Abstract
Importance
In recent years, pelvic-abdominal dynamics has become a research topic in the field of pelvic floor dysfunction (PFD), and the relationship between diastasis of the rectus abdominis (DRA) and stress urinary incontinence (SUI) has been controversial. The study is helpful to further strengthen perinatal education, accurately identify the risk factors of SUI and DRA, and improve the quality of life of puerperae.
Objective
This study aimed to investigate the association of SUI and DRA in women with PFD as measured by vaginal palpation or pelvic floor biofeedback machine testing.
Study Design
A total of 301 patients diagnosed with female PFD who were 6–8 weeks postpartum at The Fifth People's Hospital of Zhuhai between May 2018 and April 2021 were enrolled. The prevalence rates and potential influencing factors of SUI and DRA were analyzed.
Results
A total of 29.5% (89 of 301) of the patients were diagnosed with SUI, and 31.9% (96 of 301) were diagnosed with DRA. Binary logistic regression showed that a history of delivery (P = 0.012; odds ratio [OR], 1.982) and vaginal delivery with perineal lacerations or episiotomy (P = 0.016; OR, 2.187) were risk factors for SUI. High birth weight (weight>4.0 kg, P < 0.001; OR, 14.507) was a risk factor for DRA.
Conclusions
A history of delivery and vaginal delivery with perineal lacerations or episiotomy increased the risk of SUI, and high birth weight was an independent risk factor for DRA. Early intervention, including exercise therapy, manual therapy, and neuromuscular electrical stimulation, may be important for patients with PFD having these risk factors.
WHY THIS MATTERS
Female pelvic floor dysfunction (PFD) is a disease in which the function and position of pelvic organs are abnormal. Stress urinary incontinence (SUI), one of the most common symptoms of PFD, refers to involuntary urine leakage when abdominal pressure increases, such as when sneezing, coughing, laughing, or exercising. Several studies have observed a wide prevalence of SUI among several countries, ranging from 5% to 60%. Furthermore, the prevalence of SUI increases with age. Postpartum SUI seriously affects the quality of life of the woman and may be related to postpartum depression and anxiety. We found that the prevalence of diastasis of the rectus abdominis in patients with PFD at 6–8 weeks postpartum was 31.9%, similar to that in previous studies. This study showed that a history of delivery and vaginal delivery were risk factors for SUI, and vaginal delivery with episiotomy further increased this risk. Therefore, for adult women with the aforementioned risk factors, clinicians and rehabilitation therapists should actively evaluate pelvic floor function in the early postpartum period and develop a rehabilitation exercise program to strengthen pelvic floor muscle function, which may help improve the quality of life of puerperae.
Simply Stated
This study aimed to explore the risk factors for postpartum stress urinary incontinence (SUI) and diastasis of the rectus abdominis, which may provide a theoretical basis for postpartum management and timing options for rehabilitation treatment. Patients with pelvic floor dysfunction (n = 301) from the Fifth People's Hospital of Zhuhai were enrolled in this study to analyze the potential risk factors for diastasis of the rectus abdominis and SUI using binary logistic regression, particularly the effects of a history of delivery, the mode of delivery, and the birth weight of the newborns. The univariate analysis of SUI in this study showed that the history and mode of delivery, rather than age, body mass index, gestational weeks, and birth weight, were risk factors for urinary incontinence. Therefore, for patients with pelvic floor dysfunction, a history of delivery and the mode of delivery could be important indicators to guide intervention strategies for postpartum SUI.
Female pelvic floor dysfunction (PFD) is a disease in which the function and position of pelvic organs are abnormal.1 Pelvic floor dysfunction is mainly induced by damage or defects and dysfunction of the pelvic floor support structure. The main clinical manifestations are stress urinary incontinence (SUI), pelvic organ prolapse, sexual dysfunction, and chronic pelvic pain. Stress urinary incontinence, one of the most common symptoms of PFD, refers to involuntary urine leakage when abdominal pressure increases, such as when sneezing, coughing, laughing, or exercising.2 Several studies have observed a wide prevalence of SUI among several countries, ranging from 5% to 60%.3–5 Furthermore, the prevalence of SUI increases with age.6 Postpartum SUI seriously affects the quality of life of the woman and may be related to postpartum depression and anxiety.7
Diastasis of the rectus abdominis (DRA) refers to the separation of the bilateral DRA at the midline. The prevalence of DRA in the postpartum period is 35–60%.8,9 Numerous studies have shown that DRA leads to complications, such as abdominal muscle weakness and abdominal distention.8,10 Long-term DRA may influence the stability of the pelvis and spine, increase low back pain, and cause chronic pelvic pain.11,12 The pelvic-abdominal dynamics doctrine states that the abdominal and pelvic floor muscles have a synergistic function.13 During contraction of the pelvic floor muscles, the abdominal muscles effectively co-contract and promote contraction of the pelvic floor muscles. Whether DRA affects the occurrence of PFD and SUI remains unclear and requires further investigation. Identifying high-risk factors for SUI and DRA as early as possible is crucial for improving patients' long-term quality of life (QOL).
Multiple epidemiologic studies have shown that PFD, SUI, and DRA affect a large population of women.4,14,15 However, for patients diagnosed with PFD, potential risk factors for SUI and DRA have yet to be elucidated. This study retrospectively analyzed the clinical information of 301 patients diagnosed with PFD to explore the risk factors for postpartum SUI and DRA, which may provide a theoretical basis for postpartum management and timing options for rehabilitation treatment.
MATERIALS AND METHODS
This study retrospectively collected data from 301 women who were 6–8 weeks postpartum and diagnosed with PFD at The Fifth People's Hospital of Zhuhai between May 2018 and April 2021. The eligibility criteria included the following: (1) age ≥18 years, (2) delivery after full-term gestation, (3) absence of postpartum lochia, (4) reading and understanding abilities, and (5) volunteering to complete the survey. The exclusion criteria were as follows: (1) transaminitis or urinary infection; (2) chronic kidney disease, diabetes, chronic constipation, or urine leakage; (3) history of surgery; (4) family history of pelvic organ prolapse or urinary incontinence; (5) unwillingness to cooperate; and (6) inability to complete the survey.
Pelvic Floor Muscle Strength Examination
Pelvic floor muscle strength was measured using vaginal palpation or pelvic floor biofeedback machine testing. For manual palpation, examiners gently pressed the posterior vaginal wall with the index finger and middle finger, palpated the deep pelvic floor muscles, and examined the power of muscle contraction. The strength of the pelvic floor muscles was evaluated using the modified Oxford grading system.16 It consists of a 6-point scale: 0, no contraction; 1, flicker; 2, weak; 3, moderate; 4, good (with lift); and 5, strong. For manometry, a Phenix USB4 pelvic floor biofeedback instrument was used to evaluate the strength of the pelvic floor muscles using the model of muscle strength test. The electrode was placed into the vagina, the patients retracted and relaxed the anus according to the instructions, and the data were recorded accordingly.
Diagnostic Criteria of PFD and SUI
The diagnostic criteria for PFD included a muscle fiber strength of the pelvic floor ≤3/5. The diagnostic criteria for SUI included involuntary outflow of urine on sudden increase in abdominal pressure, such as while coughing, sneezing, laughing, or strenuous exercise.2
Test Method and Diagnostic Criteria for DRA
Manual palpation was performed. Patients were placed in the supine position, with the knees flexed and hands placed on either sides of the body. They were asked to produce abdominal constrictions and perform half sit-ups. Both hands touched the knees as much as possible until the shoulders left the bed. The examiner palpated the edges of the DRA on both sides along the white line of the abdomen using the index and middle fingers. The palpation positions were the umbilicus, 4.5 cm above the umbilicus, and 4.5 cm below the umbilicus. Diastasis of the rectus abdominis was defined as a distance of ≥20 mm between any of the 3 positions and the ventral midline.17
Statistical Analysis
Statistical analyses were performed using SPSS version 22.0 (IBM Corp, Armonk, New York). The metrological data followed a normal distribution and were expressed as mean ± SD. The counting data were expressed as percentage, and the comparison between groups was assessed using the χ2 test. Bivariate logistic regression analysis was used to assess risk factors for SUI and DRA. The statistic power (1 − β) of binary logistic regression analysis for the primary outcome (ie, the occurrence of SUI/DRA) under the sample size in this study was 0.83 (α = 0.05). Statistical significance was set at P < 0.05. This study was approved by the Ethics Committee of The Fifth People's Hospital of Zhuhai.
RESULTS
A total of 301 study participants were included in the study, and the average age of the participants was 29.6 years. Clinical information and demographics of the participants were collected. Among them, 88 were diagnosed with SUI, representing a prevalence of 29.2%, and 96 were diagnosed with DRA, representing a prevalence of 31.9%. Of these, 21 had both SUI and DRA. There were 129 women (42.9%) with no history of delivery, whereas 172 (57.1%) had a history of delivery. A total of 53 (17.6%) and 166 (55.1%) women had experienced vaginal birth with/without laceration (including perineal lateral incision), respectively, whereas 82 (27.2%) had undergone cesarean delivery.
There were significant differences in SUI incidence rates between multiparous and nulliparous women and among those with different modes of delivery (Table 1). No significant differences were found among the other factors. Binary logistic regression analysis was performed using the prevalence of SUI as the dependent variable, and history and mode of delivery as independent variables. The results showed that a history of delivery (P = 0.012; odds ratio [OR], 1.982) and vaginal delivery with perineal lacerations or episiotomy (P = 0.016; OR, 2.187) were independent risk factors for SUI (Table 2).
TABLE 1.
Basal and Clinical Data in Group of SUI and Non-SUI Patients
| Factors | Sample Size | SUI (n = 88) | Non-SUI (n = 213) | χ 2 | P |
|---|---|---|---|---|---|
| Age, y | 1.366 | 0.256 | |||
| <29.6 | 156 | 41 (26.2%) | 115 (73.7%) | ||
| ≥29.6 | 145 | 47 (32.4%) | 98 (67.6%) | ||
| BMI | 4.922 | 0.086 | |||
| <24 | 68 | 27 (39.7%) | 41 (60.3%) | ||
| 24–30 | 196 | 50 (25.5%) | 146 (74.5%) | ||
| ≥30 | 37 | 11 (29.7%) | 26 (70.3%) | ||
| Gestational weeks | 0.316 | 0.599 | |||
| <40 wk | 192 | 54 (28.1%) | 138 (71.9%) | ||
| ≥40 wk | 109 | 34 (31.2%) | 75 (68.8%) | ||
| Delivery history | 7.527 | 0.007* | |||
| Primipara | 129 | 27 (20.9%) | 102 (79.1%) | ||
| Maternal | 172 | 61 (35.5%) | 111 (64.5%) | ||
| Delivery mode | 7.506 | 0.023* | |||
| Cesarean delivery | 82 | 16 (19.5%) | 66 (80.5%) | ||
| Spontaneous delivery | 53 | 13 (24.5%) | 40 (75.5%) | ||
| Spontaneous delivery with perineal tears or episiotomies | 166 | 59 (35.5%) | 107 (64.5%) | ||
| Neonatal birth weight | 0.389 | 0.823 | |||
| <2,500 | 39 | 13 (33.3%) | 26 (66.7%) | ||
| 2,500–4,000 | 215 | 62 (28.8%) | 153 (71.2%) | ||
| ≥4,000 | 47 | 13 (27.7%) | 34 (72.3%) | ||
| DRA | 3.692 | 0.058 | |||
| Yes | 96 | 21 (21.9%) | 75 (78.1%) | ||
| No | 205 | 67 (32.7%) | 138 (67.3%) | ||
| Education | 0.310 | 0.958 | |||
| Junior high and below | 47 | 18 (38.3%) | 29 (61.7%) | ||
| Senior high | 44 | 18 (40.9%) | 26 (59.1%) | ||
| University | 195 | 83 (42.6%) | 112 (57.4%) | ||
| Master degree or above | 15 | 6 (40.0%) | 9 (60.0%) | ||
| Per-capita monthly household income | 3.672 | 0.159 | |||
| <¥3,000 | 135 | 52 (38.5%) | 83 (61.5%) | ||
| ¥3,000–5,000 | 133 | 40 (30.1%) | 93 (69.9%) | ||
| >¥5,000 | 33 | 15 (45.5%) | 18 (54.5%) |
BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); DRA, diastasis of the rectus abdominis; SUI, stress urinary incontinence.
TABLE 2.
Binary Logistic Regression Analysis of Variables Associated With SUI in PFD Patients
| Factors | Regression Coefficient | Wald χ2 | OR | P | 95% CI |
|---|---|---|---|---|---|
| Delivery history | 0.684 | 6.302 | 1.982 | 0.012 | 1.162–3.381 |
| Delivery mode | 6.234 | 0.044 | |||
| Spontaneous delivery | 0.343 | 0.641 | 1.409 | 0.423 | 0.609–3.264 |
| Spontaneous delivery with perineal tears or episiotomies | 0.783 | 5.779 | 2.187 | 0.016 | 1.155–4.140 |
CI, confidence interval; OR, odds ratio; PFD, pelvic floor dysfunction; SUI, stress urinary incontinence.
There were significant differences in the DRA incidence rates among the different birth weight groups (Table 3). No significant differences were found among the other factors, including age, body mass index (BMI), nulliparity, gestational week, and delivery method. Binary logistic regression analysis was performed using the prevalence of DRA as the dependent variable and birth weight as the independent variable. The results showed that a higher birth weight (P < 0.001; OR, 14.507) was an independent risk factor for DRA (Table 4).
TABLE 3.
Basal and Clinical Data in Group of DRA and Non-DRA
| Factors | Sample Size | DRA (n = 96) | Non-DRA (n = 205) | χ 2 | P |
|---|---|---|---|---|---|
| Age, y | 1.104 | 0.323 | |||
| <29.6 | 156 | 54 (34.6%) | 102 (65.4%) | ||
| ≥29.6 | 145 | 42 (29.0%) | 103 (71.0%) | ||
| BMI | 2.320 | 0.542 | |||
| <24 | 68 | 21 (30.9%) | 47 (69.1%) | ||
| 24–30 | 196 | 62 (31.6%) | 134 (68.4%) | ||
| ≥30 | 37 | 13 (35.1%) | 24 (64.9%) | ||
| Gestational weeks | 1.503 | 0.248 | |||
| <40 wk | 192 | 66 (34.4%) | 126 (65.6%) | ||
| ≥40 wk | 109 | 30 (27.5%) | 79 (72.5%) | ||
| Delivery history | 2.143 | 0.169 | |||
| Primipara | 129 | 47 (36.4%) | 82 (63.6%) | ||
| Maternal | 172 | 49 (28.5%) | 123 (71.5%) | ||
| Delivery mode | 0.993 | 0.623 | |||
| Cesarean delivery | 82 | 26 (31.7%) | 56 (68.35) | ||
| Spontaneous delivery | 53 | 14 (26.4%) | 39 (73.6%) | ||
| Spontaneous delivery with perineal tears or episiotomies | 166 | 56 (33.7%) | 110 (66.3%) | ||
| Neonatal birth weight | 0.389 | <0.001* | |||
| <2,500 | 39 | 5 (12.8%) | 34 (87.2%) | ||
| 2,500–4,000 | 215 | 59 (27.4%) | 156 (72.6%) | ||
| ≥4,000 | 47 | 32 (68.1%) | 15 (31.9%) |
BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); DRA, diastasis of the rectus abdominis.
TABLE 4.
Binary Logistic Regression of Variables Associated With DRA in PFD Patients
| Factors | Regression Coefficient | Wald χ2 | OR | P | 95% CI |
|---|---|---|---|---|---|
| Neonatal birth weight | 31.255 | 0.000 | |||
| 2,500–4,000 | 0.945 | 3.530 | 2.572 | 0.960 | 0.960–6.890 |
| ≥4,000 | 2.675 | 21.854 | 14.507 | 0.000 | 4.727–44.521 |
CI, confidence interval; DRA, diastasis of the rectus abdominis; OR, odds ratio; PFD, pelvic floor dysfunction.
Finally, all patients received bioelectric stimulation twice a week and were reviewed after a 5-week period. Regarding type I muscles, the muscle strength of 14 patients increased to 4/5. For type II muscles, the muscle strength of 53 patients increased to 4/5 (Table 5). In patients with SUI and DRA, 70.45% (62 of 88) and 31.25% (30 of 96) recovered after bioelectric stimulation treatment, respectively (Supplemental Table 1, http://links.lww.com/UROGYN/A401).
TABLE 5.
Changes of Pelvic Muscle Strength Before and After Treatment
| Pretreatment | Posttreatment | |
|---|---|---|
| Strength of type I pelvic muscle | ||
| <Grade 4 | 301 | 287 |
| ≥Grade 4 | 0 | 14 |
| Strength of type II pelvic muscle | ||
| <Grade 4 | 301 | 248 |
| ≥Grade 4 | 0 | 53 |
DISCUSSION
Pregnancy and delivery may cause damage to the abdominal and pelvic floor muscles in adult women.18 Diastasis of the rectus abdominis and PFD, represented by SUI, are common problems that affect maternal health. Long-term DRA may cause a decrease in the stability of the spine, leading to back pain and abdominal distention,19 whereas SUI, with a high incidence among adult women, causes serious physical and psychological burdens. Patients with PFD (n = 301) from the Fifth People's Hospital of Zhuhai were enrolled in this study. We aimed to analyze the potential risk factors for DRA and SUI using binary logistic regression, particularly the effects of a history of delivery, the mode of delivery, and the birth weight of the newborns.
Previous studies have reported that both PFD and SUI are related to women's anxiety, depression, and increased scores, which profoundly affect QOL. The results of this study indicate that the incidence of SUI was 29.5% in patients with PFD. Pelvic floor muscle fascia relaxation in patients with PFD is significantly correlated with SUI occurrence. The univariate analysis of SUI in this study showed that the history and mode of delivery, rather than age, BMI, gestational weeks, and birth weight, were risk factors for urinary incontinence. Consistent with a meta-analysis by Zhou et al20 involving more than 70,000 adult women, this study found that women who experienced more than 1 delivery had a high incidence of SUI (57.1% vs 42.9%). Studies have reported that pelvic floor muscles and connective tissue may be damaged during childbirth, which may result in impaired urination. In addition, compared with women who underwent cesarean delivery, there was a 6% increase in SUI in women who delivered vaginally, whereas women who underwent episiotomy at the time of vaginal delivery had an even higher incidence of SUI (35.5% vs 24.5%, respectively). This result is consistent with the results of Guo et al.20–22 Mechanical stretching during vaginal delivery may cause damage to the supporting structure of the pelvic floor, whereas vaginal delivery with episiotomy, compared with natural lacerations, may cause greater injury to the pelvic floor muscles. Therefore, for patients with PFD, a history of delivery and the mode of delivery could be important indicators to guide intervention strategies for postpartum SUI.
In recent years, pelvic-abdominal dynamics has become a research topic in the field of PFD,23 and the relationship between DRA and SUI has been controversial.24,25 The pelvic-abdominal dynamics theory states that there is a synergistic effect between the functions of the abdominal and pelvic floor muscles. When the abdominal muscles are damaged, the pelvic floor muscles lack effective assistance in the contraction process, which may exacerbate PFD. This study found that the prevalence of DRA in patients with PFD at 6–8 weeks postpartum was 31.9%,26 similar to that in previous studies. Logistic regression analysis revealed that an increase in birth weight was a key risk factor for DRA. This may be related to the enlargement of the uterus and the increase in abdominal wall pressure caused by the high-weight fetus. In terms of the relationship between DRA and SUI, Bo et al27 and Braga et al28 reported that postpartum DRA in the primipara is not associated with SUI, whereas Spitznagle et al29 reported a correlation between the two. In our study, we found that there was no significant correlation between DRA and the occurrence of SUI in patients with PFD. This is inconsistent with the conclusions of Spitznagle et al29 and may be attributed to the different clinical characteristics of the study participants. Spitznagle et al enrolled adult women with an average age of 52.45 years, whereas our study focused on patients with postpartum PFD, with an average age of 29.6 years. We speculated that in patients with postpartum PFD, impaired pelvic floor muscle strength, rather than the strength of the DRA, may be the key factor leading to the occurrence of SUI.
In summary, women diagnosed with PFD 6–8 weeks postpartum were more likely to have SUI and DRA, and there are a variety of risk factors, including the number of deliveries, mode of delivery, and birth weight. This study showed that a history of delivery and vaginal delivery were risk factors for SUI, and vaginal delivery with episiotomy further increased this risk. For adult women with the aforementioned risk factors, clinicians and rehabilitation therapists should actively evaluate pelvic floor function in the early postpartum period and develop a rehabilitation exercise program to strengthen pelvic floor muscle function.30 Of note, we found no significant association between DRA and the development of SUI in the overall cohort. However, an increase in birth weight may increase the risk of maternal DRA. If this factor exists, treatment and rehabilitation of the DRA should be performed early after delivery.31 At the same time, moderate exercise during pregnancy could prevent the occurrence of fetal macrosomia and may also have a preventive effect for DRA.32 Looking for DRA earlier after delivery and early rehabilitation (intervention) may help to further reduce the prevalence of DRA by 6 months, which may help improve the QOL of puerperae.
Supplementary Material
Footnotes
This study was supported by Project of Zhuhai Municipal Health and Health Bureau (No. ZH24013310210077PWC).
The authors have declared they have no conflicts of interest.
Author contributions: X.L. designed, collected the data, and wrote the manuscript. Q.W. and Y.C. collected the data. J.L. analyzed the data. Y.W. revised the manuscript.
IRB statement: The study was granted exemption on February 18, 2018, by the Fifth People's Hospital of Zhuhai Institutional Review Board (IRB: zhdwrmyy201802).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.urogynecologyjournal.org).
The editors wish to thank Amy L O’Boyle, R. Keith Huffaker, and Patricia Lynn Hudson for their contribution to the review of this article.
Contributor Information
Xiaohong Liu, Email: 16787522@qq.com.
Qin Wang, Email: wangqinlucky520@163.com.
Yanling Chen, Email: myling518@163.com.
Jiamao Luo, Email: ljm_21@qq.com.
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