Abstract
OBJECTIVES:
To describe trajectories of pelvic floor symptoms and support from 3rd trimester to 1 year postpartum in primiparas following vaginal delivery and to explore factors associated with their resolution between 8 weeks and 1 year postpartum.
METHODS:
597 nulliparas ≥18 years delivered vaginally at term completed the Epidemiology of Prolapse and Incontinence Questionnaire and Pelvic Organ Prolapse Quantification examination at 3rd trimester, 8 weeks and 1 year postpartum.
RESULTS:
At one year postpartum, 41%, 32% and 23% of participants reported stress urinary incontinence (SUI), nocturia and flatus incontinence, respectively, and 9% demonstrated maximal vaginal descent (MVD) ≥ 0 cm. For more common symptoms, incidence rates between 3rd trimester and 8 weeks postpartum ranged from 6% for urinary frequency to 22% for difficult bowel movements and resolution rates between 8 weeks and 1 year postpartum ranged from 23% for SUI to 73% for pain. Between 3rd trimester and 8 weeks postpartum, 13% demonstrated de novo MVD ≥ 0 cm. For most symptoms, the presence of the same symptom before delivery decreased the probability of resolution between 8 weeks and 1 year. However, the sensitivities of pre-delivery vaginal bulge and MVD ≥ 0 cm for those outcomes at 1 year postpartum was overall low (10–12%).
CONCLUSION:
One year postpartum, urinary and bowel symptoms are common in primiparas delivered vaginally. A substantial portion of this burden is represented by symptoms present before delivery, while most of the prevalence of worse anatomic support is accounted for by denovo changes following delivery.
Keywords: prevalence, prolapse, postpartum, urinary incontinence, vaginal birth
INTRODUCTION
Pregnancy and delivery, particularly vaginal birth, increase the frequency of pelvic floor symptoms. Symptoms may be transient,1 but some may persist and be bothersome one year postpartum.2–4 Stress urinary incontinence (SUI) and anal incontinence (AI) during pregnancy increase the risk for each symptom postpartum.3–10 Little is known about when the elevated risk of vaginal birth on pelvic organ prolapse (POP) first appears.1,11–13 With some exceptions, 1,7,9–11,14–17 many cohort studies do not collect data beginning in pregnancy, most focus on a narrow range of pelvic floor symptoms, and few evaluate both subjective and objective measures of pelvic floor support.
Cross-sectional studies and post-delivery cohort studies have yielded valuable information about symptom burden; however, further knowledge about trajectories of the full range of pelvic floor symptoms and anatomic support, beginning before delivery, as well as factors associated with resolution are needed to target prevention and intervention efforts. Therefore, our aims were to describe the trajectories of individual pelvic floor symptoms and anatomic support at 3rd trimester, 8 weeks postpartum and 1 year postpartum in primiparas following vaginal delivery and to explore factors associated with resolution of symptoms and worse anatomic support between 8 weeks and 1 year postpartum.
MATERIAL AND METHODS
Data for this analysis are drawn from the Motherhood And Pelvic health (MAP) study, a cohort study designed to test the effects of early postpartum physical activity and intra-abdominal pressure on pelvic floor health one year postpartum. Participating institutional review boards approved the study. Participants completed written informed consent. Methods for the parent study have been published.18 Briefly, we recruited nulliparas during the third trimester at seven academic and community health clinics and followed those delivered vaginally at term for one year postpartum. Participants completed the Pelvic Organ Prolapse Quantification Examination (POP-Q)19, the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ)20, and the Incontinence Severity Index (ISI)21 in the 3rd trimester and 8 weeks and 1 year postpartum. In this ancillary analysis, we include only participants that completed questionnaires at all three time-points. We considered a symptom on the EPIQ as positive if the participant responded affirmatively and the bother score on the corresponding visual analogue scale (VAS) was >0, on a 0–100 scale. If the bother score was missing, we categorized the symptom as absent. Those that responded more than “never” to experiencing urinary leakage on the ISI answered EPIQ questions related to the impact of urinary incontinence (UI) on quality of life. We categorized pelvic floor support using two dichotomous cut-points: 1) maximal vaginal descent (MVD; the most distal of Ba, Bp or C) as <0 cm (above the hymen; better support) vs ≥0 cm (at or below the hymen; worse support) and 2) POP-Q Stages 0 and 1 vs Stage 2.
The sample size for this analysis derives from that of the parent study. We also assessed adequacy of sample size for the resolution analysis. For denominators at 8 weeks postpartum of ≥ 100, there is ≥ 80% power to detect a resolution relative risk (RR) of ≥ 2.0 by unadjusted chi-squared analysis at the Bonferroni-adjusted 0.63% significance level (0.0063=0.05/8 tests in supplementary Table 4 when the probability of symptom resolution in the factor referent category is 50% or higher. In the case of a preventive factor, the detectable RR is 0.5 or lower.
We compared the prevalence of each symptom and anatomic support across the three time-points using modified Poisson regression22 with random subject effects and considered a p value of <0.017 (0.05/3 time-points) significant. To analyze total effects of factors predicting resolution between 8 weeks and 1 year, the denominator was women with the symptom at 8 weeks. We chose adjustment variables based on directed acyclic graphs (DAG) and adjusted only for the variables required by the DAG, not the full set of predictors, due to concerns about sparse cells.23,24 We reported RR and 95% confidence intervals (CI) from minimally adjusted modified Poisson regressions,22 and chi-squared or Fisher’s exact test for ethnicity and age, which did not require adjustment. For resolution of worse support, we used Fisher’s exact test for the association with MVD ≥ 0cm at 3rd trimester, unadjusted. We considered a p value of <0.0063 significant as noted above. Finally, using prognostic test characteristics, we describe the predictive value of symptoms and worse support pre- and 8 weeks post-delivery on the presence of that symptom or worse anatomic support at 1 year postpartum. We used SAS version 9.4 (SAS Institute, Inc. Carey, NC).
To quantify how strong an uncontrolled variable would have to be, in order to overturn our findings pertaining to predictors of symptom resolution between 8 weeks and 1 year, we calculated E-values for confounding and selection bias.25,26,27
RESULTS
Of 597 participants included in this ancillary analysis, 44 had only questionnaire follow-up and therefore lack POP-Q data at 1 year. Figure 1 summarizes participant flow. Table 1 describes population characteristics. Of participants still eligible after delivery, those completing 1-year follow-up were older (28.8 vs 26.0 years, p<0.001) and less likely to be Hispanic (17.8% vs 32.6%, p<0.001).
Figure 1.
Participant flow
Table 1.
Participant characteristics
| N (%) | |
|---|---|
| At third trimester | |
| Age, years, mean (SD) | 28.8 (5.0) |
| 18 to < 25 | 138 (23.1) |
| 25 to ≤ 35 | 390 (65.3) |
| > 35 | 69 (11.6) |
| Pre-pregnancy body mass index (kg/m2), mean (SD) | 24.5 (5.0) |
| < 25 | 392 (65.8) |
| 25 to < 30 | 129 (21.6) |
| ≥ 30 | 75 (12.6) |
| Ethnicity | |
| Hispanic | 102 (17.1) |
| Non-Hispanic | 495 (82.9) |
| Race | |
| Asian | 5 (0.8) |
| Black/African American | 25 (4.2) |
| Caucasian/White | 553 (92.6) |
| Other | 14 (2.3) |
| Education | |
| High school or less | 63 (10.6) |
| Some college/completed college | 356 (59.6) |
| Graduate or professional degree | 178 (29.8) |
| Maximal vaginal descent | |
| < 0 centimeters | 578 (96.8) |
| ≥ 0 centimeters | 19 (3.2) |
| POP-Q stage | |
| Stage 1 | 464 (77.7) |
| Stage 2 | 133 (22.3) |
| At delivery | |
| Duration of second stage, minutes, mean (SD) | 103.3 (79.4) |
| Infant birthweight (grams), mean (SD) | 3323.1 (391.4) |
| ≤ 4000 grams | 562 (95.9) |
| > 4000 grams | 24 (4.1) |
| Forceps | |
| No | 554 (92.8) |
| Yes | 43 (7.2) |
| Vacuum | |
| No | 586 (98.2) |
| Yes | 11 (1.8) |
| Episiotomy | |
| No | 543 (91.3) |
| Yes | 52 (8.7) |
| 3rd or 4th degree perineal laceration | |
| No | 572 (96.3) |
| Yes | 22 (3.7) |
| At 8 weeks postpartum | |
| Days since delivery to questionnaire, mean (SD) | 50.9 (9.6) |
| Body mass index (kg/m2), mean (SD) | 26.2 (4.9) |
| < 25 | 285 (48.1) |
| 25 to <30 | 198 (33.4) |
| ≥ 30 | 110 (18.6 |
| Maximal vaginal descent | |
| < 0 centimeters | 513 (86.4) |
| ≥ 0 centimeters | 81 (13.6) |
| POP-Q stage | |
| Stage 0, 1 | 283 (47.6) |
| Stage 2 | 311 (52.4) |
| Breastfeeding | |
| No | 62 (10.4) |
| Yes | 534 (89.6) |
| Constipation | |
| No | 537 (90.3) |
| Yes | 58 (9.7) |
| At 1 year postpartum | |
| Days since delivery to questionnaire, mean (SD) | 384.9 (34.1) |
| Body mass index (kg/m2), mean (SD) | 24.9 (5.7) |
| < 25 | 330 (59.7) |
| 25 to < 30 | 138 (25.0) |
| ≥ 30 | 85 (15.3) |
| Maximal vaginal descent | |
| < 0 centimeters | 502 (90.8) |
| ≥ 0 centimeters | 51 (9.2) |
| POP-Q | |
| Stage 0, 1 | 292 (52.8) |
| Stage 2 | 261 (47.2) |
| Breast feeding | |
| No | 323 (54.1) |
| Yes | 274 (45.9) |
| Constipation | |
| No | 567 (95.9) |
| Yes | 24 (4.1) |
SD – standard deviation; kg/m2 – kilogram/meter2; POP-Q – pelvic organ prolapse quantification
Table 2 summarizes the prevalences of symptoms and anatomic support at each time-point. Prevalence rates of lower urinary tract symptoms were similar at 8 weeks and 1 year postpartum, except for SUI and difficulty emptying the bladder, which were higher at 1 year, while prevalence rates of pain and difficult bowel movements were lower at 1 year. Sensation of vaginal bulge, needing to splint for bowel movements and AI of gas had similar prevalence rates at each time-point. The prevalence of worse anatomic support, whether dichotomized as MVD ≥ 0 cm ≥ Stage II POP, increased after delivery. No participant had > Stage II POP.
Table 2.
Prevalence of symptoms and anatomic support at each time-point
| Symptom | 3rd trimester N(%) | 8 weeks postpartum N(%) | 1 year postpartum N(%) |
|---|---|---|---|
| Urinary urgency | 87 (15%)* | 116 (20%) | 102 (17%) |
| Nocturia | 511 (88%)* | 162 (28%) | 186 (32%)*** |
| Frequency | 374 (65%)* | 73 (12%) | 75 (13%)*** |
| Urgency urinary incontinence | 56 (9%)* | 115 (19%) | 91 (15%)*** |
| Stress urinary incontinence | 295 (50%)* | 169 (29%)** | 240 (41%)*** |
| Difficulty emptying bladder | 39 (7%)* | 17 (3%)** | 32 (5%) |
| Pain | 183 (31%)* | 119 (20%)** | 76 (13%)*** |
| Bulge | 31 (5%) | 40 (7%) | 31 (5%) |
| Difficult bowel movement | 224 (38%) | 202 (34%)** | 124 (21%)*** |
| Splint | 31 (5%) | 40 (7%) | 31 (6%) |
| Anal incontinence – gas | 140 (24%) | 136 (23%) | 135 (23%) |
| Anal incontinence – liquid | 14 (2%) | 22 (4%) | 24 (4%) |
| Anal incontinence – solid | 0 (0%) | 2 (0.3%) | 2 (0.3%) |
| Support at/below hymen | 19 (3%)* | 81 (14%)** | 51 (9%)*** |
| POP-Q stage 2 | 133 (22%)* | 311 (52%) | 261 (47%)*** |
POP-Q – pelvic organ prolapse quantification
P<0.017 for comparison between 3rd trimester and 8 weeks postpartum
P<0.017 for comparison between 8 weeks postpartum and 1 year postpartum
P<0.017 for comparison between 3rd trimester and 1 year postpartum
Supplementary Table 1 displays levels of symptom bother. Mean bother at the 3 time-points ranged from 31.4 to 74.3. Between one-fourth and one-third of all women reported that UI negatively impacted their quality of life at each time point (supplementary Table 2).
Table 3 summarizes resolution and incidence rates. Lower urinary tract symptoms resolved between third trimester and 8 weeks postpartum in 50% (for urgency UI) to 97% (for difficulty emptying) of women; and between 8 weeks and 1 year, in 23% (for SUI) to 60% (for urinary frequency). Defecatory symptoms including difficult bowel movements, vaginal splinting, and AI of gas resolved between each of the two time-points in 44–59% of participants. Incidence rates for pelvic floor symptoms between 3rd trimester and 8 weeks postpartum ranged from 0.3% (for anal incontinence of solid stool) to 22% (for difficult bowel movements). Between 8 weeks and 1 year postpartum, incidence rates for symptoms were below 10% except for SUI, nocturia, and AI of gas.
Table 3.
Resolution and incidence rates between each time-point
| Symptom | Resolution: 3rd trimester to 8 weeks postpartum | Incidence: 3rd trimester to 8 weeks postpartum | Resolution: 8 weeks to 1 year postpartum | Incidence: 8 weeks to 1 year postpartum |
|---|---|---|---|---|
| Urinary urgency | 55/86 (64%) | 84/506 (17%) | 56/116 (48%) | 42/477 (9%) |
| Nocturia | 354/502 (71%) | 8/69 (12%) | 73/155 (47%) | 97/422 (23%) |
| Frequency | 314/369 (85%) | 11/200 (6%) | 43/72 (60%) | 43/517 (8%) |
| Urgency urinary incontinence | 28/56 (50%) | 85/532 (16%) | 66/114 (58%) | 41/476 (9%) |
| Stress urinary incontinence | 155/290 (53%) | 29/292 (10%) | 38/165 (23%) | 110/420 (26%) |
| Difficulty emptying bladder | 38/39 (97%) | 16/556 (3%) | 9/17 (53%) | 24/578 (4%) |
| Pain | 129/182 (71%) | 64/397 (16%) | 86/118 (73%) | 42/468 (9%) |
| Bulge | 26/31 (84%) | 34/555 (6%) | 30/40 (75%) | 20/550 (4%) |
| Difficult bowel movement | 99/218 (45%) | 79/364 (22%) | 113/200 (57%) | 35/386 (9%) |
| Splint | 16/30 (53%) | 26/562 (5%) | 23/39 (59%) | 14/551 (3%) |
| Anal incontinence – gas | 77/140 (55%) | 71/446 (16%) | 59/133 (44%) | 60/452 (13%) |
| Anal incontinence – liquid | 12/14 (86%) | 20/575 (3%) | 14/22 (64%) | 16/570 (3%) |
| Anal incontinence – solid | NA | 2/595 (0.3%) | 2/2 (100%) | 2/593 (0.3%) |
| Support at/below hymen | 12/19 (63%) | 74/575 (13%) | 61/78 (78%) | 34/473 (7%) |
| POP-Q stage 2 | 38/133 (29%) | 216/461 (47%) | 129/291 (44%) | 98/260 (38%) |
POP-Q – pelvic organ prolapse quantification
Between 3rd trimester and 8 weeks postpartum, 13% developed de novo worse support categorized, as MVD ≥ 0 cm. Between 8 weeks and 1 year postpartum, worse support resolved in 78%. Corresponding incidence rates were higher, and resolution rates lower, when anatomic stage II POP was used as the support cut-point (Table 3).
Trajectories for each individual symptom and anatomic support between the 3 time-points are shown in Supplementary Figure 1a–l. Table 4 summarizes the prognostic test characteristics for using pre-existing symptoms or support to predict 1-year symptoms or support. For symptoms except sensation of vaginal bulge, 28% to 95% of women reporting a symptom 1 year postpartum reported the same symptom before delivery; this reflects the sensitivity or true positive rate of the presence of a pre-delivery symptom in predicting the symptom at 1 year. For sensation of vaginal bulge and for worse anatomic support, the sensitivities of pre-delivery findings on 1-year outcomes were lower, between 10% and 12%. Negative predictive values were uniformly high. The presence of urgency, SUI and AI at both pre-delivery and 8 weeks postpartum had the highest positive predictive values (83.9%, 85.5% and 72.3%, respectively) for reporting the same symptom at 1 year postpartum.
Table 4.
Prognostic test characteristics of symptoms or support before and 8 weeks postpartum after vaginal delivery in predicting symptoms or anatomic support 1 year postpartum.
| Prognostic Factor (%) | Prognostic Factor (%) | Prognostic Factor (%) | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Symptom present at 3rd trimester | Symptom present at 8 weeks postpartum | Symptom present at both 3rd trimester and 8 weeks postpartum | |||||||||||
| Symptom or support | Prevalence at 1 year postpartum N(%) | Se | Sp | PPV | NPV | Se | Sp | PPV | NPV | Se | Sp | PPV | NPV |
| Urinary urgency | 102 (17%) | 44.1 | 91.6 | 52.3 | 88.7 | 58.8 | 88.7 | 52.2 | 91.2 | 25.5 | 99.0 | 83.9 | 86.4 |
| Nocturia | 186 (32%) | 95.4 | 15.7 | 33.8 | 88.4 | 45.7 | 82.2 | 53.7 | 77.1 | 44.0 | 83.5 | 54.6 | 76.8 |
| Frequency | 75 (13%) | 85.1 | 38.0 | 15.5 | 95.0 | 38.8 | 92.2 | 40.0 | 91.8 | 32.8 | 93.6 | 40.7 | 91.2 |
| Urgency UI | 91 (15%) | 28.4 | 94.0 | 45.5 | 88.1 | 53.4 | 86.9 | 42.0 | 91.3 | 18.2 | 97.6 | 57.1 | 87.1 |
| Stress UI | 240 (41%) | 79.7 | 70.7 | 64.6 | 83.8 | 53.2 | 89.3 | 76.9 | 74.0 | 48.5 | 94.5 | 85.5 | 73.3 |
| Difficulty emptying | 32 (5%) | 28.1 | 94.7 | 23.1 | 95.9 | 25.0 | 98.4 | 47.1 | 95.8 | 0.0 | 99.8 | 0.0 | 94.6 |
| Pain | 76 (13%) | 50.0 | 71.4 | 20.0 | 90.9 | 41.7 | 82.9 | 25.9 | 90.8 | 25.0 | 93.0 | 34.0 | 89.7 |
| Bulge | 31 (5%) | 10.0 | 95.0 | 9.7 | 95.1 | 33.3 | 94.8 | 25.6 | 96.3 | 3.3 | 99.3 | 20.0 | 95.0 |
| Difficult bowel movement | 124 (21%) | 69.4 | 71.1 | 38.9 | 89.8 | 71.1 | 75.9 | 43.9 | 90.8 | 52.9 | 88.2 | 54.2 | 87.6 |
| Splint | 31 (6%) | 30.0 | 96.2 | 30.0 | 96.2 | 53.3 | 95.9 | 41.0 | 97.5 | 26.7 | 98.9 | 57.1 | 96.2 |
| AI, all types | 142 (24%) | 51.1 | 82.3 | 47.6 | 84.2 | 56.9 | 86.9 | 57.8 | 86.5 | 34.3 | 95.9 | 72.3 | 82.2 |
| Support at/below hymen | 51 (9%) | 11.8 | 97.8 | 35.3 | 91.6 | 33.3 | 87.8 | 21.8 | 92.8 | 7.8 | 99.4 | 57.1 | 91.4 |
Se – Sensitivity (% positive agreement)
Sp – Specificity (% negative agreement)
PPV – Positive predictive value
NPV – Negative predictive value
UI – urinary incontinence
AI – anal incontinence
In the subgroup of women with persistent symptoms between 8 weeks and 1 year, mean changes in bother scores ranged from −12.2 (less bother) to +16.4 (more bother) and only a minority reported 50% or greater improvement (cut-point chosen a priori) in bother scores (supplementary Table 3).
In tests of association of symptom resolution between 8 weeks and 1 year postpartum and key risk factors (supplementary Table 4) except for nocturia, pain, and UUI, the presence of the same symptom or worse support before delivery decreased the probability of resolution at 1 year. E-Values for confounding and selection bias are summarized in supplementary Table 5.
DISCUSSION
In this cohort of primiparas following vaginal birth, women experienced an array of pelvic floor symptoms at 3rd trimester, 8 weeks, and 1 year postpartum. By 1 year postpartum, fewer than one-quarter experienced each specific pelvic floor symptom, except for nocturia (32%) and SUI (41%). Except for SUI, pelvic floor symptoms resolved in roughly half or more women between each of the time-points. Mean symptom bother was moderate at every time-point and changed little in women with persistent symptoms between 8 weeks and 1 year.
Prevalence rates vary between studies due to different populations, time points and questionnaires. Prevalence rates in our population for lower urinary tract and bowel symptoms were in the range of those reported in other prospective cohorts of primiparas.8–10,28 Prevalence rates at 1 year postpartum were lower, or similar, to those at 8 weeks postpartum, except for SUI. Most postpartum women engage in less physical activity for the first few months postpartum;29 and it is possible that the subsequent increase in activity levels may provoke SUI later in the postpartum year.
In our population, the prevalence of worse anatomic support using the hymen as a cut-point at 1 year postpartum (9%) is similar to that of a recent large population study (13.2%).30 Not surprisingly, the prevalence of Stage II POP was higher, consistent with most prior studies evaluating objective pelvic organ support in the postpartum period.1,13,15,16 In one exception, only 2% of primiparas demonstrated Stage II POP 1 year postpartum.1 Patterns of resolution and incidence in our population for objectively measured support depended on the cut-point used, with resolution rates being higher than incidence rates using the cut-point of ≥ 0 cm but lower or similar using POPQ Stage II.
Average levels of bother for all symptoms at 8 weeks and 1 year postpartum were > 40, except for nocturia at 8 weeks. These results are similar to a cross-sectional analysis of 198 primiparas in which 40–90% with pelvic floor symptoms at 1 year reported severe levels of bother.2 The magnitude of prevalence and bother highlights the importance of identifying women who are experiencing pelvic floor symptoms postpartum.
Pre-delivery symptoms were an important predictor of many 1-year outcomes and also decreased the probability that a symptom present at 8 weeks postpartum would resolve by 1 year postpartum. However, for the symptom of vaginal bulge and the anatomic finding of worse support, the sensitivities of pre-delivery findings in predicting 1-year prevalence were only about 10%. We found that urgency, SUI and AI when reported both before and 8 weeks following delivery predicted the presence of each symptom at 1 year postpartum in a large majority of women, while nocturia, UUI, difficulty with bowel movements and splinting did so in over half.
Our results expand on those of others by demonstrating that a wide array of pelvic floor symptoms during pregnancy persist at 1 year postpartum.3,5–10,17,31–33 This highlights the fact that pregnancy itself plays a substantial role in postpartum pelvic floor symptoms. While it is possible that pregnancy serves as a kind of ‘stress test’ for the pelvic floor, we as well as others did not prospectively collect pelvic floor symptoms or support before pregnancy, and therefore cannot draw firm conclusions about incidence rates during pregnancy. Most studies have focused on UI. In nulliparous women, rates of urinary incontinence are low,34 however, UI before pregnancy increases the risk of UI during pregnancy,35,36 and UI during pregnancy in turn is a significant risk factor for both postpartum UI and UI later in life.5,32,37 Additionally, AI and defecatory dysfunction present during pregnancy predict these symptoms not only 12 months postpartum, but also up to 10 years postpartum.8,38 Consistent with others, we found that while few women demonstrated worse support during pregnancy, this finding significantly increased the risk of worse support 1 year postpartum.11 However, most of the 1-year prevalence of worse support was composed of incident cases after delivery.
Strengths of this study include the follow-up rate between pregnancy and 1 year postpartum, similar to or higher than that reported in other cohorts (37% to 77%),15,30,39–41 except Chen et al who reported 100% follow-up.11 Trained study personnel masked to participant questionnaire responses performed all POP-Q examinations. We captured both pelvic floor symptoms and support prospectively before delivery, at 8 weeks, and 1 year postpartum using validated instruments. However, we did not use the thresholds validated in the EPIQ for predicting women at high risk of being diagnosed with POP, SUI, OAB or AI, as our goal was to investigate specific symptoms, rather than pelvic floor conditions, in young postpartum women. We studied only test characteristics of previous symptoms on 1-year symptom prevalences and thus these results should not be constructed as full predictive models.
Some findings related to symptom resolution should be considered exploratory in nature. We did not always have sufficient samples to analyze symptoms and risk factors, but we did have sufficient power to draw conclusions about risk factors for those symptoms experienced by >100 women at 8 weeks or those with resolution rates > 50%. We chose a limited number of independent risk factors to study; there are others that may also be important, but given that the sample sizes were determined by the number of women with each symptom at 8 weeks, we opted to limit the number to those of greatest clinical interest.
Our findings do not apply to primiparas delivered by cesarean, who have been shown to have lower postpartum prevalence rates of UI and worse support than those delivered vaginally.9,10,15 Our results may not be generalizable to other populations as our population consists primarily of caucasian women with body mass index <30. In particular, positive predictive value is affected by population prevalence which could impact the ability of using our results to counsel other populations.
CONCLUSIONS
At one year postpartum, urinary and bowel symptoms are common, and bother is substantial, in primiparas delivered vaginally. Our results have three primary clinical implications. First, nulliparas in late gestation that do not experience a pelvic floor symptom appear be unlikely to experience it 1 year after vaginal birth. For women deliberating between vaginal and cesarean delivery based on minimizing pelvic floor symptoms, this information can provide perspective. Second, the postpartum visit is an ideal opportunity to query women about pelvic floor symptoms, as some may be markers for that same symptom 1 year postpartum. Given high positive predictive values for certain symptoms, the low risk and cost of appropriate behavioral therapies, and the fact that the harm of treating women with a ‘false positive’ symptom (that is, one that resolves by 1 year) is low, treatment should be offered. Third, understanding how to prevent or intervene in symptoms present prior to delivery could not only reduce the burden of bothersome pelvic floor symptoms experienced by postpartum women, but may also reduce the overall burden of pelvic floor symptoms in women long-term.
Supplementary Material
Supplementary Figures 1a-l. Trajectories for each pelvic floor symptoms and support at 3rd trimester, 8 weeks postpartum and 1 year postpartum. Subject numbers do not always add up to the predecessor due to missing data. Across symptoms, for any given time-point, the number of missing ranged from 0-9.
Acknowledgments
Disclosures and Funding: This project was supported by Grant Number 1P01HD080629 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors report no conflicts of interest.
Contributor Information
Audra Jolyn HILL, Obstetrics and Gynecology, University of Utah, Salt Lake City, UT.
Jingye YANG, University of Utah, Salt Lake City, UT.
Liliana I. MARTINEZ, University of Utah, Salt Lake City, UT.
Ingrid NYGAARD, University of Utah Health Sciences Center, Salt Lake City, UT.
Marlene J. EGGER, Division of Public Health, Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Figures 1a-l. Trajectories for each pelvic floor symptoms and support at 3rd trimester, 8 weeks postpartum and 1 year postpartum. Subject numbers do not always add up to the predecessor due to missing data. Across symptoms, for any given time-point, the number of missing ranged from 0-9.