Childbirth and pelvic floor dysfunction
Mar 10, 2022
Compared to a generation ago, women are having children at a later age, with bigger babies and some at higher BMIs.
Not only are their obstetrics care fraught with more challenges, the combination of factors can also lead to pelvic floor dysfunction in the postpartum period which persist later in life. The symptoms experienced is both distressing to the women and not well discussed or disclosed. As GPs, you may often be the first person that a woman reaches out to, and you can make a significant improvement to their lives by starting some simple treatment plans.
How common is it?
Pelvic floor dysfunction generally refers to pelvic organ prolapse, urinary or faecal incontinence. Of these issues prolapse and stress or urge urinary incontinence are the most common problems. The most bothersome by far is urinary incontinence which occurs in 1 in 4 women in the first 3 months postpartum. Unfortunately, 1 in 10 of these women will leak at least 1-3 times weekly and 70% will still have the same severity of leakage by 1 year postpartum. Even more sadly, there is on average a 10 year delay between symptom onset and initiation of correct treatment or surgery. Yet, in a large cohort study of 10 million woman in USA, a woman has a 20% lifetime risk of needing surgery for incontinence or prolapse by the time she is 80yrs old.
Risk factors for pelvic floor dysfunction
- Increasing maternal age
- Increasing number of pregnancies
- Increased BMI
- Fetal macrosomia
- Operative vaginal delivery, especially forceps
- Genetics i.e. family history of prolapse or incontinence
- Incontinence during pregnancy
What treatments are available?
While incontinence and prolapse occur 2-3 times more commonly in vaginal delivery, patients who undergo an elective caesarean section still have a 10-15% risk of urinary and faecal incontinence. This is because pregnancy itself has been shown to cause significant strain on the pelvic floor. Thus, recommending elective CS is not the solution. In addition, many of the risk factors for pelvic floor dysfunction are not modifiable. Where risk factors are modifiable, the focus should be on weight loss, minimising BMI pre-pregnancy, smoking cessation and management of constipation.
Postpartum conservative treatment for prolapse and incontinence include:
- Pelvic floor muscle training
- Lifestyle modifications – as listed above
Generally, symptoms are expected to improve to a degree once the patient stops breastfeeding. Should these not be effective vaginal pessaries can be fitted and used as an interim solution until a women’s family is complete.
Various surgical treatments for stress incontinence exist and have excellent long term success of 80-90%. These include:
- Laparoscopic burch colposuspension
- Retropubic midurethral sling
- Pubovaginal sling
- Periurethral bulking agent
Transoburator sling or TOT is generally NOT suitable as it is associated with 10% risk of chronic groin pain and is extremely difficult to remove. Ultimately, the choice of best surgery is tailored to the patient depending on urodynamic findings and under the care of a specialist who can provide a balanced risk and benefit profile. Similarly, various surgical options exist for vaginal prolapse but is much more variable depending on the type and severity of prolapse.
Picture from Continence Foundation of Australia
What can you do as GPs to help your patients?
- Education for women on pelvic floor exercises during pregnancy or postpartum with a physiotherapist. This has been shown to reduce incontinence postpartum in the short term via randomised trials.
- Encourage lifestyle modification in women postpartum – weight loss, management of constipation, caffeine reduction, smoking cessation
- If incontinence or prolapse symptoms still persist by 1-2 year post childbirth despite physiotherapy, it is unlikely to spontaneously resolve. Consider referral to a Urogynaecologist for further treatment.
Below resources are from both national and international urogynaecological societies on which GPs can give to women to help with their education and treatment.
Dr Zhuoran Chen
385 Crown Street
Wollongong NSW 2500
P: 1300 971 265
F: 02 4226 6196