Pelvic floor disorders (PFDs) affect many pregnant and newly postpartum women. These conditions, including urinary incontinence, anal incontinence, and pelvic organ prolapse (POP), can be overshadowed by common pregnancy and postpartum concerns (TABLE 1).1 With the use of a few quick screening questions, however, PFDs easily can be identified in this at-risk population. Active management need not be delayed until after delivery for women experiencing bother, as options exist for women with PFDs during pregnancy as well as postpartum.
In this article, we discuss the common PFDs that obstetric clinicians face in the context of case scenarios and review how you can be better equipped to care for affected individuals.
CASE 1 Screening
A 30-year-old woman (G1P1) presents for her routine postpartum visit after an operative vaginal delivery with a second-degree laceration.
How would you screen this patient for PFDs?
Why screening for PFDs matters
While there are no validated PFD screening tools for this patient population, clinicians can ask a series of brief open-ended questions as part of the review of systems to efficiently evaluate for the common PFDs in peripartum patients (see “Screening questions to evaluate patients for peripartum pelvic floor disorders” below).
Pelvic floor disorders in the peripartum period can have a significant negative impact. In pregnancy, nearly half of women report psychological strain due to the presence of bowel, bladder, prolapse, or sexual dysfunction symptoms.2 Postpartum, PFDs have negative effects on overall health, well-being, and self-esteem, with significantly increased rates of postpartum depression in women who experience urinary incontinence.3,4 Proactively inquiring about PFD symptoms, providing anticipatory guidance, and recommending treatment options can positively impact a patient in multiple domains.
Screening questions to evaluate patients for peripartum pelvic floor disorders
Sometimes during pregnancy or after having a baby, a woman experiences pelvic floor symptoms. Do you have any of the following?
- leakage with coughing, laughing, sneezing, or physical activity
- urgency to urinate or leakage due to urgency
- bulging or pressure within the vagina
- pain with intercourse
- accidental bowel leakage of stool or flatus
CASE 2 Stress urinary incontinence
A 27-year-old woman (G1P1) presents 2 months following spontaneous vaginal delivery with symptoms of urine leakage with laughing and running. Her urinary incontinence has been improving since delivery, but it continues to be bothersome.
What would you recommend for this patient?
Conservative SUI management strategies in pregnancy
Urinary tract symptoms are common in pregnancy, with up to 41.8% of women reporting urinary symptom distress in the third trimester.5 During pregnancy, estrogen and progesterone decrease urethral pressure that, together with increased intra-abdominal pressure from the gravid uterus, can cause or worsen stress urinary incontinence (SUI).6
During pregnancy, women should be offered conservative therapies for SUI. For women who can perform a pelvic floor contraction (a Kegel exercise), self-guided pelvic floor muscle exercises (PFMEs) may be helpful (see “Pelvic floor muscle exercises” below). We recommend that women start with 1 to 2 sets of 10 Kegel exercises per day and that they hold the squeeze for 2 to 3 seconds, working up to holding for 10 seconds. The goal is to strengthen and improve muscle control so that the Kegel squeeze can be paired with activities that cause SUI.
For women who are unable to perform a Kegel exercise or are not improving with a home PFME regimen, referral to pelvic floor physical therapy (PFPT) can be considered. While data support the efficacy of PFPT for SUI treatment in nonpregnant women,7 data are lacking on PFME in pregnancy.
In women without urinary incontinence, PFME in early pregnancy can prevent the onset of incontinence in late pregnancy and the postpartum period.8 By contrast, the same 2020 Cochrane Review found no evidence that antenatal pelvic floor muscle therapy in incontinent women decreases incontinence in mid- or late-pregnancy or in the postpartum period.8 As the quality of this evidence is very low and there is no evidence of harm with PFME, we continue to recommend it for women with bothersome SUI.
Incontinence pessaries or vaginal inserts (such as Poise Impressa bladder supports) can be helpful for SUI treatment. An incontinence pessary can be fitted in the office, and fitting kits are available for both. Pessaries can safely be used in pregnancy, but there are no data on the efficacy of pessaries for treating SUI in pregnancy. In nonpregnant women, evidence demonstrates 63% satisfaction 3 months post–pessary placement for SUI.7
We do not recommend invasive procedures for the treatment of SUI during pregnancy or in the first 6 months following delivery. There is no evidence that elective cesarean delivery prevents persistent SUI postpartum.9
Pelvic floor muscle exercises1
To identify and engage the proper pelvic floor muscles:
- Insert a finger in the vagina and squeeze the vaginal muscles around your finger.
- Imagine you are sitting on a marble and have to pick it up with the vaginal muscles.
- Squeeze the muscles you would use to stop the flow of urine or hold back flatulence.
Perform sets of 10, 2 to 3 times per day as follows:
- Squeeze: Engage the pelvic floor muscles as described above; avoid performing Kegels while voiding.
- Hold: For 2 to 10 seconds; increase the duration to 10 seconds as able.
- Relax: Completely relax muscles before initating the next squeeze.
Reference
1. UpToDate. Patient education: pelvic muscle (Kegel) exercises (the basics). 2018. https://uptodatefree.ir/topic.htm?path=pelvic-muscle-kegel-exercises-the-basics. Accessed February 24, 2021.
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