Incontinence, bladder neck mobility, and sphincter ruptures in primiparous women

Effects of Different Delivery Modes on Pelvic Floor Function in Parturients 6–8 Weeks after Delivery Using Transperineal Four-Dimensional Ultrasound

Objective

To evaluate the effects of different delivery modes on pelvic floor function in parturients 6–8 weeks after delivery using transperineal four-dimensional ultrasound.

Methods

Pelvic floor function 6–8 weeks after delivery in 40 vaginal delivery parturients between November 2018 and December 2020 was assessed by four-dimensional ultrasound, with 40 selective cesarean section delivery parturients as a control group. The imaging results of the two groups were compared.

Results

The levels of clinical indexes such as UVJ-M, A_r, A_v, θ, D_r, D_v, and ARJ-VDv in the selective cesarean section group were significantly lower than those in the vaginal delivery group 6–8 weeks after delivery (P < 0.05). However, no significant difference in CV-VD was observed under Valsalva action and at rest between the two groups (P > 0.05). No significant difference in ARJ-VD was found at rest between the two groups (P > 0.05). The incidence of pelvic organ prolapse in the selective cesarean section group (40.0%) was significantly lower than that in the vaginal delivery group (62.5%) (P < 0.05). No significant difference in the parameters of pelvic diaphragm hiatus at rest was observed between the two groups (P > 0.05). The parameters of pelvic diaphragm hiatus under maximum Valsalva action in the vaginal delivery group were significantly higher than those in the selective cesarean section group (P < 0.05). Whether the patient was complicated with diabetes had no significant effect on the functional injury of pelvic floor muscle (P > 0.05).

Conclusion

The pelvic floor function 6–8 weeks after delivery was significantly more affected in vaginal delivery than in selective cesarean section. Selective cesarean section had certain but limited protective effect on maternal pelvic floor tissue.

Physiotherapy according to the BeBo Concept as prophylaxis and treatment of urinary incontinence in women after natural childbirth

Pelvic floor muscle dysfunctions can lead to urinary incontinence, a condition which often affects women both during pregnancy and after childbirth. As a result of this, certain exercises are recommended during and after pregnancy to prevent and treat this incontinence, and the BeBo Concept is one of these methods used to prevent pelvic floor muscle dysfunction. The aim of the present study was to evaluate the effects of a 6-week course of physical therapy according to the BeBo Concept on the improvement of perineal muscle strength and endurance as well as urinary continence in women after their first vaginal delivery. The study was conducted on a group of 56 women who were randomly assigned to the exercise (n = 30) or control (n = 26) group. The exercising group participated in a 6-week physical therapy program according to the BeBo Concept. Pelvic floor muscles were assessed using the perineometer and palpation Perfect Test. UDI6 and ICIQ-SF questionnaires were used to obtain information about the symptoms of urinary incontinence, evaluate the frequency, severity and impact of urine leakage on the quality of life. In all women after natural childbirth, regardless of treatment, it was observed that measured parameters improved, but the improvement was slightly more explicit in those who participated in the Bebo Concept exercise group (e.g. ICIQ-SF exercise group p = 0.001, control group p = 0.035). Due to its positive impact on the pelvic floor, this exercise program should be recommended to women after natural childbirth.

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.

Fishing for (in)continence: long-term follow-up of women with OASIS-still a taboo

PURPOSE

Obstetric anal sphincter injuries (OASIS) increase the risk for pelvic floor dysfunctions. The goal of this study was to examine the long-term outcomes after OASIS on pelvic floor functions and quality of life.

MATERIAL AND METHODS

Between 2005 and 2013, 424 women had an OASIS at the Women University Hospital Ulm. Out of these 71 women completed the German pelvic floor questionnaire, which includes questions regarding prolapse symptoms as well as bladder, bowel and sexual function. In addition, 64 women were physically examined, including a speculum examination to evaluate the degree of prolapse, a cough test to evaluate urinary stress incontinence (SI) and an evaluation of both pelvic floor sphincter (modified Oxford score) and anal sphincter contraction.

RESULTS

A high rate of pelvic floor disorders after OASIS was found, as 74.6% of women reported SI, 64.8% flatus incontinence and 18.3% stool incontinence, respectively. However, only few women stated a substantial negative impact on quality of life. The clinical examination showed that a positive cough test, a weak anal sphincter tone and a diagnosed prolapse correlated with the results of the self-reported questionnaire.

CONCLUSION

On one hand, OASIS has an influence on pelvic floor function going along with lots of complaints, while on the other hand, it still seems to be a taboo topic, as none of the participants spoke about the complaints after OASIS with a doctor. Therefore, the gynecologist should actively address these issues and offer therapy options for the women with persisting problems.

Epidemiological Features of the Bladder Neck Rest Position and Mobility

The data concerning epidemiological determinants of the bladder neck (BN) mobility are scarce. The aim of the study was to determine epidemiological features and identify factors influencing BN position at rest and BN mobility in patients without pelvic organ prolapse (POP). Seven hundred and ninety-six patients that attended two outpatient clinics were enrolled in the study. Position and mobility of the BN were measured with the use of pelvic floor ultrasound. Demographic and functional factors that were hypothesized to influence BN mobility were assessed. Vaginal deliveries (VDs) and age ≥65 were associated with lower BN position at rest. Higher BN mobility was observed in women with stress urinary incontinence (SUI). In obese women, higher BN position and lower BN mobility was observed compared to non-obese women, and it was correlated with longer urethras in this group of patients. VDs and their number were associated with increased BN mobility, independently of body mass index (BMI). To conclude, obesity, VDs, and age are factors associated with changes in bladder neck position at rest and its mobility. Higher BMI correlates with restricted BN mobility, and, therefore, the incidence of SUI in obese patients is probably not connected to BN hypermobility.

Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review.

METHODS

We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI.

RESULTS

We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I² = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I² = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I² = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I² = 95 %). Following primary repair of OASIS, 55 % (46-63, I² = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I² = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I² = 98 %).

INTERPRETATION

Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.

Pelvic floor biometry in asymptomatic primiparous women compared with nulliparous women: a single-center study in Southern China

OBJECTIVE

This study aimed to investigate pelvic floor biometry of asymptomatic primiparous women compared with nulliparous women by using four-dimensional transperineal ultrasound (4D TPUS).

METHODS

From July 2015 to February 2017, 722 women were enrolled and divided into the nulliparous group (n = 292), the vaginal delivery group (n = 272), and the elective cesarean section group (n = 158). The ultrasound parameters of 4D TPUS were compared among the groups.

RESULTS

The vaginal delivery group had a significantly greater bladder neck descent (η² = 0.04), retrovesical angles on Valsalva maneuver (η² = 0.01), urethral rotation (η² = 0.01), levator hiatus area on Valsalva maneuver (η² = 0.02), urethral inclination angle (η² = 0.02), and funneling of the proximal urethra (η² = 0.11) than the other two groups. Comparison of the two modes of delivery (vaginal delivery and cesarean section) also showed significant differences in the above-mentioned ultrasound parameters.

CONCLUSION

There are significant differences in pelvic floor biometry between asymptomatic primiparous women and nulliparous women, as well as between women with vaginal delivery and those with elective cesarean section.

[Childbirth pelvic floor trauma: Anatomy, physiology, pathophysiology and special situations - CNGOF perineal prevention and protection in obstetrics guidelines]

OBJECTIVES

To assess whether pelvic size and shape, spinal curvature, perineal body length and genital hiatus size are associated with the incidence of childbirth pelvic floor trauma. Special situations, such as obesity, ethnicity and hyperlaxity, will also be studied.

METHODS

A bibliographic research using Pubmed and Cochrane Library databases was conducted until May 2018. Publications in English and French were selected by initial reading of the abstracts. Randomized trials, meta-analyzes, case-control studies and large cohorts were studied in a privileged way.

RESULTS

A pubic arch angle<90° (measured clinically) does not appear to increase the risk of OASIS (Level 3), but appears to be a risk factor for postnatal anal incontinence at short-term, but not at long-term (Level 3). Measurement of pelvic dimensions and the subpubic angle is not recommended to predict OASIS or to choose the mode of delivery for the purpose of protecting the perineum (GradeC). Prenatal measurement of both perineal body (Level 3) and genital hiatus (Level 2) does not predict the incidence of 2nd or 3rd degree OASIS. Therefore, the routine prenatal measurement of the length of the perineal body or the genital hiatus is not recommended for any objective related to perineal protection (Grade C). Levator avulsion, resulting in a widening of the genital hiatus, is potentially a source of long-term pelvic floor dysfunction. Biomechanical models suggest that performing a mediolateral episiotomy and applying the fingers to the posterior perineum at the time of expulsive phase may reduce pelvic floor trauma. Obese women have a longer perineal body (Level 3), and obesity does not seem to increase the risk of OASIS (Level 2). There is no difference between Asian and non-Asian women perineal body (Level 3). No studies have validated that the liberal practice of episiotomy in Asian women reduced the risk of OASIS. It is therefore not recommended to practice an episiotomy for simple ethnic reasons in Asian women (GradeC). Compared to white women, black women do not appear to have an increased risk of OASIS and even appear to have a decreased risk of perineal tears of all stages (Level 2). Ligament hyperlaxity seems to be associated with an increased risk of OASIS (Level 2).

CONCLUSIONS

Prenatal assessment of pelvis bone, spine curvature, perineal body and genital hiatus do not allow to predict the incidence of childbirth pelvic floor trauma. Obesity and ethnicity are not risk factors for OASIS.

Method and reliability of measuring midurethral area and echogenicity, and changes during and after pregnancy

Introduction and hypothesis

Internal closure of the urethral sphincter is one of the mechanisms in maintaining continence. Little is known about changes in the urethral sphincter during pregnancy. We designed this study to develop a reliable method to measure the area and mean echogenicity of the midurethra during and after pregnancy and to assess changes over time.

Methods

Two observers independently segmented the urethra as follows: in the sagittal plane, the urethra was positioned vertically, the marker was placed in the middle section of the lumen of the urethra, and eight tomographic US images of 2.5 -mm slices were obtained. The central image was selected, and area and mean echogenicity were calculated automatically. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) and their 95% confidence intervals (CI). Two hundred and eighty women underwent TPUS at 12 weeks and 36 weeks of gestation and 6 months postpartum, and 3D/4D transperineal ultrasound (TPUS) images of 40 pregnant nulliparous women were used for the reliability study. Paired t tests were used to assess changes in echogenicity and area.

Results

The ICC for measuring the area was substantial, at 0.77 and for measuring mean echogenicity was almost perfect, at 0.86. In the total study group (n = 280), midurethral area and mean echogenicity were significantly lower 6 months after delivery compared with 12 and 36 weeks of gestation.

Conclusions

Our protocol for measuring area and mean echogenicity of the midurethra is reliable. This study indicates that structural changes in the midurethraoccur during pregnancy.

Gestational Urinary Incontinence in Nulliparous Pregnancy- A Pilot Study

INTRODUCTION

Urinary Incontinence (UI) in pregnancy is more than a disease; it is a social problem that necessitates special care and management. The exact rationales and biological facts behind urinary incontinence during pregnancy are unclear and multivariate.

AIM

This pilot study was designed to examine the direct effect of gestational factors (e.g., physical and metabolic/hormonal) on the presence of Gestational Urinary Incontinence (GUI), in nulliparous pregnant women.

MATERIALS AND METHODS

This was a questionnaire-based study comprising of 61 nulliparous pregnant woman who had not experienced any Urinary Incontinence (UI) before their pregnancies. Patients were examined during their pregnancies within the framework of the antenatal care program continued at the Division of Perinatology, Hacettepe University, Ankara, Turkey, between January 2015 and December 2016. A 'urinary incontinence questionnaire' was used three times during different periods of gestation (11-14, ~24 and ~37 gestational weeks) for each patient. Statistical analysis was performed using the SPSS software version 20.0. The Chi-Square test or Fisher's-exact test was used to compare proportions in groups.

RESULTS

The prevalence of total urinary incontinence (stress urinary incontinence, urge urinary incontinence and mixed urinary incontinence) in nulliparous pregnant women was 4.9% (n=3), 9.8% (n=6) and 26.2% (n=16) at 11-14, ~24 and ~37 gestational weeks, respectively. Stress urinary incontinence was found to be 3.3% (n=2), 6.6% (n=4) and 16.4% (n=10) at 11-14, ~24 and ~37 gestational weeks, respectively. Urge urinary incontinence frequency was found to be 1.6% (n=1), 3.3% (n=2), 6.6% (n=4), and mixed urinary incontinence frequency was 0% (n=0), 0% (n=0), 3.3% (n=2) at 11-14, ~24 and ~37 gestational weeks, respectively. Maternal age, birth weight of the neonate and gestational age at birth had no statistically significant effect on GUI.

CONCLUSION

Urinary incontinence is an important issue during pregnancy and related symptoms are more common in third trimester.

Differences in urinary incontinence symptoms and pelvic floor structure changes during pregnancy between nulliparous and multiparous women

Background

This study was performed to compare changes in urinary incontinence (UI) symptoms and pelvic floor structure during pregnancy between nulliparous and multiparous women.

Methods

A cross-sectional survey was performed among pregnant women from July 2016 to January 2017. In total, 358 pregnant women from two hospitals underwent an interview and pelvic floor transperineal ultrasound assessment. A questionnaire regarding sociodemographic, gynecological, obstetric features and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) were used for the interview. Imaging data sets were analyzed offline to assess the bladder neck vertical position (BNVP), urethral angles (α, β, and γ angles), and hiatal area (HA) at rest and at maximal Valsalva maneuver (VM).

Results

After excluding 16 women with invalid data, 342 women were included. The prevalence (χ² = 9.15, P = 0.002), frequency (t = 2.52, P = 0.014), usual amount of UI (t = 2.23, P = 0.029) and scores of interference with daily life (t = 2.03, P = 0.045) during pregnancy were higher in multiparous than nulliparous women. A larger bladder neck descent (BND) (F = 4.398, P < 0.001), HA (F = 6.977, P < 0.001), α angle (F = 2.178, P = 0.030), β angle (F = 4.404, P < 0.001), and γ angle (F = 2.54, P = 0.011) at VM were discovered in pregnant women with UI than without UI. Multiparous women had a significantly higher BND (t = 2.269, P = 0.024) and a larger α angle (F = 2.894, P = 0.004), β angle (F = 2.473, P = 0.014), and γ angle (F = 3.255, P = 0.001) at VM than did nulliparous women.

Conclusion

Multiparous women experienced more obvious UI symptoms and pelvic floor structure changes during pregnancy than did nulliparous women.

Pelvic floor muscle biometry and pelvic organ mobility in East Asian and Caucasian nulliparae

OBJECTIVE

To compare the differences in levator ani muscle biometry and hiatal dimensions between pregnant nulliparous Caucasian and East Asian women.

METHODS

Offline analysis of three/four-dimensional ultrasound volume data obtained from two groups of pregnant nulliparous women, Caucasian and East Asian, was performed. Volume acquisition was performed in the late third trimester using the same method in both groups, in the context of two prospective observational studies with identical entry criteria. Pelvic organ descent and levator hiatal dimensions were assessed using the volumes acquired on Valsalva maneuver, and pubovisceral muscle thickness was measured from the volumes obtained on pelvic floor muscle contraction (PFMC).

RESULTS

Datasets of 200 East Asian and 168 Caucasian women were analyzed. Compared with Caucasian women, East Asian women had a significantly lower body mass index. All indices of pelvic organ descent were significantly higher in the Caucasian group than in the East Asian group. The difference, expressed as a percentage, in levator hiatal area on both Valsalva maneuver and PFMC was markedly greater in Caucasian (32% vs. 19%; P < 0.001) than in East Asian (24% vs. 20%; P = 0.01) women. After controlling for potential confounders using multivariate regression analysis, racial origin remained the only significant factor associated with differences in pelvic organ descent and hiatal dimensions. The thickness and area of pubovisceral muscle were significantly higher in the East Asian group.

CONCLUSIONS

Pregnant women of East Asian racial origin have a thicker pubovisceral muscle, smaller hiatus and less mobility of pelvic organs than do pregnant Caucasian women.

Ultrasound assessment of urethral support in women with stress urinary incontinence during and after first pregnancy

OBJECTIVE

To investigate the association of bladder neck position, bladder neck mobility, and levator hiatal dimensions with symptoms of stress urinary incontinence (SUI) using transperineal ultrasonography in women during and after their first pregnancy.

METHODS

In this prospective observational study, 280 nulliparous pregnant women were evaluated at 12 weeks of gestation, 36 weeks of gestation, and 6 months postpartum. At each visit, symptoms of SUI were assessed and transperineal ultrasound examination was performed at rest, on pelvic floor contraction, and on Valsalva maneuver. Bladder neck position, bladder neck mobility, and levator hiatal dimensions were determined offline. Independent-samples t tests were used to compare ultrasound data between women with and without SUI. Because multiple t tests were performed, the statistical significance level was corrected using the Bonferroni method.

RESULTS

There were 18.8% women who reported symptoms of SUI at 12 weeks of gestation, 47.2% at 36 weeks of gestation, and 37.5% at 6 months postpartum. During pregnancy, women with SUI had a significantly larger hiatal area compared with women without SUI (P=.001-.003). After childbirth, women with SUI had a significantly more caudal and dorsal position of the bladder neck on Valsalva maneuver than women without SUI (P=.004 and P=.001, respectively). There were no significant differences in bladder neck mobility between women with and without SUI.

CONCLUSION

Stress urinary incontinence during first pregnancy is associated with a larger hiatal area. After childbirth, SUI is associated with a more caudal and dorsal position of the bladder neck on Valsalva maneuver.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is the most common type of urinary incontinence (UI) in pregnant women and is known to have detrimental effects on the quality of life in approximately 54.3 %. Pregnancy is the main risk factor for the development of SUI. This review provides details of the pathophysiology leading to SUI in pregnant women and SUI prevalence and treatment during pregnancy.

METHODS

We conducted a PubMed search for English-language and human-study articles registered from January 1990 to September 2012. This search was performed for articles dealing with prevalence and treatment of SUI during pregnancy. In the intervention studies, we included studies that used a randomized controlled trial (RCT) design or studies comparing a treatment intervention to no treatment.

RESULTS

A total of 534 articles were identified; 174 full-text articles were reviewed, and 28 of them met eligibility criteria and are reported on here. The mean prevalence of SUI during pregnancy was 41 % (18.6-60 %) and increased with gestational age. The increasing pressure of the growing uterus and fetal weight on pelvic-floor muscles (PFM) throughout pregnancy, together with pregnancy-related hormonal changes, may lead to reduced PFM strength as well as their supportive and sphincteric function. These cause mobility of the bladder neck and urethra, leading to urethral sphincter incompetence. Pelvic floor muscle exercise (PFME) is a safe and effective treatment for SUI during pregnancy, without significant adverse effects.

CONCLUSIONS

Understanding these issues can be useful for health-care professionals when informing and counseling pregnant women to help prevent SUI during pregnancy and the postpartum period.

Characteristics of patients seeking outpatient rehabilitation for pelvic-floor dysfunction

BACKGROUND

Pelvic-floor dysfunction (PFD) affects a substantial proportion of individuals, especially women.

OBJECTIVE

The purposes of this study were: (1) to describe the characteristics of individuals with disorders associated with PFD who were seeking outpatient physical therapy services and (2) to identify the prevalence of specific pelvic-floor disorders in the group.

DESIGN

This was a prospective, longitudinal, cohort study of 2,452 patients (mean age=50 years, SD=16, range=18-91) being treated in 109 outpatient physical therapy clinics in 26 states (United States) for their PFD.

METHODS

This study examined patient demographic variables and summarized patient self-reported responses to questions related to urinary and bowel functioning at admission prior to receiving the therapy for their PFD disorders.

RESULTS

Patients primarily were female (92%), were under 65 years of age (39%: 18 to <45 years; 39%: 45 to <65 years; 21%: 65 years or older), and had chronic symptoms (74%). Overall, 67% of the patients reported that they had urinary problems, 27% reported bowel problems, and 39% had pelvic pain. Among those who had urinary or bowel disorders, 32% and 54% reported leakage and constipation, respectively, as their only problem. Among patients who had pelvic pain, most (56%) reported that the pain was in the abdominal area. Combinations of urinary, bowel, or pelvic-floor pain disorders occurred in 31% of the patients.

LIMITATIONS

Because this study was a secondary analysis of data collected prospectively, the researchers were not in control of the data collection procedure. Missing data were common.

CONCLUSIONS

Data suggested most patients with PFD receiving outpatient physical therapy services were female, younger than 65 years, and had disorders lasting for more than 90 days. Combinations of urinary, bowel, or pelvic-floor pain disorders were not uncommon.

Long-term outcome after obstetric injury: a retrospective study

OBJECTIVE

To examine problems experienced by women after vaginal delivery with and without a sphincter tear and compare those with less and more severe injuries.

DESIGN

Retrospective questionnaire study. Setting. Regional hospital in Sweden.

SAMPLE

A total of 324 women with and 309 without sphincter tears.

METHODS

Questionnaires were sent out four to eight years after delivery enquiring about the existence and time course of gas incontinence, fecal incontinence, dyspareunia and perineal pain. A question about vacuum delivery was also included.

MAIN OUTCOME MEASURES

Prevalence of persisting symptoms.

RESULTS

The reply rate was 77%. About 10% of the women with a sphincter tear had fecal incontinence initially, compared with 3% among those without a sphincter tear. In women with moderate or severe tears, 20 and 31%, respectively, had gas incontinence, compared with 6% of women without a tear. Dyspareunia and perineal pain were present 18-23% of women in the tear groups compared with 9-12% of those without a tear. Almost 45% of women with initial symptoms had remaining problems after four to eight years. There was a significantly higher risk for symptoms after vacuum extraction (p < 0.001).

CONCLUSIONS

Gas incontinence, fecal incontinence, dyspareunia and perineal pain were common problems after delivery. The prevalence of persisting symptoms was high even among women without a tear. The higher prevalence after vacuum extraction delivery indicates that there are more complications associated with this mode of delivery than previously thought.

Pelvic floor ultrasound in incontinence: what's in it for the surgeon?

There is increasing interest in imaging techniques such as magnetic resonance and ultrasound amongst pelvic floor surgeons, as evidenced by the number of workshops and conference presentations in this field. Ultrasound is employed more commonly, due to much lower costs, greater accessibility and practicability. Consequently, this review focuses on sonography. At this time, imaging is probably under-utilised in urogynaecology and female urology, although it has the potential to greatly benefit our patients. In this review, I will outline the main uses of imaging in the work-up of women with urinary incontinence, before and after treatment, and focus on areas in which this benefit to patients and clinicians is most evident.

What harm does a second delivery to the pelvic floor?

OBJECTIVE

To compare the pelvic floor function of primiparous women to women after a second delivery regarding symptoms of urinary and anal incontinence, anal sphincter ruptures and bladder-neck mobility.

METHODS

A questionnaire evaluating symptoms of urinary and anal incontinence was used in nulliparous women before and 27 months after childbirth. Furthermore these symptoms were correlated with functional changes of the pelvic floor based on a careful gynecologic examination as well as perineal and endoanal ultrasound.

RESULTS

112 nulliparous women were included, 49 women returned for follow-up on average 27 months (SD 4.4 months) after the first delivery. 39 women (group A) had just one delivery, 10 women (group B ? 10/49) had had a second delivery. Apart from levator ani muscle strength, no significant difference between pelvic floor function of group A vs group B was demonstrable. Furthermore, we could show no significant difference for symptoms of urinary (11 (28.2%) vs. 5 (50.0%)) and anal incontinence (14 (35.9%) vs. 4 (40.0%)) between both groups. However, we found a lasting increase of stress urinary and anal incontinence as well as overactive bladder symptoms after one or more deliveries. The position of the bladder neck at rest was lower in both groups compared to the position before the first delivery and bladder neck mobility increased after one or more deliveries.

DISCUSSION

Our study shows several statistically significant changes of the pelvic floor function even on average 27 months after delivery, but a subsequent delivery did not compromise the pelvic floor any further.