid data, 521 women were analyzed. β angle, γ angle and hiatal area had limited predictive value for stress urinary incontinence during pregnancy, with area under curves of 0.558-0.648. The final predictive model included body mass index gain since pregnancy, constipation, previous delivery mode, β angle at rest, and bladder neck funneling. The nomogram based on the final model showed good discrimination with a C-index of 0.789 and satisfactory calibration (p = 0.828), both of which were supported by external validation. Decision curve analysis showed that the nomogram was clinically useful.

CONCLUSIONS

The nomogram incorporating both the pelvic floor ultrasound parameters and clinical factors has been validated to show good discrimination and calibration, and could be an important tool for stress urinary incontinence risk prediction at an early stage of pregnancy.

Will cesarean section increase the risk of interstitial cystitis/painful bladder syndrome?

AIMS

A high number of patients with interstitial cystitis/painful bladder syndrome (IC/PBS) have a history of pelvic surgeries, and cesarean section is one of the most common pelvic surgeries in women. This study aimed to investigate if cesarean section increases the risk of IC/PBS.

METHODS

Women who exclusively gave birth through cesarean section or vaginal delivery were identified from a nationwide database between 2002 and 2013. All were followed up during the study period to detect the event of IC/PBS. The IC/PBS hazard ratio (HR) in the cesarean cohort was compared with the vaginal delivery cohort with and without matching for confounding factors.

RESULTS

The unmatched group included 22 158 cesarean deliveries and 40 214 vaginal deliveries. The IC/PBS HR in the cesarean cohort compared with that in the vaginal delivery cohort was 1.370 (95% confidence interval [CI], 0.903-2.079; P = 0.139). In the matched group, 8368 women were matched in each cesarean and vaginal delivery cohort using propensity scores for age and comorbidities. The IC/PBS HR was 0.725 (95%CI, 0.358-1.471; P = 0.373). Both HRs in these two groups were not significantly different. The incidence density of IC/PBS in delivered women, non-delivery women, and the general female population were not significantly different either (0.310, 0.255, and 0.292 per 1000 person-years, respectively; P = 0.549).

CONCLUSIONS

The risk of IC/PBS was not different between cesarean and vaginal delivery after controlling the confounding factors in this cohort study. Cesarean section has no causal effect on IC/BPS. Furthermore, delivery was not a risk factor for IC/PBS.

Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review

INTRODUCTION AND HYPOTHESIS

Pregnancy and delivery are well-established risk factors for pelvic floor dysfunction (PFD), but the physiopathology, such as the delivery route, is not well understood. This study evaluated the impact of delivery route on the pelvic floor muscles via 3D ultrasound.

METHODS

This review is registered in the PROSPERO database. The criteria for inclusion were prospective studies with 3D translabial ultrasound assessment in primigravida women during pregnancy and postpartum published in English, Spanish or Portuguese between 1980 and 2016. We excluded studies that did not include the topic of urogenital hiatus measurement and literature reviews. The MeSH terms were obstetric delivery, postpartum period, labor, parturition, three-dimensional images, ultrasonography, pelvic floor, and pelvic floor disorders.

RESULTS

The search retrieved 155 articles. After analysis, 6 articles were included. Four studies showed that vaginal delivery (VD) was associated with a larger hiatal area. One study associated the hiatal area with levator ani muscle (LAM) defects in VD. Four articles evaluated the bladder neck, 3 of which showed a significant increase in bladder neck mobility associated with VD and 1 showed decreased bladder neck elevation, not associated with the delivery mode; the first 3 articles all evaluated LAM injuries and showed an association between VD and LAM injury. Women who underwent VD presented defects of the puborectalis muscle.

CONCLUSIONS

Vaginal delivery was associated with a higher number of LAM injuries, puborectalis defects, increased bladder neck mobility, and enlargement of the hiatal area.

Pelvic floor symptoms and quality of life changes during first pregnancy: a prospective cohort study

INTRODUCTION AND HYPOTHESIS

We describe pelvic floor function in nulliparous pregnant women.

MATERIALS AND METHODS

Nulliparous midwifery patients completed the Incontinence Severity Index (ISI), Pelvic Floor Impact Questionnaire (PFIQ-7), Wexner Fecal Incontinence Scale (W), and answered questions about sexual activity and perineal pain at baseline during the first (T1), second (T2), or third trimester (T3) and repeated in late T3. They also underwent a Pelvic Organ Prolapse Quantification (POP-Q) exam at their baseline visit. Data were compared across trimesters. Analysis of variance (ANOVA) and logistic regression accounted for repeated measures and was controlled for age and education.

RESULTS

We recruited 627 women. In T1, 124 women gave baseline data and completed questionnaires; in T2, 403; and in early T3, 96 (496 repeated questionnaires in later T3). Besides an increase in genital hiatus and perineal body (all adjusted p < .05), physical exam measures did not differ between trimesters. As pregnancy progressed, urinary incontinence (UI) (T1 = 33, T2 = 44, T3 = 69% women with ISI >0, all comparisons p < .02) and Incontinence Impact Questionnaire (IIQ-7) scores increased. Fecal incontinence (FI) increased (T1 = 8, T2 = 15, T3 = 16% from T2 to T3, p = .04); the Colorectal-Anal Impact Questionnaire (CRAIQ-7) scores did not. Perineal pain increased (T1 = 17, T2 = 18 and T3 = 40%, all adjusted p < .001), and sexual activity decreased (T1 = 94, T2 = 90, T3 = 77% sexually active, T1 vs T3 and T2 vs T3, p < .001) as pregnancy progressed.

CONCLUSIONS

During pregnancy, women experience worsening UI, FI, and perineal pain. UI symptoms are associated with a negative impact on quality of life (QoL). Sexual activity decreased and POP-Q stage did not change.

Existe alteração na função dos músculos do assoalho pélvico e abdominais de primigestas no segundo e terceiro trimestre gestacional?

RESUMO O objetivo deste estudo é comparar a função dos músculos do assoalho pélvico no segundo e terceiro trimestre gestacional de primigestas. Foi desenvolvido em duas unidades de Saúde da Família do município de Aracaju (SE). As gestantes foram submetidas a três avaliações da função dos músculos do assoalho pélvico por meio da eletromiografia de superfície: até 16 semanas gestacionais, entre a 24ª-28ª e 34ª-36ª semanas gestacionais. Foram registrados valores de repouso, contrações voluntárias máximas e contrações sustentadas. Os dados foram tabulados no Microsoft Excel e analisados estatisticamente no programa Statistica. Adotou-se um nível de significância de 5% (p≤0,05). Participaram do estudo 19 primigestas, com média de idade de 21,74±3,65 anos. Houve aumento da massa corporal no 3º trimestre gestacional em relação ao período pré-gestacional e diminuição da média do sinal dos músculos do assoalho pélvico durante o repouso ao longo das três avaliações. A musculatura abdominal diminuiu a média do sinal no repouso e durante a contração sustentada nas avaliações 2 e 3 comparadas à avaliação 1. Pode-se concluir que outros fatores, além dos relacionados ao aumento da massa corporal materna, podem estar associados à sobrecarga nos MAP durante a gestação logo no primeiro trimestre. Essa sobrecarga pode fazer que as gestantes apresentem um tônus muscular próximo ao limite superior de referência, alterando o padrão de atividade eletromiográfica principalmente no repouso, a fim de manter a função de sustentação dos órgãos pélvicos e de continência.

Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor

Pelvic floor dysfunction (PFD), although seems to be simple, is a complex process that develops secondary to multifactorial factors. The incidence of PFD is increasing with increasing life expectancy. PFD is a term that refers to a broad range of clinical scenarios, including lower urinary tract excretory and defecation disorders, such as urinary and anal incontinence, overactive bladder, and pelvic organ prolapse, as well as sexual disorders. It is a financial burden on the health care system and disrupts women's quality of life. Strategies applied to decrease PFD are focused on the course of pregnancy, mode and management of delivery, and pelvic exercise methods. Many studies in the literature define traumatic birth, usage of forceps, length of the second stage of delivery, and sphincter damage as modifiable risk factors for PFD. Maternal age, fetal position, and fetal head circumference are nonmodifiable risk factors. Although numerous studies show that vaginal delivery affects pelvic floor structures and their functions in a negative way, there is not enough scientific evidence to recommend elective cesarean delivery in order to prevent development of PFD. PFD is a heterogeneous pathological condition, and the effects of pregnancy, vaginal delivery, cesarean delivery, and possible risk factors of PFD may be different from each other. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist; therefore, the isolated effects of these variables on the pelvic floor are difficult to study. The routine use of episiotomy for many years in order to prevent PFD is not recommended anymore; episiotomy should be used in selected cases, and the mediolateral procedures should be used if needed.

Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy

OBJECTIVE

To study postpartum changes in pelvic floor morphology in a cohort of primiparous women.

METHODS

Transperineal ultrasound measurements taken at five examination points, both prepartum and postpartum, provided data for comparison. Three hundred nulliparous pregnant women were examined at 21 weeks of gestation and 274 (91%) at 37 weeks of gestation. At 6 weeks postpartum, 285 (95%) women were examined, 198 (66%) at 6 months, and 178 (59%) at 12 months using transperineal ultrasonography at rest, during contraction, and during Valsalva maneuver. The levator hiatus area, bladder neck mobility, and rest-to-Valsalva hiatal area difference were assessed.

RESULTS

Approximately 85% had vaginal and 15% had cesarean deliveries. Demographic characteristics of the patients lost to follow-up were similar to the patients not lost to follow-up. In the vaginal group, a significant decrease in all measurements was seen during the first 6 months postpartum, being most pronounced for the levator hiatus area during Valsalva maneuver (-3.5 cm; P<.001). In the cesarean delivery group, no significant changes between examination points were found postpartum. Only the vaginal delivery group showed significant increases in all measurements when comparing the status at 12 months postpartum with 21 weeks of gestation, most pronounced for levator hiatus area during Valsalva maneuver (3 cm; P<.001). However, comparing the two delivery groups at 12 months postpartum, the only significant difference found was levator hiatus area during contraction.

CONCLUSION

The levator ani muscle has the ability to recover after pregnancy and delivery, although not all women recover to pregnancy level. Most of the recovery occurs during the first 6 months postpartum. Significant pregnancy-induced changes are not shown to persist 1 year postpartum.

LEVEL OF EVIDENCE

: II.

Ultrasound imaging of the pelvic floor: changes in anatomy during and after first pregnancy

OBJECTIVES

To describe changes in the absolute values of levator hiatal dimensions and in the contractility and distensibility of the levator hiatus during pelvic floor contraction and Valsalva maneuver, using three/four-dimensional (3D/4D) transperineal ultrasound in women during and after their first pregnancy.

METHODS

Two-hundred and eighty nulliparous pregnant women underwent ultrasound examination at 12 and 36 weeks' gestation and 6 months postpartum. Hiatal dimensions were measured at rest, on pelvic floor contraction and on Valsalva maneuver. The contractility and distensibility were determined by the difference between hiatal dimensions at rest and those on contraction or Valsalva, respectively. After exclusions, there were 231 datasets from women at rest, 199 for pelvic floor contraction and 230 for Valsalva maneuver. Data at 36 weeks' gestation and 6 months postpartum were compared with data at 12 weeks' gestation.

RESULTS

At 36 weeks' gestation, the absolute values of hiatal dimensions and the contractility and distensibility of the levator hiatus were significantly increased compared with those at 12 weeks' gestation. Women who delivered vaginally showed a persistent significant increase in hiatal dimensions on Valsalva, whereas women who delivered by prelabor or first-stage Cesarean section showed no significant changes in hiatal dimensions on Valsalva. After both vaginal and Cesarean section delivery, there was a persistent increase in the distensibility of the hiatus during Valsalva compared with in early pregnancy.

CONCLUSION

During first pregnancy, the absolute values of levator hiatal dimensions and the contractility and distensibility of the levator hiatus increase. Regardless of delivery mode, increased distensibility of the levator hiatus during Valsalva persists after childbirth. This increased pelvic floor distensibility may play a role in the development of pelvic floor dysfunction in later life.

Assessing the impact of twin pregnancies on the pelvic floor using 3-dimensional sonography: a pilot study

OBJECTIVES

The purpose of this study was to compare the morphologic characteristics of the pelvic floor musculature between women with twin and singleton pregnancies.

METHODS

We conducted a cross-sectional case-control study of 40 nulliparous women aged 20 to 38 years to compare women with singleton pregnancies (n = 23) to women with twin pregnancies (n = 17). Biometric measurements of the levator hiatus and the sagittal and coronal diameters were made by transperineal 3-dimensional sonography between the 28th and 38th gestational weeks. Comparisons were statistically assessed by the unpaired Student t test and Mann-Whitney U test.

RESULTS

For the women with singleton pregnancies, the mean sagittal diameters at rest, during the Valsalva maneuver, and during pelvic floor contraction were 5.3, 5.7, and 4.5 cm, respectively, and the mean coronal diameters under these conditions were 3.8, 4.1, and 3.6 cm. For the women with twin pregnancies, the corresponding values were as follows: mean sagittal diameters, 5.3, 5.8, and 4.6 cm; and mean coronal diameters, 4.3, 4.3, and 3.8 cm. The differences in coronal diameters were statistically significant at rest (P < .01) and during contraction (P = .04). The mean levator hiatal areas for the women with singleton pregnancies were 14.6, 16.9, and 11.7 cm(2) at rest, during Valsalva, and during contraction, respectively; for the women with twin pregnancies, these values were 16.0, 18.6, and 12.6 cm(2).

CONCLUSIONS

Hiatal measurements were higher in twin than in singleton pregnancies, with coronal diameters reaching significance at rest and during contraction, suggesting that pelvic support undergoes greater changes during twin pregnancy.

Specific obstetrical risk factors for urinary versus anal incontinence 4 years after first delivery

AIM

Delivery can be complicated by urinary or anal incontinence (UI or AI). We hypothesized that the mechanisms of injury may differ for UI and AI. Hence, obstetrical risk factors may be specific for different types of incontinence.

DESIGN

Data on maternal characteristics were collected at first delivery. Data on incontinence were obtained by a questionnaire completed by 627 women 4 years after first delivery. UI was defined by "Do you have involuntary loss of urine" and AI by "Do you have involuntary loss of flatus or stool". A multinomial logistic regression analysis was conducted to assess risk factors for UI only, AI only, and UI+AI.

RESULTS

Twenty-two percent of women reported UI only, 6.5% AI only, and 6.5% both. Risk factors associated with UI only were age (at first delivery)≥ 30 (OR 2.27 [95% CI 1.47-3.49]), pre-existing UI (6.44 [2.19-19.0]) and pregnancy UI (3.64 [2.25-5.91]). Risk factors associated with AI only were length of the second active stage> 20minutes (2.86 [1.15-7.13]) and third degree perineal tear (20.9 [1.73-252]). Significant predictors of UI+AI were age ≥ 30 (2.65 [1.29-5.46]), no epidural (4.29 [1.65-11.1]), third degree perineal tear (20.0 [1.28-314]), and UI before pregnancy (32.9 [9.00-120]). Cesarean delivery was not significantly associated with UI, AI, or UI+AI, although for all three outcomes, the adjusted odds ratios were substantially less than one.

CONCLUSION

We found specific associations between obstetrical risk factors and urinary versus anal incontinence 4 years after first delivery. Our results are consistent with the hypothesis that the underlying mechanisms of injury differ for UI and AI.

[Urinary incontinence 6 months after childbirth]

BACKGROUND AND OBJECTIVE

Urinary incontinence initiated before and right after delivery and persisting 3 months after delivery tends to become chronic. We intended to estimate the persistence of urinary incontinence 6 months postpartum and to analyse the different factors associated with it.

PATIENTS AND METHODS

Follow-up study 6 months after delivery of women presenting urinary incontinence symptoms in gestation or in the first 2 months of postpartum. The dependent variable was the persistence and the independent variables were grouped in obstetric and non-obstetric. Odds ratio (OR) were calculated with their confidence interval at 95% (IC 95%) in the bivariate analysis. The variables that showed an important risk of persistence of incontinence were used to perform a multivariate model of logistic regression.

RESULTS

The persistence of incontinence 6 months after delivery was 21.4% (CI 95% 16-26.7). The risk of persistence increased with the Kristeller maneuver (OR 7.89, CI 95% 3.04-20.49), not weight recovery (OR 3.64, CI 95% 1.10-12.02), not practising pelvic floor muscle exercises in postpartum (OR 9.36, CI 95% 2.71-32.33), appearance of incontinence after delivery (OR 6.66, CI 95% 2.37-18.68) and the weight of the newborn>3.5 kg (OR 6.76, CI 95% 2.54-18.03), all of them explaining 58% of the variability of persistence.

CONCLUSION

21.4% of women with urinary incontinence caused by pregnancy/delivery will continue to have it 6 months postpartum. An important part of this persistence is associated with some factors easy to modify.

Biomechanics of the female pelvic floor: a prospective trail of the alteration of force-displacement-vectors in parous and nulliparous women

OBJECTIVE

We hypothesize that the holistic and multiplanar depiction of pelvic floor structures by dynamic MRI is of particular value in rendering information about the extent of functional changes that can lead to pelvic floor dysfunction.

METHODS

134 women were prospectively included for assessment of their pelvic floor function.

RESULTS

Study groups differed significantly in the direction of their force-displacement-vectors. A shift from ventral to dorsal is present depending on parity, mode of delivery and age. Maternal age and body height correlated to the force-displacement-vector, whereas maternal weight did not. Pressing direction proved to be dependent on the inclination of the pelvis and the aperture of the levator hiatus while remaining independent from the aperture of the abdominal wall.

CONCLUSION

Biomechanical data interpretation uncovered the pathogenetic relevance of progressive retroflection of the force-displacement-vector. This is responsible for the onset of a vicious cycle of trauma-related force deflection perpetuating pelvic floor traumatization.

The relationship between urethral mobility and parity

OBJECTIVE

Urethral mobility is associated with stress urinary incontinence (SUI) and urodynamic stress incontinence, and this is particularly true for mid-urethral mobility. The purpose of this study was to determine whether there is a significant relationship between segmental urethral mobility and vaginal parity in women undergoing urodynamic testing for prolapse or lower urinary tract symptoms.

DESIGN

Retrospective study. SETTING Tertiary referral service for multichannel urodynamic testing.

POPULATION

Women undergoing urodynamic testing for lower urinary tract symptoms or pelvic organ prolapse.

METHODS

The stored 3D translabial ultrasound volume data sets of 648 women were assessed. Measurements were performed using post-processing software in volumes obtained at rest and on maximal Valsalva manoeuvre. Analysis was based on a co-ordinate system using the dorsocaudal margin of the pubic symphysis. The urethral length was traced and divided into five equal segments. Mobility vectors are determined by the formula radical[(y(V) - y(R))(2) + (x(V) - x(R))(2)], where V indicates Valsalva and R indicates rest, with 'x' as the vertical distance and 'y' as the horizontal distance from the dorsocaudal margin of the pubic symphysis.

MAIN OUTCOME MEASURES

Mobility vector lengths.

RESULTS

The distal urethra is consistently the least mobile part of the organ, regardless of parity. Vaginal childbirth seems to increase urethral mobility by about 20% for all urethral segments (all P < or = 0.009). The first vaginal delivery showed the greatest effect, particularly on mid-urethral mobility.

CONCLUSIONS

There is a significant association between urethral mobility and vaginal delivery in women seen for symptoms of pelvic floor dysfunction, affecting all segments of the urethra equally. Most of this effect seems to result from the first vaginal birth.

Three-dimensional ultrasound of the pelvic floor 2 days after first delivery: influence of constitutional and obstetric factors

OBJECTIVES

Morphological changes of the pelvic floor during pregnancy and delivery can be visualized by three-dimensional (3D) perineal ultrasound. The aim of this study was to compare biometric measurements of the levator ani muscle according to maternal constitutional factors, delivery mode and size of the baby immediately after the first delivery.

METHODS

In this prospective observational study, 130 primiparae were recruited (all of them Caucasians with singleton pregnancy and cephalic presentation). A 3D perineal ultrasound scan was performed on the second day after delivery with standardized settings. Volumes were obtained at rest and on Valsalva maneuver, and biometric measurements of the levator hiatus were determined in the axial plane. Different obstetric and constitutional parameters were obtained from our clinical files.

RESULTS

All biometric measurements of the levator hiatus were significantly greater in the vaginal delivery group than in the Cesarean section group (P < 0.001), whereas subgroup analysis within the vaginal (spontaneous vs. operative vaginal) and Cesarean (primary vs. secondary) delivery groups did not show statistically significant differences. There was no demonstrable influence of maternal constitutional factors (age, body mass index (BMI)) or different obstetric parameters (length of second stage of labor, episiotomy, maternal injuries) on levator hiatus size postpartum, even in subgroups that delivered vaginally. Women with de novo postpartum stress incontinence showed a significantly higher mean levator hiatus transverse diameter and larger hiatal area on Valsalva maneuver (P < 0.05). There was also a positive but very weak correlation between the newborn's head circumference and hiatal dimensions at Valsalva maneuver (P < 0.05).

CONCLUSIONS

Pelvic floor imaging by 3D ultrasound is easily accessible even on the first days after delivery and can provide useful information on morphological changes of the levator ani muscle. In our study, women with vaginal or operative vaginal delivery had a significantly larger hiatal area and transverse diameter than women who delivered by Cesarean section. Maternal constitutional factors (BMI, age) and duration of second stage of labor had no influence on the biometric measurements of hiatal area, whereas weight and head circumference of the baby showed a positive correlation with area of the levator hiatus.

Pelvic floor trauma following vaginal delivery

PURPOSE OF REVIEW

Recent years have seen a steady increase in the information available regarding pelvic floor trauma in childbirth. A review of this information is timely in view of the ongoing discussion concerning elective caesarean section.

RECENT FINDINGS

In addition to older evidence regarding pudendal nerve injury, it has recently been shown that inferior aspects of the levator ani and fascial pelvic organ supports such as the rectovaginal septum can be disrupted in childbirth. Such trauma is associated with pelvic organ prolapse, bowel dysfunction, and urinary incontinence. Elective caesarean section seems to have a limited protective effect that appears to weaken with time. Older age at first delivery may be associated with a higher likelihood of trauma and subsequent symptoms.

SUMMARY

Pelvic floor trauma is a reality, not a myth. It is currently not possible, however, to advise patients as to whether avoidance of potential intrapartum pelvic floor trauma is worth the risk, cost, and effort of elective caesarean section. In some women this may well be the case. The identification of women at high risk for delivery-related pelvic floor trauma should be a priority for future research in this field.

Displacement and recovery of the vesical neck position during pregnancy and after childbirth

AIMS

(i) To describe the displacement and recovery of the vesical neck position during pregnancy and after childbirth and (ii) to discriminate between compliance of the vesical neck supporting structures with and without pelvic floor contraction.

METHODS

We focussed on the biomechanical properties of the vesical neck supporting structures during pregnancy and after childbirth by calculating the compliance and the hysteresis as a result from of abdominal pressure measurements and simultaneous perineal ultrasound.

RESULTS

This study shows that compliance of the supporting structures remains relatively constant during pregnancy and returns to normal values 6 months after childbirth. Hysteresis, however, showed an increase after childbirth, persisting at least until 6 months post partum.

CONCLUSIONS

Vaginal delivery may stretch and or load beyond the physiological properties of the pelvic floor tissue and in this way may lead to irreversible changes in tissue properties which play an important role in the urethral support continence mechanism.

Urodynamic and ultrasound characteristics of incontinence after radical hysterectomy

AIMS

To test whether symptoms of urinary incontinence after radical hysterectomy could be objectified with urodynamics and ultrasound.

METHODS

This case-control study comprised 100 women who underwent radical hysterectomy for cervical cancer without post-operative radiotherapy. Fifty women reporting urinary incontinence were matched with 50 women reporting continence. All women were assessed with ultrasound of the bladder neck movements and urodynamics.

RESULTS

No differences were found in ultrasound or urodynamic findings regarding mobility of the bladder neck, maximal detrusor pressure, post-voiding residual urine, flow of urine, or bladder capacity. A significant reduction in urethral pressure at rest and at contraction among the incontinent women was, however, demonstrated. Among urge-incontinent women, urethral pressure at rest was significantly lower than among continent and stress-incontinent women, respectively. Stress-incontinent women had significantly lower urethral pressure at contraction than did urge-incontinent and continent women.

CONCLUSIONS

No differences in urodynamic or ultrasound findings were observed between the two groups, except for an overall difference in the intraurethral pressure. A decrease in the urethral pressure could contribute to the characterization of incontinence after radical hysterectomy, indicating that the urethral sphincter mechanism plays a role in the pathophysiology. In this study design, the mobility of the bladder neck did not play any role.

A urogynecologist's view ofthe pelvic floor effects of vaginal delivery/cesarean section for the urologist

Pregnancy and parturition have been implicated in the development of pelvic floor dysfunction. These disorders include urinary incontinence, fecal incontinence, pelvic organ prolapse, and other pelvic and sexual dysfunctions. The urologist caring for women with urinary dysfunction needs to be familiar with the causes of pelvic floor dysfunction and their implications. Defects of the pelvic floor have clearly resulted from the traumatic effect of vaginal delivery. The likely mechanisms of injuries during vaginal delivery involve stretching and compression of the pudendal nerve and peripheral branches, as well as an additional tearing of muscles and connective tissue. Optimal management of labor and optimal techniques of repair of unavoidable sphincteric lacerations, ante- and postpartum pelvic floor muscle conditioning, and timely and proper indications for cesarean delivery will minimize the effect of incidental traumatic delivery.

Postpartum urinary incontinence: a comparison of vaginal delivery, elective, and emergent cesarean section

The aim of this study was to assess the impact of delivery on the pelvic floor and whether cesarean section (C/S) can prevent pelvic floor injury. Five hundred thirty nine women were divided into three groups according to the delivery method adopted: elective C/S, emergent C/S, and vaginal delivery. A urinary incontinence questionnaire survey was conducted around 1 year postpartum. Emergent C/S may be a major risk factor for postpartum urinary incontinence and interfere with the benefit of elective C/S for preventing pelvic floor injury. Hence, not all C/S deliveries can reduce the likelihood of postpartum urinary incontinence. The key lies in whether the C/S is performed before labor.

Ultrasound imaging of the female perineum: the effect of vaginal delivery on pelvic floor dynamics

OBJECTIVE

To assess the use of perineal ultrasound in the evaluation of the influence of vaginal delivery on urethral mobility and on the contraction strength of the levator ani muscles.

METHODS

This was a prospective observational study of 70 nulliparous women. Each woman underwent perineal ultrasound assessment at 36-38 weeks' gestation and at 1 week and 3 months following delivery. During each examination we assessed: the posterior urethrovesical angle at rest, urethral mobility during Valsalva maneuver and movement of the anorectal angle and levator sling angle during contraction of the levator ani.

RESULTS

The urethrovesical angle and the urethral mobility increased significantly after delivery (P < 0.0001). The levator sling excursion decreased proportionally. The anorectal excursion had decreased significantly by the examination 3 months after birth.

CONCLUSIONS

Perineal sonography provides objective assessment criteria for urethral mobility and for contraction strength of the levator ani muscles and detects changes in the anatomy and function of the pelvic floor after vaginal delivery.

Peripartum urinary incontinence in a racially diverse obstetrical population

To determine the rates of urinary incontinence in a racially diverse, tertiary care obstetrical population during the third trimester and postpartum using a validated symptom-screening questionnaire. Third trimester prenatal patients receiving obstetric care at Loyola University Medical Center between March and November 2003 participated in this prospective study approved by the Institutional Review Board. Third-trimester participants completed the 15-item, validated Medical, Epidemiological, and Social Aspects of Aging (MESA) questionnaire and the Hunskaar Severity Index. The MESA was readministered to participants during a 6- to 8-week postpartum visit. One hundred and thirteen women completed antenatal and postpartum MESAs. Seventy-four percent (83 of 113) of the patients in the third trimester were categorized as incontinent. The postpartum incontinence rates decreased to 44% (50 of 113). Twenty-one percent (24 of 113) of the participants after delivery reported pure stress incontinence, 3% (3 of 113) urge incontinence, and 20% (23 of 113) mixed incontinence. Only 4% (5 of 113) of the women developed de novo incontinence postpartum: three reported symptoms of pure stress incontinence and two reported symptoms consistent with urge incontinence. The MESA questionnaire identifies more women with antenatal and postpartum urinary incontinence than currently described in the literature.