By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
Dr. Ghetti reports no financial relationships relevant to this field of study.
SYNOPSIS: Nulliparous women experience worsening urinary incontinence, fecal incontinence, and perineal pain in pregnancy. Urinary incontinence symptoms are associated with a negative effect on quality of life.
SOURCE: Rogers RG, Ninivaggio C, Gallagher K, et al. Pelvic floor symptoms and quality of life changes during first pregnancy: A prospective cohort study. Int Urogynecol J 2017; Apr 17. doi: 10.1007/s00192-017-3330-7. [Epub ahead of print].
The objective of this study was to describe pelvic floor changes during pregnancy in nulliparous women. This was a planned secondary analysis of a longitudinal study titled Alterations in the Pelvic Floor in Pregnancy, Labor and the Ensuing Years (APPLE) that followed women through pregnancy, childbirth, and two years following delivery. Eligible women were 18 years or older, nulliparous, and low risk. Subjects completed validated symptom severity and quality-of-life measures. A physical exam was performed one time during pregnancy. For this secondary analysis, the authors sought to recruit 630 nulliparous women in the first or second trimester. Longitudinal data were analyzed using ANOVA, mixed linear models, and generalized linear models. Urinary outcomes were assessed using the Incontinence Severity Index, Questionnaire for Urinary Diagnosis, and Incontinence Impact Questionnaire (IIQ-7). Bowel-related outcomes were assessed using the Wexner FI scale and the Colorectal–Anal Impact Questionnaire. The POP-Q was used to evaluate for prolapse on physical exam. Subjects completed the Present Pain Intensity scale. Sexual activity was self-reported.
The researchers recruited 627 nulliparous women from nurse-midwifery clinics from 2006 to 2011. Mean subject age was 24.2 ± 5 years. Subjects had an average of 14 years of education and about half were white and half were Hispanic. Mean body mass index was 25.1 ± 5.7 kg/m2. By study design, the majority (84%) of women were recruited in the first or second trimesters, and most women (80%) had paired data. Urinary incontinence symptoms increased across trimesters. Thirty-three percent of subjects reported any urinary incontinence in the first trimester vs. 69% in the third trimester. Similarly, 6% reported moderate to severe incontinence in the first trimester vs. 24% in the third trimester. The type of incontinence did not change across trimesters. IIQ-7 scores increased significantly into the third trimester, indicating worsening incontinence-related quality of life by the third trimester. More than 50% of women reported any anal incontinence in all three trimesters, but few reported fecal incontinence (8-16%), and quality of life did not vary between trimesters. Perineal pain increased across trimesters, with 40% of subjects describing any perineal pain in the third trimester, and self-reported sexual activity decreased across trimesters.
COMMENTARY
The findings reported in this study add to the existing literature regarding pelvic floor symptoms in pregnancy. Several other large studies highlight the important changes in pelvic floor function that occur during the course of pregnancy. Solans-Domènech et al reported a 39.1% rate of urinary incontinence, with an increased prevalence by trimester in a cohort of 1,128 healthy continence nulliparous women.1 Boyle et al reported a 19% rate of urinary incontinence in pregnancy in 5,599 nulliparous women with no prior incontinence history.2 A multicenter prospective pregnancy cohort study of 1,507 women found that the prevalence of urinary incontinence increased from 10.8% in the 12 months before the index pregnancy to 55.9% in the third trimester. The low rates of fecal incontinence reported by Rogers et al also are reported in several large studies, including the above-mentioned study by Solans-Domènech et al.
This study’s main limitation is that the physical examination was performed only once during the pregnancy. Unlike questionnaire measures, there were no longitudinal physical examination data and few conclusions could be drawn regarding anatomic changes during pregnancy.
In previous issues of OB/GYN Clinical Alert, we have discussed pelvic floor changes related to pelvic floor injury at the time of delivery. This study reports that urinary incontinence, anal incontinence, and perineal pain increase throughout pregnancy, underscoring pelvic floor changes that occur during pregnancy even before those attributed to delivery. Studies have found that cesarean delivery is not completely protective against the development of pelvic floor disorders.2 This and prior studies suggest that pregnancy itself affects pelvic floor function. The unanswered question is how. Some suggested mechanisms include increased pressure of the gravid uterus, pregnancy-related hormonal and soft tissue changes, as well as altered body mechanics related to increased weight and weight distribution, all of which affect pelvic floor musculature and function.3 Pelvic floor muscle exercises have been shown to be a safe and effective treatment for urinary incontinence during pregnancy.4
This study further highlights the natural history of pelvic floor symptoms in pregnancy. Obstetric providers can comfortably discuss and educate patients about the known progression of pelvic floor symptoms during pregnancy. Routinely talking to patients to elicit new or worsening pelvic floor symptoms throughout pregnancy may allow patients to initiate pelvic floor physical therapy earlier in pregnancy and improve their quality of life.
REFERENCES
- Solans-Domenech M, Sanchez E, Espuna-Pons M; Pelvic Floor Research Group. Urinary and anal incontinence during pregnancy and postpartum: Incidence, severity, and risk factors. Obstet Gynecol 2010;115:618-628.
- Boyles SH, Li H, Mori T, et al. Effect of mode of delivery on the incidence of urinary incontinence in primiparous women. Obstet Gynecol 2009;113:134-141.
- Sangsawang B, Sangsawang N. Stress urinary incontinence in pregnant women: A review of prevalence, pathophysiology, and treatment. Int Urogynecol J 2013;24:901-912.
- Sampselle CM, Miller JM, Mims BL, et al. Effect of pelvic muscle exercise on transient incontinence during pregnancy and after birth. Obstet Gynecol 1998;91:406-412.
Nulliparous women experience worsening urinary incontinence, fecal incontinence, and perineal pain in pregnancy. Urinary incontinence symptoms are associated with a negative effect on quality of life.
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