Does the severity of spontaneous genital tract trauma affect postpartum pelvic floor function?

We describe the impact of genital trauma on pelvic floor function in a low-risk cohort of women after vaginal birth. Questionnaires (Present Pain Intensity Scale, Incontinence Impact Questionnaire, Fecal Incontinence Score, and Intimate Relationship Scale) were completed up to 12 weeks postpartum. Severity of trauma was recorded at delivery. Overall follow-up was 444/565 (79%). Major trauma (trauma that involved perineal muscles or required suturing) occurred in 20%; 20% delivered intact. At 12 weeks, 10% complained of perineal pain; 24% reported anal (AI) and 27% urinary incontinence (UI). Women with trauma were no more likely than those intact to complain of UI or AI, sexual inactivity, or perineal pain postpartum (all P = NS). Women with major trauma had weaker pelvic floor exercise strength than those who delivered intact or with minor trauma (odds ration 3.06, 95% confidence interval 1.41–6.63). Pelvic floor complaints postpartum were common but not associated with severity of genital trauma in a cohort of low-risk women.     

Sexual Function in Women with and without Urinary Incontinence and/or Pelvic Organ Prolapse

The sexual function of women with and without urinary incontinence and/or pelvic organ prolapse (UI/POP) was compared using a condition-specific validated questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). Eighty-three women with UI/POP and 56 without agreed to participate. PISQ scores were significantly lower among women with UI/POP than in those without (P = 0.003). No differences in the stages of sexual excitement were noted between groups. The frequency of intercourse was less with UI/POP than without (P = 0.04). Women with UI/POP restricted sexual activity for fear of losing urine more frequently than did those without (P= 0.005). No differences were reported in patients’ or partners’ sexual satisfaction. This study found that women with UI/POP have poorer sexual functioning than those without, as measured by the PISQ, and report less frequent sexual activity. In addition, women with UI/POP are more likely to restrict sexual activity for fear of incontinence, although they report similar levels of satisfaction with their sexual relationships as do women without UI/POP.     

Stress urinary incontinence and counseling and practice of pelvic floor exercises postpartum in low-income Hispanic women

The purpose of the study was to provide estimates of stress urinary incontinence (SUI) and practice of pelvic floor muscle training (PFMT) postpartum as well as counseling during and after pregnancy among Hispanic women. Two hundred Hispanic women were surveyed 6 months postpartum. Twenty-three percent had SUI with onset primarily during pregnancy (70%). Only 20% had received information regarding SUI and PFMT during pregnancy or postpartum. Most women not counseled wished they were (81%). Less counseling occurred among Hispanic women with lower levels of education (odds ratio [OR] = .39; 95% confidence interval [CI] = 0.19–0.82; p = 0.02) and those whose primary language was Spanish (OR = .36; 95% CI = 0.15–0.87; p = 0.02), while higher rates occurred among women with a forceps delivery (OR = 2.94; 95% CI = 1.06–7.78; p = 0.03). Fifty-seven percent of women counseled practiced the exercises. Primary reasons for noncompliance were belief that PFMT would not help (47%), and not understanding the instructions (39%). SUI and PFMT counseling is low among Hispanic women. Most women desire such information, and improvement in performance of PFMT among this group is possible. An erratum to this article can be found at     

Pelvic floor disorders among indigenous women living in Xingu Indian Park, Brazil

Introduction and hypothesis  Current assessment for pelvic floor disorders (PFDs) allows comparison between different communities. Methods  A total of 377 indigenous women living in Xingu Indian Park were evaluated. The pelvic organ prolapse quantification (POP-Q) was the system used to quantification the staging of pelvic support. The pelvic floor muscle strength was assessed by a perineometer. Logistic regression analysis was used to determine risk factors that were associated with prolapse. Results  Only 5.8% of women reported urinary incontinence. The overall distribution of POP-Q stage system was the following: 15.6% stage 0, 19.4% stage I, 63.9% stage II and 0.8% stage III. Parity and age were the risk factors for pelvic organ prolapse (p < 0.0001). Conclusions  Urinary incontinence was uncommon in Xingu indigenous women. Like non-indigenous communities, age and parity were the most important risk factors to the genital prolapse.     

Urinary retention is uncommon after colpocleisis with concomitant mid-urethral sling

The purpose of this study was to evaluate the effect of colpocleisis and concomitant mid-urethral sling on voiding function. This is an IRB-approved, retrospective case series of women who underwent a colpocleisis with concomitant synthetic mid-urethral sling for treatment of stress urinary incontinence (SUI) between January 2005 and September 2007. Thirty-eight women with pelvic organ prolapse and SUI symptoms were included. Thirty percent had a post-void residual (PVR) greater than 100 ml preoperatively. PVRs were normal in all but two women after surgery. Median prolapse and urinary subscales of the pelvic floor distress inventory improved significantly after surgery [75 (50–100) vs. 0 (0–38), p < 0.0001 and 44 (8–100) vs. 0 (0–50), p < .0001, respectively]. Colpocleisis with concomitant mid-urethral sling improves urinary symptoms without causing significant urinary retention. This combination may be offered to elderly women with SUI who are undergoing colpocleisis regardless of preoperative PVR.     

The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence

The aim of this study was to evaluate the effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence. A prospective comparison design of 99 matched pairs (n=198) of mothers, a training group and a control group, was used. Eight weeks postpartum the training group attended an 8-week intensive pelvic floor muscle exercise course, training in groups led by a physical therapist for 45 minutes once a week. In addition they were asked to exercise at home at least three times per week. The control group followed the ordinary written postpartum instructions from the hospital. Pelvic floor muscle strength was measured pretreatment at the eighth, and post-treatment at the 16th week after delivery, using a vaginal balloon catheter connected to a pressure transducer. Vaginal palpation and observation of inward movement of the balloon catheter during contraction were used to test the ability to perform correct the pelvic floor muscle contraction. Urinary leakage was registered by interview, specially designed instruments to measure how women perceive SUI, and a standardized pad test. At baseline (8 weeks postpartum) there was no significant difference in the number of women with urinary incontinence in the training group compared to the control group. At 16 weeks postpartum, after the 8-week treatment period, there was a significant (P<0.01) difference in favor of the training group. In addition, a significantly greater improvement in pelvic floor muscle strength between test 1 and test 2 was found in the training group compared to the control group. The results show that a specially designed postpartum pelvic floor muscle exercise course is effective in increasing pelvic floor muscle strength and reducing urinary incontinence in the immediate postpartum period. EDITORIAL COMMENT: This paper is one of only a few looking at the efficacy of a rigorous pelvic floor muscle exercise training regime to help women with incontinence in the postpartum period. Whether or not these results will translate long-term into a lower incidence of urinary incontinence as these women age, is unknown, and may never be known. However, this paper points out that there is a definite benefit from pelvic floor muscle exercise for the treatment of postpartum incontinence, and we can use this information to more strongly counsel our patients in the use of these exercises.     

Does avulsion of the puborectalis muscle affect bladder function?

Introduction and hypothesis  The levator ani muscle is generally thought to play a role in urinary continence, with incontinence assumed to be due to abnormal muscle function or morphology. This study examined whether avulsion of the puborectalis muscle is associated with symptoms or signs of bladder dysfunction. Methods  In a retrospective observational study, we reviewed the records of 425 women who had attended a urogynecological unit for independent flowmetry, multichannel urodynamic testing, and 4D pelvic floor ultrasound. Results  Mean age was 55 years (range, 17–87 years). Of 420 women with complete datasets, 104 (25%) were diagnosed with a puborectalis muscle avulsion. These women were less likely to suffer from stress urinary incontinence (SUI; P < 0.001) and urodynamic stress incontinence (USI; P = 0.065) and more likely to present with symptoms of prolapse (P < 0.001) and show signs of voiding dysfunction (P = 0.005). The negative association between avulsion and SUI persisted in multivariate models. Conclusion  Puborectalis muscle trauma is not associated with an increased risk of SUI or USI in a urogynecological population, even when controlling for symptoms or signs of prolapse and previous surgery.     

The development of an Incontinence Treatment Motivation Questionnaire for patients undergoing pelvic floor physiotherapy in the treatment of stress incontinence

Introduction and hypothesis  The aim of this paper is to develop a motivation questionnaire regarding perseverance in pelvic floor muscle training (PFMT) supervised by physiotherapists for stress urinary incontinence. Methods  Sixteen semi-structured interviews were conducted in women with stress urinary incontinence that revealed 15 common themes; 117 items were constructed and reviewed by continence advisors. Surviving items (n = 73) were administered to 210 women. Data were analysed for item properties, factor analysis was used to examine the questionnaire structure and tests of convergence/divergence used to check for sensitivity. Results  The Incontinence Treatment Motivation Questionnaire (ITMQ) comprises 18-items in five scales, assessing attitudes towards treatment (72.62% of explained variance; α = 0.87), reasons for not doing PFMT (55.73%; α = 0.74), living with incontinence (62.70% variance; α = 0.70), desire for treatment (65.37% variance; α = 0.74) and the effect of incontinence severity on PFMT (51.62% variance, α = 0.68). Scales were generally sensitive to known group differences. Conclusions  This study represents the first effort to develop a motivation scale for PFMT. This validated Motivation Questionnaire is an instrument to test the impact of motivation upon cure, in PFMT. The work was carried out at the Pelvic Floor Unit, St George Hospital, Kogarah, NSW, Australia 2217.     

A Retrospective Comparison of Abdominal Sacrocolpopexy with Burch Colposuspension versus Sacrospinous Fixation with Transvaginal Needle Suspension for the Management of Vaginal Vault Prolapse and Coexisting Stress Incontinence

The objective of this study was to compare the surgical outcome of abdominal sacrocolpopexy and Burch colposuspension with sacrospinous fixation and transvaginal needle suspension in the management of vaginal vault prolapse and coexisting stress incontinence. One hundred and seventeen women with vaginal vault prolapse and coexisting stress incontinence were surgically managed over a 7-year period. The first 61 consecutive women who underwent sacrospinous fixation and transvaginal needle suspension comprised the vaginal group, and the following 56 consecutive women who underwent abdominal sacrocolpopexy and Burch colposuspension comprised the abdominal group. Office records were reviewed to assess the presence of recurrent prolapse and urinary incontinence during postoperative follow-up. Objective follow-up was available for 101 women. Mean duration of follow-up was 24.0 ± 15 months for the vaginal group, and 23.1 ± 12.6 months for the abdominal group. The incidence of recurrent prolapse to or beyond the hymen (33% vs. 19%, P = 0.0505) and lower urinary tract symptoms (26% vs. 13%, P = 0.0506) were significantly higher in the vaginal group than in the abdominal group. Our data suggest that the combined abdominal approach has a lower incidence of recurrent prolapse and lower urinary tract symptoms than the combined vaginal approach in managing vaginal vault prolapse and coexisting stress incontinence.     

Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence

The aim of the study was to determine the immediate effect of timing a pelvic muscle contraction with the moment of expected leakage (the Knack maneuver) to preempt cough-related stress incontinence. Women performed a standing stress test using three hard coughs without and then with the Knack maneuver. Volume of urine loss under both conditions was quantified with paper-towel test. Two groups of women were tested: nonpregnant women (n = 64) and pregnant women (n = 29). In nonpregnant women, wetted area decreased from a median (range) of 43.2 (0.2–183.7) cm² without the Knack maneuver to 6.9 (range of 0 to 183.7 cm²) with it (p < 0.0001); while in pregnant women it decreased from 14.8 (0–169.7) cm² to 0 (0–96.5) cm², respectively (p = 0.001). This study confirms the effect from the Knack maneuver as immediate and provides a partial explanation for early response to widely applied pelvic muscle training regimens in women with stress incontinence.     

Stress Incontinence in Women Under 50: Does Urodynamics Improve Surgical Outcome?

The aim of the study was to determine whether urodynamic testing improves the outcome of retropubic surgery in women aged 50 or younger. A retrospective study was undertaken of 212 women aged 50 or younger who underwent retropubic surgery at a medical school-affiliated hospital between February 1991 and July 1997. Excluded were patients with prior retropubic urethropexy and known low urethral closure pressures. The surgery was performed by one urogynecologist and two urologists. The minimal evaluation by the urogynecologist was a focused incontinence questionnaire, pelvic neurologic examination, pelvic floor grading, cough stress test, urinalysis, postvoid residual, cotton swab test and supine empty stress test. Full urodynamics consisted of uroflowmetry, subtracted cystometry, urethral closure pressure, cough leak-point pressure and cystourethroscopy. Subjective postoperative follow-up at 1–4 years was by annual questionnaire. The urogynecologist’s patients were in group I (95 women with full urodynamic studies) and group II (36 women with minimal testing). The urologists’ patients were in group III (81 women with a very minimal work-up and cystourethroscopy). A review of seven variables revealed no difference between the groups. In terms of cured, improved and failed, there was also no difference in outcome. There was a difference in postoperative voiding problems (though not stress incontinence) in group III compared to group I (P = 0.005) and group II (P = 0.002). Our conclusion was that all women with stress incontinence should undergo a careful minimal evaluation. In women aged 50 or younger urodynamic studies may be avoided unless there is significant stress incontinence, complex symptoms, a positive supine empty stress test, marked prolapse, or a history of prior retropubic urethropexy.     

Pelvic prolapse and urinary incontinence in nulliparous college women in relation to paratrooper training

The objective of this study was to determine whether paratrooper training is associated with pelvic support defects or urinary incontinence. Nulliparous women at The United States Military Academy were examined using the Pelvic Organ Prolapse Quantification System and completed a questionnaire regarding incontinence and exercise prior to undergoing summer military training. The exam and questionnaire were repeated following training. One hundred sixteen women completed the study (80.6%), 37 of whom had attended paratrooper training. Women who attended paratrooper training were significantly more likely to have stage II prolapse (RR = 2.72, 1.37 < RR < 5.40; p = 0.003). Additionally, women who attended paratrooper training were significantly more likely to have worsening in their pelvic support regardless of initial prolapse stage (RR = 1.57, 1.12 < RR < 2.20; p = 0.01). Twenty-four women complained of urinary incontinence; however, this was not associated with paratrooper training. The forces transmitted to the female pelvis during paratrooper training are significant and cause pelvic support defects. Presented at the combined AUGS/SGS Joint Scientific Meeting, July 2004.     

A randomized controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence

A randomized controlled trial was carried out to evaluate the extent to which a program of reinforced pelvic floor muscle exercises (PFME) reduces urinary incontinence 1 year after delivery. Two hundred and thirty women who were incontinent 3 months postpartum were randomized to either a control group doing standard postnatal pelvic floor muscle exercises (n=117) or to an intervention group (n=113) who saw a physiotherapist for instruction at approximately 3, 4, 6 and 9 months postpartum. Results collected 12 months after delivery included prevalence and frequency of incontinence and PFME, sexual satisfaction, perineometry measurements and pad tests. Twenty-six (22%) of the control group and 59 (52%) of the intervention group withdrew before the final assessment. The prevalence of incontinence was significantly less in the intervention group than in the control group (50% versus 76%,P=0.0003), and this group also did significantly more PFME. There were no significant differences between the groups as regards sexual satisfaction, perineometry measurements or pad test results.     

Does cesarean protect against fecal incontinence in primiparous women?

The objective of this study was to identify factors associated with new onset of postpartum fecal incontinence in primiparous women. A population-based study was conducted that surveyed all women delivering between 2002 and 2003 in Oregon. Factors associated with fecal incontinence were identified using logistic regression analysis. A total of 6,152 primiparous women completed the survey 3–6 months postpartum with 2,482 reporting a new onset of fecal incontinence (FI) after childbirth. Vaginal delivery was associated with a greater risk of FI compared to cesarean (odds ratio = 1.45; 95% confidence interval, 1.29 to 1.64). However, vaginal delivery without laceration or instrument assistance did not increase the risk of FI over cesarean. Being overweight (body mass index ≥30 kg/m²), pushing for greater than 2 h, and constipation were independently associated with postpartum FI (p < 0.05) regardless of route of delivery. This study provides important data to inform counseling and management of primiparous women. Funding  This study was supported by the National Institute of Child Health and Human Development (R01 HD41139-04). NICHD did not influence any part of this work.     

Assessment of sexual function in women with pelvic floor dysfunction

Forty-seven women participated in a pilot study for a multi-centre randomized controlled trial of the effectiveness of pelvic floor muscle training (PFMT) for women with prolapse. Women with symptomatic stage I or II prolapse [measured by Pelvic Organ Prolapse Quantification (POP-Q)] were randomized to a 16-week physiotherapy intervention (PFMT and lifestyle advice; n = 23) or a control group receiving a lifestyle advice sheet (n = 24). Symptom severity and quality of life were measured via postal questionnaires. Blinded POP-Q was performed at baseline and follow-up. Intervention women had significantly greater improvement than controls in prolapse symptoms (mean score decrease 3.5 versus 0.1, p = 0.021), were significantly more likely to have an improved prolapse stage (45% versus 0%, p = 0.038) and were significantly more likely to say their prolapse was better (63% versus 24%, p = 0.012). The data support the feasibility of a substantive trial of PFMT for prolapse. A multi-centre trial is underway.     

Coital urinary incontinence: impact on quality of life as measured by the King’s Health Questionnaire

The aim of this present study was to measure the impact of coital urinary incontinence (UI) on sexually active women quality of life (QoL). Epidemiological, observational, cross-sectional, and multicenter study including 633 sexually active women seeking treatment for UI and/or overactive bladder in a gynecological clinic, aged between 24 and 83 years. All women filled out the King’s Health Questionnaire—KHQ. With this questionnaire, we had a complete register of the different urinary symptoms, included coital UI, and the extent of how they affect patient’s life and the measurement of impact on the patient’s QoL by the KHQ score. Prevalence of coital incontinence in sexually active women was 36.2%, classifying this impact as low (59.8%), moderate (32.3%), and high (7.9%). Women reporting coital incontinence had similar mean age and body mass index (BMI) to those women without coital incontinence. Women with coital incontinence had higher scores (worse QoL) in all the dimensions and in the KHQ global score (p < 0.05). Coital incontinence was the only variable showing an independent relation to KHQ global score (B = 10.1; 95% confidence interval = 1.7–18.6) in a multiple regression model adjusted to age, BMI, and the other urinary symptoms under study. One third of the sexually active women with urinary symptoms had coital incontinence. Among sexually active women with urinary symptoms, patients with coital urinary incontinence had a higher impact on their QoL than those without coital incontinence. Coital incontinence is independently related to a KHQ high score, which suggest worse QoL.     

Incontinence pessaries: size, POPQ measures, and successful fitting

Introduction and hypothesis  The aim of the study was to determine whether successful incontinence pessary fitting or pessary size can be predicted by specific POPQ measurements in women without advanced pelvic organ prolapse. Methods  In a multicenter study, women with stress urinary incontinence (SUI) and POPQ stage ≤2 were randomized to three treatment arms: (1) incontinence pessary, (2) behavioral therapy, or (3) both. This study evaluates incontinence pessary size, POPQ measures, and successful fitting in the 266 women assigned to treatment arms 1 and 3. Results  Two hundred thirty-five women (92%) were successfully fitted with an incontinence ring (n = 122) or dish (n = 113). Hysterectomy, genital hiatus (GH), and GH/total vaginal length (TVL) ratios did not predict unsuccessful fitting (p > 0.05). However, mean TVL was greater in women successfully fitted (9.6 vs. 8.8 cm, p < 0.01). Final pessary diameter was not predicted by TVL, point D, or point C (p > 0.05). Conclusions  The vast majority of women with SUI can be successfully fitted with an incontinence pessary, but specific POPQ measures were not helpful in determining incontinence pessary size. Supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the NIH Office of Research on Women's Health at National Institutes of Health (U10 HD54215, U10 HD41267, U10 HD41250, U10 HD41261, U10 HD54214, U10 HD54241, U10 HD54136, and U01 HD41249).     

The Prevalence of Urinary and Fecal Incontinence in Canadian Secondary School Teenage Girls: Questionnaire Study and Review of the Literature

The purpose of this study was to examine the prevalence of pelvic floor dysfunction and incontinence in the Canadian nulligravid secondary school female teenage population. During the University of Toronto day in 1996, female visitors to the Obstetrics and Gynecology Department booth were asked to complete anonymous pelvic floor and continence questionnaires, which were thoroughly explained to them and completed during their visit. Out of the 332 completed forms, 69% were completed by nulligravid teenagers in secondary school. These students formed our study population. The prevalence of urgency urinary incontinence (UUI) symptoms was 17% and of stress urinary incontinence (SUI) symptoms was 15%. In all candidates these reported symptoms were mild, occurring less than once a week. Occasional minor fecal incontinence (involuntary loss of flatus or fecal staining) was 38%; of these, 92% reported loss of flatus. Major fecal incontinence with loose bowel movements was reported by 3% of the study population. Two girls (1%) reported nocturnal enuresis. Weight directly correlated with SUI symptoms and fecal incontinence, but not with UUI. Fecal incontinence correlated with SUI symptoms (P = 0.0152), but not with UUI. Ten per cent of the study population were sexually active, but sexual activity did not correlate with incontinence problems. Voiding habits were markedly variable: 30% were infrequent voiders (three times or fewer per day). Nocturia was reported by 3%. We concluded that in nulligravid teenage female students minor fecal incontinence appears to be the most common incontinence type; urge incontinence was slightly more common than SUI. Unlike UUI, SUI symptoms were more prevalent with fecal incontinence, which were affected by weight. There appears to be a problem with a high prevalence of poor voiding habits.     

Vaginal smooth muscle cell apoptosis is increased in women with pelvic organ prolapse

To compare the smooth muscle content and apoptosis of the vagina in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in women with (n = 6) or without (n = 6) anterior vaginal wall prolapse undergoing hysterectomy. Smooth muscle of the vagina was studied by immunohistochemistry. Digital image analysis was used to determine the fractional area of smooth muscle in the histologic cross-sections. Apoptosis was assessed by TUNEL assay. The fractional area of non-vascular smooth muscle in the vagina of women with anterior vaginal wall prolapse was significantly decreased compared to women without prolapse (0.36 ± 0.12 vs. 0.16 ± 0.12 P = 0.021) and the apoptotic index was significantly higher compared to women without prolapse (0.04 ± 0.01 vs. 0.02 ± 0.03, P = 0.041). The fraction of smooth muscle in the vagina is significantly decreased and the rate of apoptosis is higher in women with anterior vaginal wall prolapse compared to women without prolapse.     

Combined trans- and periurethral injections of bulking agents for the treatment of intrinsic sphincter deficiency

The purpose of this study was to compare Contigen combined with Durasphere to Contigen injections alone for the treatment of stress urinary incontinence (SUI) with intrinsic sphincter deficiency (ISD). Subjective and objective incontinence outcomes were compared at 2 weeks and 6 months. We compared rates of urinary retention and future incontinence surgery between groups. Thirty-three women underwent combined injections, and 51 underwent Contigen injections. Two weeks postoperatively, more women in the combined group were cured (72.7 vs. 39.2%, P = 0.003), but this difference diminished at 6 months (33.3 vs. 29.4%, P = 0.70). Retention was more common in the combined group (P = 0.002, odds ratio [OR] = 0.062 [95% confidence interval {CI} = 0.007, 0.52]). Twenty-three women in the Contigen and ten in the combined group underwent subsequent incontinence surgery (P = 0.17, OR = 2.03 [95% CI = 0.80, 5.1]). Combining Contigen and Durasphere injections to treat SUI with ISD does not improve outcomes compared to Contigen injections alone. This paper was presented at the 32nd Annual Meeting of the American Association of Gynecologic Laparoscopists, Las Vegas, Nevada, November 19–22, 2003.