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Reviews in Gynaecological Practice 5 (2005) 15–22 www.elsevier.com/locate/rigp

Childbirth and the pelvic floor: ‘‘the gynaecological consequences’’

Christian Phillips a,1, Ash Monga b,*

a The North Hampshire Hospital, Aldermaston Road, Basingstoke, Hampshire RG24 9NA, UK b Princess Anne Hospital, Coxford Road, Southampton SO16 5YA, UK

Received 28 May 2004; accepted 15 September 2004

Abstract

This review addresses the effects of on the pelvic floor, urinary continence mechanisms and the . Genitourinary affects 15% of women and stress incontinence 20–30%. The major risk factors are age and childbirth, with severity increasing with parity. There are three mechanisms of support for the pelvic organs and bladder . These are (i) the muscular component: and urethral sphincter with their intact supply, (ii) the endopelvic fascial connections with the levator ani, and (iii) the posterior angulation of the . Childbirth causes direct myogenic damage, dennervation and defects in the endopelvic along with widening of the . Elective without labour has in the past thought to be protective. More recent data suggests this effect to be less pronounced and antenatal stress incontinence appears the most important predictive factor for the development of postnatal stress incontinence. The targeting of pelvic floor exercises under direct supervision from a physiotherapist have shown a reduction in the development of short and long term stress urinary incontinence. Perineal trauma can effect up to 85% of women after vaginal delivery. The consequences of this include perineal pain and lasting up to 12 months postnatally. Nulliparity and the use of forceps have been identified as the major risk factors along with occipito- posterior , macrosomia and as secondary factors. The role of selective mediolateral episiotomy and methods of perineal repair are discussed. # 2004 Elsevier B.V. All rights reserved.

Keywords: Childbirth; Pelvic floor; Stress urinary incontinence; Continence mechanisms; Perineal trauma; Prevention of stress incontinence; Episiotomy

1. Introduction tinence, and perineal trauma, its subsequent repair, dyspareunia and perineal pain. The strength of the muscles of the pelvic floor and other supporting structures of the pelvic organs are affected by various events that occur during a ’s lifetime. and childbirth have a pronounced influence on 2. Epidemiology maternal and physiology. After this, and aging have a secondary effect on the pelvic floor. This Genitourinary prolapse is a common and distressing review concentrates on the long term gynaecological condition affecting up to 15% of the female population and consequences of pregnancy and childbirth with respect to is responsible for around 20% of women on waiting lists pelvic floor weakness, its incidence, its pathophysiology and for major gynaecological surgery [1]. It is defined as the ways in which it may be prevented. protrusion of a pelvic or structure beyond its normal The longer-term gynaecological sequelae of pelvic floor confines within the . Epidemiological studies have weakness are , stress urinary incon- shown a woman has an 11.1% lifetime risk of undergoing a single operation for prolapse or incontinence by the age of 80 [2]. The incidence of women admitted to hospital with * Corresponding author. Tel.: +44 2380 798504; fax: +44 2380 794801. E-mail addresses: [email protected] (C. Phillips), prolapse is 2.04 per 1000 person-years of risk [3].The [email protected] (A. Monga). main risk factors associated with prolapse are parity and 1 Tel.: +44 171 594 7575; fax: +44 171 594 7580. increasing age, whilst smoking and obesity are secondary

1471-7697/$ – see front matter # 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.rigp.2004.09.002 16 C. Phillips, A. Monga / Reviews in Gynaecological Practice 5 (2005) 15–22 factors. Recurrence rates are high, rising with time after 3.1. Muscular supports [3]. Cumulative risk of recurrence rose from 1% after 3 years to 5% after 15 years. Women have a 5.5 The muscular support of the pelvic viscera is mainly times higher risk of recurrence if their hysterectomy is for provided by the levator ani muscles: iliococcygeus and prolapse rather than other . The Womens’ Health pubococcygeus. The iliococcygeus muscles form a sheet- Initiative studied approximately 27,000 women. This study like structure extending from the arcus tendineus ante- quotes prevalence rates for each type of prolapse; uterine riorly, travelling behind the to meet a midline raphe prolapse; 14%, ; 34% and ; 18% of fused posteriorly to the coccyx. The two muscles act as a women [4]. Prolapse is rare in Afro-Carribean women plate lying over the urogenital hiatus, upon which the compared with a Caucasian population, which may be due pelvic viscera lie. When the levator ani muscles relax the to differences in their connective tissue [5].Studiesof urogenital hiatus widens and the suspensory , sisters have shown that genetic predisposition may be more made of connective tissue are left holding the and importantthanotherriskfactorssuchasparityinthe vagina in place. This has been confirmed using three- development of prolapse [6]. dimensional ultrasound of the levator ani hiatus. Measure- Urinary incontinence is defined by the International ments show that the hiatus is larger in women with Continence society as the involuntary loss of urine that is a prolapse than in those without [18]. Control of levator tone social or hygienic problem. In population estimates the at rest and at stress is maintained by an intact nerve supply. incidence of urinary incontinence ranges from 20 to 30%, The levator ani muscles are innervated by the anterior with 7–12% of women perceiving it as a problem [7].Itis sacral nerve roots of S2–4. The pubococcygeus muscle estimated that 1–4% of the population suffer restriction to forms a sling-like structure around the urogenital hiatus their daily activities because of their incontinence. Risk andsoisinvolvedinsphinctericmechanismsofthe factors for the development of urinary incontinence are age . The pubococcygeus muscle, along with the and childbirth. The prevalence of urinary symptoms peaks external anal sphincter is innervated by branches of the at 45–55 years and again at 70 years [8]. Severe forms of pudendal nerve (S2–4). incontinence are more common with older age, with a 30% greater prevalence for each 5-year increase in age [9]. 3.2. Connective tissue supports Stress incontinence affects 16% of 17–25-year olds and is more common in parous women compared with nullipar- Integrity of the endopelvic fascia is also important in ous women [10]. Workers have found that stress the support of the uterus, bladder and bowel. Anteriorly incontinence in the nulliparous population is associated the pelvic fascia forms the pubourethral ligaments. These with inherent deficiencies in their connective tissue lie either side of the midline to form an aponeurotic plate [11,12]. Urinary symptoms are found antenatally in up supporting the cranial aspect of the proximal urethra. The to 60% of pregnant women [13]. Postnatally, the pubourethral ligaments extend anteriorly becoming con- prevalence of urinary incontinence varies in reports from tinuous with the suspensory of the . The 6to34%[14–16]. endopelvic fascia then extends as a fibrous band running from the symphysis pubis anteriorly, widening posteriorly to attach to the . This structure called the arcus 3. Normal anatomy of pelvic support tendineus fascia pelvis (ATFP) is also known as the ‘‘white line’’, and can easily be seen in the space of Retzius at The uterus and vaginal apex are supported by a muscular colposuspension. The fascia extends continuously from component, which requires an intact nerve supply, and a the symphysis pubis anteriorly, the arcus tendineus fascial component. Damage to any of these can lead to and levator ani muscles laterally to the ischial spines prolapse of the pelvic organs. posteriorly, enveloping the pelvic organs. In areas the Victor Bonney described three mechanisms of support fascia forms condensations called ligaments, e.g. the that exist in the female pelvis: constriction, suspension and uterosacral/cardinal complex. The endopelvic fascia is flap-valve closure [17]. made up mainly of connective tissue and in various proportions according to site and structure [19]. 1. Constriction of the vagina by the levator ani occludes the The cardinal ligaments contain perivascular connective levator hiatus through which prolapse of pelvic structures tissue whereas the uterosacral ligaments are predomi- can occur. nantly smooth muscle and connective tissue [20,21] 2. The angulation of the vagina, which allows it to close (see Fig. 1). Mengert demonstrated in experiments on against the levator plate on increasing the intra- cadavers that the urterosacral ligaments, and abdominal pressure. paracolpium are most important in the support of the 3. Fascia and ligaments suspend the uterus, bladder uterus and vagina and this has been further shown to and bladder neck, and rectum to the pelvic side- involve three levels of support to the pelvic viscera walls. [22,23]: C. Phillips, A. Monga / Reviews in Gynaecological Practice 5 (2005) 15–22 17

Fig. 1. Section through demonstrating blood vessels (BV), (N), smooth muscle bundles (SM) and connective tissue (CT).

 Level 1 extends upper 1/3 of the vagina and the ropes to the endopelvic fascia and suspensory ligaments. If suspending the uterus and vaginal apex to the lateral the water level were to fall significantly then excessive pelvic side walls. forces would be placed on the mooring ropes. After an  Level 2 attaches the mid-portion of the vagina directly to assault such as childbirth, neuromuscular damage may cause the pelvic walls forming the pubocervical and rectova- a reduction in levator resting tone and a widening of the ginal fascia. urogenital hiatus. The uterus and vagina are therefore only supported by the endopelvic fascia of the parametrium and The Hammock hypothesis for urethral support was de- paracolpium. If the fascia is inherently weak or already rived after anatomical dissection and correlation with ma- damaged then the ligaments will stretch and lead to prolapse. gnetic resonance imaging [24]. The pubocervical fascia between the anterior vaginal wall and the bladder retains continuity with the arcus tendineus and the levator ani to 4. Pathophysiology of prolapse and stress urinary form a ‘‘hammock’’ below the bladder neck and urethra. incontinence: evidence of pelvic floor damage This continuity is important in maintaining continence of urine as well as supporting the bladder neck and urethra. The following factors are implicated in the aetiology of prolapse and stress urinary incontinence:  Level 3 direct attachment of lower portion of vagina to surrounding structures without paracolpium.  Mechanical trauma to the pelvic floor musculature.  Damage to the nerve supply to the pelvic floor muscles. Loss of support at each level gives rise to different types of  Insult to the endopelvic fascia. prolapse. Damage to the upper suspensory fibres of the pa- racolpium can lead to prolapse of the uterus and vaginal apex. 4.1. Myogenic damage Loss of level 2 support anteriorly would give rise to urethr- ocele, cystourethrocele or cystocele, often accompanied by There is histological and imaging evidence that stress incontinence. Loss of continuity of the rectovaginal mechanical trauma causes rupture of the pelvic musculature fascia and the pelvic side-wall would lead to rectocele. at delivery. Studies using magnetic resonance imaging of the Support of the pelvic viscera is achieved by the interplay pelvic floor after vaginal delivery have demonstrated areas of the three mechanisms described. The analogy of a boat in of muscle deficiency within the striated muscle of the pelvic dry dock has been used. The water supports the weight of the floor as a direct consequence of childbirth [25]. Imaging of boat whilst the mooring ropes hold it in position. The water the levator ani has shown an association between severity of is analogous to the levator ani muscles and the mooring prolapse and loss of muscle size on measurement of the 18 C. Phillips, A. Monga / Reviews in Gynaecological Practice 5 (2005) 15–22 pubococcygeus muscle, which correlated with muscle forceps delivery, prolonged second stage of labour, third strength [26]. Measurements of the genital hiatus also show degree perineal tears and macrosomia [35]. a correlation between increasing severity of prolapse and reduction in muscle bulk [27]. Histological examination of 4.3. Damage to the endopelvic fascia biopsies of levator ani from mice have shown characteristics of myogenic injury occur after parturition [28]. This is been There are numerous studies that show prolapse occurs in supported by histological examination of cadaveric association with defined defects in the supporting endopelvic levator ani where fibre density also suggested direct fascia, which can be demonstrated on vaginal examination. At myogenic damage [29]. operation, defects can be dissected and repaired, akin to a hernia repair, as a treatment for prolapse [36,37].During 4.2. Neuromuscular injury parturition tears in the connective tissue can occur which are not clinically apparent after delivery. With further vaginal Damage to the nerve supply of the pelvic floor caused by deliveries and the defects may become larger, more childbirth may cause progressive denervation of the apparent and the bladder and bowel begin to protrude into the musculature. Subsequent re-innervation of the pelvic floor vagina resulting in a cystocele or rectocele. It is believed that leads to an altered function, morphology and neurophysiol- some women are more susceptible to connective tissue ogy. Histological, histochemical and electromyography damage during vaginal delivery due to an inherent weakness studies have measured the degree of re-innervation and have in their connective tissue. It has been suggested that if it were assumed this is the result of denervation caused by delivery possible to isolate these individuals prior to pregnancy or [30,31]. The exact nature of denervation injury during labour then elective caesarean section may prevent/reduce parturition is unknown but one mechanism may be pudendal their chance of developing prolapse. Collagen is the most nerve compression. The pudendal nerves innervate the levator important component of the connective tissue with regard to ani muscles from the second, third and fourth sacral nerve providing the tissue strength and prolapse is more common in roots (S2–4). During its course from S2–4 to the levators, the women with disorders of collagen metabolism [38]. Altered pudendal nerve passes around the ischial spine which is a collagen fibre orientation and thickness has been showed potential site for compression by the fetal during histologically in women with prolapse [39]. Urodynamic childbirth. Prolonged pudendal nerve terminal motor latency stress incontinence is increased in premenopausal nulliparous (PNTML) has been reported after childbirth, but may also be women with reduced collagen content in their anterior vaginal as a result of other , such as demyelination. Snooks wall [11]. Jackson et al. showed a reduction in the total et al. showed that women having a vaginal delivery had collagen content of vaginal fascia in premenopausal women significantly prolonged PNTML and greater perineal dis- with prolapse compared with controls [40]. In addition they placement on straining compared with controls [32]. PNTML showed a reduction in the ratio of stronger mature pyridino- are further significantly prolonged in primiparas who had a line cross-link to the weaker cross-link hydroxylysino-keto- forceps delivery rather than a normal vaginal delivery. norleucine (HLKNL) and an increase in matrix metallopro- Caesarean section had no effect on neurophysiology teinase activity in this tissue, suggesting increased collagen compared with controls [32]. Although pelvic floor neuro- degradation. However, the vaginal fascia does not support the pathy has been demonstrated in many women immediately uterus or bladder. Recent work has shown that similar after delivery, most will recover neuromuscular function and (although less pronounced) changes in collagen metabolism only few will suffer long term problems. Sultan et al. occur in the uterosacral ligaments of women with uterine measured PNTML at 34 weeks and at 6 weeks and 6 prolapse [41,42]. months post-partum [33]. Their results supported the findings Pregnancy itself has an effect on the connective tissue. of Snooks et al., but also showed that PNTML can be Landon et al. examined the biochemical properties of rectus prolonged in women who have a caesarean section after the sheath fascia in pregnant women compared with non- onset of labour indicating that pudendal nerve damage may pregnant controls [43]. They found that during pregnancy not be due to pregnancy but labour, irrespective of vaginal the fascia becomes more elastic and weaker than outside delivery. In view of the conflicting data on PNTML, the pregnancy and women with stress incontinence showed reliability of PNTML measurement is already being exaggerated changes in fascial strength during pregnancy challenged. compared with those without stress incontinence. It is not known why neuromuscular function is regained in some women after childbirth while others continue to have permanent damage. Decreased neuromuscular function 5. Prevention can be seen in women with greater perineal descent on straining. It has been postulated that repeated stretching of 5.1. The role of elective caesarean section the pudendal nerve by straining causes recurrent injury to the nerve, preventing it from recovery [32–34]. Factors A survey found 31% of female obstetricians would prefer associated with greater pelvic floor nerve damage are parity, elective caesarean section to vaginal delivery, with 80% of C. Phillips, A. Monga / Reviews in Gynaecological Practice 5 (2005) 15–22 19 those doctors indicating fear of perineal damage as their when performed postnatally, especially in the well motivated main reason [44]. Although caesarean section under regional patient. [48,49]. However, they have not been shown to be anaesthesia is now safer than ever, maternal risks include effective in the treatment of established prolapse. Studies haemorrhage, , ileus, and have shown that simple verbal advice and leaflets result in no Mendleson’s syndrome. The risk of hysterectomy due to improvement in the prevention of postnatal stress urinary haemorrhage after caesarean section is 10 times that after incontinence [50]. Randomised controlled trials have shown vaginal delivery, whilst the risk of maternal mortality is 16- that antenatal pelvic floor exercises lead to a reduction the fold by caesarean section. Furthermore, the majority of development of short and long term postnatal stress urinary damage to the pelvic floor occurs during the first vaginal incontinence [51,52]. delivery. It may therefore be better clinically to only offer caesarean section to women at a high risk of perineal floor damage if vaginal delivery occurred, in the absence of any 6. The perineum other clinical indication. Some centres advocate caesarean section in women with a history of anal incontinence or who Vaginal delivery can cause significant long term damage have had successful surgery for prolapse or urodynamic to the perineum including perineal discomfort, dyspareunia stress incontinence [45], as these conditions have been and anal sphincter damage and weakness. These symptoms shown to deteriorate with subsequent vaginal deliveries. are often long-standing and may require repeated gynae- Chaliha et al. looked at antenatal urinary symptoms and cological surgery. Therefore, the clinician at delivery should physical markers of collagen weakness such as aim to minimise the amount of trauma encountered by the hypermobility, striae, perineal descent, prolapse, perineal patient in an attempt to prevent later consequences. body length and antenatal incontinence, in an attempt to predict post-partum urinary incontinence [13]. Unfortu- 6.1. Prevalence nately, they found no relationship with antenatal assessment and the development of urinary incontinence. King et al. An estimated 85% of women will sustain some degree of found that the antenatal detection of increased bladder neck perineal trauma during vaginal delivery with 60–70% of mobility on ultrasound predisposed to postnatal incon- these women requiring suturing [53]. Perineal discomfort tinence, however the specificity of this test does not allow and pain in the days after a vaginal delivery is common. this technique to be clinically useful [46]. Abraham et al. showed that perineal pain may persist up to 6 Wilson et al. studied a population of around 7800 women months after vaginal delivery (range 0–6 months), 20% for 6 years after delivery. They found that 27% of women experiencing discomfort for more than 2 months [54]. It took who were incontinent at 3 months postnatal were continent up to 3 months (range 1–12 months) for women to have at 6 years follow-up. Conversely 32% of women who were without discomfort. Twenty percent of continent at 3 months postnatal had developed urinary women took longer than 6 months before sexual intercourse incontinence after 6 years. They found the biggest predictor became comfortable. Factors associated with prolonged of stress incontinence at 6 years postpartum was the perineal discomfort and pain, are also associated with presence of stress incontinence prior to pregnancy. increased perineal trauma at the time of delivery such as the Caesarean section only appeared to be partially protective use of forceps and vaginal (not perineal) tearing. Disruption 6 years after delivery. For women who had two or three of the internal and external anal sphincters can lead to short caesarean sections the group found the prevalence of urinary and long term anal and faecal incontinence in up to 10% of incontinence after 6 years was 32% compared with 46% in women after vaginal delivery, especially if not recognised women who had a vaginal delivery. Mode of vaginal delivery and corrected at primary repair [55–57]. (spontaneous, ventouse or forceps) did not influence outcome. The group estimated they would have to perform 6.2. Pathophysiology and prevention of perineal damage seven caesarean sections to prevent one woman from being incontinent which would not be economically or ethically Studies have also shown a relationship between perineal viable [47]. pain and the extent of perineal disruption [58,53]. The aim of the attending obstetrician/midwife should therefore be to 5.2. Pelvic floor exercises minimise the degree of perineal trauma during vaginal delivery. Guarding the perineum and applying pressure to Perhaps a more appropriate form of prevention is the fetal head during normal vaginal delivery causes less antenatal pelvic floor exercises, as they are less invasive post-partum pain than if the midwife keeps her poised, and have less morbidity and mortality compared with not touching the head or perineum [59]. Two recent large caesarean section. Properly performed pelvic floor exercises retrospective studies have identified major risk factors for have been shown to be effective in the treatment of perineal trauma and anal sphincter disruption during established urodynamic stress incontinence as well as delivery. One reviewed the case notes of 2078 vaginal reduce the incidence of short and longterm incontinence deliveries over a 2-year period examining maternal age, 20 C. Phillips, A. Monga / Reviews in Gynaecological Practice 5 (2005) 15–22 race, weight, gestational age, parity, smoking, duration of Inadequate repair of an episiotomy or vaginal tear can first and second stage of labour, oxytocin usage, method of also lead to longstanding perineal discomfort and dyspar- delivery (spontaneous, vacuum, forceps), infant eunia, and so attention to anatomy and good surgical weight, epidural usage and midline episiotomy [60]. technique is important. The type of suture material used, Nulliparity and forceps delivery were recognised as risk surgical technique and skill of operator are the three major factors for perineal and anal sphincter injury [61]. A further factors that influence outcome after primary repair [72]. study looked at a database of 91,206 over a 10-year However, training of midwives and doctors in perineal period. Again nulliparity and forceps delivery were major anatomy appears to be poor with a minority of doctors and risk factors for perineal laceration (RR 6.97 and 5.69, midwives aware of the structures cut whilst performing an respectively). Occiput posterior position, second stage episiotomy [56]. Immediate complications also include >120 min, delivery by an obstetrician, episiotomy and haemorrhage, infection and wound dehiscence, whilst long greater than 3000 g were secondary risk factors. term complications include perineal pain and dyspareunia. Assisted vaginal delivery using vacuum extraction causes The Royal College of Obstetricans and Gynaecologists significantly less perineal trauma than forceps as well less recommend the use of an absorbable suture such as vicryl (or disruption to anal sphincter function [62,63]. Two large vicryl rapide) or dexon for perineal repair rather than catgut randomised controlled trials have shown that antenatal as they are associated with less perineal pain, analgesia used perineal massage may have some benefit in reducing the and wound dehiscence and that the repair should be in three incidence of second and third degree tears, episiotomy or layers using a loose non-locking technique for the vaginal instrumental delivery, particularly in nulliparous women tissues and perineal body and a subcuticular technique for aged 30 years and above [64,65]. the skin [72]. Two randomised controlled trials showed that a two-stage perineal repair leaving the skin unsutured 6.3. The role of episiotomy significantly reduces pain and dyspareunia 3 months after delivery compared with the traditional three stage closure, Historically, it was believed that episiotomy reduces with no increase in dehiscence after two stage repair [73,74]. perineal injury and anal sphincter tears by controlling the plane and extent of tissue damage. However, there is increasing evidence to suggest that elective episiotomy may 7. Conclusions not protect the perineum from trauma [66,67]. Median episiotomy, as practised in some countries such as the United Pregnancy and childbirth have a significant impact on the States, is associated with a weaker pelvic floor and a greater development of prolapse and urinary symptoms both during incidence of tears involving the anal sphincter [60].In pregnancy and long term. Risk factors can be identified but as addition spontaneous perineal tears are associated with less yet there are no clinical scoring systems in use to detect perineal pain and normal neuromuscular function on women at risk of long term postpartum symptoms. electromyography [68]. Mediolateral episiotomy, as prac- Prophylactic caesarean section does not represent a viable tised in the United Kingdom, should only be used alternative due to its increased morbidity and mortality selectively. In a study published in the Lancet, 1555 compared with vaginal delivery, as well as the significant cost nulliparous and 1051 primiparous women undergoing implications. Properly trained antenatal pelvic floor exercises vaginal delivery were randomised to selective or routine may help reduce the incidence of postpartum stress mediolateral episiotomy [69]. Episiotomy was performed in incontinence but are less useful in the treatment of established 30.1% of women in the selective group and 82.6% of women prolapse. Major risk factors associated with the development allocated to receiving routine episiotomy. Although anterior of perineal trauma are nulliparity and forceps delivery. Other perineal trauma was slightly increased in the selective group, secondary factors include length of second stage, macro- posterior perineal surgical repair, perineal pain, healing somia, degree of perineal trauma and the adequacy of the complications and dehiscence were all less frequent in primary repair. Every attempt should therefore be made by the women receiving selective mediolateral episiotomy. One clinicians at delivery to reduce duration of second stage and study has shown that nulliparous women have a higher risk perineal trauma as well as ensuring they are properly skilled in of developing a third degree perineal laceration and that performing the primary repair. mediolateral episiotomy may prevent anal sphincter tears in these women, especially if other risk factors such as high birthweight and epidural analgesia were present [70].A 8. Practice points prospective survey of practice by obstetricians and midwives suggests obstetricians perform larger which are Prolapse and incontinence angled further from the sagittal plane than midwifery practice [71]. Such differences in practice need to assessed  Support of the pelvic floor and continence mechanisms by prospective observational studies along with association require a muscular component with an intact nerve supply with outcome. and fascial connections. C. Phillips, A. Monga / Reviews in Gynaecological Practice 5 (2005) 15–22 21

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