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International Urogynecology Journal
Published in: International Urogynecology Journal 3/2018

01-03-2018 | Review Article

A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques

Authors: Hans Van Geelen, Donald Ostergard, Peter Sand

Published in: International Urogynecology Journal | Issue 3/2018

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Abstract

The objective of this narrative review is to study the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques with quantitative data carried out during pregnancy and after childbirth. A literature search in MEDLINE and relevant and up-to-date journals from 1960 until April 2017 was performed for articles dealing with the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement methods. Only studies describing objective measurement techniques. i.e., urodynamics, ultrasound (US), magnetic resonance imaging (MRI), Pelvic Organ Prolapse Quantification (POP-Q) system, and neurophysiologic tests carried out throughout pregnancy and after childbirth are included. Relevant studies presenting objective quantitative data are analyzed and briefly summarized. The number of studies meeting selection criteria was relatively few. Pregnancy, especially first pregnancy, is associated bladder neck lowering, increased bladder neck mobility, pelvic organ descent, decreased levator ani strength, and decreased urethral resistance. These changes are accentuated after vaginal delivery. Data on the impact of obstetrical and neonatal variables are transient and seem of less importance. Cesarean delivery is not completely protective. In most women, pelvic floor muscle function recovers in the year after delivery. Objective measurement techniques during pregnancy may allow identification of women susceptible to pelvic floor dysfunction later in life and offer the opportunity for counseling and preventive treatment strategies.
Literature
1.
2.
Lowder JL, Ghetti C, Nikolajski C, Oliphant SS, Zyczinski HM. Body image perceptions in women with pelvic organ prolapse: a qualitative study. Am J Obstet Gynecol. 2011;204:441.e1–5.CrossRef
3.
Barlow BH, Samsioe G, Van Geelen JM. A study of European womens’ experience of the problems of urogenital ageing and its management. Maturitas. 1997;27:239–47.CrossRefPubMed
4.
Subak LL, Waetjen LE, van den Eeden S, et al. Cost of pelvic organ surgery in the United States. Obstet Gynecol. 2001;98:646–51.PubMed
5.
Sung VW, Washington B, Raker CA. Costs of ambulatory care related to pelvic floor disorders in the United States. Am J Obstet Gynecol. 2010;202:483 e1–4.CrossRef
6.
Rortveit G, Brown JS, Thom DH, Van Den Eeden SK, Creasman JM, Subak ll. Symptomatic pelvic organ prolapse: prevalence and risk factors in a population based, racially diverse cohort. Obstet Gynecol. 2007;109:1396–403.CrossRefPubMed
7.
Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM. Parity, mode of delivery, and pelvic floor disorders. Obstet Gynecol. 2006;107:1253–60.CrossRefPubMed
8.
9.
10.
Slieker-ten Hove M, Pool-Goudzwaard EM, Steegers Theunissen R, Burger C, Vierhout M. Symptomatic pelvic organ prolapse and possible risk factors in a general population. Am J Obstet Gynecol. 2009;200(2):184 e1–7.CrossRef
11.
Foldspang A, Mommsen S, Djurhuus JC. Prevalent urinary incontinence as a correlate of pregnancy, vaginal childbirth and obstetric techniques. Am J Public Health. 1999;89:209–13.CrossRefPubMedPubMedCentral
12.
Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford family planning association study. Br J Obstet Gynaecol. 1997;104:579–85.CrossRefPubMed
13.
Maclennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynecol. 2000;107:1460–70.CrossRef
14.
Carley ME, Turner RJ, Scott DE, Alexander JM. Obstetric history in women with surgically corrected adult urinary incontinence or pelvic organ prolapse. J Am Assoc Gynecol Laparosc. 1999;6:85–9.CrossRefPubMed
15.
Francis WJA. The onset of stress incontinence. J Obstet Gynaecol Brit Emp. 1960;67:899–903.CrossRef
16.
Chaliha C, Bland JM, Monga A, Stanton SL, Sultan AH. Pregnancy and delivery: a urodynamic viewpoint. Br J Obstet Gynaecol. 2000;107:1354–9.CrossRef
17.
Asmussen M, Ulmsten U. Simultaneous urethrocystometry and urethra pressure profile measurements with a new technique. Acta Obstet Gynecol Scand. 1975;54:1–4.CrossRef
18.
Iosif S, Ulmsten U. Comparative urodynamic studies of continent and stress-incontinent women in pregnancy and in the puerperium. Am J Obstet Gynecol. 1981;140:645–50.CrossRefPubMed
19.
Van Geelen JM, Lemmens WAJG, Eskes TKAB, MartinCB. The urethral pressure profile in pregnancy and after delivery in healthy nulliparous women. Am J Obstet Gynecol. 1982;144:636–49.CrossRefPubMed
20.
Van Geelen JM, Doesburg WH, Martin CB Jr, TKAB E. Urodynamic studies in the normal menstrual cycle: the relationship between hormonal changes during the menstrual cycle and the urethral pressure profile. Am J Obstet Gynecol. 1981;141:384–92.CrossRefPubMed
21.
Meyer S, Bachelard O, DeGrandi P. Do bladder neck mobility and urethral sphincter function differ during pregnancy compared with during the nonpregnant state. Int Urogynecol J Pelvic Floor Dysfunct. 1998;9:397–404.CrossRefPubMed
22.
Meyer S, Schreyer A, De Grandi P, Hohlfeld P. The effects of birth on urinary continence mechanisms and other pelvic-floor characteristics. Obstet Gynecol. 1998;92:613–8.PubMed
23.
Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder neck in urinary stress incontinence. Obstet Gynecol. 1995;85:224–9.CrossRef
24.
Dietz HP, Eldridge A, Grace M, Clarke B. Test-retest reliability of the ultrasound assessment of bladder neck mobility. Int Urogynecol J. 2003;14(SI):S57–8.
25.
Gordon D, Pearce M, Norton P, Stanton SL. Comparison of utrasound and lateral chain urethrocystography in the determination of bladder neck descent. Am J Obstet Gynecol. 1989;160:182–5.CrossRefPubMed
26.
Troeger C, Gugger M, Holzgreve W, Wight E. Correlation of perineal ultrasound and lateral chain urethrocystography in the anatomic evaluation of the bladder neck. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:380–4.CrossRefPubMed
27.
King JK, Freeman RM. Is antenatal bladder neck mobilty a risk factor for postpartum stress incontinence. Br J Obstet Gynaecol. 1998;105:1300–7.CrossRefPubMed
28.
Dietz HP, Clarke B, Herbison P. Bladder neck mobility and urethral closure pressure as predictors of genuine stress incontinence. Int Urogynecol J. 2002;13:289–93.CrossRef
29.
Jundt K, Scheer L, Schiessl B, Karl K, Friese K, Peschers UM. Incontinence, bladder neck mobility, and sphincter ruptures in primiparous women. Eur J Med Res. 2010;15:246–52.CrossRefPubMedPubMedCentral
30.
Peschers U, Fanger G, Schaer GN, Vodusek DB, Delancey JOL, Schuessler B. Bladder neck mobility in continent nulliparous women. Br J Obstet Gynaecol. 2001;108:320–4.
31.
Reed H, Freeman RM, Waterfield A, Adekanmi O. Prevalence of bladder neck mobility in asymptomatic nonpregnant nulliparous volunteers. Br J Obstet Gynaecol. 2004;111:172–5.CrossRef
32.
Peschers U, Schaer GN, Anthuber C, Delancey JOL, Schuessler B. Changes in vesical neck mobility following vaginal delivery. Obstet Gynecol. 1996;88:1001–6.CrossRefPubMed
33.
Pesschers UM, Schaer G, DeLancey J, Schuessler B. Levator ani function before and after childbirth. Br J Obstet Gynaecol. 1997;104:1004–8.CrossRef
34.
Dietz HP, Bennett MJ. The effect of childbirth on pelvic organ mobility. Obstet Gynecol. 2003;102:223–8.CrossRefPubMed
35.
Wijma J, Weis-Potters AE, de Wolf BTHM, Tinga DJ, Aarnoudse JG. Anatomical and functional changes in the lower urinary tract during pregnancy. Br J Obstet Gynaecol. 2001;108:726–32.
36.
Wijma J, Weis-Potters AE, de Wolf BTHM, Tinga DI, Aarnoudse JG. Anatomical and functional changes in the lower urinary tract following spontaneous vaginal delivery. Br J Obstet Gynaecol. 2003;110:658–63.CrossRef
37.
Toozs-Hobson P, Balmforth J, Cardozo L, Khullar V, Athanasiou S. The effect of mode of delivery on pelvic floor functional anatomy. Int Urogynecol J. 2008;19:407–16.CrossRef
38.
Shek KL, Dietz HP. Intrapartum risk factors for levator trauma. Br J Obstet Gynaecol. 2010;117:1485–92.CrossRef
39.
Shek KL, Dietz HP. The effect of childbirth on hiatal dimensions. Obstet Gynecol. 2009;113:1272–8.CrossRefPubMed
40.
Siafarikas F, Staer Jensen J, Hilde G, Bo K, Engh ME. The levator ani muscle during pregnancy and major levator ani defects diagnosed postpartum: a three and four-dimensional ultrasound study. Br J Obstet Gynaecol. 2015;122(8):1083–91.CrossRef
41.
Staer-Jensen J, Siafarikas F, Hilde G, Benth JS, Bo K, Engh ME. Post partum recovery of levator hiatus and bladder neck mobility in relation to pregnancy. Obstet Gynecol. 2015;125:531–9.CrossRefPubMed
42.
DeLancey JO, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol. 2003;101:46–53.PubMedPubMedCentral
43.
44.
Majida M, Braekken H, Umek W, et al. Interobserver repeatabilty of three- and four-dimensional transperineal ultrasound assessment of pelvic floor muscle anatomy and function. Ultrasound Obstet Gynecol. 2009;33:567–73.CrossRefPubMed
45.
Notten KJ, Kluivers KB, Fütterer JJ, et al. Netherlands trial register. Translabial three-dimensional ultrasonography compared with magnetic resonance imaging in detecting levator ani defects. Obstet Gynecol. 2014;124:1190–7.CrossRefPubMed
46.
Schwertner-Tiepelmann N, Thakar R, Sultan AH, Tunn R. Obstetric levator ani muscle injuries: current status. Ultrasound Obstet Gynecol. 2012;39:372–83.CrossRefPubMed
47.
48.
Shek KL, Kruger J, Dietz HP. The effect of pregnancy on hiatal dimensions and urethral mobility: an observational study. Int Urogynecol J. 2012;23:1561–7.CrossRefPubMed
49.
Van Veelen GA, Schweitzer KJ, Van der Vaart CH. Ultrasound imaging of the pelvic floor: changes in anatomy during and after first pregnancy. Ultrasound Obstet Gynecol. 2014;44:476–80.CrossRefPubMed
50.
Grob AT, Withagen MI, Van de Waarsenburg MK, Schweitzer KJ, Van der Vaart CH. Association of first trimester echogenicity of the puborectalis muscle with mode of delivery. Obstet Gynecol. 2016;127:1021–6.CrossRefPubMed
51.
Snooks SJ, Swash M, Setchell M, Henry MM. Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet. 1984;8:546–50.CrossRef
52.
Snooks SJ, Swash M, Henry MM, Setchell M. Risk factors in childbirth causing damage to the pelvic floor innervation. Int J Color Dis. 1986;1:20–4.CrossRef
53.
Allen RE, Hosker GL, ARB S, Warrell DW. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol. 1990;97:770–9.CrossRefPubMed
54.
Sultan AH, Kamm MA, Hudson CN. Pudendal nerve damage during labor: prospective study before and after childbirth. Br J Obstet Gynaecol. 1994;101:22–8.CrossRefPubMed
55.
Tetzschner T, Sorensen M, Jonnson L, Lose G, Christansen J. Delivery and pudendal nerve function. Acta Obstet Gynecol Scand. 1997;76:324–31.CrossRefPubMed
56.
Elenskaia K, Thakar R, Sultan AH, Scheer I, Onwude J. Effect of childbirth on pelvic organ support and quality of life: a longitudinal cohort study. Int Urogynaecol J. 2013;24:927–37.CrossRef
57.
Sze EH, Sherard GB 3rd, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol. 2002;100:981–6.PubMed
58.
O’Boyle AL, O’Boyle JD, Calhoun B, Davis G. Pelvic organ support in pregnancy and postpartum. Int Urogynecol J. 2005;16:69–72.CrossRef
59.
Chen Y, Li F-Y, Lin X, Chen J, Chen C, Guess MK. The recovery of pelvic organ support during the first year postpartum. Br J Obstet Gynaecol. 2013;120:1430–3.CrossRef
60.
Zhu L, Bian XM, Long Y, Lang JH. Role of different childbirth strategies on pelvic organ prolapse and stress urinary incontinence: a prospective study. Chin Med J. 2008;121:213–5.PubMed
61.
Handa VL, Nygaard I, Kenton K, Cundiff GW, Ghetti CH, Ye W, et al. Pelvic organ support among primiparous women in the first year after childbirth. Int Urogynecol J. 2009;20:1407–11.
62.
Nygaard IE, Clark E, Clark L, Egger MJ, (MAP project), et al. Physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery: a protocol for a mixed-methods prospective cohort study. BMJ Open. 2017;7:e014252.CrossRefPubMedPubMedCentral
63.
Reimers C, Staer-Jensen J, Siafarikas F, Saltythe-Benth J, Bö K, Ellstrom Engh N. Change in pelvic organ support during pregnancy and the first year postpartum: a longitudinal study. Br J Obstet Gynaecol. 2016;123:821–9.CrossRef
64.
Ulmsten U, Ekman G, Giertz G, Malmström A. Different biochemical composition of connective tissue in continent and stressincontinent women. Acta Obstet Gynecol Scand. 1987;66:455–7.CrossRefPubMed
65.
Jackson SR, Avery NC, Tarlton JF, Eckford SD, Abrams P, Bailey AJ. Changes in metabolism of collagen in genitourinary prolapse. Lancet. 1996;347:1658–61.CrossRefPubMed
66.
Keane DP, Sims TJ, Abrams P, Bailey AJ. Analysis of collagen status in premenopausal nulliparous women with genuine stress incontinence. Br J Obstet Gynaecol. 1997;104:994–8.CrossRefPubMed
67.
Landon CR, Crofts CE, Smith ARB, Trowbridge EA. Mechanical properties of fascia during pregnancy: a possible factor in the development of stress incontinence of urine. Contemp Rev Obstet Gynaecol. 1990;2:40–6.
68.
Mc Lennan MT, Harris JK, Kariuki B, Meyer S. Family history as a risk factor for pelvic organ prolapse. Int Urogynecol J. 2008;19:1063–9.CrossRef
69.
Lince SL, Kempen LC, Vierhout ME, Kluivers KB. A systematic review of clinical studies on hereditary factors in pelvic organ prolapse. Int Urogynaecol J. 2012;23:1327–133671.CrossRef
70.
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or cesarean delivery. Br J Obstet Gynaecol. 2013;120:152–60.CrossRef
71.
Vergeldt TFM, Weemhoff M, Inthout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J. 2015;26:1559–73.CrossRefPubMedPubMedCentral
72.
Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Urinary incontinence after vaginal delivery or cesarean section. N Engl Med J. 2003;348:900–7.CrossRef
73.
Hendrix SL, Clark A, Nygaard I, Aragaki A, Bernabei V, McTiernan A. Pelvic organ prolapse in the Women’s health initiative: gravity and gravidity. Am J Obstet Gynecol. 2002;186:1160–6.CrossRefPubMed
74.
Thom DH, Van Den Eeden SK, Brown JS. Evaluation of parturition and other reproductive variables as risk factors for urinary incontinence in later life. Obstet Gynecol. 1997;90:983–9.CrossRefPubMed
75.
Tegerstedt G, Miedel A, Maehle-Schmidt M, Nyren O, Hammarström M. Obstetric risk factors for symptomatic prolapse: a population-based approach. Am J Obstet Gynecol. 2006;194:75–81.CrossRefPubMed
76.
Leijonhufvud A, Lundholm C, Cnattingius S, Granath F, Andolf E, Altman D. Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Am J Obstet Gynecol. 2011;204:70e1.CrossRef
77.
Volloyhaug I, Morkved S, Salvesen O, Salvesen K. Pelvic organ prolapse and incontinence 15-23 years after first delivery: a crossectional study. Br J Obstet Gynaecol. 2015;122:964–71.CrossRef
78.
Handa VL, Blomquist JL, Knoepp LR, Leise R, Hoskey KA, McDermott K, et al. Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth. Obstet Gynecol. 2011;118:777–84.
79.
Glazener C, Elders A, Macarthur C, Wilson D, ProLong Study Group, et al. Childbirth and prolapse: long term associations with the symptoms and objective measurement of pelvic organ prolapse. Br J Obstet Gynaecol. 2013;120:161–8.CrossRef
80.
Van Kessel K, Reed S, Newton K, Meier A, Lentz G. The second stage of labor and stress urinary incontinence. Am J Obstet Gynecol. 2001;184:1571–5.CrossRefPubMed
81.
Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Vaginal delivery parameters and urinary incontinence: the Norwegian EPINCONT study. Am J Obstet Gynecol. 2003;189:1268–74.CrossRefPubMed
82.
Viktrup L, Rortveit G, Lose G. Risk of stress urinary incontinence twelve years after the first pregnancy and delivery. Obstet Gynecol. 2006;108:248–54.CrossRefPubMed
83.
Goldberg RP, Abramov Y, Botros S, Sand P, et al. Delivery mode is a major environmental determinant of stress urinary incontinence: results of the Evanston northwestern twin sisters study. Am J Obstet Gynecol. 2005;193(6):2149–53.CrossRefPubMed
84.
Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol. 1996;103:154–61.CrossRefPubMed
85.
Boyles SH, Li H, Mori T, Osterweil P, Guis JM. Effect of mode of delivery on the incidence of urinary incontinence in primiparous women. Obstet Gynecol. 2009;113:134–41.CrossRefPubMed
86.
Gordon H, Logue M. Perineal muscle function after childbirth. Lancet. 1985;20:123–5.CrossRef
87.
Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Data Base Syst Rev 2011;(12):cd0003882pub4.
88.
Boyle R, Hay-Smith EJ, Cody JD, Morkved S. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2012;10:cd007471pub2.
89.
Hagen S, Glazener C, McClurg D, Logan J, et al. Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPOL): a multicentre randomized controlled trial. Lancet. 2017;389:393–402.CrossRefPubMed
90.
Pelaez M, Gonzalez-Cerron S, Montejo R, Barakat R. Pelvic floor muscle training included in a pregnancty exercise program is effective in primary prevention of urinary incontinence: a randomized controlled trial. Neurourol Urodyn. 2014;33:67–71.CrossRefPubMed
91.
Van Brummen HJ, Bruinse HW, van de Pol G, Heintz APM, van der Vaart CH. The effect of vaginal and cesarean delivery on lower urinary tract symptoms: what makes the difference? Int Urogynecol J. 2007;18:133–9.CrossRef
Metadata
Title
A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques
Authors
Hans Van Geelen
Donald Ostergard
Peter Sand
Publication date
01-03-2018
Publisher
Springer London
Published in
International Urogynecology Journal / Issue 3/2018
Print ISSN: 0937-3462
Electronic ISSN: 1433-3023
DOI
https://doi.org/10.1007/s00192-017-3540-z

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