Do Measures of Muscular Fitness Modify the Effect of Intra-abdominal Pressure on Pelvic Floor Support in Postpartum Women?

Technologies for Evaluation of Pelvic Floor Functionality: A Systematic Review

Pelvic floor dysfunction is a common problem in women and has a negative impact on their quality of life. The aim of this review was to provide a general overview of the current state of technology used to assess pelvic floor functionality. It also provides literature research of the physiological and anatomical factors that correlate with pelvic floor health. This systematic review was conducted according to the PRISMA guidelines. The PubMed, ScienceDirect, Cochrane Library, and IEEE databases were searched for publications on sensor technology for the assessment of pelvic floor functionality. Anatomical and physiological parameters were identified through a manual search. In the systematic review, 114 publications were included. Twelve different sensor technologies were identified. Information on the obtained parameters, sensor position, test activities, and subject characteristics was prepared in tabular form from each publication. A total of 16 anatomical and physiological parameters influencing pelvic floor health were identified in 17 published studies and ranked for their statistical significance. Taken together, this review could serve as a basis for the development of novel sensors which could allow for quantifiable prevention and diagnosis, as well as particularized documentation of rehabilitation processes related to pelvic floor dysfunctions.

Potential role of physical labor and cultural views of menstruation in high incidence of pelvic organ prolapse in Nepalese women: a comparative study across the menstrual cycle

Introduction

Pelvic organ prolapse (POP) is a significant health concern for young Nepali women, with potential risk factors including pelvic floor trauma from vaginal delivery and heavy lifting. The prevalence of symptomatic POP (SPOP) among nulliparous women in Nepal is 6%, while the general population of Nepali women aged 15-49 years reports a prevalence of 7%. Surprisingly, the average age of SPOP onset in Nepal is 27 years, challenging the assumption that postmenopausal age and vaginal delivery are the sole risk factors. This study aims to investigate the influence of increased intra-abdominal pressure (IAP) during lifting tasks on pelvic organ descent in Nepali women across different menstrual cycle stages.

Methods

The study included 22 asymptomatic Nepali women aged 18-30 years who regularly engage in heavy lifting. Intra-abdominal pressure was measured intra-vaginally during typical and simulated lifting tasks, which encompassed various scenarios such as ballistic lifting, ramped lifting, and pre-contraction of pelvic floor muscles, as well as coughing, Valsalva maneuver, and pelvic floor contractions. Pelvic floor displacement was recorded using transperineal ultrasound during menstruation, ovulation, and the mid-luteal phase.

Results

Results indicated that pelvic floor displacement was greater during menstruation than ovulation when performing a simulated ballistic lifting task (6.0 ± 1.6 mm vs. 5.1 ± 1.5 mm, p = 0.03, d = 0.6). However, there was no significant difference in pelvic floor displacement during lifting when the pelvic muscles were pre-contracted.

Conclusion

These findings suggest that lifting heavy loads during menstruation may increase the risk of stretching and injuring pelvic floor supportive tissues, potentially contributing to SPOP in young Nepali women. Pre-contracting pelvic floor muscles during lifting tasks may offer a protective effect. Understanding these factors could aid in developing targeted preventive measures and raising awareness about the impact of heavy lifting on pelvic floor health among Nepali women.

Strenuous physical activity, exercise, and pelvic organ prolapse: a narrative scoping review

INTRODUCTION AND HYPOTHESIS

High-intensity physical activity and exercise have been listed as possible risk factors for pelvic organ prolapse (POP). The aim of the present study is to conduct a literature review on the prevalence and incidence of POP in women who engage in regular physical activity. In addition, we review the effects of a single exercise or a single session of exercise on pelvic floor support. Finally, the effect of exercises on POP in the early postpartum period is reviewed.

METHODS

This is a narrative scoping review. We searched PubMed and Ovid Medline, the Physiotherapy Evidence Database (PEDro), and the Cochrane Database of Systematic Reviews up to May 2022 with the following MeSH terms: "physical activity" AND "exercise" AND "pelvic floor" AND "pelvic organ prolapse".

RESULTS

Eight prevalence studies were retrieved. Prevalence rates of symptomatic POP varied between 0 (small study within different sports) and 23% (Olympic weightlifters and power lifters). Parity was the only factor associated with POP in most studies. Three studies evaluated the pelvic floor after a single exercise or one session of exercise and found increased vaginal descent or increased POP symptoms. One prospective cohort study reported the development of POP after 6 weeks of military parashot training, and one randomized trial reported increased POP symptoms after transverse abdominal training. There is scant knowledge on exercise and POP in the postpartum period.

CONCLUSIONS

Prevalence of POP in sports varies widely. Experimental and prospective studies indicate that strenuous exercise increased POP symptoms and reduced pelvic floor support.

Comparison of in vivo visco-hyperelastic properties of uterine suspensory tissue in women with and without pelvic organ prolapse

The uterine suspensory tissue (UST) complex includes the cardinal (CL) and uterosacral "ligaments" (USL), which are mesentery-like structures that play a role in resisting pelvic organ prolapse (POP). Since there is no information on the time-dependent material properties of the whole structure in situ and in vivo, we developed and tested an intraoperative technique to quantify in vivo whether there is a significant difference in visco-hyperelastic behavior of the CL and USL between women with and without POP. Thirteen women with POP (cases) and four controls scheduled for surgery were selected from an ongoing POP study. Immediately prior to surgery, a computer-controlled linear servo-actuator with a series force transducer applied a continuous, caudally directed traction force while simultaneously recording the resulting cervical displacement in the same direction. After applying an initial 1.1 N preload, a ramp rate of 4 mm/s was used to apply a maximum force of 17.8 N in three "ramp-and-hold" test trials. A simplified bilateral four-cable biomechanical model was used to identify the material behavior of each ligament. For this, the initial cross-section areas of the CL and USL were measured on 3-T magnetic resonance image-based 3D models from each subject. The time-dependent strain energy function of CL/USL was defined with a three-parameter hyperelastic Mooney-Rivlin material model and a two-term Prony series in relaxation form. When cases were compared with controls, the estimated time-dependent material constants of CL and USL did not differ significantly. These are the first measurements that compare the in vivo and in situ visco-hyperelastic response of the tissues comprising the CL and USL to loading in women with and without prolapse. Larger sample sizes would help improve the precision of intergroup differences.

Pelvic Floor Support and Symptoms 1 Year Postpartum in Relation to Excess Body Habitus Before, During and After First Vaginal Birth

IMPORTANCE

Obesity may be a modifiable risk factor for pelvic floor disorders.

OBJECTIVES

The objective of this study is to determine associations between weight, weight changes, and cumulative exposure to excess body mass index (BMI) from prepregnancy to 1 year postpartum on pelvic floor support and symptoms 1 year after first vaginal birth.

STUDY DESIGN

In 645 primiparous women who gave birth vaginally, we assessed anatomic pelvic floor support, pelvic floor symptoms and BMI at the third trimester, 5 - 10 weeks, and 1 year postpartum; we also assessed BMI prepregnancy and predelivery. Using multivariable models, we determined associations between pelvic floor outcomes 1 year postpartum and BMI quartiles at different timepoints, gestational weight gain, and postpartum weight retention. We evaluated associations between stress urinary incontinence (SUI) and moderate/severe urinary incontinence (UI) 1 year postpartum and cumulative excess BMI from prepregnancy to 1-year postpartum (BMI1year).

RESULTS

Body mass index was not associated with anatomic support, composite symptom burden, overactive bladder, anal incontinence, or constipation at any timepoint. Gestational weight gain and postpartum weight retention were not associated with any 1-year outcome. Body mass index at every timepoint was positively associated with SUI and moderate/severe UI; BMI1year was most predictive. Cumulative excess BMI was positively associated with SUI and moderate/severe UI but only slightly more predictive of these outcomes than BMI1year alone.

CONCLUSIONS

Body mass index over the pregnancy trajectory was not associated with outcomes other than UI. The small advantage of cumulative exposure to excess BMI over BMI1year in predicting SUI and moderate/severe UI suggests that BMI1year adequately captures risk of these 1-year outcomes.

Relative and Maximal Intra-abdominal Pressure and Postpartum Pelvic Floor Outcomes in Primiparas Delivered Vaginally

OBJECTIVES

This study aimed to explore associations between relative and maximal intra-abdominal pressure (IAP) on pelvic floor outcomes in primiparas delivered vaginally.

METHODS

At 5-10 weeks and 1 year postpartum, we measured absolute IAP by vaginal sensor while participants lifted a weighted car seat (IAPLIFT) and performed isometric trunk flexion endurance (IAPTFE) and seated maximal strain (IAPSTRAIN). Primary outcomes, completed 1 year postpartum, included worse pelvic floor support (descent to or beyond the hymen) and positive symptom burden (bothersome symptoms in ≥2 of 6 domains on the Epidemiology of Prolapse and Incontinence Questionnaire). We calculated relative IAP (as absolute IAP/IAPSTRAIN).

RESULTS

Of 542 participants, 9.7% demonstrated worse support and 54.3% demonstrated symptom burden at 1 year postpartum. In multivariable analyses, absolute IAPLIFT and absolute IAPTFE at 5-10 weeks postpartum were not associated with worse support. As relative IAP at 5-10 weeks increased, the prevalence of worse support decreased (prevalence ratio [PR] of 0.77 [95% confidence intervals (CIs), 0.63-0.94] and PR of 0.79 [95% CI, 0.67-0.93]) per 10% increase for relative IAPLIFT and relative IAPTFE, respectively. This was largely due to IAPSTRAIN, which increased the prevalence of worse support (PR, 1.15 [95% CI, 1.06-1.25]) per 10 cm H2O increase. One year postpartum, only IAPSTRAIN increased the prevalence of worse support (PR, 1.11 [95% CI, 1.02-1.20]) per 10 cm H2O. Of all IAP measures at both time points, only absolute IAPLIFT at 1 year significantly increased the prevalence of symptom burden (PR, 1.11 [95% CI, 1.05-1.18]) per 10 cm H2O.

CONCLUSIONS

This exploratory analysis suggests that postpartum IAPSTRAIN may increase the prevalence of worse support in primiparas delivered vaginally.

Habitus and Pelvic Floor Symptoms and Support 1 Year Postpartum

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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