Influence of pelvic floor disorders on quality of life in women

Levator ani muscle assessment and its correlation with recurrence of pelvic organ prolapse: a pelvic floor MRI study

PURPOSE

The levator ani muscle (LAM) plays a vital role in pelvic floor support. Understanding its influence on pelvic organ prolapse (POP) recurrence is essential for improving surgical techniques and postoperative care. This study hypothesized that patients with impaired preoperative LAM integrity, as assessed by pelvic floor MRI, had a higher risk of POP recurrence after pelvic floor repair surgery.

METHODS

This retrospective study enrolled 38 patients with POP who underwent pelvic floor repair surgery. The patients were categorized into recurrence and non-recurrence groups based on gynecological examinations and Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20) scores. The structural and functional characteristics of the LAM were evaluated using preoperative static and dynamic MRI. A comparative analysis was performed between the two groups, and the Spearman correlation coefficient was used to quantitatively assess the correlation between LAM measurements and postoperative symptoms.

RESULTS

The comparative analysis showed that the recurrence group had significantly more LAM injury, thinner puborectalis and iliococcygeus muscles, longer H-lines and M-lines, and larger levator hiatus compared to the non-recurrence group (p<0.05). Furthermore, significant correlations were found between LAM thickness and injury and PFDI-20 scores, with thinner and more severely injured LAM associated with more severe postoperative symptoms (p<0.05).

CONCLUSIONS

Incorporating pelvic floor MRI assessment of LAM into preoperative evaluation might help identify patients at higher risk for POP recurrence, allowing for optimized patient management and care.

The Role of Rehabilitation for Women with Cancer

As the prevalence of female cancer survivors increases, their quality of life (QOL) and function have become key areas of focus in the context of survivorship and rehabilitation needs. Although behavioral modifications may help to decrease the development of malignancy, women are still at increased risk of developing a cancer diagnosis in their lifetime. Cancer and its treatment can lead to significant functional impairments and symptomatic challenges. However, rehabilitation interventions and medical management provide options to address these issues throughout the oncological continuum of care. With appropriate treatment, women are enabled to experience improved QOL and performance status.

Progress in the genetics and epigenetics of pelvic floor disorder

Pelvic floor disorder (PFD) is a common gynecological disorder, and with the ageing of the population, PFD has a serious impact on the physical and mental health of patients and their quality of life. The most prominent of these are pelvic organ prolapse (POP) and urinary incontinence (UI), about which the etiology is still unclear, and it is urgent to explore their pathogenesis. Advances in genetics and epigenetics have provided new insights into the pathophysiology of PFD. Candidate genes and genome-wide association studies have identified susceptibility genes for POP and UI. These susceptibility genes typically promote POP by affecting pelvic floor connective tissue. The role of susceptibility genes in UI is multifactorial and includes promoting inflammation, damaging pelvic floor connective tissue, and modulating neurogenic effects. The association of epigenetic changes with POP and UI has also been investigated. DNA methylation studies have identified several important pathways associated with POP. miRNAs play an important role in the development of POP and UI, and this may be an important therapeutic direction for the future. The studies conducted so far have shown that genetic and epigenetic techniques are of great importance in exploring the etiology of PFD and that more in-depth studies are needed in the future.

Impact of sleep on postpartum health outcomes: a systematic review and meta-analysis

OBJECTIVE

To examine the impact of postpartum sleep interventions and postpartum sleep on maternal health outcomes.

DESIGN

Systematic review with random-effects meta-analysis. Online databases were searched on 12 January 2024.

STUDY ELIGIBILITY CRITERIA

Studies of all designs (except case studies and reviews) in all languages were eligible if they contained information on the population (individuals up to 1-year post partum), sleep interventions/exposures including (type, duration, frequency, alone or in combination with other components), comparator (control or different duration, frequency or type of sleep intervention) and outcomes: mental health, cardio-metabolic, postpartum weight retention (PPWR), low back pain and pelvic girdle pain, breastfeeding and urinary incontinence.

RESULTS

60 studies (n=20 684) from 14 countries were included. 'High' certainty of evidence showed that sleep interventions were associated with a greater decrease in depressive symptom severity compared with no intervention (five randomised controlled trials; n=992; standardised mean difference -0.27, 95% CI -0.40 to -0.14; small effect). Sleep interventions had no impact on the odds of developing depression ('moderate' certainty of evidence) or anxiety or anxiety symptom severity ('low' certainty of evidence). Additionally, 'low' certainty of evidence demonstrated no effect on cardiometabolic outcomes (systolic blood pressure, diastolic blood pressure, mean arterial pressure), anthropometric measures (maternal weight, body mass index) or prevalence of exclusive breastfeeding. 'Low' certainty of evidence from observational studies found that high-quality sleep reduces the odds of developing anxiety and reduces the severity of depression and anxiety symptoms. 'Low' and 'very low' certainty of evidence from observational studies found that shorter sleep duration is associated with greater PPWR.

CONCLUSIONS

Postpartum sleep interventions reduced the severity of depression symptoms.

Differences in Pelvic Organ Prolapse and Diastasis Recti Abdominis Between Primiparous and Age-Matched second-Parous Females After Vaginal Delivery: A Retrospective Cohort Study

Purpose

This study aims to investigate the differences in pelvic floor dysfunction (PFD) and diastasis recti abdominis (DRA) between primiparous and second-parous females with known risk factors controlled.

Patients and Methods

49 primiparous and 49 age-matched second-parous postpartum after spontaneous vaginal delivery were included between October and December 2023. Independent variables include weight, height, body mass index (BMI), fetal weight, gestational weight gain (GWG). Main outcome measurements include vaginal resting pressure (VRP) and maximum voluntary contraction pressure (MVCP) indicating pelvic floor muscle strength, the stage of anterior (APOP) and posterior pelvic organ prolapse (PPOP) and inter-recti distance (IRD) indicating DRA. Independent t-test and Chi-square test of independence were used to analyze differences between two groups for continuous and categorical variables, respectively.

Results

No significant differences were found in terms of vaginal pressure measurements between two groups (VRP: t (96) = 0.07, p = 0.942; MVCP: t (96) = 0.40, p = 0.689). Second-parous group showed significantly more severe DRA with larger IRD than primiparous group (t (96) = -2.405, p = 0.018). No significant association was found between parity and APOP stage (χ2(1) = 2.67, p = 0.102) in this current study; however, second-parous females demonstrated greater PPOP stage than primiparous females (χ2(1) = 5.24, p = 0.022).

Conclusion

Second-parous females at similar age are more likely to experience PPOP than primiparous group after spontaneous vaginal delivery. Greater public attention with plausible actions should be taken for second-parous female group to prevent more severe postpartum pelvic floor dysfunction.

Do We Have the Evidence to Produce Tools to Enable the Identification and Personalization of Management of Women's Pelvic Floor Health Disorders Through the Perinatal and Perimenopausal Periods? ICI-RS 2024

INTRODUCTION

There is an increasing recognition of the impact of ageing on pelvic floor health and the consequences in populations with rising proportions of women over the age of 65 years. A think tank was held at the ICI-RS 2024 to discuss the evidence to support the personalisation of women's pelvic floor health during the perinatal and perimenopausal period.

METHODS

Data was collected and presented on the evidence to support the development of tools to personalise pelvic floor health care. Epidemiological, imaging, patient-reported outcomes, and evidence of tool development questionnaires were discussed. The current evidence and research gaps for potential intervention to prevent the pelvic floor disorders of pelvic organ prolapse, overactive bladder, urinary incontinence and faecal incontinence during the perinatal and perimenopasual time periods were discussed and identified.

RESULTS

Epidemiological studies highlight that vaginal delivery and in particular operative vaginal delivery is the single biggest modifiable risk factor for the future development of pelvic floor dysfunction. The oestrogen depletion resulting from the perimenopause and menopause can lead to the development of Genitourinary syndrome of menopause (GSM) which is associated with the risk of developing pelvic floor dysfunction. Ultrasound is a useful technique for assessing the pelvic floor and has been used to assess bladder neck mobility, distensibility of the puborectalis muscle and the striated urethral sphincter volume antenatally with some studies reporting a correlation between these measurements and the need for Caesarean section and development of postpartum stress urinary incontinence. Further studies are needed to standardise these measurements. There are no patient reported outcome questionnaires validated for use in the perinatal and postmenopausal period. The UR- choice tool has been developed to counsel women on the risk of postpartum pelvic floor disorders occurring. However, further evaluation in larger numbers is required.

CONCLUSION

There is significant interest in developing tools to counsel women on the risks of developing pelvic floor dysfunction post partum and after the menopause. Further evaluation of the UR-choice tool was considered a research priority. The timepoint of cervical screening for research into interventions such as pelvic floor health education, lifestyle optimisation and perimenopausal vaginal oestrogen supplementation was identified.

From insight to action: a qualitative study of the postpartum return to recreational exercise and sport in Ireland and the UK

Individuals who were active before and during pregnancy face significant barriers to return postpartum, and participation in exercise and sport often decreases significantly during this period. Evidence is beginning to emerge regarding elite athletes' experiences with returning to sport postpartum. Understanding the experiences of recreational participants is essential to improve wider participation postpartum. This qualitative study aimed to describe the experiences of those returning to recreational exercise or sport postpartum, and to identify actions to support such a return. 14 mothers from the UK and Ireland, participated in one-to-one interviews. Interviews were transcribed verbatim and analysed using contemporary reflexive thematic analysis. Six themes were generated: (1) The challenging transition to motherhood, (2) Regaining, reclaiming and role modelling: motivators for returning, (3) Changed bodies and reframed minds: the experience and benefits of returning, (4) The mental load: adaptation, priorities, judgement and guilt, (5) Lack of appropriate knowledge and professional support and (6) Support, environment, culture and provision. Participants gave detailed accounts of the experience of returning to recreational exercise or sport postpartum. A list of actionable steps to support the return to recreational exercise and sport postpartum was generated from the data. These include the training of relevant professionals, the delivery of guidance during antenatal and postpartum care, the provision of opportunities to return postpartum and the embedding of policy to support such a return. The study provides actionable recommendations and future research directions to support postpartum mothers in resuming recreational exercise and sport.

Determining the levels of pelvic floor disorders in women diagnosed with urinary incontinence: a mix-method study

Introduction

Urinary incontinence (UI) significantly affects women's quality of life and may contribute to pelvic floor disorders. This study aimed to investigate the impact of UI on pelvic floor disorders through a mixed-methods approach.

Methods

A convergent parallel design was employed, integrating quantitative and qualitative data. Quantitative data were collected using the "Global Pelvic Floor Disorders Questionnaire," and semi-structured interviews were conducted for qualitative insights. Quantitative data were analyzed using SPSS 26.0, while qualitative data underwent content analysis with MAXQDA Pro 22 software.

Results

Among the participants, 41.7% were diagnosed with stress urinary incontinence, which was associated with the highest level of discomfort. Qualitative findings revealed four main categories: effects on daily life, emotional and psychological effects, coping strategies, and treatment approaches and expectations. Participants reported that UI led to social isolation, reduced self-esteem, and increased anxiety.

Discussion

The findings highlight that UI adversely affects both the physical and psychosocial well-being of women. Addressing this condition requires a holistic approach combining medical treatment with psychosocial support to mitigate its multifaceted impact.

Evaluating the Efficacy of Combined Intravaginal Estriol Therapy and Kegel Exercises in Managing Menopausal Atrophic Vulvovaginitis

Background: This is a prospective study. Atrophic vulvovaginitis (VVA), a prevalent condition resulting from estrogen deficiency after the menopause, is characterized by symptoms such as vaginal dryness, itching, burning, dyspareunia, and urinary discomfort. Standard treatment involves systemic estrogen replacement therapy (HRT) and localized estrogen treatments, such as estriol. However, many women with moderate-to-severe VVA may not fully benefit from estrogen therapy alone. Non-hormonal adjunctive treatments, such as pelvic floor exercises (e.g., Kegel exercises), are being explored to enhance clinical outcomes. Objectives: This study investigates the combined effect of local estriol therapy and Kegel exercises in improving VVA symptoms in postmenopausal women. Methods: Fifty postmenopausal women diagnosed with VVA were enrolled and divided into three severity groups: mild, moderate, and severe. All participants received estriol therapy (0.5 mg vaginal tablets daily for 10 days each month) for the first three months. Following this, Kegel exercises were introduced for an additional three-month period, alongside continued estriol therapy. Symptom improvement was evaluated after six months, with outcomes categorized as complete remission, partial remission, or no remission. Results: Significant improvements in symptom remission were observed, particularly in the moderate and severe groups. In the mild VVA group, 81.82% achieved complete remission with combined therapy compared to 68.18% with estriol alone. In the severe group, complete remission was observed in 40% of patients receiving combined therapy compared to 20% with estriol therapy alone. These findings suggest that Kegel exercises enhance the effectiveness of estriol by improving local blood circulation, which facilitates better estrogen absorption and distribution. Conclusions: The addition of Kegel exercises to local estriol therapy significantly improves symptom remission rates, especially in moderate and severe VVA cases. This approach offers a promising strategy for managing postmenopausal VVA, particularly in cases that do not fully respond to estrogen therapy alone.

Long-term health outcomes and quality of life in women with untreated pelvic floor dysfunction: a single-center cohort study

Objective

This study aimed to evaluate the long-term health outcomes and quality of life (HRQoL) associated with untreated pelvic floor dysfunction (PFD) in women, and to identify key factors contributing to symptom severity.

Methods

A cohort of 1,651 women aged 18 years and older with untreated PFD were recruited between June 2018 and August 2023. Data on sociodemographic, lifestyle factors, and clinical history were collected via questionnaires and clinical assessments. The Pelvic Floor Distress Inventory (PFDI-20) and Short Form-12 (SF-12) were used to assess symptom severity and HRQoL.

Results

The study found that 56% of participants experienced urinary incontinence (UI), 52% had pelvic organ prolapse (POP), and 47% reported gynecological disorders. Sleep apnea (OR: 18.3, p < 0.001) and menopause (OR: 2.48, p < 0.001) were significantly associated with higher symptom severity, while postpartum complications had a protective effect (OR: 0.01, p < 0.001). Obesity was inversely associated with symptom severity (OR: 0.3, p < 0.001). HRQoL scores showed that 97.6% of participants had high physical functioning (mean PF: 67.36 ± 11.62), but vitality (VT) was notably lower, with 27.8% scoring below 50 (mean VT: 54.84 ± 6.60). FI (p = 0.006) and pelvic pain (p = 0.001) were linked to significantly poorer physical functioning and higher bodily pain.

Conclusion

Untreated PFD has a profound impact on HRQoL, especially in women with sleep apnea, menopause, and pelvic pain. Early diagnosis and intervention are critical to mitigating these effects and improving long-term outcomes. These findings highlight the urgent need for targeted public health strategies to address untreated PFD.

Antenatal Anovaginal Distance, a Potential Indicator of Perineal Damage during Pregnancy

BACKGROUND/OBJECTIVES

Perineal injuries, including episiotomies and spontaneous tears, are common complications during childbirth, often leading to significant discomfort and prolonged recovery for women. This retrospective observational cohort study aimed to explore the relationship between antenatal anovaginal distance (AVD) and the incidence of perineal injuries in a cohort of pregnant women evaluated for pelvic floor health at 28 to 32 weeks of gestation.

METHODS

Conducted at the University Hospital of Padua over 18 months, the study included 416 women who underwent vaginal delivery at term. Based on AVD, the study participants were divided into two groups: AVD-N group, which included 252 patients with AVD ≥ 2 cm, and the AVD-R group, which included 164 with AVD < 2 cm. The results of the pelvic floor assessment and those related to childbirth were then examined in relation to AVD (reduced vs. normal).

RESULTS

The study found that women with reduced AVD were more likely to experience perineal injuries. Specifically, the incidence of episiotomy and severe perineal tears (3rd and 4th degree) was significantly higher in the reduced AVD group (p < 0.05). Furthermore, a lower AVD was associated with increased perineal muscle hypertonicity and a higher likelihood of operative delivery with episiotomy. Logistic regression analysis confirmed that reduced AVD was an independent risk factor for perineal injuries, regardless of other maternal or neonatal characteristics.

CONCLUSIONS

These results suggest that AVD measurement during pregnancy may help identify women at higher risk of perineal trauma, enabling more personalized obstetric care to mitigate these outcomes.

Cultural considerations in gastroenterology: barriers to care and a call for humility and action

Culture is a broadly defined term and patients' cultural identity may show up in the medical setting in visible and invisible ways. In this paper, we aim to discuss cultural considerations in gastrointestinal (GI) care. Our definition of "culture" reflects the commonly ascribed race and ethnicity and will also discuss other minority groups such as sexual and gender minorities (SGMs). We will review what is known about rates of GI conditions across various cultural groups, acknowledging that our data reflect inequity in representation. While the healthcare system has overall shown an increased awareness of the role that systemic and institutional racism plays in affecting patient care, this has not been widely studied in the context of GI though has a profound impact. Multiple factors affect the interaction between patients' cultural identities and engagement in and quality of GI care. Stigma related to cultural factors or cultural intersection has the capacity to shape if, when, and how medical care is approached, received and applied. Conditions and symptoms in GI are often complicated; health literacy (HL) is the ease with which patients can navigate getting from diagnosis to treatment and engage in self-management and also interacts with cultural context. Some aspects of a patient's experience, background and skill are imperceptible and require the healthcare provider to attend to treatment with humility, respect and self-reflection if they wish to effectively engage. We introduce the concept of cultural humility to GI and offer practical suggestions for those providing clinical care. We also call for future investment in a diverse healthcare delivery system and continued legislation to promote social equity.

Bidirectional Relationships between Sarcopenia and Pelvic Floor Disorders

Sarcopenia and pelvic floor disorders (PFDs) are prevalent and often cooccurring conditions in the aging population. However, their bidirectional relationship and underlying mechanisms remain underexplored. This narrative review aims to elucidate this relationship by exploring potential causative interplays, shared pathophysiological mechanisms, and common risk factors. A comprehensive literature search was conducted to identify relevant studies focusing on epidemiological associations, interaction mechanisms, and implications for patient care. While epidemiological studies demonstrate associations between sarcopenia and PFDs, our findings reveal a cyclical relationship where sarcopenia may exacerbate PFDs through mechanisms such as decreased muscle strength and mobility. Conversely, the presence of PFDs often leads to reduced physical activity due to discomfort and mobility issues, which in turn exacerbate the muscle atrophy associated with sarcopenia. Additionally, shared risk factors such as physical inactivity, nutritional deficiencies, metabolic syndrome, and menopausal hormonal changes likely contribute to the onset and progression of both conditions. These interactions underscore the importance of concurrently integrated care approaches that address both conditions. Effective management requires comprehensive screening, the recognition of contributing factors, and tailored exercise regimens supported by a multidisciplinary approach. Future research should focus on longitudinal studies tracking disease progression and evaluating the efficacy of multidisciplinary care models in optimizing patient outcomes.

Quality of Life and Sexual Function after Laparoscopic Posterior Vaginal Plication Plus Sacral Colpopexy for Severe Posterior Vaginal Prolapse

BACKGROUND

Laparoscopic sacral colpopexy (LSC) is the gold standard treatment for women with apical/anterior pelvic organ prolapse (POP). For isolated posterior vaginal prolapse, instead, the literature suggests fascial native tissue repair. This is a retrospective 2-year quality-of-life follow-up study after laparoscopic posterior plication (LPP) combined with LSC in patients with anterior/apical prolapse combined with severe posterior colpocele. The primary endpoint was to evaluate the subjective outcomes quality of life (QoL), sexual function, and patient satisfaction rate. The secondary endpoint was to evaluate perioperative and anatomical outcomes at the 2-year follow-up.

METHODS

A total of 139 consecutive patients with anterior and/or apical prolapse (POP-Q stage ≥ II) and severe posterior vaginal prolapse (posterior POP-Q stage ≥ III) were retrospectively selected from our database among women who underwent, from November 2018 to February 2021, a "two-meshes" LSC. The patients were classified into Group A (81 patients; LSC plus LPP) and Group B (67 patients; LSC alone). The primary endpoint was evaluated using the Patient Global Impression of Improvement (PGI-I), the Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the Female Sexual Distress Scale (FSDS), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and the EuroQol (EQ-5D). The secondary endpoint was studied using the POP-Q study and an intra-, peri-, and post-operative complications assessment. Two-year follow-up data were analyzed for the study.

RESULTS

At 2 years, all women showed a statistically significant amelioration of their symptoms on the QoL questionnaires. We found a statistical difference in favor of posterior plication in terms of the PGI-I successful outcome rate (Group A versus B: 85.3% versus 67.1%), FSDS (median 11 versus 21), and PISQ-12 (median 89 versus 62) (p < 0.05 for all comparisons). A significant improvement of all EQ-5D values was observed from baseline to 2-year follow-up, and only for the "pain/discomfort" domains did we observe a significant improvement in LSC plus LPP patients versus LSC alone (p < 0.05). LSC plus LPP women showed, at 2 years, a significant amelioration of their Ap and GH POP-Q points. We observed no statistical differences in terms of intra-post-operative complications or anatomic failure rate between groups.

CONCLUSIONS

Our LPP approach to LSC appears to be a safe, feasible, and effective treatment for advanced pelvic organ prolapse with a significant impact on the patient's general health and sexual quality of life. Adding laparoscopic posterior vaginal plication to "two-meshes" sacral colpopexy is recommended in patients with apical/anterior prolapse and concomitant severe posterior colpocele. This surgical approach, in addition to improving the anatomical results of these patients, is associated with a significant improvement in sexual and quality of life indexes.

Association of eating behavior with symptoms of pelvic floor disorders in middle-aged women: An observational study

BACKGROUND

Estrogen deficiency during menopause, aging, reproductive history, and factors increasing intra-abdominal pressure may lead to structural and functional failure in the pelvic floor. Lifestyle choices, such as eating behavior, may contribute to pelvic floor disorders.

OBJECTIVES

The objective of the study was to investigate associations of eating behavior with symptoms of pelvic floor disorders, that is, stress urinary incontinence, urgency urinary incontinence, fecal incontinence, and constipation or defecation difficulties among middle-aged women.

DESIGN

A cross-sectional, observational study was performed using a population sample of 1098 Finnish women aged 47-55 years.

METHODS

Eating behavior, food consumption frequency, demographical, gynecological, and physical activity variables were assessed using self-report questionnaires. Logistic regression models were used to assess the associations of eating behavior, food frequency, and symptoms of pelvic floor disorders. Models were adjusted with demographical, gynecological, and physical activity variables.

RESULTS

In adjusted models, middle-aged women with disordered eating style were more likely to experience the symptoms of stress urinary incontinence (odds ratio (OR) 1.5, p = 0.002), and constipation or defecation difficulties (OR 1.4, p = 0.041). Adding body mass index into the models abolished associations. Of the studied food items, more frequent consumption of ready-made, highly processed foods (OR 1.5, p = 0.001), and fast foods (OR 1.5, p = 0.005) were independently associated with symptoms of stress urinary incontinence regardless of eating style, whereas consuming ready-made foods (OR 1.4, p = 0.048) was associated with symptoms of urgency urinary incontinence. Daily consumption of fruits (OR 0.8, p = 0.034) was independently associated with symptoms of stress urinary incontinence. Furthermore, we observed that daily consumption of porridge was associated with symptoms of constipation or defecation difficulties (OR 1.7, p = 0.010) independently of eating style. Alcohol consumption (OR 0.9, p = 0.015) was inversely associated with constipation and defecation difficulties. Women with overall higher quality diet had lower odds for stress urinary incontinence (OR 0.9, p = 0.002).

CONCLUSION

This study provides proof-of-concept evidence to the hypothesis that eating behavior and consuming certain food items are associated with perceived pelvic floor disorders. As a preventive action, eating behavior of women with the risk of these symptoms should be assessed, and guidance toward healthy eating patterns should be provided.