Victoria L. Handa

Fecal and urinary incontinence in primiparous women

OBJECTIVE: To prospectively investigate the relationship between anal sphincter tears and postpartum fecal and urinary incontinence. METHODS: The Childbirth and Pelvic Symptoms study was a prospective cohort study performed by the Pelvic Floor Disorders Network to estimate the prevalence of postpartum fecal and urinary incontinence in primiparous women: 407 with clinically recognized anal sphincter tears during vaginal delivery, 390 without recognized sphincter tears (vaginal controls), and 124 delivered by cesarean before labor. Women were recruited postpartum while hospitalized and interviewed by telephone 6 weeks and 6 months postpartum. We assessed fecal and urinary incontinence symptoms using the Fecal Incontinence Severity Index and the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, respectively. Odds ratios were adjusted for age, race, and clinical site. RESULTS: Compared with the vaginal control group, women in the sphincter tear cohort reported more fecal incontinence (6 weeks, 26.6% versus 11.2%; adjusted odds ratio [AOR] 2.8, 95% confidence interval [CI] 1.8–4.3; 6 months, 17.0% versus 8.2%; AOR 1.9, 95% CI 1.2–3.2), more fecal urgency and flatal incontinence, and greater fecal incontinence severity at both times. Urinary incontinence prevalence did not differ between the sphincter tear and vaginal control groups. Six months postpartum, 22.9% of women delivered by cesarean reported urinary incontinence, whereas 7.6% reported fecal incontinence. CONCLUSION: Women with clinically recognized anal sphincter tears are more than twice as likely to report postpartum fecal incontinence than women without sphincter tears. Cesarean delivery before labor is not entirely protective against pelvic floor disorders. LEVEL OF EVIDENCE: II-3

Pelvic floor disorders 5-10 years after vaginal or cesarean childbirth.

OBJECTIVE: To estimate differences in pelvic floor disorders by mode of delivery. METHODS: We recruited 1,011 women for a longitudinal cohort study 5–10 years after first delivery. Using hospital records, we classified each birth as: cesarean without labor, cesarean during active labor, cesarean after complete cervical dilation, spontaneous vaginal birth, or operative vaginal birth. At enrollment, stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders. RESULTS: Compared with cesarean without labor, spontaneous vaginal birth was associated with a significantly greater odds of stress incontinence (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.5–5.5) and prolapse to or beyond the hymen (OR 5.6, 95% CI 2.2–14.7). Operative vaginal birth significantly increased the odds for all pelvic floor disorders, especially prolapse (OR 7.5, 95% CI 2.7–20.9). These results suggest that 6.8 additional operative births or 8.9 spontaneous vaginal births, relative to cesarean births, would lead to one additional case of prolapse. Among women delivering exclusively by cesarean, neither active labor nor complete cervical dilation increased the odds for any pelvic floor disorder considered, although the study had less than 80% power to detect a doubling of the odds with these exposures. CONCLUSION: Although spontaneous vaginal delivery was significantly associated with stress incontinence and prolapse, the most dramatic risk was associated with operative vaginal birth. LEVEL OF EVIDENCE: II

Female sexual function and pelvic floor disorders

OBJECTIVE: To investigate the hypothesis that pelvic floor disorders are associated with female sexual problems, independently of other related factors. METHODS: The study population included 301 adult women seeking outpatient gynecologic and urogynecologic care. Pelvic floor disorders were assessed with the Pelvic Floor Disorders Inventory-20 (PFDI-20) and the pelvic organ prolapse quantification examination. Sexual function was assessed with the Personal Experiences Questionnaire. Using ordinal regression analysis, we identified characteristics and conditions associated with decreased libido, infrequent orgasm, decreased arousal, and dyspareunia. RESULTS: Sexual function was poorer among 78 women (26%) without a current sexual partner than among 223 with a partner (P<.01). Among the 223 with a current partner, women with a high Pelvic Floor Disorders Inventory score were significantly more likely to report decreased arousal (P<.01), infrequent orgasm (P<.01), and increased dyspareunia (P<.01). A similar pattern was observed for the urinary, colorectal-anal, and prolapse scales of the Pelvic Floor Disorders Inventory, although some associations were marginally significant. Stage III–IV prolapse was significantly associated with infrequent orgasm (P=.02), but other sexual complaints were not more common with increasing prolapse stage. CONCLUSION: Pelvic floor symptoms are significantly associated with reduced sexual arousal, infrequent orgasm, and dyspareunia. We conclude that sexual function is worse in women with symptomatic prolapse but not in women with asymptomatic prolapse. LEVEL OF EVIDENCE: II

Do older women use estrogen replacement? Data from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE)

OBJECTIVES: The primary purpose of this study was to determine the prevalence of current and past estrogen use among older, community‐dwelling, postmenopausal women. The secondary purpose was to describe factors associated with estrogen use in this population.

Pelvic Floor Disorders After Vaginal Birth Effect of Episiotomy, Perineal Laceration, and Operative Birth

OBJECTIVE: To investigate whether episiotomy, perineal laceration, and operative delivery are associated with pelvic floor disorders after vaginal childbirth. METHODS: This is a planned analysis of data for a cohort study of pelvic floor disorders. Participants who had experienced at least one vaginal birth were recruited 5–10 years after delivery of their first child. Obstetric exposures were classified by review of hospital records. At enrollment, pelvic floor outcomes, including stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders. RESULTS: Of 449 participants, 71 (16%) had stress incontinence, 45 (10%) had overactive bladder, 56 (12%) had anal incontinence, 19 (4%) had prolapse symptoms, and 64 (14%) had prolapse to or beyond the hymen on examination. Forceps delivery increased the odds of each pelvic floor disorder considered, especially overactive bladder (odds ratio [OR] 2.92, 95% confidence interval [CI] 1.44–5.93), and prolapse (OR 1.95, 95% CI 1.03–3.70). Episiotomy was not associated with any of these pelvic floor disorders. In contrast, women with a history of more than one spontaneous perineal laceration were significantly more likely to have prolapse to or beyond the hymen (OR 2.34, 95% CI 1.13–4.86). Our multivariable results suggest that one additional woman would have development of prolapse for every eight women who experienced at least one forceps birth (compared with delivering all her children by spontaneous vaginal birth). CONCLUSION: Forceps deliveries and perineal lacerations, but not episiotomies, were associated with pelvic floor disorders 5–10 years after a first delivery. LEVEL OF EVIDENCE: II

Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms

OBJECTIVE The objective of this study was to determine the minimum threshold level at which maximum anatomic prolapse predicts bothersome pelvic floor symptoms. STUDY DESIGN We performed a cross-sectional study of women older than 40 years undergoing gynecologic and urogynecologic examinations using Pelvic Organ Prolapse Quantification (POP-Q) examinations to assess support and Pelvic Floor Distress Inventory questionnaires to assess symptoms. Across the spectrum of prolapse severity, we calculated receiver operating characteristic (ROC) curves and areas under the curves (AUCs) for each symptom. RESULTS Of 296 participants, age was 56.3 +/- 11.2 years, and 233 (79%) were white. POP-Q stage was 0 in 39 (13%), 1 in 136 (46%), 2 in 89 (30%), and 3 in 33 (11%). ROC analysis for each symptom revealed an AUC of 0.89 for bulging/protrusion; 0.81 for splinting to void; 0.55-0.62 for other prolapse and urinary symptoms; and 0.48-0.56 for bowel symptoms. Using a threshold of 0.5 cm distal to the hymen, the sensitivity (69%) and specificity (97%) were high for protrusion symptoms but poor for most other symptoms considered. CONCLUSION Vaginal descensus 0.5 cm distal to the hymen accurately predicts bulging/protrusion symptoms; however, we could not identify a threshold of prolapse severity that predicted other pelvic floor symptoms.

Sexual Function 6 Months After First Delivery

OBJECTIVE: To explore the association of anal sphincter laceration and sexual function 6 months postpartum in the Childbirth and Pelvic Symptoms (CAPS) cohort. METHODS: The primary CAPS study, a prospective cohort study, was designed to estimate the postpartum prevalence and incidence of urinary and fecal incontinence. Three cohorts of new mothers (vaginal delivery with a third- or fourth-degree anal sphincter tear, vaginal delivery without a third- or fourth-degree anal sphincter tear, and cesarean delivery without labor) were compared at 6 months postpartum. Sexual function was assessed with the Pelvic Organ Prolapse/Urinary Incontinence/Sexual Function Short Form Questionnaire (PISQ-12). Urinary and fecal incontinence were assessed using the Medical Epidemiological and Social Aspects of Aging questionnaire and the Fecal Incontinence Severity Index, which is embedded within the Modified Manchester Health Questionnaire. RESULTS: Most women (459 [90%]) of those with partners reported sexual activity at the 6-month visit. Fewer women whose delivery was complicated by anal sphincter laceration reported sexual activity when compared with those who delivered vaginally without sphincter laceration (88 compared with 94%, P=.028). The mean PISQ-12 score (39±4) did not differ between delivery groups (P=.92). Pain (responses of “sometimes,” “usually,” or “always”) during sex affected one of three sexually active women (164 [36%]). CONCLUSION: At 6 months postpartum, primiparous women who delivered with anal sphincter laceration are less likely to report sexual activity. LEVEL OF EVIDENCE: II

Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: A randomized controlled trial

OBJECTIVE: To compare the effectiveness of a continence pessary to evidence-based behavioral therapy for stress incontinence and to assess whether combined pessary and behavioral therapy is superior to single-modality therapy. METHODS: This was a multisite, randomized clinical trial (Ambulatory Treatments for Leakage Associated with Stress Incontinence [ATLAS]) that randomly assigned 446 women with stress incontinence to pessary, behavioral therapy, or combined treatment. Primary outcome measures, at 3 months, were Patient Global Impression of Improvement and the stress incontinence subscale of the Pelvic Floor Distress Inventory. A priori, to be considered clinically superior, combination therapy had to be better than both single-modality therapies. Outcome measures were repeated at 6 and 12 months. Primary analyses used an intention-to-treat approach. RESULTS: At 3 months, scores from 40% of the pessary group and 49% of the behavioral group were “much better” or “very much better” on the Patient Global Impression of Improvement (P=.10). Compared with the pessary group, more women in the behavioral group reported having no bothersome incontinence symptoms (49% compared with 33%, P=.006) and treatment satisfaction (75% compared with 63%, P=.02). Combination therapy was significantly better than pessary as shown on the Patient Global Impression of Improvement (53%, P=.02) and Pelvic Floor Distress Inventory (44%, P=.05) but not better than behavioral therapy; it was therefore not superior to single-modality therapy. Group differences were not sustained to 12 months on any measure, and patient satisfaction remained above 50% for all treatment groups. CONCLUSION: Behavioral therapy resulted in greater patient satisfaction and fewer bothersome incontinence symptoms than pessary at 3 months, but differences did not persist to 12 months. Combination therapy was not superior to single-modality therapy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00270998. LEVEL OF EVIDENCE: I

Risk Factors for Fecal and Urinary Incontinence After Childbirth: The Childbirth and Pelvic Symptoms Study

OBJECTIVE: To identify risk factors for postpartum FI and UI.METHODS: Secondary analysis of data from the CAPS study, which estimated the prevalence of postpartum FI and UI in primiparous women with clinically recognized anal sphincter tears after vaginal delivery, compared with women who delivered vaginally without recognized tears or by cesarean before labor. A total of 921 women were enrolled while in the hospital and 759 (82%) were interviewed by telephone 6 months postpartum. FI was assessed using the FISI and UI using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire. FI risk factor analyses were conducted within each group, because of higher prevalence in the tear group. UI analyses were conducted with the groups combined.RESULTS: In women with sphincter tears, FI at 6 months was associated with white race (OR 6.1, 95% CI 1.3–29.4), antenatal UI (OR 2.2, CI 1.1–4.3), 4th versus 3rd degree tear (OR 2.0, CI 1.0–4.0), older age at delivery (OR 1.6 per 5 yr, CI 1.2–2.1), and higher body mass index (BMI) (OR 1.3 per 5 kg/m2, CI 1.0–1.7). No factors were associated with FI in the vaginal or cesarean control groups. Across all groups, risk factors for postpartum UI were antenatal UI (OR 3.5, CI 2.4–5.2), less education (OR 2.0, CI 1.4–2.8), and higher BMI (OR 1.2 per 5 kg/m2, CI 1.1–1.4); cesarean delivery was protective (OR 0.5, CI 0.3–0.9).CONCLUSIONS: Postpartum FI and UI are associated with few modifiable risk factors. However, the presence of antenatal UI and high BMI may help clinicians target at-risk women for early intervention.

Racial Differences in Pelvic Anatomy by Magnetic Resonance Imaging

OBJECTIVES: To use static and dynamic magnetic resonance imaging (MRI) to compare dimensions of the bony pelvis and soft tissue structures in a sample of African-American and white women. METHODS: This study used data from 234 participants in the Childbirth and Pelvic Symptoms Imaging Study, a cohort study of 104 primiparous women with an obstetric anal sphincter tear, 94 who delivered vaginally without a recognized anal sphincter tear and 36 who underwent by cesarean delivery without labor. Race was self-reported. At 6–12 months postpartum, rapid acquisition T2-weighted pelvic MRIs were obtained. Bony and soft tissue dimensions were measured and compared between white and African-American participants using analysis of variance, while controlling for delivery type and age. RESULTS: The pelvic inlet was wider among 178 white women than 56 African-American women (10.7±0.7 cm compared with 10.0.+0.7 cm, P<.001). The outlet was also wider (mean intertuberous diameter 12.3±1.0 cm compared with 11.8±0.9 cm, P<.001). There were no significant differences between racial groups in interspinous diameter, angle of the subpubic arch, anteroposterior conjugate, levator thickness, or levator hiatus. In addition, among women who delivered vaginally without a sphincter tear, African-American women had more pelvic floor mobility than white women. This difference was not observed among women who had sustained an obstetric sphincter tear. CONCLUSION: White women have a wider pelvic inlet, wider outlet, and shallower anteroposterior outlet than African-American women. In addition, after vaginal delivery, white women demonstrate less pelvic floor mobility. These differences may contribute to observed racial differences in obstetric outcomes and to the development of pelvic floor disorders. LEVEL OF EVIDENCE: II