Influence of pregnancy and mode of delivery on pelvic floor function: a review of literature.

Pelvic floor disorders (PFDs), such as pelvic organ prolapse (POP) and urinary incontinence (UI), severely affect women's quality of life. Among these, stress urinary incontinence (SUI) is the most common, impacting a significant proportion of women. In the US, the lifetime risk of undergoing surgery for UI or POP stands at 20%. Pregnancy-related factors, notably delivery method and UI occurrence during pregnancy, have a potent correlation with PFD onset. The pathophysiology of PFDs during pregnancy is complex, with factors like increased intra-abdominal pressure, changes in bladder neck mobility, and shifts in pelvic floor muscle strength and collagen metabolism playing pivotal roles. PFD risk factors span across pregnancy, labor, and the postnatal phase and include UI or fecal incontinence (FI) during pregnancy, advanced maternal age, elevated BMI, multiple births, instrumental and spontaneous vaginal deliveries, and newborns weighing over 4000 grams. Conversely, Cesarean deliveries are linked with a reduced long-term risk of UI and POP compared to vaginal births. Current prognostic models can predict the likelihood of PFD development based on variables such as delivery method, number of births, and familial history. Preventive measures encompass lifestyle changes like caffeine reduction and weight management, alongside pelvic floor muscle training (PFMT) during pregnancy. Thus, expectant mothers are advised to participate in physical activities, prominently including PFMT.

The Influence of Successful Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse on Depression, Anxiety, and Insomnia-A Prospective Intervention Impact Assessment Study.

Introduction: The association between pelvic floor disorders (PFDs) and psychiatric conditions is an area of emerging interest. The causal direction of this relationship, however, remains ambiguous; it is unclear whether PFDs directly contribute to the deterioration of mental health or if pre-existing psychiatric conditions such as depression exacerbate the symptoms of PFDs. This study aimed to evaluate the effects of successful surgical treatment for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) on symptoms of depression, anxiety, and insomnia. Materials and Methods: This investigation focused on patients who underwent successful surgical interventions for SUI and POP. Both subjective and objective symptoms of PFDs, along with psychiatric status, were assessed before and after the surgical procedures. Results: This study found that successful surgical treatment of SUI and POP led to a significant reduction in anxiety scores. Additionally, in patients with SUI, successful treatment was objectively associated with a decrease in the severity of insomnia. Alleviation of symptoms associated with the lower urinary tract, prolapse, and colorectal-anal region following POP surgery was correlated with improvements in depression and anxiety but not insomnia. Subjectively assessed improvements in SUI subjective symptoms were linked to reductions in the severity of depression, anxiety, and insomnia in patients who underwent anti-incontinence surgery. Conclusions: These findings suggest a potential cause-and-effect relationship between PFDs and certain psychiatric disorders, highlighting the importance of successful treatment of PFDs in mitigating symptoms of depression, anxiety, and insomnia.

Influence of Stress Urinary Incontinence and Pelvic Organ Prolapse on Depression, Anxiety, and Insomnia-A Comparative Observational Study.

BACKGROUND: Among pelvic floor disorders (PFDs), overactive bladder is a well-recognized condition affecting mental health. The aim of this study was to assess whether there is a correlation between stress urinary incontinence (SUI), pelvic organ prolapse (POP), and mental health in comparison to control subjects and whether objective or subjective aspects of diseases are responsible for the aforementioned symptoms. METHODS: 192 patients with SUI, 271 with symptomatic prolapse (>2 in the POPQ scale), and 199 controls without pelvic floor disorders were included in this study. Patients completed questionnaires assessing levels of depression, anxiety, and insomnia. The 1-h pad test and IIQ-7 questionnaires were collected in SUI. The pelvic organ prolapse quantification scale and the POPDI6, UDI6, and CRADI-8 questionnaires were used in POP patients. RESULTS: Higher scores in psychiatric scales were observed in SUI (p < 0.05) and POP (p < 0.05) compared to control. There were no correlations between the objective severity of PFDs and psychological symptoms, while subjective complaints correlated with psychological health. In conclusion, we showed that subjective perceptions of SUI and POP are factors that augment psychiatric symptoms, while objective severity is not correlated with mental status. CONCLUSIONS: Our findings suggest that patients with PFDs necessitate multidisciplinary attention, including psychiatric care.

Epidemiological Features of the Bladder Neck Rest Position and Mobility.

The data concerning epidemiological determinants of the bladder neck (BN) mobility are scarce. The aim of the study was to determine epidemiological features and identify factors influencing BN position at rest and BN mobility in patients without pelvic organ prolapse (POP). Seven hundred and ninety-six patients that attended two outpatient clinics were enrolled in the study. Position and mobility of the BN were measured with the use of pelvic floor ultrasound. Demographic and functional factors that were hypothesized to influence BN mobility were assessed. Vaginal deliveries (VDs) and age ≥65 were associated with lower BN position at rest. Higher BN mobility was observed in women with stress urinary incontinence (SUI). In obese women, higher BN position and lower BN mobility was observed compared to non-obese women, and it was correlated with longer urethras in this group of patients. VDs and their number were associated with increased BN mobility, independently of body mass index (BMI). To conclude, obesity, VDs, and age are factors associated with changes in bladder neck position at rest and its mobility. Higher BMI correlates with restricted BN mobility, and, therefore, the incidence of SUI in obese patients is probably not connected to BN hypermobility.

Impact of Midurethral Sling Implantation on Sexual Function in Women with Stress Urinary Incontinence.

Stress urinary incontinence (SUI) negatively influences sexual functions. However, the available data on sexual activity of patients who underwent midurethral sling (MUS) implantation are inconsistent. Our aim was to evaluate the impact of MUS implantation on sexual functions of women with SUI. We enrolled 171 patients undergoing the MUS procedure. Preoperative examination included the cough test, 1 h pad test and the Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA Revised (PISQ-IR). All patients had the retropubic sling implanted. Follow-up visits were performed 6-12 months after surgery. Objective cure rate was obtained in 90.98% of patients. Coital incontinence was reported by 56% of women before the surgery, and 8.6% afterwards. Among women who gained continence, significant improvement in sexual function was observed in the majority of the domains. In women who were not objectively cured (9.02%), we did not observe improvement in sexual life. All these patients indicated fear of leaking urine during sexual activity as the main cause of avoiding sex, similarly as before operation. To conclude, successful treatment of SUI with MUS significantly improves the quality of sexual life. On the other hand, persistent incontinence appears to be the most probable cause of lack of improvement in the quality of sexual life.

Does Previous Pelvic Organ Prolapse Surgery Influence the Effectiveness of the Sub-Urethral Sling Procedure?

Pelvic organ prolapse (POP) often co-occurs with stress urinary incontinence. There is no consensus on whether prolapse repair and anti-incontinence surgery should be performed concomitantly or separately, in a two-step manner. The present study evaluated the effects of the tension-free vaginal tape (TVT) procedure in patients who had previously undergone pelvic floor repair (study group), compared to women who underwent TVT insertion only (control group). The study group comprised 84 patients who underwent the TVT procedure but had previously also undergone surgical POP repair. The control group consisted of 250 women in whom the TVT was inserted. The primary objective was to compare the objective cure rate and the secondary objective was to compare the subjective cure rate in both groups. Negative pad test was achieved in over 91% in both groups. Objective and subjective cure rates were compared, as well as complication rates. Significant improvement was observed in the postoperative 1-h pad test in all patients. In all patients, we observed significant improvement in the quality of life, with no differences between the groups. No differences were found in the occurrence of postoperative urinary retention, urgency and frequency of daytime micturition, or vaginal erosion between the groups. The current results demonstrate that the two-step approach to pelvic reconstruction and anti-incontinence surgery is as safe and effective as primary TVT implantation.

Demographic risk factors for mid-urethral sling failure. Do they really matter?

Age, obesity and vaginal deliveries (VD) are recognized risk factors for stress urinary incontinence (SUI). According to many authors, the abovementioned risk factors for incontinence also increase the risk of mid-urethral sling (MUS) failure. Our aim was to evaluate the objective and subjective effectiveness of retropubic MUS in 12 months observation, relative to the three potential risk factors of failure: obesity, age and VDs. A prospective observational study including 238 women who underwent retropubic MUS implantation was performed. Patients were divided into subgroups: obese vs non-obese, <65 vs ≥65 years old and no history of VD vs ≥1 VD. Follow-up took place between 6 and 12 months post-surgery. Cough test, 1-hour pad test, pelvic floor ultrasound examination, and Incontinence Impact Questionnaire 7 (IIQ-7) results were assessed pre- and post-operatively. Of the 238 patients, 208 (86.3%) completed a minimum follow-up period of 12 months. Significant improvement in the pad test was observed in all patients (83.2 ± 78.6 g vs 0.7 ± 3.3 g). Negative cough test results were obtained in over 94% of patients. Significant improvement in the IIQ7 results was observed in all patients (74.2 ± 17.7 vs 5.5 ± 13.4). No significant differences in all the analyzed parameters with regard to BMI, age and parity were observed. No combination of risk factors influenced the objective and subjective cure rates. Our study demonstrated that older age, obesity and history of VDs have no impact on objective and subjective sling effectiveness in a short term observation. There is no influence of combined demographic features on the failure risk.

Demographic features of female urethra length.

AIMS: To determine cohort urethral length, identify epidemiological factors influencing the parameter and to establish the percentage of cases with clinically relevant outsized urethras. METHODS: Prospective cohort study conducted in two tertiary clinical centers between 2013 and 2017. Nine hundred and twenty seven consecutive adult, Caucasian females attending outpatients' clinics were included. The urethral length has been measured in pelvic floor ultrasound examination. The exclusion criteria were inadequate bladder filling (<200 mL; >400 mL), previous history of pelvic floor surgery, and no consent. RESULTS: Urethral length varied from 19 to 45 mm. The distribution of the examined parameter was normal. Obese patients had significantly longer urethras as compared to non-obese subjects. Number of vaginal deliveries was connected with shorter urethral length. The limitations of the study are: analysis only of Caucasian patients and subjects without previous pelvic floor surgeries. CONCLUSIONS: Differences in urethral length in the female population were demonstrated. Thirty percent of patients have atypical urethras that may be a risk factor for sling surgery failure. We therefore postulate introduction of urethral measurement before the procedure.

Is Bariatric Surgery a Prophylaxis for Pelvic Floor Disorders?

INTRODUCTION: Obesity is one of the well-documented risk factors of pelvic floor disorders (PFDs). The PFDs include urinary and fecal incontinence (UI, FI) and pelvic organ prolapse (POP). Surgery-induced weight loss improves different kinds of incontinence as well as POP symptoms. However, there is a lack of evidence how bariatric surgery influences pelvic floor anatomy and function in women without previous PFDs and whether it may be concerned as PFD prophylaxis tool. MATERIALS AND METHODS: The present analysis is a prospective, non-randomized case-control study from January 2014 to September 2017. Participants underwent pelvic floor ultrasound examination with bladder neck position estimation at rest, during levator ani tension, and at Valsalva maneuver before surgery and 12-18 months after. Pelvic organ prolapse quantification (POPQ) > 2 stage and PFD complaints were the exclusion criteria. RESULTS: Fifty-nine patients underwent bariatric surgery (57 sleeve gastrectomy and 2 gastric bypass). Mean BMI decreased from 43.8 ± 5.9 to 29 ± 4.6 kg/m2 after surgery (p < 0.001). Statistically significant higher position of the bladder neck at rest, during tension, and at Valsalva maneuver (p < 0.05) was shown after surgery. We did not demonstrate differences in bladder neck mobility and bladder neck elevation at tension after weight loss. CONCLUSIONS: Bariatric surgery is associated with a betterment of bladder neck position at rest, tension, and Valsalva maneuver in women without PFDs. We postulate that bariatric surgery may be a tool for PFD prevention. It does not improve levator ani function and does not limit bladder neck mobility, which implicates that it has no influence on preexisting pelvic dysfunction.

Does the suburethral sling change its location?

OBJECTIVES: To ascertain whether a phenomenon of sling migration exists after suburethral sling placement, whether this might be responsible for suboptimal sling location and persistent incontinence, and whether a link exists between sling dislocation or migration and risk factors, such as obesity or age. METHODS: The present prospective cohort study was carried out in a group of 244 patients who underwent retropubic sling implantation. Sling location was determined by means of pelvic floor ultrasound, and calculated relative to the individual patient's urethral length measured before the procedure. The sling location was visualized on 1 day, and 1 and 6 months post-surgery. Overweight/obese and elderly patients were analyzed separately to assess the possible influence of those factors on sling location. RESULTS: The mean urethral length in the studied cohort was 28.76 ± 3.67 mm. The mean tape position 1 day post-surgery was 66.18 ± 8.43% of the urethral length, and it did not change 1 and 6 months post-surgery in the whole group. Similar results were obtained in elderly and overweight/obese patients. CONCLUSIONS: Suboptimal sling location appears to result from incorrect surgical technique, and should be diagnosed and treated early after the primary surgery. Sling location does not change after mid-term follow up.

The Outcome of Repeated Mid Urethral Sling in SUI Treatment after Vaginal Excisions of Primary Failed Sling: Preliminary Study.

Mid urethral sling is the standard in SUI treatment. Nevertheless, the risk of reoperation reaches 9%. There is no consensus as to the best treatment option for complications. A question is raised: what is the optimal way to achieve the best result in patients after primary failure? The aim of the study was to evaluate the outcomes of repeat MUS surgery in patients after excision of the sling with recurrent SUI. We compared its effectiveness with uncomplicated cases treated with TVT. 27 patients who underwent the repeated MUS and 50 consecutive patients after primary TVT were enrolled in the study. After 6 months, we have found that 24 (88.46%) patients from repeat sling group and 48 (96%) patients after primary sling were dry (1-hour pad test, 2 g or less). The difference between groups was not significant. We showed statistically significant improvement of quality of life in both groups. In conclusion, we showed that repeated sling after MUS excision is almost as effective as primary MUS. We postulate that sling excision and repeated MUS may be the best option for persistent SUI and/or complications after MUS procedures. Further multicenter observations are ongoing as to provide results on bigger group of cases.

Obesity and Pelvic Floor Disorders: A Review of the Literature.

Overweight and obesity are becoming a worldwide health problem associated with numerous co-morbidities. National costs of obesity and pelvic flor disorders have been rising since the 1950s across the world. Obesity is thought to have a very strong effect on pelvic floor disorders, and, considering the high prevalence of both problems worldwide, it is of utmost importance to evaluate the association between these pathologies as well as the impact of obesity on treatment efficacy. This review is based on a selection of reports in the literature (PubMed search), including guidelines and Cochrane reviews. Obesity seems to be a well-documented risk factor for lower urinary tract symptoms (LUTS) and is a predictor of exacerbation of stress urinary incontinence (SUI) and overactive bladder (OAB). Weight loss is also associated with improvement or resolution of SUI and OAB. In the case of pelvic organ prolapse (POP), weight loss is associated with improvement in quality of life. Although obesity is associated with POP in general, the exact role of obesity in symptomatic POP remains uncertain. While outcomes of anti-incontinence surgery among obese women are similar to those in non-obese women, postoperative urge incontinence is more likely to occur. It seems that obesity is not a risk factor for postoperative complications or short-term efficacy of POP surgical treatment. Long-term effects are still uncertain. Obesity is a strong risk factor for LUTS, but in most cases it does not affect efficacy of operative treatment. It may be associated with some post-operative complications. Weight loss in many cases allows avoiding surgical intervention.