The Relationship of Obstetric Factors to Aspects of Pelvic Floor Trauma And Dysfunction 20 Years Post-delivery
Background The pelvic floor (levator ani and covering endopelvic fascia) has an important role in supporting the bladder, vagina, uterus and rectum. Pelvic floor trauma in women may result in urinary and faecal incontinence, and also pelvic organ prolapse. It is a very common problem affecting around half of women having at least one type of pelvic floor dysfunction, particularly later in life. The aetiology of pelvic floor dysfunction is likely to be multifactorial, although childbearing is probably the most significant predisposing factor in women – vaginal delivery resulting in stretching and avulsion of levator ani muscles, damage to anal sphincter, along with nerve trauma are important factors.The development of functional imaging has revolutionised our understanding of the pelvic floor during and after birth. There is however a lack of information on the long-term relationship between obstetric factors with pelvic floor trauma and the relationship between these obstetric injuries and long-term pelvic floor function. Objectives To investigate the relationship between obstetric history and the clinical and ultrasound diagnosis of levator avulsion (LA) and damage to the anal sphincter 20 years after childbirth. We also aimed to examine the relationship of these obstetric injuries to symptoms and signs of pelvic floor dysfunction and to compare digital palpation of LA with ultrasound diagnosis. Design Twenty-year longitudinal study. Setting Maternity unit in Dunedin. Population Women dwelling in the community. Methods Data from women were collected 20 years after an index birth by postal questionnaire, and women were invited for examination and ultrasound assessment. Logistic regression investigated associations between ultrasound diagnoses and symptoms and signs of pelvic floor dysfunction. Main outcome measures Objective measures of prolapse (POP-Q) and ultrasound confirmation of LA and obstetric anal sphincter injuries (OASIS). Subjective report of pelvic floor dysfunction measured by the pelvic organ prolapse symptom score (POP-SS), Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) score, any urinary and faecal incontinence. Results Of 1248 women at initial recruitment, 1191 questionnaires were sent and 464 (39%) returned questionnaires at 20 years. 196 of these returned for clinical assessment. The mean age for the examined respondents was 50.8 years. The overall LA rate was 15.2% and OASIS rate was 12.5%. Agreement between palpation and transperineal ultrasound diagnosis of LA was 91% (kappa 0.32). Forceps delivery was associated with significantly greater LA rate compared with vaginal delivery (26% vs. 13%, OR 2.45, 95% CI 1.04-5.08, p=0.04); as well as higher OASIS rate but that did not reach significance (21% versus 11%, OR 2.2, 95% CI 0.87-5.59, p=0.098). LA was significantly associated with more objectively measured POP-Q, “bothersome” prolapse and faecal incontinence, but had no association with prolapse symptoms by POP-SS. LA was significantly associated with greater sexual dysfunction by PISQ-12 scores (mean difference 2.3, 95% CI 0.2-4.4; p=0.015), less adequate vaginal tone for woman’s satisfaction and poorer pelvic muscle strength. Women with OASIS had a higher prevalence of urinary and faecal incontinence but this did not reach statistical significance. OASIS is associated with significantly greater sexual dysfunction by PISQ-12 scores (mean difference 3.65, 95% CI 5.9-1.4, p<0.001), but no significant difference in vaginal tone or pelvic floor muscle strength. Conclusions Forceps delivery has a long term deleterious effect on pelvic floor structures, particularly with LA. Sonographic evidence of LA is strongly linked with long term pelvic floor dysfunction including objective and bothersome prolapse, and faecal incontinence. Both LA and OASIS were significantly associated with sexual dysfunction in our group of perimenopausal women. The association of sexual dysfunction with both LA and OASIS 20 years after delivery has not been previously described and further studies are indicated to validate these findings.
Advisor: Wilson, Don; Herbison, Peter
Degree Name: Master of Medical Science
Degree Discipline: Department of Women's and Children's Health
Publisher: University of Otago
Keywords: urogynaecology; new zealand; Dunedin; ProLong study; pelvic floor; pelvic floor dysfunction; pelvic floor trauma; levator ani; levator avulsion; puborectalis avulsion; OASIS; obstetric anal sphincter injuries; pelvic organ prolapse; urinary incontinence; anal incontinence; faecal incontinence; POP-Q; translabial ultrasound; transperineal ultrasound; sexual dysfunction; PISQ-12; obstetric practice; forceps delivery; obstetric factors; delivery; childbirth; caesarean; instrumental delivery
Research Type: Thesis