Abstract
[Purpose] Pelvic floor dysfunction is an important health-care issue, with pregnancy, childbirth, and menopause as the most important risk factors. Insufficient knowledge about pelvic floor dysfunction is the largest barrier to seeking care. The aim of this study was to investigate the level of knowledge and information on pelvic floor dysfunction in peripartum and menopausal women. [Subjects and Methods] The present study was a cross-sectional survey. A valid and reliable questionnaire of 48 items was distributed to 402 women who were pregnant or had recently given birth and to 165 postmenopausal women. All answers were analyzed and interpreted. The study was approved by an ethics committee (B300201318334). [Results] On a VAS scale of 0 to 10, the mean ratings of the peripartum and postmenopausal women concerning their knowledge were 4.38 (SD 2.71) and 4.92 (SD 2.72). Peripartum women held significantly more pessimistic perceptions about the occurrence of postpartum pelvic floor dysfunction. The results showed that 75% of the peripartum women and 68% of the postmenopausal women felt insufficiently informed or want to get better informed. [Conclusion] The results reveal sparse knowledge about the pelvic floor among women of all ages and that a major proportion of them would be interested in more information. Amelioration of common knowledge could improve help-seeking behavior in women.
Keywords: Pelvic floor dysfunction, Women, Knowledge
INTRODUCTION
Pelvic floor dysfunction (PFD) is present in a wide range of clinical conditions, such as urinary incontinence (UI), anal and fecal incontinence (FI), pelvic organ prolapse (POP), pelvic pain syndromes, sexual dysfunction, and defecation problems1). PFD occurs when the pelvic floor muscles (PFMs) are either too weak or too tight or are incorrectly used. Because of its high prevalence, its invalidating effects on quality of life and its impact on health-related economics, PFD is considered an important health-care issue2).
The major known risk factors associated with PFD include pregnancy and childbirth, obesity, menopause, and chronic obstructive pulmonary disease3). Most frequently, vaginal partus and prolonged labor are related to PFD1, 4). Several published guidelines recommend pelvic floor muscle training (PFMT) as a first-line treatment but also as a prevention strategy for PFD5, 6). This type of treatment has become more widely available in many parts of the world, yet the prevalence rates of PDF-related symptoms remain high in adult women, e.g. up to 46% for UI7, 8). Therefore, one can only assume that prevention and treatment of PFD are not handled as well in women as they could be.
Previous research suggested that insufficient knowledge and misperceptions about PFD are the largest barriers to seeking care9,10,11). Moreover knowledge has been shown to improve compliance with treatment and can induce behavioral changes12).
Previously, we observed an important lack of knowledge about PFMs and PFD in young nulliparous women13). In this survey, we explored whether the knowledge of women about PFMs and PFD differ with age, pregnancy, parity, and menopause. We also aimed to evaluate whether women are satisfied with the information they received on this subject.
SUBJECTS AND METHODS
A written cross-sectional survey was conducted amongst a large group of European women who agreed to participate. Two different groups were included. One group consisted of women in the peripartum (PP) period (from the second half of gestation till the first three months after delivery); the other group consisted of postmenopausal (PMP) women over 50 years of age. Purposive chunk sampling was performed14): PP women were recruited during the “Baby Boom fair” in Antwerp (the largest fair for future and young parents), during baby swimming classes, and during stock sales of maternity wear and baby clothes. PMP women were recruited during a lecture organized by “Actual Thinking”, a regional association of pluralistic women.
Exclusion criteria were health-care training and lack of Dutch proficiency. Participants filled in the questionnaire immediately after receiving it and returned it immediately after filling it in.
The Human Research Ethics Committee of the University Hospital of Antwerp (Belgium) approved the study (B300201318334); data were recorded anonymously, and written informed consent was obtained from all the participants.
A literature search could not identify existing psychometrically tested questionnaires that could answer the research questions of the current study. Therefore, a new questionnaire was developed, through item generation, reduction, and “sampling to redundancy”, according to “the Delphi process”14, 15). The questionnaire was based on that developed for nulliparous women13), though 5 questions were added to collect data about gravidity, parity, and menopause. The questionnaire consisted of 48 questions: 5 on demographic characteristics, 5 on gravidity and parity, 1 on menopause, 6 on PF structure and function, 12 on PFD and risk factors, 3 on sexual (dys)function, 4 on PFT, 5 on education and gathering of information about this topic, and 1 on worries about PF. A female body figure was included to evaluate topographical knowledge (Appendix 1).
The design, wording, form, and order of questions can affect the type of responses obtained; thus careful design was used to minimize bias in the results16). Questions were phrased in a socially and culturally sensitive manner, avoiding complex terminology. Succinct and unbiased response formats, “open” (free) and “closed” (structured) text15), were used (depending on the information we intended to gather). Indecisive response options (e.g., “I don’t know” and “other”) were included in order to enhance the response rates15, 17).
Validity was examined by collecting expert opinions from 4 involved experts (2 urologists, 1 pelvic floor therapist, and 1 gynecologist), and 3 independent experts (a gynecologist, a gastroenterologist, and a general practitioner). The questionnaire was evaluated for face and content validity. A pilot study was performed among the target population (22 volunteers) to evaluate whether respondents interpreted questions in a consistent manner18), to judge the appropriateness of each included question, and to record the time required to complete the questionnaire.
Descriptive statistics were generated in IBM SPSS Statistics 20.0 for Windows (IBM Corp., Armonk, NY, USA). Stability and validity testing were performed by using Kappa statistics and intraclass correlation coefficients (ICC) to define agreement for each question. The χ2 test was used to analyze the differences between groups, and the Kruskal Wallis test was used for scale parameters. To account for multiple testing, the significance level was set at 0.001.
RESULTS
Test-retest reliability: Sixteen participants completed the questionnaire a second time after 2–4 days. The k value was over 0.80 for 86% of the questions, indicating perfect agreement, and 14% of the questions had a k value between 0.61 and 0.80, indicating substantial agreement. For the one item about knowledge (a visual analogue scale), there was high agreement (ICC single measures 0.92, average measures 0.96) between test-retest answers. Asessement of content and face validity indicated that the questions were well interpreted and gave an accurate measurement of the concept and that the content assessed all fundamental aspects of PFMs and PFD. All women returned the questionnaire, giving a response rate of 100%. The time required to complete the questionnaire ranged from 10 to 20 minutes.
Demographic characteristics and gravidity-parity: A total of 402 PP women (mean age 29.8; 19 to 43 years old) and a total of 156 PMP women (mean age 65.3; 50 to 86 years old) were included (Figs. 1 and 2). The highest achieved degree of education was bachelor’s or master’s degree in 270 (67%) PP women and 95 (62%) PMP women, high school in 126 (31%) PP women and 55 (36%) PMP women and elementary school in 5 (1%) PP women and 3 (2%) PMP women. The educational degree in the two groups did not differ significantly (p=0.461). All PMP women were of European nationality, as were the majority (99%) of the PP women. Most PP women were Caucasian (385, 96%); 7 (2%) were Asian, and 3 (0.7%) were black. Most PMP women were Caucasian (151, 99%); one PMP woman was black. The majority of the PP women (295 women, 73%) were on average 23 weeks (SD 8.0 weeks) pregnant, and 221 of them were pregnant for the first time (nulliparous pregnant women). All PMP women declared that they were in the postmenopausal period. Gravidity and parity (G-P) differed significantly (p<0.001) between PP and PMP women. PP women had been pregnant once on average (mean 1.05 ± 1.88), and the mean parity was 0.67 (± 0.88); PMP women had a mean gravidity of 2.8 (± 1.60) and mean parity of 2.54 (± 1.29). In PMP women, a significantly higher number of episiotomies (PP women 0.16 ± 0.44; PMP women 1.17 ± 1.24; p<0.001) and instrumental vaginal deliveries (PP women 0.010 ± 0.099; PMP women 0.099 ± 0.55; p=0.001) were performed.
Fig. 1.
PP women distributed by current status of pregnancy/post delivery and their number of deliveries (PP, peripartum; N, number of participants)
Fig. 2.
PMP women distributed by their number of deliveries (PMP, postmenopausal; N, number of participants)
Pelvic floor structure and function: Differences in knowledge between women based on difference in parity (or experience) and difference in age shown in Table 1. Most PP women (351, 88%) and most PMP women (140, 93%) knew that the PF contains muscles. One-third of PP and PMP women answered that the PF also includes bones, joints, and tendons and ligaments. Furthermore, 75 (51%) PMP women also thought the PF includes arteries and nerves, which was significantly more (p<0.001) than the number of PP women (125, 31%). The majority of all participants (370, 92%, PP women; 142, 91%, PMP women) located the PF correctly on the figure of the female body. On the other hand, 30 (8%) PP women and 9 (9%) PMP women located the PF in the abdomen (above the os ileum) or at the caput femoris.
Table 1. Differences in knowledge between women based on the difference in parity (or experience) and difference in age.
| Item/question | Group | N | |
|---|---|---|---|
| Knowledge of PFD | |||
| Number of openings in PF=3** | |||
| NulliP P | 221 | Correct, 28 (13%); UK, 151 (68%) | |
| MultiP PP | 181 | Correct, 44 (24%); UK, 95 (53%) | |
| PMP | 140 | Correct, 46 (33%); UK, 0 (0%) | |
| Causes of PFD: vaginal delivery** | |||
| NulliP P | 221 | 116 (53%) | |
| MultiP PP | 181 | 138 (76%) | |
| PMP | 146 | 80 (55%) | |
| Causes of PFD: constipation** | |||
| NulliP P | 221 | 15 (7%) | |
| MultiP PP | 181 | 20 (11%) | |
| PMP | 145 | 36 (25%) | |
| Fear: for UI (yes answers) / no fear for PFD at all** | |||
| NulliP P | 221 | 51 (23%)/131 (59%) | |
| MultiP PP | 181 | 81 (45%)/68 (38%) | |
| PMP | 156 | 89 (57%)/44 (28%) | |
| Occasional UI normal? (yes answers) | |||
| NulliP P | 221 | 27 (12%) | |
| MultiP PP | 181 | 17 (9%) | |
| PMP | 150 | 25 (17%) | |
| SUI normal? (Yes answers) | |||
| NulliP P | 221 | 43 (20%) | |
| MultiP PP | 181 | 29 (16%) | |
| PMP | 151 | 36 (24%) | |
| Precautionary pad normal? (yes answers) | |||
| NulliP P | 220 | 94 (43%) | |
| MultiP PP | 181 | 71 (39%) | |
| PMP | 149 | 70 (47%) | |
| Diminished force of PFMs after delivery? (yes answers)** | |||
| NulliP P | 219 | 182 (83%) | |
| MultiP PP | 178 | 162 (91%) | |
| PMP | 152 | 110 (72%) | |
| Consequences of pregnancy and delivery: UI** | |||
| NulliP P | 221 | 162 (73%) | |
| MultiP PP | 181 | 144 (80%) | |
| PMP | 156 | 60 (39%) | |
| Consequences of pregnancy and delivery: stool problems** | |||
| NulliP P | 221 | 35 (16%) | |
| MultiP PP | 180 | 76 (42%) | |
| PMP | 156 | 33 (21%) | |
| Consequences of pregnancy and delivery: flatulence** | |||
| NulliP P | 221 | 16 (7%) | |
| MultiP PP | 181 | 27 (15%) | |
| PMP | 156 | 5 (3%) | |
| Consequences of pregnancy and delivery: perineal pain** | |||
| NulliP P | 221 | 104 (47%) | |
| MultiP PP | 180 | 85 (47%) | |
| PMP | 156 | 38 (24%) | |
| Complaints of pain/ UI/ FI/ dyspareunia after delivery: immediately PP/1 month PP/6 months PP | |||
| Knowledge about sexual (dys)function related to the PFMs | |||
| Do the PFMs play a role in orgasm? | |||
| NulliP P | 221 | 117 (53%) | |
| MultiP PP | 181 | 111 (61%) | |
| PMP | 141 | 78 (55%) | |
| UI during sexual intercourse normal? | |||
| NulliP P | 221 | 12 (5%) | |
| MultiP PP | 181 | 9 (5%) | |
| PMP | 145 | 19 (13%) | |
| Occasional dyspareunia normal? | |||
| NulliP P | 221 | 66 (30%) | |
| MultiP PP | 181 | 52 (29%) | |
| PMP | 146 | 49 (34%) | |
| Continuous dyspareunia normal? | |||
| NulliP P | 221 | 4 (2%) | |
| MultiP PP | 180 | 6 (3%) | |
| PMP | 146 | 4 (3%) | |
| Knowledge about pelvic floor therapy | |||
| Do you know what PFT means? (no answers)** | |||
| NulliP P | 221 | 192 (87%) | |
| MultiP PP | 180 | 123 (68%) | |
| PMP | 135 | 100 (74%) | |
| Ever received PFT? (yes answers)** | |||
| NulliP P | 221 | 22 (10%) | |
| MultiP PP | 180 | 76 (42%) | |
| PMP | 146 | 35 (24%) | |
| Prenatal physiotherapy useful? (yes answers) | |||
| NulliP P | 221 | 184 (83%) | |
| MultiP PP | 180 | 137 (76%) | |
| PMP | 147 | 124 (84%) | |
| Postnatal physiotherapy useful? (yes answers) | |||
| NulliP P | 221 | 196 (89%) | |
| MultiP PP | 181 | 168 (93%) | |
| PMP | 147 | 134 (91%) | |
| Education and gathering of information about the topic | |||
| Estimation of knowledge (0–10)** | |||
| NulliP P | 220 | 3.71 (SD 2.59) | |
| MultiP PP | 181 | 5.21 (SD 2.62) | |
| PMP | 147 | 4.92 (SD 2.72) | |
| Ever received information? (yes answers)** | |||
| NulliP P | 219 | 62 (28%) | |
| MultiP PP | 179 | 133 (74%) | |
| PMP | 141 | 80 (57%) | |
| Ever searched for information? (yes answers) | |||
| NulliP P | 221 | 55 (25%) | |
| MultiP PP | 181 | 51 (28%) | |
| PMP | 128 | 46 (36%) | |
| Sufficiently informed? (no answers)** | |||
| NulliP P | 221 | 178 (81%) | |
| MultiP PP | 180 | 94 (52%) | |
| PMP | 137 | 77 (56%) | |
| Interested in more information? (yes answers)** | |||
| NulliP P | 221 | 195 (88%) | |
| MultiP PP | 180 | 107 (59%) | |
| PMP | 138 | 94 (68%) | |
NulliP P and MultiP PP give similar answers, while PMP expect significantly (**p<0.001) less complaints immediately PP and 1 month PP; at 6 months PP, no significant differences between groups were found (for questions 23–26, see Appendix 1). NulliP P: group of nulliparous pregnant women; MultiP PP: group of multiparous pregnant women and postnatal women (until 3 months post delivery); PMP women: postmenopausal women; UK: unknown (answered with “I don’t know”); UI: urinary incontinence; SUI: stress urinary incontinence; PFMs: pelvic floor muscles; PFT: pelvic floor therapy. ** The difference between groups for this item is significant (p<0.001)
The closure function (181 PP women, 45%; 64 PMP women, 41%) and support function (193 PP women, 48%; 90 PMP women, 58%) were known best. No significant differences between groups were found. Eight (2%) PP and 13 (8%) PMP women knew about the sexual function (p=0.005), and 33% (n=133) of PP women and 19% (n=30) of PMP women answered that they did not know what the PFMs do or why we need them (p=0.003).
Almost all participants were aware that PFMs could be consciously contracted (380 PP women, 94%; 143 PMP women, 97%). A significant larger proportion (73%, n=114) of PMP women were aware of the squeezing and lifting movement that the PFMs normally makes during an analytic contraction, whereas to 241 (60%) PP women (p<0.001) were aware of this.
A great portion of the women (246 PP women, 61%; 61 PMP women, 43%) did not know how many normal anatomical openings there are in the female PF. Only 72 (18%) PP women and 46 (33%) PMP women answered “three” and were able to name them correctly. No significant differences between PP and PMP groups were found, although Table 1 does indicate that nulliparous pregnant women knew significantly less.
Knowledge of PFD: The answers for the questions about the causes of PFD are shown in Table 1. PMP women answered significantly more frequently that obesity and constipation can cause PFD. The results for the questions about the occurrence of PFD are also shown in Table 1. Significant differences between groups were found for the answers for the following questions: “Is it normal that the pelvic floor muscles are not as strong after childbirth as before?” (more PP women answered “yes”), “Is it normal that a healthy woman experiences pain in the pelvic floor after childbirth?” (more PP women answered “yes”), “Is it normal that a healthy woman occasionally loses urine after childbirth?” (more PP women answered “yes”), “Is it normal that an average women experiences pain during intercourse after childbirth?” (more PP women answered “yes” at one month postpartum, and more PMP women answered “I don’t know” at 6 months postpartum). A significant greater percentage of PP women answered that UI and pain in the pelvic floor are consequences to expect of a vaginal delivery (Table 1).
Most participants in both groups (203 PP women, 71%; 69 PMP women, 87%) thought that a perineal rupture causes more damage to the PFMs than an episiotomy. Most of them answered that it is “the vagina” that tears during a perineal tear. Furthermore, 90% (n=250) of PP women answered that a vaginal delivery causes more damage to the PFMs than a caesarean, which was a significantly greater portion compared with the proportion of PMP women (77%, n=52; p<0.001). A significant difference between groups was found for the knowledge of POP: for 296 (74%) PP women and 76 (49%) PMP women (p<0.001) had no knowledge of POP. Finally, 19% (n=76) of PP women and 36% (n=55) of PMP women were able to describe which organs could descend in the pelvis.
Sexual (dys)function: No significant differences were found between groups (Table 1). A greater percentage of PMP women answered “yes” while a greater percentage of PP women did not know whether UI during sexual intercourse is normal.
Pelvic floor therapy: No significant difference was found between PP and PMP women in terms of the percentage of women that had ever received pelvic floor therapy (PFT), both being 24%, although results in Table 1 show that PFT was mostly received after the first pregnancy. Nulliparous pregnant women received significantly less PFT. Only those women in the two groups who had received PFT answered that they were aware of the current treatment strategies.
Education and gathering of information: On a VAS scale of 0 to 10 (0, no knowledge; 10, very high knowledge), the mean ratings of the PP and PMP women for their general knowledge about the PF were 4.38 (SD 2.71) and 4.92 (SD 2.72) respectively. The Kruskall-Wallis test revealed a significant difference of p<0.001. Half of the PP women (n=201, 51%) and 61 (43%) of the PMP women never received information about the PF. Table 1 shows a significant difference in received information between nulliparous women who were pregnant for the first time and parous women. There was no significant difference between the proportion of currently pregnant multiparous or post-delivery women who had been informed and the PMP women who had experienced their peripartum period years previously.
Only 14/195 PP women had received PFM information before pregnancy, such as during yoga or Pilates classes, back school, or sporting activities. IN the informed PP women, 93% (n=181) of the informed PP women received the information during their pregnancy or after their delivery. In contrast, 27/80 informed PMP women (34%) received information during their peripartum period. This means that the majority of this group (n=53, 66%, received information about PF in their PMP period and thus at a higher age. A large number of women were interested in more information on the topic (75% of PP women and 68% of PMP women). No significant difference was found between the PP and PMP groups.
Worries about PF: The majority (n=89, 57%) of the PMP women expressed a concern about urinary incontinence; this was significantly higher than in the PP group (n=132, 33%). No significant difference was found for fear of fecal incontinence (7 PP women, 12%; 16 PMP women, 10%; p=0.484) or fear of prolaps (26 PP women, 7%; 16 PMP women, 10%; p=0.128).
DISCUSSION
The results of this extended survey show moderate actual knowledge about PFMs and PFD in PP and PMP women. The questionnaire was not constructed to rate the degree of knowledge. The answers could not always be considered wright or wrong. On the contrary, the questions were constructed to reveal better comprehension of the current knowledge and ideas of women about this topic.
To the best of our knowledge, all previous studies have focused on the knowledge of PFMT and not on the general knowledge women have about PFMs and PFD19, 20). Mandimika et al. recently investigated the knowledge of UI and POP among a population of community-dwelling woman10). Similar to our results, they found a global lack of knowledge about UI and POP among community-dwelling women, with more pronounced knowledge gaps among nonwhite women. Our present study investigated the knowledge of a broad range of all PFD symptoms and compared the results in different phases of life (age groups).
Previously, we observed an important lack of knowledge in young nulliparous women about the PFMs and PFD13). Young women who had never been exposed to PFD risk factors such as pregnancy and delivery rated their actual knowledge about these topics as 2.4 ± 2.01/10. The results of the present study reveal slightly better actual knowledge with PP and PMP women scoring their own knowledge significantly higher (4.4 ± 2.71/10 for PP women and 4.9 ± 2.72/10 for PMP women). Thus we can conclude that the actual knowledge of women about the PFMs and PFD differ with age, pregnancy, parity, and menopause. But it is certainly remarkable that the level of knowledge did not differ significantly between PP and PMP women for most of the questions and that it still remains poor (less than 5/10).
PP and PMP women showed the same trend in acceptance of PFD symptoms after delivery: most women agree that certain PFD symptoms could be considered normal immediately after childbirth but should improve or disappear after 3 to 6 months. Nevertheless, significant differences were found for these questions between the two groups. More PP women accepted PFD complaints. Their illness perceptions about PFD after childbirth were more pessimistic, and this was in agreement with the results found in nulliparous women. In our opinion, it is important to use education about this topic to prevent young women from accepting PFD symptoms and to empower help-seeking behavior.
A significant difference between groups existed with respect to parity. Parity and gravidity were significantly higher in the PMP group compared with the PP group. But the general knowledge about PFMs and PFD did not differ between these groups. This led us to the conclusion that higher numbers of pregnancies and deliveries do not seem to improve knowledge about the PF.
It is remarkable that only half of the PP and PMP women ever received information about the PF and that a majority of them would welcome more information. When information was provided, it was mostly during pregnancy or around delivery in the PP group; most PMP women got information in the postmenopausal period, which is rather late.
The participating PMP women were significantly better aware of PFD risk factors such as obesity and constipation. Similar results were found for POP: PMP women were better aware of this PFD symptom. Better knowledge of these symptoms and contributing factors, at a younger age, could affect help-seeking behavior10, 19) and positively influence prevention of PFD.
Also, PMP women were significantly more occupied with and in fear of PFD. This may be related to the higher prevalence of PFD in their age group. Information and education about complaints, syndromes, and pathologies has been shown to affect cognition and perceptions20, 21) of patients about their complaints. Furthermore previous research has also suggested education as a means of avoiding catastrophizing behavior of patients22).
Information about the PF was received rather late in life, so timely prevention was not possible. This shows that there is work to be done to better inform all women. One can only encourage the trend that we observed that more women these days are already getting informed about this topic during their childbearing years. Nevertheless the results of this study confirm the need to reach more women with good information, and the authors suggest information should be offered repeatedly to ensure it is not forgotten. Improved knowledge about such things as bladder behavior, PFM exercises, and stool habits would likely make a great difference. Further work is needed to determine how such education should be provided and who should provide it.
A shortcoming of the present study may be that the participants were young women of Belgian ethnicity with mid to high levels of education. Previous research revealed better knowledge about urologic topics in white women compared with other races10, 23). More research in women with different demographic characteristics could help define how general our findings are.
In 2013, Buurman et al. performed a qualitative research about women’s perceptions about PFD and their help-seeking behavior. Several women explicitly mentioned embarrassment as an impediment for seeking help21). In general, PF problems are still a taboo for most women. The low number of women in our study that took active steps to get help or information confirms these statements. Our results clearly reveal that the majority of women of all ages are aware of the problem, feel badly informed, and are interested in more information. This is a strong argument further work on improving and intensifying PF education. Future research must investigate how women would like to be informed and which campaigns would be the most effective, with the best compliance.
To conclude, there is sparse knowledge about the pelvic floor among women of all ages. Most postmenopausal women get informed during the postmenopausal period, which is very late. A major proportion of women would be interested in more information. Improving common knowledge about PFMs and PFD could improve help-seeking behavior in women but could also have a role in the prevention of PFD.
Conflict of interest
The authors declare that there are no conflicts of interest regarding the publication of this paper.
Acknowledgments
The authors would like to thank all the women and PF therapists who participated in this study. The authors are also grateful to Dr. Kristien Wouters for her advice and help with the statistical analysis. Finally, the authors would like to thank the Sirate32 Foundation for their practical help.
Appendix 1.
Questionnaire
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