Parity, mode of delivery, and pelvic floor disorders

Prevalence and risk factors of urinary incontinence in pregnant Korean women

OBJECTIVE

This study aimed to evaluate the prevalence of urinary incontinence (UI) and its associated risk factors among pregnant Korean women, as UI significantly impacts their quality of life.

METHODS

A cross-sectional study involving singleton pregnant women was conducted between April and December 2023. Data were collected using a questionnaire assessing demographic information and UI symptoms. The International Consultation on Incontinence Questionnaire-UI short form was used to diagnose UI.

RESULTS

A total of 824 pregnant women from three centers participated, with an overall prenatal UI prevalence of 40.2% (331/824). Stress UI was most common (77.1%), followed by mixed UI (16.9%), and urgency UI (6.0%). Risk factors for UI included prior delivery mode, specifically vaginal delivery (adjusted odds ratio [aOR], 5.61; 95% confidence interval [CI], 1.40-22.50; P=0.015) and combined vaginal and cesarean delivery (aOR, 23.14; 95% CI, 1.77-302.74; P=0.017). Additionally, second trimester (aOR, 1.99; 95% CI, 1.19-3.32; P=0.009) and third trimester (aOR, 4.44; 95% CI, 2.65-7.40; P<0.001) were associated with increased UI risk. Conversely, drinking alcohol before pregnancy was a protective factor (aOR, 0.72; 95% CI, 0.53-0.99; P=0.046).

CONCLUSION

Approximately 40% of Korean pregnant women experience prenatal UI. Prior delivery mode and advanced gastrointestinal age are significant risk factors. Further research with postpartum and long-term follow-ups is needed.

De novo urethral hypermobility at 6 months after first delivery as a risk factor for stress urinary incontinence 12 years postpartum

OBJECTIVE

The aim of the study was to analyze the association between de novo urethral hypermobility 6 months postpartum and stress urinary incontinence (SUI) symptoms at 6 months and 12 years after first delivery. Risk factors associated with the development of postnatal urethral hypermobility were also examined.

METHODS

A longitudinal cohort study was conducted on primigravid women, after excluding those with UI before pregnancy and/or urethral hypermobility (rotational angle ≥30°) at term. At 6 months postpartum, SUI was assessed based on symptoms and introital ultrasound performed to measure rotational angle (difference between urethro-pelvic angle at rest and at maximum Valsalva). Twelve years after delivery, women were sent a questionnaire including SUI assessment and questions on parity, current age, and body mass index. Continuous variables were compared using student's t-test and qualitative variables using chi-squared tests. A logistic regression model was constructed including variables that reached statistical significance (P < 0.05) in the univariate analysis.

RESULTS

Of the 314 women who completed the 6-month follow-up, 265 (84.4%) were successfully contacted and completed the questionnaire at 12 years and these formed the study group. In 127 women (47.9%), de novo urethral hypermobility had developed by 6 months postpartum. There was no association between urethral hypermobility and SUI symptoms 6 months postpartum (OR: 1.17; 95% CI: 0.59-2.33). Twelve years after delivery, however, SUI was reported by 110 women overall (41.5%) and nearly half of the women who developed postnatal urethral hypermobility (61/127, 48.0%).

CONCLUSION

De novo urethral hypermobility 6 months postpartum constitutes a risk factor for SUI 12 years later.

Association of Constipation with Modes of Delivery: A Retrospective Questionnaire-based Study

INTRODUCTION AND HYPOTHESIS

Pelvic floor damage can contribute to pelvic floor dysfunction, including constipation. Most studies focus on constipation during pregnancy, whereas information regarding the mode of delivery in relation to constipation is limited. We hypothesise that women with a history of vaginal delivery report constipation more often than women with a history of caesarean section.

METHODS

This was a retrospective cross-sectional multicentre study conducted in the Netherlands. All included patients (n = 2,643) completed the Groningen Defecation and Fecal Continence questionnaire to assess bowel problems of the last 6 months. Parametric tests, Chi-squared, univariable and multivariable regression analyses were performed.

RESULTS

Among 2,643 parous women, 2,248 delivered vaginally (85.1%) and 395 (14.9%) by caesarean section. Altogether, 649 women (24.6%) suffered from constipation. Women in the vaginal delivery group were constipated more often than women in the caesarean section group (25.5% versus 19.0%, p = 0.005). For women who had delivered vaginally, multivariable regression analysis showed an odds ratio for constipation of 1.47 (95% confidence interval, 1.109-1.938, p = 0.007). The odds ratio for constipation in women with a spontaneous perineal tear was 1.4 times higher than in women with an intact perineum (p = 0.030). Furthermore, the vaginal delivery group reported difficulties regarding bowel emptying (p = 0.048), straining (p = 0.027), incomplete defecation (p = 0.043), not able to defecate daily (p = 0.018), manually assisted defecation (p = 0.015) and had higher Renzi scores (p = 0.043) more often.

CONCLUSIONS

Women in the vaginal delivery group have higher prevalences and odds ratios for constipation. Furthermore, a perineal tear during vaginal delivery increases the odds ratio for constipation.

Projecting future prolapse outcomes with induction of labor at 39 weeks: a decision analysis

INTRODUCTION AND HYPOTHESIS

In 2018, the ARRIVE trial (A Randomized Trial of Induction Versus Expectant Management) concluded that routine induction of labor (IOL) at 39 weeks gestation decreases cesarean delivery risk, with slightly lighter birthweight infants. We debated whether routine IOL would improve, worsen, or not change POP risk compared with expectant management (EM).

METHODS

We constructed a decision analysis model with a lifetime horizon where nulliparous women reaching 39 weeks underwent IOL or EM. Subsequent vaginal versus cesarean delivery varied based on prior deliveries for up to four births. Subsequent delivery prior to 39 weeks and distribution of gestational age, birthweight, and delivery mode between 24 and 39 weeks was modeled from national data. We modeled increased POP risk with increasing vaginal parity, forceps delivery, and weight of largest infant delivered vaginally, accounting for differential infant weights in each strategy.

RESULTS

IOL and EM have similar population-wide POP risk (15.9% and 15.7% respectively). Among women with only spontaneous vaginal deliveries that reached 39 weeks or beyond, the prevalence of POP was 20% after one delivery and 29% after four deliveries, with no difference between groups. The cesarean rate was lower with IOL (27.8% versus 29.8%). Sensitivity analysis revealed no meaningful thresholds among the variables, supporting model robustness.

CONCLUSION

While routine induction of labor at 39 weeks results in a meaningfully higher vaginal delivery rate, there was no increase in POP, possibly due to the protective effect of lower birthweight.

Impact of parity on pelvic floor morphology and function: A retrospective study

To analyze the effect of parity on pelvic floor morphology and function during the postpartum period. A total of 971 participants, who attended the Fujian Maternity and Child Health Hospital (Fuzhou, China) between December 2019 and August 2021, were included. All participants were assessed using the modified Oxford scale (MOS), pelvic floor surface electromyography, and 3-dimensional pelvic floor ultrasound to assess pelvic floor morphology and function. Multivariate analysis revealed no differences among primipara, deuteripara, and tertipara in pre-baseline rest, phasic contraction, endurance contraction, post-baseline rest, and MOS, except for tonic contraction (P = .020), the amplitude of which was lower in primipara than in deuteripara in post hoc comparison (P = .008). Differences in bladder neck presentation and bladder neck descent were statistically significant in multivariate analysis (P = .002, P = .001, respectively), with the value of bladder neck presentation in primiparas being greater than that of deuteriparas and tertipara (P = .002, P = .008, respectively), and the value of bladder neck descent was lower than that of deuteripara and tertipara in further post hoc comparisons (P = .002, P = .003, respectively). Functional impairment was not statistically associated with parity according to the MOS score or surface electromyography. However, parity was significantly correlated with descent of the bladder neck, and most of the effects appeared to occur during the first delivery.

Sexual dysfunction in patients after cystocele surgery. Is the g-spot a myth or reality?

The anterior wall of the vagina is very rich in nerves, blood vessels, and exocrine glands. This anatomical region is related to female sexual desire. During the anterior colporrhaphy operation, dissection of the anterior vaginal wall causes damage to this area, which may lead to decreased sexual satisfaction. In the present study, we aimed to investigate sexual function after anterior vaginal wall surgery.

METHODS

Totally 89 patients who had undergone the anterior colporrhaphy operation between May 2021 and December 2021 were included in the study. The patients' sexual function was investigated before surgery and six months after surgery. The effects on sexual function were determined according to the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire.

RESULTS

According to our study results, orgasm and orgasm intensities decreased after anterior colporrhaphy surgery (p = 0.000; p = 0.000), while sexual desire or arousal did not change (p = 0.405; p = 0.052). In addition, an increase in pain was observed during sexual intercourse after surgery (p = 0.000). No statistically significant difference was observed in the PISQ-12 score before or after anterior colporrhaphy surgery (p = 0.675).

CONCLUSION

Based on the results of our study, we found a remarkable decrease in orgasm in these patients. Furthermore, we think that it is appropriate to recommend conservative or alternative treatments for the early stages of cystocele. Nevertheless, larger-scale studies may be designed to reveal the importance of this region in sexual function.

Pelvic floor parameters predict postpartum stress urinary incontinence: a prospective MRI study

OBJECTIVE

To investigate the pelvic floor changes in primiparas with postpartum stress urinary incontinence (SUI) after vaginal delivery using pelvic floor MRI.

MATERIALS AND METHODS

Fifty-two women were enrolled in the primiparous stress urinary incontinent (PSUI) group and 51 in the primiparous continent (PC) group. Thirty nulliparas were also recruited as the nulliparous control (NC) group. Levator ani muscle (LAM) injury, levator hiatus area (LHA), H-line, M-line, the distance from the bladder neck and cervix to the pubococcygeal line (B-PCL and U-PCL), levator plate angle, the anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, functional urethral length, and a bladder neck funnel were evaluated on MRI images. Univariate and multivariate logistic regression analyses were used to explore anatomical predictors for SUI.

RESULTS

The primiparas in the PSUI group showed more obvious LAM injuries than in the PC groups (p = 0.001). LAM function assessment: the PSUI group had larger LHA and shorter B-PCL and U-PCL than the other groups during straining. Assessment of urethral mobility and function: the PSUI group had larger anterior angle of the urethra, bladder neck descent, retrovesicourethral angle, and shorter functional urethral length than the other two groups (all p < 0.05). Up to 88.5% of primiparas in the PSUI group showed bladder funnel (p < 0.001). The logistic regression analysis showed that retrovesicourethral angle, functional urethral length, and the presence of bladder funnel were significantly associated with postpartum SUI (p < 0.05).

CONCLUSIONS

Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel may be anatomical predictors for SUI in the early postpartum period. Urethral sphincter dysfunction plays an essential role in developing postpartum SUI.

CRITICAL RELEVANCE STATEMENT

This study used several measurements to reflect the anatomical structure and functional changes of the pelvic floor to identify the best anatomical predictors associated with postpartum stress urinary incontinence (SUI), aiming to provide new insights into treatment strategies for postpartum SUI.

KEY POINTS

• Increased retrovesicourethral angle, shortened functional urethral length, and the presence of bladder funnel are more commonly seen in primiparas with SUI. • The combination of retrovesicourethral angle, functional urethral length, and bladder funnel had the highest diagnostic performance in predicting postpartum SUI (AUC=0.947). • Urethral sphincter dysfunction may be the main pathophysiological foundation in SUI development.

Pelvic floor disorder and relevant factors in Iranian women of reproductive age: a cross-sectional study

BACKGROUND

With high severity and prevalence, pelvic floor disorder is a health issue that women face worldwide. Different demographic-obstetric factors are involved in the emergence of this dysfunction that can have many adverse effects on a woman's quality of life. Hence, this study aimed to determine the prevalence of pelvic floor disorder and its related socio-demographic and obstetric factors among Iranian women of reproductive age.

METHODS

The statistical population of this cross-sectional study included 400 woman of reproductive age (15-49 years) covered by the health centers of Tabriz, Iran in 2022. The cluster sampling method was employed to select the participants. The data collection tools were a socio-demographic and obstetric characteristics questionnaire and the PDFI-20 (Pelvic Floor Distress Inventory-20). The chi-squared test was conducted to determine the association between socio-demographic and obstetric characteristics and prevalence of pelvic floor disorder in a bivariate analysis, whereas the multivariate logistic regression test was used in a multivariate analysis.

RESULTS

The general prevalence of pelvic floor disorder was 76%. The prevalence rates of pelvic organ prolapse distress 6 (POPDI-6), colorectal-anal distress 8 (CRAD-8), and urinary distress (UDI-6) were 54.3%, 61.8%, and 49.3%, respectively. The results of the multivariate logistic regression test indicated that constipation (odds ratio = 5.62; 95% CI 1.97 to 16.03; P = 0.001) increased the risk of pelvic floor disorder.

CONCLUSIONS

According to the findings, the prevalence of pelvic floor disorder is high among Iranian women of reproductive age. This condition is correlated with constipation. Therefore, screening is recommended through valid tools in addition to offering preventive measures such as preventing and curing constipation to reduce the risk of pelvic floor disorder.

How do reproductive history and anthropometry in midlife relate to later risk of pelvic organ prolapse? A prospective cohort study

INTRODUCTION AND HYPOTHESIS

The objective was to examine the association between reproductive and anthropometric factors and later risk of pelvic organ prolapse (POP).

METHODS

We carried out a prospective cohort study including 11,114 female nurses > 44 years from the Danish Nurse Cohort. In 1993, the study population was recruited through the Danish Nurse Organization and self-reported data on age, height, weight, age at menarche, age at first birth and number of childbirths were obtained. POP diagnosis was obtained from the National Patient Registry. Risk of POP was estimated using COX regression and presented as hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

Overall, 10% of the women received a diagnosis of POP within a median follow-up of 22 years. A 4% increase in risk of POP was seen for each increasing BMI (kg/m²) unit at baseline. Compared to women of normal weight, higher risks of POP were seen in overweight (HR 1.18: 1.02-1.36) and obese women (HR 1.33: 1.02-1.74), while underweight had a lower risk (HR 0.51: 0.27-0.95). Compared to women with one childbirth, women with no childbirths had a reduced risk of 57% while increased risks of 46%, 78% and 137% were observed in women with two, three and four childbirths. Women with menarche before the age of 12 tended to have a higher risk of POP as did women who were 30-33 years at their first childbirth.

CONCLUSIONS

POP is a common health problem in women, and BMI and number of childbirths are strong predictors.

Evaluation of urinary continence status and its influence on quality of life after gyneco-oncological treatment of female pelvic malignancies at an oncological center

Urinary incontinence (UI) could negatively affect a person's quality of life (QoL). This study investigates the association among gynecological cancers, their treatments, UI, and its effect on the QoL of survivors of gynecological cancer. This cross-sectional questionnaire-based study included 121 cases from 405 patients who had undergone gyneco-oncological therapy. The participants were asked whether they experienced any form of UI and whether it impacted their QoL. The following therapies were used to treat the 12 gynecologic tumor types found in the participants: surgery (n = 116, 95.87%), chemotherapy (CTx) (n = 51, 42.2%), radiotherapy (RTx) (n = 31, 25.6%), and antibody therapy (ABT) (n = 11, 9.1%). No significant association was determined between tumor type and UI. However, body mass index (BMI), radical hysterectomy, vulvar or vaginal surgery, and presence of UI before treatment had significant impacts on the presence of UI. The surgical access routes, CTx, ABT, and hysterectomy had significant impacts on the severity of UI after treatment. Among all patients, 55.4% reported very good QoL. These reports of good QoL by patients could be due to their very good adjustment to the situation, with regard to being diagnosed with and receiving treatment for cancer, or due to the patients considering UI to not be much of an issue. Additionally, 34% of patients reported they had not been informed about the risk of UI before treatment. Informing patients about UI as one of the risks of therapy before initiating the treatment is crucial as patients who had been informed beforehand coped with UI far better than those who were not informed. Hence, the treatment of UI is often successful, so patients should be encouraged to receive urogynecological consultation.

A rare case of obstructed labor due to sever uterine prolapse; a case report and literature review

INTRODUCTION

Uterine prolapse in pregnancy is a rare problem reported in literature and might increase problems such as emergency cesarean section, preterm delivery, and other materno-fetal complications. Prolapse becomes a life-threatening condition for both mother and baby when it creates a labor abstraction.

PRESENTATION OF CASE

Here, a 37 years old lady (BMI = 26, gestational age = 37 weeks), without any obvious risk factors, with sever uterine prolapse (stage IV) and obstructed labor was presented. Congested and incarcerated cervix along with the onset of uterine contractions led to emergency cesarean section, by incision made in fundal part of uterus, because the lower segment was not accessible or visible at all. Apical and lateral vaginal defect in the patient was corrected at cesarean section time.

CONCLUSION

As a result: with timely action for cesarean delivery, maternal-fetal complications were reduced, however the correction of apical uterovaginal defects during cesarean time is possible and improves the quality of life of women in the reproductive age.

Pelvic floor symptoms from first pregnancy up to 8 years after the first delivery: a longitudinal study

BACKGROUND

Despite the strong association between vaginal childbirth and pelvic floor dysfunction, genetic factors, pregnancy, advancing age, and lifestyle also play a role. The pelvic floor undergoes substantial changes during pregnancy which may contribute to pelvic floor dysfunction. On the other hand, these changes may be favorable to allow for vaginal delivery. However, there is a lack of studies assessing pelvic floor symptoms over time according to delivery mode, which includes women prior to delivery.

OBJECTIVE

The aim of this study was to describe urinary incontinence, vaginal symptoms, and bowel control symptoms from 21 weeks of gestation in the first pregnancy and up to 8 years after the first delivery, stratified by delivery mode.

STUDY DESIGN

This is a longitudinal observational cohort study. 300 nulliparous women were recruited during their first pregnancy. Pelvic floor symptoms were assessed at 21 and 37 weeks of gestation, and 6 weeks, 6 months, 12 months and 8 years after first delivery using the International Consultation on Incontinence Questionnaire (ICIQ) modules: the urinary incontinence sum score; the weighted vaginal symptom sum score; the vaginal-associated quality of life score; the bowel control sum score; and the bowel-associated quality of life sum score. Delivery mode at first delivery defined delivery groups as: normal vaginal, operative vaginal and cesarean delivery. A linear mixed model analysis was used to assess symptom scores over time and to assess the differences in symptom scores between the delivery groups.

RESULTS

Of the 300 women included in the study, of which 193 attended the 8-year follow-up. Pelvic floor symptoms differed in women with vaginal and cesarean delivery. The symptom scores showed a non-linear statistically significant trend. In women, who delivered vaginally, there was an increase of urinary incontinence and vaginal symptom scores already during pregnancy. In women, who later delivered by cesarean, there was a decrease of symptoms scores during pregnancy, and overall lower symptom scores compared to women with vaginal delivery until 12 months after first delivery. Pelvic floor symptoms scores increased from 12 months to 8 years after the first delivery and exceeded pregnancy levels in all delivery groups, however overall symptom scores were low. Differences between delivery groups were not statistically significant.

CONCLUSION

Pelvic floor symptoms differed in women with vaginal and cesarean delivery from the first pregnancy up to 8 years after the first delivery. These differences were recognizable already prior to first delivery.

New Method for Genital Aesthetic Surgery: An Easy-To-Learn Two-Step Approach With Acellular Dermal Matrix (ADM)

BACKGROUND

Vaginal laxity, usually accompanied with prolapse symptoms, affects women's sexual satisfaction and quality of life. Vaginal tightening surgery aims to reinforce the peri-vaginal muscle strength and restore the normal vaginal anatomy.

OBJECTIVES

The objective of this study was to introduce a new surgical approach with vaginal tightening using acellular dermal matrix (ADM).

METHODS

In this retrospective study, we analyzed data from 80 patients with vaginal laxity who underwent surgery from April 2017 to April 2021. Three-dimensional transvaginal ultrasound (3D-TVS) and the Female Sexual Function Index (FSFI) were evaluated among the patients.

RESULTS

The mean age of the patients was 44.6 years. The mean patient follow-up was 13.2 months. No infection, rectovaginal fistula, or implant explantation occurred. 3D-TVS demonstrated a significant reduction of introital diameter on a maximum Valsalva maneuver (2.3 cm vs. 4.1 cm; p<0.05) and the reconstruction of acute vaginal angulation. FSFI orgasm subscore increased significantly.

CONCLUSIONS

Vaginal tightening with ADM is a minimally invasive surgery with safety and efficacy for patients with vaginal laxity.

Profile of women with pelvic organ prolapse at the University Hospital of the West Indies risk factors and presentation

POP affected 40% of participants in the WHI trial. Risk factors include parity, vaginal delivery, large babies, advancing age, obesity, hysterectomy and lifting. Data suggest African-American women have a lower prevalence of symptomatic POP than other racial groups. Literature review did not show a study of risk factors and symptoms in a black population. Cross-sectional study of women with POP attending urogynaecology clinic at the UHWI from May to October 2013, using an interviewer administered questionnaire was performed and analysed using SPSS version 19 program (SPSS Inc., Chicago, IL). One hundred and eight participants were included: 94.7% postmenopausal (mean 65.08 years) and 94.5% parous (mean 4). Risk factors included obesity (mean BMI 28.82 kg/m²), hysterectomy (28.7%), heavy lifting (51.9%) and chronic cough (13.9%). Symptoms included stress incontinence (40.7%), stranguria (16.7%), faecal incontinence (13.9%), constipation (31.5%), coital urinary and faecal incontinence (6.3%, 12.6%). We concluded risk factors for POP in this population correlates with other studies. Stress urinary incontinence and constipation most frequently reported symptoms in this population.Impact StatementWhat is already known on this subject? Pelvic organ prolapse (POP) is a common condition with multifactorial aetiology. As seen in systematic reviews (Vergeldt TFM, Weemhoff M, IntHout J, Kluivers KB. 2015. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. International Urogynecology Journal 26(11):1559-1573). Study shows white women appeared to have more overall symptoms both from prolapse, as well as urinary symptoms, as compared with black women (Ford AT, Eto CU, Smith M, Northington GM. 2019. Racial differences in pelvic organ prolapse symptoms among women undergoing pelvic reconstructive surgery for prolapse. Female Pelvic Medicine & Reconstructive Surgery 25:130-133).What do the results of this study add? The result highlights the fact that Black women are exposed to similar risk factors and have similar symptoms to other racial groups for POP.What are the implications of these findings for clinical practice and/or further research? These findings can be used to educate women with risk factors about the possibility of developing symptomatic POP. Further research is needed to ascertain the prevalence of POP and to assess knowledge and attitude in this population as we hypothesise that there is generalised assumption in that being black is protective from POP.

Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior and posterior vaginal walls, uterus (cervix), or apex of the vagina (vaginal vault or cuff scar after hysterectomy). Although POP can be asymptomatic, if the bulge extends beyond the opening of the vagina, it can have a significant impact on a woman's quality of life. Findings include vaginal bulging toward or through the vaginal introitus that the patient may feel, palpate, or see with a mirror. If a woman is bothered by her prolapse, she should be offered both nonsurgical and surgical treatments.

International urogynecology consultation chapter 1 committee 2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs

INTRODUCTION AND HYPOTHESIS

This narrative review describes the existing epidemiologic literature and identifies gaps regarding pelvic organ prolapse (POP) prevalence, incidence, natural history, and current and future service needs.

MATERIALS AND METHODS

A PubMed search identified relevant citations published in 2000 or later. Pre-specified criteria were used to screen titles, abstracts, and manuscripts, including reference sections. Study findings were summarized to define what is known, identify gaps in current knowledge, and suggest priority areas for future research.

RESULTS

The reported prevalence of POP varies widely (1-65%) based on whether its presence is ascertained by symptoms (1-31%), pelvic examination (10-50%), or both (20-65%). Most existing population-based surveys do not include physical examination data. White women from higher income countries are overrepresented in the existing literature. Incidence and natural history data are limited and consist mainly of cohorts that follow women after pregnancy or menopause. Given global increases in aging populations in well-resourced countries, the need for POP treatment is anticipated to increase in the coming decades. In lower and middle income countries (LMICs) where demographic trends are different, there is a dearth of information about anticipated POP service needs.

CONCLUSION

Future POP incidence, prevalence, and natural history studies should include non-white women from LMICs and should combine pelvic examination data with validated patient-reported outcome measures when feasible. Anticipated future service needs differ globally, with a greater demand for POP treatment services in well-resourced settings where aging populations are prevalent.

Comparison of diagnostic value of two-dimensional ultrasound and clinical examination in fetal weight estimation

Background:

Estimation of fetal weight during pregnancy plays an important role in prenatal and intrapartum care and is more important in pregnancies after 37 weeks to determine the type of delivery. The aim of this study was to compare and evaluate the accuracy and diagnostic value of two-dimensional ultrasound and clinical examination in estimating fetal weight and pregnancy outcomes.

Materials and Methods:

This cross-sectional study was conducted on 300 pregnant women without abnormal fetuses and pregnancies after 37 weeks; mothers who had a normal delivery or cesarean section were evaluated by the available method. The weight of the fetus was estimated before and after delivery, using ultrasound and clinical examination. Newborns were classified into five groups based on their fetal weight. Analysis of collected data was performed with SPSS software.

Results:

The mean age of the patients was 31 years and the mean weight of the neonates was 3450 g. At a weight of less than 3000 g, ultrasound and clinical evaluation were strongly correlated with the actual weight of the infant, but at weights of more than 3500 and 4000 g, weight estimation with ultrasound was highly accurate, and clinical examination had poor accuracy. In lower weights, square errors were fewer in both ultrasound and clinical examination, in comparison with higher weights. In higher weights, ultrasound is more reliable, and the diagnostic accuracy of clinical examination is reduced.

Conclusion:

Estimation of fetal weight with prenatal ultrasound is highly accurate. Clinical examination is more accurate in determining the weight of small fetuses and does not pay much attention to the diagnosis of macrosomic fetuses and even leads to overestimation, while ultrasound is much more accurate in diagnosing fetal macrosomia.

CORRELATION BETWEEN PELVIC FLOOR DYSFUNCTION ON DYNAMIC 3D ULTRASOUND AND VAGINAL DELIVERY, PARITY, AND AGE IN WOMEN WITH OBSTRUCTED DEFECATION SYMPTOMS

BACKGROUND

Few studies have investigated the constipation or obstructed defecation symptoms identified by using imaging, as dynamic three-dimensional ultrasound and correlate vaginal delivery, parity, and age.

OBJECTIVE

The aim of this study was to assess the prevalence of pelvic floor dysfunctions in female patients with obstructed defection symptoms and to determine whether specific pelvic floor dysfunctions identified by dynamic three-dimensional ultrasonography (echodefecography) are correlated with vaginal delivery, parity, and age. The secondary goal is to report the prevalence of coexisting pelvic floor dysfunctions.

METHODS

This is a retrospective cohort study including patients with obstructed defecation symptoms underwent echodefecographyto evaluate pelvic floor dysfunctions in the posterior compartment and correlate with vaginal delivery, parity, and age.

RESULTS

Of 889 female: 552 (62%) had had vaginal delivery and 337 (38%) were nulliparous. The prevalence of dysfunctions identified by echodefecography (rectocele, intussusception, enterocele/sigmoidocele, and dyssynergia) was similar between the two groups and was not associated with number of deliveriesor age. However, the prevalence of sphincter defects showed higher rates in women with vaginal delivery and increased with the parity. Up to 33% of patients had coexisting dysfunctions.

CONCLUSION

The prevalence of dysfunctions such as rectocele, intussusception, dyssynergia, and enterocele/sigmoidocele assessed by echodefecography in patients with obstructed defecation symptoms are found similar regardless of vaginal delivery, number of deliveries or stratified-age. In vaginal delivery, number of deliveries does impact on detection of sphincter defects and liability to fecal incontinence.

Stress and urgency urinary incontinence one year after a first birth-prevalence and risk factors. A prospective cohort study

INTRODUCTION

Few prospective studies have examined the effect of pregnancy and childbirth on stress and urgency urinary incontinence separately. The aim of the present study was to assess the extent to which pregnancy, vaginal delivery, and vaginal delivery characteristics affect the risk of significant stress and urgency incontinence 1 year after delivery.

MATERIAL AND METHODS

We conducted a prospective cohort study of 670 nulliparous women from early pregnancy to 1 year partum. The women were recruited at maternity health care service in Region Örebro County, Sweden, between October 1, 2014 and October 1, 2017 and completed questionnaires in early and late pregnancy and at 8 weeks and 1 year postpartum. Primary outcome measures were significant stress and urgency incontinence at 1 year postpartum in women who reported being continent before pregnancy. Generalized linear models were used.

RESULTS

Stress and urgency incontinence commencing before pregnancy were reported by 4% and 3% of women, respectively, in the first questionnaire in early pregnancy, and these women were excluded from subsequent analysis. Stress and urgency incontinence were reported by 21% and 8%, respectively, at 1 year postpartum, in women not reporting incontinence before pregnancy. Stress incontinence during pregnancy increased the risk of stress incontinence postpartum (risk ratio [RR] 2.48, 95% CI 1.86-3.3). Urgency incontinence during pregnancy increased the risk of urgency incontinence postpartum (RR 4.07, 95% CI 2.1-7.89). Vaginal delivery increased the risk of stress incontinence postpartum (adjusted RR 2.63, 95% CI 1.39-5.01) but not of urgency incontinence. This effect of vaginal delivery on stress incontinence was similar irrespective of incontinence status during pregnancy. The population-attributable fraction of stress incontinence associated with vaginal delivery was 0.58 (95% CI 0.23-0.77).

CONCLUSIONS

This study shows essentially different risk factors for stress and urgency incontinence, supporting stress incontinence as being the subtype mostly associated with pregnancy and childbirth, and urgency incontinence as being more stable over time. At a population level, vaginal delivery was the major risk factor for stress incontinence, followed by reporting stress incontinence during pregnancy.

The evolution of pelvic canal shape and rotational birth in humans

BACKGROUND

The human foetus typically needs to rotate when passing through the tight birth canal because of the complex shape of the pelvis. In most women, the upper part, or inlet, of the birth canal has a round or mediolaterally oval shape, which is considered ideal for parturition, but it is unknown why the lower part of the birth canal has a pronounced anteroposteriorly oval shape.

RESULTS

Here, we show that the shape of the lower birth canal affects the ability of the pelvic floor to resist the pressure exerted by the abdominal organs and the foetus. Based on a series of finite element analyses, we found that the highest deformation, stress, and strain occur in pelvic floors with a circular or mediolaterally oval shape, whereas an anteroposterior elongation increases pelvic floor stability.

CONCLUSIONS

This suggests that the anteroposterior oval outlet shape is an evolutionary adaptation for pelvic floor support. For the pelvic inlet, by contrast, it has long been assumed that the mediolateral dimension is constrained by the efficiency of upright locomotion. But we argue that the mediolateral elongation has evolved because of the limits on the anteroposterior diameter imposed by upright posture. We show that an anteroposteriorly deeper inlet would require greater pelvic tilt and lumbar lordosis, which compromises spine health and the stability of upright posture. These different requirements of the pelvic inlet and outlet likely have led to the complex shape of the pelvic canal and to the evolution of rotational birth characteristic of humans.

The obstetrical dilemma hypothesis: there's life in the old dog yet

The term 'obstetrical dilemma' was coined by Washburn in 1960 to describe the trade-off between selection for a larger birth canal, permitting successful passage of a big-brained human neonate, and the smaller pelvic dimensions required for bipedal locomotion. His suggested solution to these antagonistic pressures was to give birth prematurely, explaining the unusual degree of neurological and physical immaturity, or secondary altriciality, observed in human infants. This proposed trade-off has traditionally been offered as the predominant evolutionary explanation for why human childbirth is so challenging, and inherently risky, compared to that of other primates. This perceived difficulty is likely due to the tight fit of fetal to maternal pelvic dimensions along with the convoluted shape of the birth canal and a comparatively low degree of ligamentous flexibility. Although the ideas combined under the obstetrical dilemma hypothesis originated almost a century ago, they have received renewed attention and empirical scrutiny in the last decade, with some researchers advocating complete rejection of the hypothesis and its assumptions. However, the hypothesis is complex because it presently captures several, mutually non-exclusive ideas: (i) there is an evolutionary trade-off resulting from opposing selection pressures on the pelvis; (ii) selection favouring a narrow pelvis specifically derives from bipedalism; (iii) human neonates are secondarily altricial because they are born relatively immature to ensure that they fit through the maternal bony pelvis; (iv) as a corollary to the asymmetric selection pressure for a spacious birth canal in females, humans evolved pronounced sexual dimorphism of pelvic shape. Recently, the hypothesis has been challenged on both empirical and theoretical grounds. Here, we appraise the original ideas captured under the 'obstetrical dilemma' and their subsequent evolution. We also evaluate complementary and alternative explanations for a tight fetopelvic fit and obstructed labour, including ecological factors related to nutrition and thermoregulation, constraints imposed by the stability of the pelvic floor or by maternal and fetal metabolism, the energetics of bipedalism, and variability in pelvic shape. This reveals that human childbirth is affected by a complex combination of evolutionary, ecological, and biocultural factors, which variably constrain maternal pelvic form and fetal growth. Our review demonstrates that it is unwarranted to reject the obstetrical dilemma hypothesis entirely because several of its fundamental assumptions have not been successfully discounted despite claims to the contrary. As such, the obstetrical dilemma remains a tenable hypothesis that can be used productively to guide evolutionary research.

The association between bladder dysfunction, balance and falls in women with multiple sclerosis: The specific contribution of fear of falling

BACKGROUND

Bladder dysfunction is the most common autonomic disturbance in people with MS (PwMS). Only a few studies have examined the relationship between bladder dysfunction and falls in PwMS. Bladder dysfunction has been deemed only a secondary outcome measure, and classified by a gross measure providing a limited perspective of this disturbing symptom. Furthermore, no study to date has focused on the relationship between bladder dysfunction and balance performance in PwMS.

RESEARCH QUESTION

Determine the relationship between bladder dysfunction with balance, falls and fear of falling in women with MS.

METHODS

The study was observational, including 44 women with MS, mean age 46.3 (SD = 5.7), all with at least a mild bladder dysfunction. Outcome measures included the Urinary Incontinence Quality of Life Scale (I-QoL), Bladder Control Scale (BLCS), Timed Up and Go Test (TUG), Four Square Step Test (FSST), Falls Efficacy Scale International (FES-I), Falls status, and posturography.

RESULTS

Participants performed the TUG in 14.1 s (S.D. = 11.1), and the FSST in 20.5 s (S.D. = 22.4). A relatively large proportion (68.2 %) of women was classified as fallers. However, no differences were found between those classified as fallers (n = 30) or non-fallers (n = 14) in terms of the I-QoL and the BLCS, controlling for age, EDSS and number of vaginal deliveries. Significant correlations scores were found between the I-QoL, BLCS and FES-I (rho ∼0.47), while controlling for age, EDSS and number of vaginal deliveries. No associations were demonstrated between the bladder dysfunction outcome scores and either the TUG and/or FSST.

SIGNIFICANCE

Women afflicted with MS and suffering from bladder dysfunction tend to fall and present with more balance difficulties compared with disability-matched PwMS. Nevertheless, once bladder dysfunction is detected, the perceived severity of the condition is not associated with balance and prevalence of falling, but rather on fear of falling.

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.

Biomechanical trade-offs in the pelvic floor constrain the evolution of the human birth canal

Compared with most other primates, humans are characterized by a tight fit between the maternal birth canal and the fetal head, leading to a relatively high risk of neonatal and maternal mortality and morbidities. Obstetric selection is thought to favor a spacious birth canal, whereas the source for opposing selection is frequently assumed to relate to bipedal locomotion. Another, yet underinvestigated, hypothesis is that a more expansive birth canal suspends the soft tissue of the pelvic floor across a larger area, which is disadvantageous for continence and support of the weight of the inner organs and fetus. To test this "pelvic floor hypothesis," we generated a finite element model of the human female pelvic floor and varied its radial size and thickness while keeping all else constant. This allowed us to study the effect of pelvic geometry on pelvic floor deflection (i.e., the amount of bending from the original position) and tissue stresses and stretches. Deflection grew disproportionately fast with increasing radial size, and stresses and stretches also increased. By contrast, an increase in thickness increased pelvic floor stiffness (i.e., the resistance to deformation), which reduced deflection but was unable to fully compensate for the effect of increasing radial size. Moreover, larger thicknesses increase the intra-abdominal pressure necessary for childbirth. Our results support the pelvic floor hypothesis and evince functional trade-offs affecting not only the size of the birth canal but also the thickness and stiffness of the pelvic floor.

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 organ prolapse and Japanese lifestyle: prevalence and risk factors in Japan

INTRODUCTION AND HYPOTHESIS

Little is known about the prevalence of pelvic organ prolapse (POP). We aimed to evaluate the prevalence of POP and identify its risk factors in Japan.

METHODS

This was a single-centre, cross-sectional study. We recruited Japanese women seen for a Pap smear from July 2018 through May 2019. After providing their informed consent, subjects were asked to complete questionnaires. Pelvic organ support was assessed using the POP quantification (POP-Q) system by an examiner. Logistic regression analyses were conducted to identify risk factors for POP.

RESULTS

There were 1032 women aged 21 to 84 years. The distribution of POP-Q stage was stage 0, 38.0%; stage I, 45.0%; stage II, 16.4%; stage III, 0.6%; and stage IV, 0%. Rates (95% confidence interval [CI]) of stage II or greater in each age group were 6.6% (2.4-10.8) in 20 s-30 s; 17.6% (13.3-21.9) in 40 s; 17.1% (12.9-21.3) in 50 s; 18.0% (12.6-23.4) in 60 s; and 28.7% (19.6-37.9) in 70 s and over. Multivariate analysis revealed the following risk factors for POP, with odds ratio (95% CI): body mass index [BMI] ≥ 25 kg/m², 1.63 (1.05-2.51); BMI < 18.5 kg/m², 0.40 (0.17-0.94); hysterectomy, 4.09 (1.55-10.80); ≥ 3 vaginal deliveries, 2.26 (1.19-4.28); and ≥ 1 cup of coffee per day, 0.63 (0.43-0.92).

CONCLUSION

Among Japanese women undergoing routine gynaecological examinations, 17.1% (14.7-19.5) had POP-Q stage II or greater. Overweight, hysterectomy and ≥ 3 vaginal deliveries increased the risk for POP, whereas underweight and daily coffee consumption decreased it.

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.

Post-partum pelvic floor dysfunction assessed on 3D rotational ultrasound: a prospective study on women with first- and second-degree perineal tears and episiotomy

Purpose: To evaluate the morphology and biometry of pelvic floor structures 3 months after birth in women experiencing first- or second-degree perineal tears or undergoing episiotomy during labor.Material and methods: Prospective observational study including nulliparous women delivering at term with a clinical diagnosis of first- or second-degree perineal tears after birth or undergoing episiotomy. The role of Kristeller maneuver during labor in affecting pelvic structure and function is also explored. All women underwent 2D trans-perineal and 3D endovaginal or endoanal ultrasound 3 months after birth.Results: 115 women assessed 3 months after delivery were enrolled in the study. Compared with controls, women who experienced first-degree perineal tears had higher bladder neck-symphysis (versus 20.9 ± 4.9 versus 16.1 ± 4.9 mm, p = .017), bladder wall-pubic symphysis (22.4 ± 7.4 versus 14.2 ± 9.5 mm, p = .02) and anorectal angle-symphysis distance (12.5 ± 4.7 versus 9.3 ± 4.3 mm, p = .018). Furthermore, they have thicker internal and external anal sphincter. The incidence of partial right and left pubo-rectalis muscle avulsion was higher in women experiencing first-degree vaginal tear during labor (16.2 versus 0%, p = .004 for both). In women affected by second-degree tears, the occurrence of partial avulsion of the right and left pubo-rectalis muscle was 16.2%, while Oasis was detected in 10.8% of the cases. Women receiving Kristeller maneuver during labor had a higher incidence of either right or left puborectalis muscle avulsion.Conclusion: Women who had either first- and second-degree perineal tears or episiotomy show signs of abnormal pelvic morphometry on 3D rotational ultrasound 3 months after birth.

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.

Pregnancy, puerperium and perinatal constipation - an observational hybrid survey on pregnant and postpartum women and their age-matched non-pregnant controls

OBJECTIVE

To evaluate the prevalence of constipation during pregnancy and early puerperium.

DESIGN

Observational survey.

SETTING

Secondary and tertiary hospital in Finland.

POPULATION

Pregnant (n = 474) and postpartum (n = 403) women and a control group of 200 non-pregnant women who did not give birth in the past year.

METHODS

Women reported bowel function and other gastrointestinal symptoms on a structured questionnaire using an 11-point numerical rating scale (0 = no symptom, 10 = most severe symptom) and binominal yes/no questions during the second and third trimesters and few days and 1 month after childbirth.

MAIN OUTCOME MEASURE

Prevalence of constipation based on the Rome IV criteria.

RESULTS

The data consist of five cohorts of women: second trimester (n = 264), third trimester (n = 210), after vaginal delivery (n = 200) or caesarean section (n = 203), and a control group (n = 200). The prevalence of constipation was 40% in pregnant women and 52% (P < 0.001) in postpartum women, which was a higher prevalence than that in the control group, where 21% had constipation (P < 0.001). A few days after delivery, the prevalence of constipation was lower after vaginal delivery (47%) than caesarean section (57%, P < 0.039). One month postpartum, the prevalence of constipation was low: 9% after vaginal delivery (P = 0.002 compared with the control group) and 15% after caesarean section. Other gastrointestinal symptoms were common; pregnant women had the highest prevalence (34%) of nausea/vomiting.

CONCLUSION

The prevalence of constipation was two- to three-fold higher in pregnant women and a few days after delivery than in non-pregnant women. During puerperium, bowel function returned to or below that reported in non-pregnant women.

TWEETABLE ABSTRACT

Constipation is common in pregnancy and after delivery, but bowel function returns early in puerperium.

Laparoscopic vaginal lateral suspension: technical aspects and initial experience

BACKGROUND

Pelvic organ prolapse (POP) etiology is a combination of anatomical, physiological, genetic, lifestyle, and reproductive factors determine pelvic floor dysfunction. POP is very common across all ages women worldwide and has become an increasing socioeconomic problem with public health consequences, with symptoms that could lead to a significant decrease in quality of life.

METHODS

This study retrospectively analyzes a small case series of our initial experience of laparoscopic vaginal suspension with mesh focusing on the technical aspects of the technique. Although sacrocolpopexy and sacrohysteropexy are the most performed surgical techniques, they are associated with serious complications. Laparoscopic vaginal suspension appears reproducible and safe to learn.

RESULTS

Between November 2017 and January 2020, fifteen patients underwent laparoscopic vaginal suspension for pelvic organ prolapse repair. Despite the small number, for a minimally invasive skilled surgeon, we notice a significative reduction of the learning curve to become proficient in this procedure.

CONCLUSIONS

The diagnosis and management of pelvic organ prolapse are further complicated by what is considered "successful" treatment. Laparoscopic vaginal suspension is a feasible surgical procedure for one-stage treatment of pelvic organ prolapse.

Burden of pelvic organ prolapse in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Pelvic organ prolapse can significantly affect a woman's quality of life by compromising physical, social, psychological and sexual function. Pelvic organ disorders and its consequences have higher economic burden to the patient as well to the country. Therefore, this systematic review and met- analysis aimed to estimate the burden of POP in Ethiopia.

METHODS

International databases (MEDLINE/Pub Med, Hinari, Scopus, Google scholar, African journals and literatures were searched and seven eligible cross sectional and two case control studies were included in this systematic review and meta-analysis. Eggers test and funnel plot were computed to check publication bias across the studies. Publication bias was computed using a funnel plot and eggers test. Heterogeneity of the studies was checked using Cochrane Q-test and I2 statistic. Subgroup analysis was computed for the evidence of heterogeneity.

RESULTS

This systematic review and meta-analysis revealed that the overall national prevalence of pelvic organ prolapse in Ethiopia was 23.52% (95% CI: 61.04, 80.24). Being rural resident (AOR = 3.29; 95% CI: 1.38-7.85), I2 = 47.5%, P = 0.167), having < 18.5 BMI (AOR = 2.59; 95% CI: 1.53-4.4), I2 = 59.9%, P = 0.64), and age > 40(AOR = 7.43; 95% CI: 2.27-24.29), I2 = 75.9%, P = 0.016) were the associated risk factors for pelvic organ prolapse.

CONCLUSIONS

The pooled prevalence of pelvic organ prolapse was high. Residence, body mass index and age of the women were the predictors of pelvic organ prolpase. Creating awareness and identifying the modifiable and non modifiable risk factors for pelvic organ prolpase is a crucial strategy to prevent further complications and risk of operation.

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.

MAGNETIC RESONANCE IMAGING OF PELVIC FLOOR DYSFUNCTION, REVIEW

Pelvic floor dysfunction is an important medical and social problem in the female population. The impact of pelvic floor disorders (PFD) is likely to grow as the prevalence of these disorders increases with an aging population. Pregnancy and delivery are considered major risk factors in the development of POP and stress urinary incontinence. Pelvic floor dysfunction may involve pelvic organ prolapse and/or pelvic floor relaxation. Organ prolapse can include any combination of the following: urethra (urethrocele), bladder (cystocele), or both (cystourethrocele), vaginal vault and cervix (vaginal vault prolapse), uterus (uterineprolapse), rectum (rectocele), sigmoid colon (sigmoidocele),and small bowel (enterocele).Given the paucity of understanding of PFD pathophysiology ,multicompartmental pathology, the high rate of recurrence and repeat surgery imaging plays a major role in its clinical management.The magnetic resonance imaging (MRI) allows noninvasive, radiation-free, rapid, high-resolution evaluation the multicompartment defects in one examination.Findings reported at MR imaging of the pelvic floor are valuable for selecting candidates for surgical treatment and for indicating the most appropriate surgical approach.

Recommendations and future research initiative to optimize bladder management in pregnancy and childbirth International Consultation on Incontinence - Research society 2018

With increasing birth rates globally, obstetric bladder care and long term pelvic floor dysfunction continues to be a issue. This paper aims to provide an overview of the concerns in the antenatal, intrapartum an post partum periods and presents recommendation for the research requirements necessary and education to challenge current practice.

The mysteries of menopause and urogynecologic health: clinical and scientific gaps

OBJECTIVES

A significant body of knowledge implicates menopausal estrogen levels in the pathogenesis of the common pelvic floor disorders (PFDs). These health conditions substantially decrease quality of life, increase depression, social isolation, caregiver burden, and economic costs to the individuals and society.

METHODS

This review summarizes the epidemiology of the individual PFDs with particular attention to the understanding of the relationship between each PFD and menopausal estrogen levels, and the gaps in science and clinical care that affect menopausal women. In addition, we review the epidemiology of recurrent urinary tract infection (rUTI)-a condition experienced frequently and disproportionately by menopausal women and hypothesized to be potentiated by menopausal estrogen levels.

RESULTS

The abundance of estrogen receptors in the urogenital tract explains why the natural reduction of endogenous estrogen, the hallmark of menopause, can cause or potentiate PFDs and rUTIs. A substantial body of epidemiological literature suggests an association between menopause, and PFDs and rUTIs; however, the ability to separate this association from age and other comorbid conditions makes it difficult to draw definitive conclusions on the role of menopause alone in the development and/or progression of PFDs. Similarly, the causative link between the decline in endogenous estrogen levels and the pathogenesis of PFDs and rUTIs has not been well-established.

CONCLUSIONS

Innovative human studies, focused on the independent effects of menopausal estrogen levels, uncoupled from tissue and cellular senescence, are needed.

Effects of a selective androgen receptor modulator (SARM), GSK2849466A, on stress urinary incontinence and bladder activity in rats with ovariectomy-induced oestrogen deficiency

OBJECTIVES

To report the effect of a selective androgen receptor modulators (SARMs) on the urethral continence mechanisms in a rat model of stress urinary incontinence (SUI) induced by bilateral ovariectomy (OVX).

MATERIALS AND METHODS

Female Sprague-Dawley rats with bilateral OVX were used. Rats were divided into five groups; sham operated, vehicle-treated OVX, low-dose SARM-treated OVX (GSK2849466A: 0.005 mg/kg/day, per os [p.o.]), high-dose SARM-treated OVX (GSK2849466A: 0.03 mg/kg/day, p.o.) and dihydrotestosterone (DHT)-treated OVX (1 mg/kg/day, subcutaneous) groups. After 4 weeks of SARM treatments or 3 weeks of DHT treatment (6 weeks after OVX), rats were subjected to evaluation of the sneeze-induced continence reflex using microtransducer-tipped catheter methods, sneeze-induced leak-point pressure, and continuous cystometry measurements, followed by histological analyses of urethral tissues.

RESULTS

(i) OVX significantly impaired urethral continence function after 6 weeks to induce SUI during sneezing. (ii) Low-dose SARM treatment restored urethral baseline pressure (UBP) without affecting the amplitude of urethral response during sneezing (A-URS), partially reversing OVX-induced SUI during sneezing. (iii) High-dose SARM treatment reversed decreases in both UBP and A-URS, more effectively preventing SUI during sneezing. (iv) DHT treatment only restored A-URS without affecting UBP, partially preventing OVX-induced SUI during sneezing. (v) The high-dose SARM treatment induced hypertrophy of the striated and smooth muscle around the urethra. (vi) SARM treatment did not affect bladder function in sham or OVX rats.

CONCLUSION

Treatment with SARMs could be a more effective modality for the treatment of SUI than DHT, without affecting bladder function, by enhancing smooth- and striated muscle-mediated urethral function under stress conditions such as sneezing.

Vaginal delivery combined with vaginal tightening surgery and perineal body repair: 5 case reports

The present study aimed to investigate the feasibility of vaginal delivery combined with vaginal tightening surgery and perineal body repair.From January 2017 to April 2017, 5 cases underwent vaginal delivery combined with vaginal tightening surgery and perineal body repair. We retrospectively analyzed the clinical data.The incisions of 5 cases were all primary healing; vulva form was improved, and there were no postoperative hematoma, infection or vaginal mucosa prolapse. Sexual function was improved to different degrees. The pelvic muscle force test showed that both the type I and type II myofiber scores were increased.It is feasible to perform vaginal delivery combined with vaginal tightening surgery and perineal body repair, which is a safe and effective method for improving sex life and pelvic floor function.

Prevalence of symptomatic urinary incontinence and pelvic organ prolapse among women in rural Nepal

INTRODUCTION AND HYPOTHESIS

Although pelvic floor disorders (PFDs) are a significant public health issue in higher income countries, less is known about these disorders and associated risk factors in low income countries. We aimed to determine prevalence and associated risk factors for stress urinary incontinence (SUI), urge urinary incontinence (UUI), and pelvic organ prolapse (POP) in reproductive age women in Sarlahi District in rural Nepal.

METHODS

We conducted a community-based cross-sectional survey of parous, reproductive age women in rural Nepal and screened for pelvic floor disorders using validated screening questions for PFDs. Overall frequency of self-reported symptoms for SUI, UUI, and POP was estimated and compared across demographic and pregnancy history information.

RESULTS

Of 14,469 women available for analysis, the mean (SD, range) age was 33.5 (8.2, 13-52) years, and median (range) number of pregnancies was 4 (1-15). The prevalence of SUI was 24.1% (95% CI: 23.3-24.8), of UUI was 13.5% (95% CI: 13.0-14.1), and of POP was 8.0% (95% CI: 7.5-8.4). Bivariate analysis identified the risk of PFD increased incrementally with age and number of vaginal deliveries; these covariates were highly correlated. Multivariable logistic regression revealed age, vaginal deliveries, and previous pelvic surgeries were independently associated with PFD.

CONCLUSIONS

PFDs are common in a community of parous, reproductive age women in rural Nepal. Risk factors for these conditions are similar to risk factors found in higher income countries.

Associations Between Risk Factors and Overactive Bladder: A Meta-analysis

Age and body mass index are associated with increased risks of overactive bladder, whereas employment status is associated with a decreased risk of overactive bladder.

Objective

The purpose of this study was to investigate the risk factors of overactive bladder (OAB).

Methods

The PubMed, Embase, and Cochrane Library databases were retrieved through May 2016. Odds ratios (OR) or standard mean differences (SMDs) with 95% confidence intervals (CIs) were used to evaluate the associations between risk factors and OAB. Heterogeneity among studies was examined using χ² test based on the Q and I² tests.

Results

A total of 28 articles were analyzed in our study. The results suggested that age and body mass index were significantly higher in OAB patients than in non-OAB controls (SMDs [95% CIs], 0.30 [0.19–0.41] and 0.39 [0.24–0.53]). A significant negative association was found between employment status and OAB (OR [95% CIs], 0.64 [0.46–0.90]). However, sex, educational level, parity, vaginal delivery, race, menopause, marital status, smoking, and alcohol consumption were not significantly different in OAB and non-OAB control patients (ORs [95% CIs], 0.95 [0.59–1.55], 1.04 [0.82, 1.33], 0.98 [0.56–1.70], 1.66 [0.90–3.07], 0.98 [0.75–1.28], 1.84 [0.23–14.70], 0.97 [0.78–1.19], 0.91 [0.77–1.08], and 0.88 [0.71–1.09], respectively). In addition, the number of parities and vaginal deliveries in OAB patients also showed no significant differences compared with non-OAB control patients (SMDs [95% CI], 0.05 [−0.27 to 0.38] and −0.16 [0.40 to 0.09]).

Conclusions

This meta-analysis suggests that age and body mass index are associated with increased risks of OAB, whereas employment status is associated with a decreased risk of OAB. Further prospective studies with large sample sizes are needed to confirm this conclusion.

Cesarean delivery to prevent anal incontinence: a systematic review and meta-analysis

BACKGROUND

Cesarean delivery (CD), is increasingly recommended as a mode of delivery that prevents the anal incontinence (AI) that arises in some women after vaginal delivery (VD). The assessment of the efficacy of CD in this regard was the subject of this systematic review.

METHODS

Searches were conducted in Medline, EMBASE and the Cochrane Library. Both randomized (RCTs) and non-randomized trials (NRTs) comparing the risk of sustained fecal and/or flatus incontinence after VD or CD were sought from 1966 to 1 January, 2019. Studies were eligible if they assessed AI more than 6 months after birth, and had statistical adjustment for at least one of the three major confounders for AI: age, maternal weight or parity. In addition, each study was required to contain more than 250 participants, more than 50 CDs and more than 25 cases of AI. Data after screening and selection were abstracted and entered into Revman for meta-analysis. Analyses were done for combined fecal and flatus incontinence (comAI), fecal incontinence (FI), gas incontinence (GI), CD before or during labor, time trend of incontinence after delivery, assessment of both statistical and clinical heterogeneity, parity and late incident AI.

RESULTS

Out of the 2526 titles and abstracts found, 24 eligible studies were analyzed, 23 NRTs and one RCT. These included women with 29,597 VDs and women with 6821 CDs. Among the primary outcomes, VD was found not to be a significant predictor of postpartum comAI compared to CD in 6 studies, incorporating 18,951 deliveries (OR = 0.74; 0.54-1.02). VD was also not a significant predictor of FI in 14 studies, incorporating 29,367 deliveries, (OR = 0.89; 0.76-1.05). VD was not a significant predictor of GI in six studies, incorporating 6724 deliveries (OR = 0.96; 0.79-1.18). The strength of the grading of recommendations, assessment, development and evaluations (GRADE) evidence for each of these was low for comAI and moderate for FI and GI (upgrade for lack of expected effect). Time trend FI showed incontinence at 3 months often resolved at 1 year. Other secondary analyses assessing parity, delayed incidence of FI, clinical and statistical heterogeneity, spontaneous VD only, late risk of incidence of AI, and CD in or prior to labor all had similar results as in the primary outcomes.

CONCLUSIONS

There are three components of pelvic floor dysfunction that are thought to be caused by VD and hopefully prevented by CD: AI, urinary incontinence and pelvic floor prolapse. Of these, AI was not found to be reliably prevented by CD in this review.

Effects of delivery mode and age on motor unit properties of the external anal sphincter in women

INTRODUCTION AND HYPOTHESIS

This study aimed to assess the individual and interactive effects of delivery mode and age on the function of the external anal sphincter (EAS) by analyzing the motor unit properties with intramuscular electromyography (EMG). Results are expected to improve the understanding of delivery-related occult obstetric EAS injuries and its development over the aging process and further support early clinical detection and intervention.

METHODS

A total of 49 postpartum women were recruited into four test groups according to their age and delivery mode: young vaginal delivery (Y-VD), elderly vaginal delivery (E-VD), young cesarean section (Y-CS), and elderly cesarean section (E-CS) groups. Anorectal ultrasonography, manometry, and intramuscular EMG were employed for comprehensive evaluation of EAS function.

RESULTS

No significant difference in anorectal ultrasonography and most manometry measurements was associated with delivery age or mode. Intramuscular EMG, however, revealed a statistically significant difference in the characteristics of motor unit potentials (MUPs), including duration, turns, phases, and multiphase wave ratio between four subject groups. No significant interaction effect between age and delivery mode was found.

CONCLUSIONS

Delivery mode and age have a significant effect on the neuromuscular function of the EAS, suggesting a potential protectiveness of cesarean section against impairment to the EAS. Our results do not provide significant evidence regarding the interaction effect of delivery mode and age; further investigations are needed to confirm this conclusion.

One and the Same? Nocturnal Enuresis and Overactive Bladder in the Female Veteran Population: Evaluation of a Large National Database

OBJECTIVES

The aims of this study were to describe relationships between women given a diagnosis of nocturnal enuresis (NE) and controls without any urinary complaints and to compare women with NE with those with overactive bladder (OAB). We hypothesized that NE has unique associations with demographics and medical and psychosocial diagnoses.

METHODS

This is a secondary analysis of a database that included all female veterans who established care with a primary care provider from 1997 to 2015. International Classification of Diseases, Ninth Revision, codes identified women with a diagnosis of NE or OAB. Patient characteristics, medical diagnoses, and psychosocial factors previously described as relating to NE and/or OAB were compared between the 2 distinct comparative groups, with significance set at P < 0.05. Stepwise logistic regression was used to assess all significant findings.

RESULTS

A total of 596,815 women were identified; controls totaled 570,049, the group with OAB totaled 26,446 (4.4%), and the group with NE totaled 301 (0.05%).Multivariable analysis compared the group with NE with controls; all measured psychosocial characteristics remained significantly associated with an NE diagnosis (all Ps < 0.05), as well as obstructive sleep apnea history, stroke, self-identification as "minority," smoking, hypertension, and a body mass index higher than those of the general control population (all Ps < 0.05).When the populations with NE and OAB were compared, a diagnosis of posttraumatic stress disorder, an overdose history, depression, military sexual trauma, increasing body mass index, and younger age remained significantly associated with NE (all Ps < 0.05).

CONCLUSIONS

The association of NE with psychosocial characteristics and psychiatric illnesses persisted irrespective of the comparison population. Practitioners should investigate the diagnosis of NE in those female veterans with psychosocial issues.

Multimodal imaging assessment and histologic correlation of the female rat pelvic floor muscles' anatomy

Pelvic floor disorders negatively impact millions of women worldwide. Although there is a strong epidemiological association with childbirth, the mechanisms leading to the dysfunction of the integral constituents of the female pelvic floor, including pelvic floor skeletal muscles, are not well understood. This is in part due to the constraints associated with directly probing these muscles, which are located deep in the pelvis. Thus, experimental models and non-invasive techniques are essential for advancing knowledge of various phenotypes of pelvic floor muscle injury and pathogenesis of muscle dysfunction, as well as developing minimally invasive approaches for the delivery of novel therapeutics. The most widely used animal model for pelvic floor disorders is the rat. However, the radiological anatomy of rat pelvic floor muscles has not been described. To remedy this gap, the current study provides the first detailed description of the female rat pelvic floor muscles' radiological appearance on MR and ultrasound images, validated by correlation with gross anatomy and histology. We also demonstrate that ultrasound guidance can be used to target rat pelvic floor muscles for possible interventional therapies.

Person-Centered Care for Patients with Pessaries

Pelvic organ prolapse is a common condition affecting women of any age but more likely to occur in the aging woman. Prolapse has a significant impact on quality of life, sexuality, and body image. Vaginal support pessaries have been used since ancient times and are a safe and effective nonsurgical treatment option. Fitting a pessary results in immediate symptom improvement. A comprehensive evaluation for pessary fitting is time intensive but necessary. Nurse providers perform direct pessary care and have a role in caring for women with prolapse expanding access to care. Caregiver and family involvement is important for pessary care and follow-up.