Case 20-2004 — A 46-Year-Old Woman with Pelvic-Floor Relaxation after a Second Vaginal Delivery
http://www.100md.com
《新英格兰医药杂志》
Presentation of Case
A 46-year-old woman was admitted to the hospital because of pelvic discomfort and urinary symptoms.
The patient had been well until 10 months earlier, when she had experienced the rapid but otherwise uncomplicated vaginal delivery of her second child. A second-degree laceration (a tear in the vaginal mucosa that did not include the anal sphincter) had occurred and had been repaired. At her six-week, postpartum examination, she told her physician that she had a vaginal bulge.
On initial evaluation, the patient said she had no urinary or bowel symptoms. A physical examination revealed a third-degree cystocele (in which the anterior vaginal wall bulges beyond the level of the hymenal ring), a second-degree rectocele (in which the posterior vaginal wall bulges to the level of the hymen), and first-to-second-degree uterine prolapse (in which the uterus extends three quarters of the way down to the level of the hymenal ring). A pessary was fitted, and the woman was instructed in Kegel exercises (in which the pelvic muscles are contracted in an attempt to strengthen the pelvic floor). During the next four months, the pelvic discomfort worsened, and the patient could see the cervix protruding at the introitus. She reported urinary frequency (12 or more times daily), urgency, leaking, a slow urinary stream, and a sense of incomplete bladder emptying. She returned to her physician for further evaluation. A physical examination disclosed second-degree uterine prolapse and persistent cystocele and rectocele. The woman was admitted to the hospital. Two months before admission, urodynamic testing had been done (Table 1). There was no detrusor instability, stress urinary incontinence, or intrinsic sphincter deficiency.
Table 1. Results of Urodynamic Testing.
The patient was gravida 4, para 2 and had had two spontaneous abortions. Her first full-term pregnancy with a vaginal delivery had been three and a half years earlier and had been complicated by a second-degree laceration. The second full-term pregnancy had been complicated by cholestasis of pregnancy. Tubal ligation was performed immediately after delivery. She did not smoke and drank alcohol socially. There was no family history of uterine prolapse or urinary or fecal incontinence.
The blood pressure was 82/60 mm Hg, the heart rate 64 beats per minute, her height 155 cm, and her weight 50 kg. A general physical examination showed no abnormalities. On vaginal examination, the cystocele and rectocele were unchanged, and third-degree uterine prolapse was apparent, with the uterine cervix protruding through the hymenal ring (Figure 1). Slight cervical erosion from extravaginal exposure was present. The introitus was multiparous and had scars from the previous obstetrical lacerations. The uterus was mobile, nontender, and at the upper limits of normal size. The adnexa were normal on palpation. Rectovaginal examination confirmed these findings.
Figure 1. Photograph of the Perineum on Admission.
There is third-degree uterine prolapse, with the cervix protruding through the hymenal ring.
A therapeutic procedure was performed.
Differential Diagnosis
Dr. Lori R. Berkowitz: This patient had pelvic pressure, a vaginal bulge, and urinary symptoms. On examination, there was evidence of pelvic-floor relaxation, with moderate uterine prolapse and both cystocele and rectocele. A woman with symptomatic pelvic-organ prolapse after a vaginal delivery is hardly extraordinary. This case illustrates one extreme of a condition that is more common than many think. In our aging society, people with symptoms of prolapse and incontinence will become increasingly familiar as patients. A population-based survey of people between the ages of 15 and 97 years revealed that 46 percent of women and 11 percent of men have pelvic-floor dysfunction.1 A woman has an 11 percent lifetime risk of undergoing surgery for incontinence, pelvic-organ prolapse, or both by 80 years of age.2
To take care of this patient, I needed first to understand what anatomic conditions were contributing to her discomfort. Since problems in the various compartments — anterior (urinary incontinence), middle (uterine prolapse), and posterior (fecal incontinence) — frequently coexist, it is useful for understanding and managing a case such as this to review the normal mechanisms of support in each compartment, the effects of pregnancy on these mechanisms, and the types of dysfunction that typically cause symptoms.
Support for the pelvic organs derives from a complex interplay among the bony pelvis, pelvic musculature, connective tissue (endopelvic fascia), and nerves. The levator ani muscles — the pubococcygeus, iliococcygeus, and puborectalis — act as a shelf, with the puborectalis and pubococcygeus muscles forming a sling that encircles the pelvic viscera at the urogenital hiatus (Figure 2). The constant basal tone of the levator ani maintains the closure of the urogenital hiatus; continence is maintained both by the levator ani and by the urethral and anal sphincters. The pudendal nerve (sacral nerve roots S2, S3, and S4) innervates the external anal sphincter and the urethral sphincter; the anterior sacral nerve roots of S2, S3, and S4 innervate the levator plate.
Figure 2. Supporting Structures of the Pelvis.
The levator ani muscles — the pubococcygeus, iliococcygeus, and puborectalis — act as a shelf, and the puborectalis and pubococcygeus form a sling that encircles the pelvic viscera at the urogenital hiatus. Continence is maintained by the basal tone of the levator ani muscles and the urethral and anal sphincters.
Prolapse is defined as the abnormal location of pelvic organs. In an observational study of 497 women presenting for routine gynecologic care,3 more than half were found to have moderate-to-severe uterine prolapse. Urinary incontinence is defined as the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem.4 Most cases can be categorized as either stress, urge, or mixed urinary incontinence. Stress incontinence — the loss of urine during physical activity — is the most common type and is caused by a loss of anatomical support of the vesicourethral junction, deficiency of the urethral sphincter, or both. Urge incontinence is the loss of urine associated with a strong desire to void and is caused by overactivity of smooth muscles in the bladder wall, a condition known as detrusor instability. Urinary incontinence is reported in 35 percent of women and 4 percent of men; in the United States, it is estimated to affect 10 million adults5 and to cost more than $31 billion per year.6 Fecal incontinence, defined as the involuntary loss of flatus or feces, is present in an estimated 4 percent of women and 2 percent of men.1
Pelvic-floor dysfunction can have both mechanical and neurologic components. The pelvic connective tissues in women with pelvic-organ prolapse or urinary incontinence contain decreased collagen and have greater collagen turnover than women without prolapse.7,8 The pudendal nerve is susceptible to both compression and traction injury during childbirth, and evidence of nerve injury has been found in women with pelvic-floor dysfunction.9
The Roles of Pregnancy and Delivery in Pelvic-Floor Dysfunction
How did this patient's pregnancies contribute to her problems? The effect of delivery on the development of pelvic-floor dysfunction has been receiving increasing attention, leading some to wonder whether elective delivery by cesarean section should be offered to minimize this risk. The evidence that links pregnancy and the route of delivery with prolapse and incontinence is mixed, however.
Pelvic-Organ Prolapse
This patient's main problem was uterine prolapse. There is evidence that the nature of pelvic-organ support changes during pregnancy, regardless of the route of delivery. In one study, 58 percent of women who had delivered vaginally, 43 percent of women who had had a cesarean delivery, and 12 percent of nulliparous women noted some form of pelvic-floor dysfunction.10 A case–control study comparing women in the second or third trimester of pregnancy with nonpregnant, nulliparous women found that 47 percent of the pregnant patients had some degree of uterine prolapse, and the nonpregnant group had none.11 A recent study12 compared the incidence and progression of prolapse between women who delivered vaginally and those who underwent cesarean section after the onset of labor. There was little difference in the incidence of new or worsened prolapse between the two groups, with new prolapse present in 32 percent of patients undergoing vaginal delivery and in 35 percent of women undergoing cesarean delivery and worsened prolapse present in 17 percent and 8 percent, respectively.
Urinary Incontinence
This patient said she had urinary frequency, with a slowed stream and a feeling of incomplete emptying. Her examination showed both cystocele and rectocele. However, urodynamic testing revealed no evidence of detrusor dysfunction or true stress incontinence, and it is therefore likely that her symptoms resulted from mechanical obstruction from the prolapse.13
Although this patient did not have stress urinary incontinence, vaginal delivery has long been implicated in the development of this condition. According to two studies,14,15 an urgent need to urinate occurred in 22 percent and 62 percent of pregnant women; 8 percent and 18 percent of pregnant women, respectively, had urge incontinence or urodynamic evidence of detrusor instability. Detrusor instability occurs in only 0.5 percent of nonpregnant women. Prospective studies have shown that the number of episodes of incontinence peak in the third trimester and decrease during the postpartum period, although not to prepregnancy levels.16 In a study of 305 primiparous patients, urinary incontinence appeared before, during, or after pregnancy in 4 percent, 32 percent, and 7 percent, respectively.17 Of the women with incontinence, only 3 percent remained incontinent one year after delivery; however, 24 percent of those who had postpartum incontinence had persistent incontinence. Thus, stress incontinence that develops during pregnancy usually resolves, whereas incontinence that develops after delivery is more likely to persist, suggesting that it may be caused by nerve injury; however, postpartum incontinence affected only 2 percent of the patients in the study.
There is evidence that stress incontinence is due to pregnancy itself, rather than to vaginal delivery.18,19 In a survey of 1505 women at three months post partum,18 the prevalence of incontinence was higher in those who had given birth vaginally rather than by cesarean section (24 percent vs. 5.2 percent); however, after a woman had had three or more deliveries by cesarean section, the rate of incontinence was 37.7 percent, similar to the rate after three vaginal deliveries. An evaluation of the prevalence of urinary incontinence in menopausal women found the condition to be five times more prevalent in women who had had one or more vaginal deliveries and three and a half times more common in women who had undergone cesarean delivery than it was in nulligravid, postmenopausal women.10 A recent study showed that women who had had a vaginal delivery had only a slightly greater risk of stress incontinence than women who had delivered by cesarean section (relative risk, 1.7 and 1.5, respectively, as compared with the risk in nulliparous women); this difference disappeared in patients in all groups who were older than 50 years of age.20
It is also important to recognize that incontinence increases with age even in nulliparous women20; in a survey of 149 postmenopausal nuns, the distribution of urinary incontinence was similar to that in parous women, with no difference in the ratio of stress incontinence to urge incontinence, as would be expected if childbearing were the main risk factor for the subsequent development of stress urinary incontinence.21 Thus, pregnancy and delivery apparently cannot explain the majority of cases of incontinence in women.
Fecal Incontinence
This patient did not report loss of flatus or stool, but fecal incontinence is experienced by an estimated 6 to 16 percent of women, of whom only 20 percent report it to a health care provider.22 Vaginal delivery appears to be responsible for fecal incontinence, through a combination of compression and stretch injury to the pudendal nerve and disruption of the anal sphincter.23,24 Tears involving the rectal sphincter and mucosa (third- and fourth-degree lacerations, respectively) occur in 1 to 5 percent of vaginal deliveries and place a woman at increased risk for fecal incontinence24,25; most studies implicate the use of forceps and episiotomy.26
In summary, this patient had pelvic-floor dysfunction with third-degree uterine prolapse with both cystocele and rectocele but no evidence of urinary or fecal incontinence. It is difficult to say why she had such extreme pelvic-organ prolapse and why it continued to worsen over a short period of time. Advanced maternal age is an identified risk factor,27,28 but the duration of the second stage of labor, a commonly cited risk factor, was clearly not an issue in this patient, who had had a rapid vaginal delivery. A meta-analysis of obstetrical interventions showed that a reduction of pelvic-floor injuries could be achieved by limiting the use of forceps deliveries, episiotomies, and the length of time allotted to pushing in second-stage labor.26,29 A review of her obstetric care does not highlight any risk factors for pelvic-floor dysfunction.
Discussion of Management
What should be the approach to a woman with this condition?
When a patient has evidence of postpartum pelvic-floor relaxation, an important part of her initial care is reassuring her that most cases resolve within weeks or months after delivery. In the 19th century, Velpeau observed, "The descent of the womb, which is pretty often met with in the early periods of a confinement, in women who make improper exertions, scarcely requires anything after the reduction except rest and a horizontal posture; it is allowable only to add some astringent or syptic lotions, the use of small rags moistened with red wine."30 Studies indicate that 60 percent of women will recover some pudendal-nerve function; moreover, unilateral injury may be compensated for by reinnervation from the contralateral nerve. These factors likely lead to the improvement in pelvic support and continence that is often seen in the initial months after delivery.31,32
Conservative Management
When this patient presented at six weeks post partum, I initially recommended a pessary for relief of the prolapse and instructed her in Kegel exercises to strengthen the levator ani. Conservative management of pelvic-floor relaxation with a pessary may afford symptomatic relief and does not appear to have deleterious effects. In fact, if pelvic-floor descent is resulting in stretching of the pudendal nerve, pessary use may relieve traction neuropathy and lead to improved levator ani function.23
Kegel exercises have been shown to reduce postpartum stress incontinence, but not fecal incontinence or prolapse, when practiced by primiparous women after giving birth.33,34 A randomized, controlled trial35 showed that weekly, 20-minute sessions of group training in Kegel exercises decreased the number of episodes of incontinence by 50 percent, regardless of the type of incontinence. At six months, 88 percent of the women who had the training reported some degree of improvement, further demonstrating this method to be a highly effective, low-cost, low-effort, first-line intervention in the management of pelvic-floor dysfunction. Sixty-six percent of the women who had initial improvement with Kegel exercises were found to have continued improvement at a 10-year follow-up assessment.36
Despite conservative measures, however, this patient's prolapse problems worsened over time, which caused her considerable distress.
Surgical Management
The next issue to consider in this patient is the potential of surgical management for her condition. The type of operation will depend on her plans for future childbearing. What are the options for a woman with symptomatic pelvic-floor dysfunction who has not completed childbearing? Long-term, conservative management with a pessary is not optimal treatment for pelvic-organ prolapse in a young patient. Uterine suspensions have been performed with varying degrees of success, and subsequent pregnancies have been described. A survey of urogynecologists showed that 59 percent of respondents would perform a uterine suspension for a patient with stress incontinence before the completion of childbearing, with most recommending cesarean delivery for any future pregnancies.29
The patient under discussion had completed her childbearing and desired surgical correction. Because of her voiding symptoms, preoperative urodynamic testing was undertaken to confirm that there was no detrusor dysfunction, as well as to rule out occult stress incontinence, which can be present in up to 25 percent of patients with pelvic-organ prolapse. I performed a total vaginal hysterectomy with anterior and posterior colporrhaphy and uterosacral-ligament fixation of the vaginal vault (Figure 3). She did well postoperatively and has had complete resolution of her symptoms.
Figure 3. Photograph of the Perineum after Surgery.
The uterus has been removed, and the cystocele and rectocele have been repaired.
Prevention of Pelvic-Floor Dysfunction
This patient and many others, as well as many health care providers, may well ask: Why do providers allow vaginal births to happen at all? Clearly, there is good evidence to link vaginal delivery with the development of fecal incontinence, which is a potentially devastating condition but one that occurs rarely. The role of vaginal delivery in the development of urinary incontinence and symptomatic uterine prolapse is less clear. Against any protective effects of cesarean section, one must balance the risks of this procedure, which may include infection, thromboembolic events, hemorrhage, cystotomy, placenta previa, and placenta accreta. Many women who have had one cesarean delivery will choose or be advised to have cesarean delivery for any subsequent pregnancies; morbidity rises dramatically with the increasing number of such deliveries. Nonetheless, a survey found that 31 percent of female obstetricians would elect a cesarean delivery for their own uncomplicated pregnancy, with 80 percent citing fear of pelvic-floor injury as the reason.37
Since cesarean delivery is not without risk and since the incidence of pelvic-floor dysfunction in women undergoing cesarean delivery is not zero, further study to identify women most at risk for permanent pelvic-floor dysfunction would facilitate informed decision making. Until large trials support the abandonment of any one obstetric intervention and the adoption of another, however, providers need to continue thoughtful practice and attempt to do no harm.20
Dr. Arlan F. Fuller (Obstetrics and Gynecology): Are these problems more common among women who have had episiotomies?
Dr. Berkowitz: Since the 1980s, critical evaluations of routine episiotomy have shown that this practice is not protective of the pelvic floor, as was claimed in the 1920s, when its routine use was first advocated. The association between routine episiotomy and the increased incidence of severe obstetrical lacerations has been well described; the procedure does not protect the muscle strength of the pelvic floor and may weaken it.38,39,40
A Physician: How do you answer when a pregnant woman in your care asks for an elective primary cesarean section?
Dr. Berkowitz: I first need to understand the reason she is making the request. The data do not suggest that choosing to deliver by cesarean section will be wholly protective against pelvic-floor relaxation or urinary incontinence. Giving her access to this information may influence her decision to undergo surgery, if she has asked for that reason alone. The risk of anal dysfunction after vaginal birth is more difficult to counter with data, although I would certainly emphasize to her that this devastating injury is quite rare. It is also worth evaluating the specific clinical scenario: a 37-year-old woman who would like one or two children may not face the same obstetrical risks as a 22-year-old woman who wants a larger family. Of paramount importance to the discussion are the implications of elective repeated cesarean sections, which will probably place the patient at far greater risk for complications than will a potential procedure for stress incontinence sometime down the road.
Dr. Fuller: Are there ethnic or genetic risk factors for uterine prolapse?
Dr. Berkowitz: There are no defined ethnic predispositions.12,41 Neither the presence of a family history of incontinence, prolapse, or collagen disorders nor the presence of abdominal striae, hernias, varicose veins, or joint hyperextensibility was found to have predictive value.14
Dr. Michael F. Greene (Obstetrics and Gynecology): What is the chance that 20 or 30 years after total vaginal hysterectomy with repairs a patient such as this will have incontinence or vaginal vault prolapse?
Dr. Berkowitz: The risk of recurrence of prolapse is about 10 to 15 percent.42,43
Dr. May Wakamatsu (Obstetrics and Gynecology): Given the data, why are episiotomies still performed?
Dr. Greene: Generally, an episiotomy is performed because in the estimation of the provider, after assessing the anatomy, the length of the perineal body, and other factors, there will be more extensive and severe laceration in the absence of an episiotomy than if one is performed. To date, trials that have compared routine episiotomy and selective episiotomy have clearly demonstrated that routine episiotomy is associated with a higher incidence of third- and fourth-degree lacerations. However, episiotomy in selected cases for appropriate indications is clearly not proscribed.
Anatomical Diagnosis
Uterine prolapse, cystocele, and rectocele.
Source Information
From the Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School.
References
MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000;107:1460-1470.
Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-506.
Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 2000;183:277-285.
Abrams P, Blaivas JG, Stanton SL, Andersen JT. The standardisation of terminology of lower urinary tract function. Scand J Urol Nephrol Suppl 1988;114:5-19.
Herzog AR, Fultz NH. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990;38:273-281.
Allen RE, Hosker GL, Smith ARB, Warrell DW. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 1990;97:770-779.
Chen BH, Wen Y, Li H, Polan ML. Collagen metabolism and turnover in women with stress urinary incontinence and pelvic prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:80-87.
Goh JTW. Biomechanical properties of prolapsed vaginal tissue in pre- and postmenopausal women. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:76-79.
Gilpin SA, Gosling JA, Smith ARB, Warrell DW. The pathogenesis of genitourinary prolapse and stress incontinence of urine: a histological and histochemical study. Br J Obstet Gynaecol 1989;96:15-23.
Faundes A, Guarisi T, Pinto-Neto AM. The risk of urinary incontinence of parous women who delivered only by cesarean section. Int J Gynaecol Obstet 2001;72:41-46.
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-17.
Sze EHM, Sherard GB III, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol 2002;100:981-986.
Dietz HP, Haylen BT, Vancaillie TG. Female pelvic organ prolapse and voiding function. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:284-288.
Chaliha C, Kalia V, Stanton SL, Monga A, Sultan AH. Antenatal prediction of postpartum urinary and fecal incontinence. Obstet Gynecol 1999;94:689-694.
Chaliha C, Bland JM, Monga A, Stanton SL, Sultan AH. Pregnancy, childbirth, and delivery: a urodynamic viewpoint. BJOG 2000;107:1354-1359.
Thorp JM Jr, Norton PA, Wall LL, Kuller JA, Eucker B, Wells E. Urinary incontinence in pregnancy and the puerperium: a prospective study. Am J Obstet Gynecol 1999;181:266-273.
Viktrup L, Lose G, Rolff M, Barfoed K. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol 1992;79:945-949.
Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol 1996;103:154-161.
Iosif CS, Ingemarsson I. Prevalence of stress incontinence among women delivered by elective cesarian section. Int J Gynaecol Obstet 1982;20:87-89.
Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med 2003;348:900-907.
Buchsbaum GM, Chin M, Glantz C, Guzick D. Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol 1997;76:324-331.
Faltin DL, Sangalli MR, Curtin F, Morabia A, Weil A. Prevalence of anal incontinence and other anorectal symptoms in women. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:117-121.
Snooks SJ, Swash M, Mathers SE, Henry MM. Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg 1990;77:1358-1360.
Tetzschner T, Sorensen M, Jonsson L, Lose G, Christiansen J. Delivery and pudendal nerve function. Acta Obstet Gynecol Scand 1997;76:324-331.
Kammerer-Doak DN, Wesol AB, Rogers RG, Dominguez CE, Dorin MH. A prospective cohort study of women after primary repair of obstetric anal sphincter laceration. Am J Obstet Gynecol 1999;181:1317-1322.
Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 2000;95:464-471.
Foldspang A, Mommsen S, Djurhuus JC. Prevalent urinary incontinence as a correlate of pregnancy, vaginal childbirth, and obstetric techniques. Am J Public Health 1999;89:209-212.
Foldspang A, Mommsen S, Lam GW, Elving L. Parity as a correlate of adult female urinary incontinence prevalence. J Epidemiol Community Health 1992;46:595-600.
Davila GW, Ghoniem GM, Kapoor DS, Contreras-Ortiz O. Pelvic floor dysfunction management practice patterns: a survey of members of the International Urogynecological Association. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:319-325.
Velpeau AALM. An elementary treatise on midwifery: or principles of tokology and embryology. Philadelphia: J. Grigg, 1831.
Snooks SJ, Setchell M, Swash M, Henry MM. Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet 1984;2:546-550.
Peschers UM, Schaer GN, DeLancey JOL, Schuessler B. Levator ani function before and after childbirth. Br J Obstet Gynaecol 1997;104:1004-1008.
Meyer L, Hohlfeld P, Achtari C, De Grandi P. Pelvic floor education after vaginal delivery. Obstet Gynecol 2001;97:673-677.
Sampselle CM, Miler JM, Mims BL, DeLancey JOL, Ashton-Miller JA, Antonakos CL. Effect of pelvic muscle exercise on transient incontinence during pregnancy and after birth. Obstet Gynecol 1998;91:406-412.
Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The effect of behavioral therapy on urinary incontinence: a randomized controlled trial. Obstet Gynecol 2002;100:72-78.
Cammu H, Van Nylen M, Amy JJ. A 10-year follow-up after Kegel pelvic floor muscle exercises for genuine stress incontinence. BJU Int 2000;85:655-658.
Al-Mufti R, McCarthy A, Fisk NM. Obstetricians' personal choice and mode of delivery. Lancet 1996;347:544-544.
Combs CA, Robertson PA, Laros RK Jr. Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries. Am J Obstet Gynecol 1990;163:100-104.
Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol 1990;75:765-770.
Rockner G, Jonasson A, Olund A. The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991;70:51-54.
Sampselle CM, Harlow SD, Skurnick J, Brubaker L, Bondarenko I. Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Obstet Gynecol 2002;100:1230-1238.
Sze EHM, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997;89:466-475.
Lovatsis D, Drutz HP. Safety and efficacy of sacrospinous vault suspension. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:308-313.(Lori R. Berkowitz, M.D.)
A 46-year-old woman was admitted to the hospital because of pelvic discomfort and urinary symptoms.
The patient had been well until 10 months earlier, when she had experienced the rapid but otherwise uncomplicated vaginal delivery of her second child. A second-degree laceration (a tear in the vaginal mucosa that did not include the anal sphincter) had occurred and had been repaired. At her six-week, postpartum examination, she told her physician that she had a vaginal bulge.
On initial evaluation, the patient said she had no urinary or bowel symptoms. A physical examination revealed a third-degree cystocele (in which the anterior vaginal wall bulges beyond the level of the hymenal ring), a second-degree rectocele (in which the posterior vaginal wall bulges to the level of the hymen), and first-to-second-degree uterine prolapse (in which the uterus extends three quarters of the way down to the level of the hymenal ring). A pessary was fitted, and the woman was instructed in Kegel exercises (in which the pelvic muscles are contracted in an attempt to strengthen the pelvic floor). During the next four months, the pelvic discomfort worsened, and the patient could see the cervix protruding at the introitus. She reported urinary frequency (12 or more times daily), urgency, leaking, a slow urinary stream, and a sense of incomplete bladder emptying. She returned to her physician for further evaluation. A physical examination disclosed second-degree uterine prolapse and persistent cystocele and rectocele. The woman was admitted to the hospital. Two months before admission, urodynamic testing had been done (Table 1). There was no detrusor instability, stress urinary incontinence, or intrinsic sphincter deficiency.
Table 1. Results of Urodynamic Testing.
The patient was gravida 4, para 2 and had had two spontaneous abortions. Her first full-term pregnancy with a vaginal delivery had been three and a half years earlier and had been complicated by a second-degree laceration. The second full-term pregnancy had been complicated by cholestasis of pregnancy. Tubal ligation was performed immediately after delivery. She did not smoke and drank alcohol socially. There was no family history of uterine prolapse or urinary or fecal incontinence.
The blood pressure was 82/60 mm Hg, the heart rate 64 beats per minute, her height 155 cm, and her weight 50 kg. A general physical examination showed no abnormalities. On vaginal examination, the cystocele and rectocele were unchanged, and third-degree uterine prolapse was apparent, with the uterine cervix protruding through the hymenal ring (Figure 1). Slight cervical erosion from extravaginal exposure was present. The introitus was multiparous and had scars from the previous obstetrical lacerations. The uterus was mobile, nontender, and at the upper limits of normal size. The adnexa were normal on palpation. Rectovaginal examination confirmed these findings.
Figure 1. Photograph of the Perineum on Admission.
There is third-degree uterine prolapse, with the cervix protruding through the hymenal ring.
A therapeutic procedure was performed.
Differential Diagnosis
Dr. Lori R. Berkowitz: This patient had pelvic pressure, a vaginal bulge, and urinary symptoms. On examination, there was evidence of pelvic-floor relaxation, with moderate uterine prolapse and both cystocele and rectocele. A woman with symptomatic pelvic-organ prolapse after a vaginal delivery is hardly extraordinary. This case illustrates one extreme of a condition that is more common than many think. In our aging society, people with symptoms of prolapse and incontinence will become increasingly familiar as patients. A population-based survey of people between the ages of 15 and 97 years revealed that 46 percent of women and 11 percent of men have pelvic-floor dysfunction.1 A woman has an 11 percent lifetime risk of undergoing surgery for incontinence, pelvic-organ prolapse, or both by 80 years of age.2
To take care of this patient, I needed first to understand what anatomic conditions were contributing to her discomfort. Since problems in the various compartments — anterior (urinary incontinence), middle (uterine prolapse), and posterior (fecal incontinence) — frequently coexist, it is useful for understanding and managing a case such as this to review the normal mechanisms of support in each compartment, the effects of pregnancy on these mechanisms, and the types of dysfunction that typically cause symptoms.
Support for the pelvic organs derives from a complex interplay among the bony pelvis, pelvic musculature, connective tissue (endopelvic fascia), and nerves. The levator ani muscles — the pubococcygeus, iliococcygeus, and puborectalis — act as a shelf, with the puborectalis and pubococcygeus muscles forming a sling that encircles the pelvic viscera at the urogenital hiatus (Figure 2). The constant basal tone of the levator ani maintains the closure of the urogenital hiatus; continence is maintained both by the levator ani and by the urethral and anal sphincters. The pudendal nerve (sacral nerve roots S2, S3, and S4) innervates the external anal sphincter and the urethral sphincter; the anterior sacral nerve roots of S2, S3, and S4 innervate the levator plate.
Figure 2. Supporting Structures of the Pelvis.
The levator ani muscles — the pubococcygeus, iliococcygeus, and puborectalis — act as a shelf, and the puborectalis and pubococcygeus form a sling that encircles the pelvic viscera at the urogenital hiatus. Continence is maintained by the basal tone of the levator ani muscles and the urethral and anal sphincters.
Prolapse is defined as the abnormal location of pelvic organs. In an observational study of 497 women presenting for routine gynecologic care,3 more than half were found to have moderate-to-severe uterine prolapse. Urinary incontinence is defined as the involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem.4 Most cases can be categorized as either stress, urge, or mixed urinary incontinence. Stress incontinence — the loss of urine during physical activity — is the most common type and is caused by a loss of anatomical support of the vesicourethral junction, deficiency of the urethral sphincter, or both. Urge incontinence is the loss of urine associated with a strong desire to void and is caused by overactivity of smooth muscles in the bladder wall, a condition known as detrusor instability. Urinary incontinence is reported in 35 percent of women and 4 percent of men; in the United States, it is estimated to affect 10 million adults5 and to cost more than $31 billion per year.6 Fecal incontinence, defined as the involuntary loss of flatus or feces, is present in an estimated 4 percent of women and 2 percent of men.1
Pelvic-floor dysfunction can have both mechanical and neurologic components. The pelvic connective tissues in women with pelvic-organ prolapse or urinary incontinence contain decreased collagen and have greater collagen turnover than women without prolapse.7,8 The pudendal nerve is susceptible to both compression and traction injury during childbirth, and evidence of nerve injury has been found in women with pelvic-floor dysfunction.9
The Roles of Pregnancy and Delivery in Pelvic-Floor Dysfunction
How did this patient's pregnancies contribute to her problems? The effect of delivery on the development of pelvic-floor dysfunction has been receiving increasing attention, leading some to wonder whether elective delivery by cesarean section should be offered to minimize this risk. The evidence that links pregnancy and the route of delivery with prolapse and incontinence is mixed, however.
Pelvic-Organ Prolapse
This patient's main problem was uterine prolapse. There is evidence that the nature of pelvic-organ support changes during pregnancy, regardless of the route of delivery. In one study, 58 percent of women who had delivered vaginally, 43 percent of women who had had a cesarean delivery, and 12 percent of nulliparous women noted some form of pelvic-floor dysfunction.10 A case–control study comparing women in the second or third trimester of pregnancy with nonpregnant, nulliparous women found that 47 percent of the pregnant patients had some degree of uterine prolapse, and the nonpregnant group had none.11 A recent study12 compared the incidence and progression of prolapse between women who delivered vaginally and those who underwent cesarean section after the onset of labor. There was little difference in the incidence of new or worsened prolapse between the two groups, with new prolapse present in 32 percent of patients undergoing vaginal delivery and in 35 percent of women undergoing cesarean delivery and worsened prolapse present in 17 percent and 8 percent, respectively.
Urinary Incontinence
This patient said she had urinary frequency, with a slowed stream and a feeling of incomplete emptying. Her examination showed both cystocele and rectocele. However, urodynamic testing revealed no evidence of detrusor dysfunction or true stress incontinence, and it is therefore likely that her symptoms resulted from mechanical obstruction from the prolapse.13
Although this patient did not have stress urinary incontinence, vaginal delivery has long been implicated in the development of this condition. According to two studies,14,15 an urgent need to urinate occurred in 22 percent and 62 percent of pregnant women; 8 percent and 18 percent of pregnant women, respectively, had urge incontinence or urodynamic evidence of detrusor instability. Detrusor instability occurs in only 0.5 percent of nonpregnant women. Prospective studies have shown that the number of episodes of incontinence peak in the third trimester and decrease during the postpartum period, although not to prepregnancy levels.16 In a study of 305 primiparous patients, urinary incontinence appeared before, during, or after pregnancy in 4 percent, 32 percent, and 7 percent, respectively.17 Of the women with incontinence, only 3 percent remained incontinent one year after delivery; however, 24 percent of those who had postpartum incontinence had persistent incontinence. Thus, stress incontinence that develops during pregnancy usually resolves, whereas incontinence that develops after delivery is more likely to persist, suggesting that it may be caused by nerve injury; however, postpartum incontinence affected only 2 percent of the patients in the study.
There is evidence that stress incontinence is due to pregnancy itself, rather than to vaginal delivery.18,19 In a survey of 1505 women at three months post partum,18 the prevalence of incontinence was higher in those who had given birth vaginally rather than by cesarean section (24 percent vs. 5.2 percent); however, after a woman had had three or more deliveries by cesarean section, the rate of incontinence was 37.7 percent, similar to the rate after three vaginal deliveries. An evaluation of the prevalence of urinary incontinence in menopausal women found the condition to be five times more prevalent in women who had had one or more vaginal deliveries and three and a half times more common in women who had undergone cesarean delivery than it was in nulligravid, postmenopausal women.10 A recent study showed that women who had had a vaginal delivery had only a slightly greater risk of stress incontinence than women who had delivered by cesarean section (relative risk, 1.7 and 1.5, respectively, as compared with the risk in nulliparous women); this difference disappeared in patients in all groups who were older than 50 years of age.20
It is also important to recognize that incontinence increases with age even in nulliparous women20; in a survey of 149 postmenopausal nuns, the distribution of urinary incontinence was similar to that in parous women, with no difference in the ratio of stress incontinence to urge incontinence, as would be expected if childbearing were the main risk factor for the subsequent development of stress urinary incontinence.21 Thus, pregnancy and delivery apparently cannot explain the majority of cases of incontinence in women.
Fecal Incontinence
This patient did not report loss of flatus or stool, but fecal incontinence is experienced by an estimated 6 to 16 percent of women, of whom only 20 percent report it to a health care provider.22 Vaginal delivery appears to be responsible for fecal incontinence, through a combination of compression and stretch injury to the pudendal nerve and disruption of the anal sphincter.23,24 Tears involving the rectal sphincter and mucosa (third- and fourth-degree lacerations, respectively) occur in 1 to 5 percent of vaginal deliveries and place a woman at increased risk for fecal incontinence24,25; most studies implicate the use of forceps and episiotomy.26
In summary, this patient had pelvic-floor dysfunction with third-degree uterine prolapse with both cystocele and rectocele but no evidence of urinary or fecal incontinence. It is difficult to say why she had such extreme pelvic-organ prolapse and why it continued to worsen over a short period of time. Advanced maternal age is an identified risk factor,27,28 but the duration of the second stage of labor, a commonly cited risk factor, was clearly not an issue in this patient, who had had a rapid vaginal delivery. A meta-analysis of obstetrical interventions showed that a reduction of pelvic-floor injuries could be achieved by limiting the use of forceps deliveries, episiotomies, and the length of time allotted to pushing in second-stage labor.26,29 A review of her obstetric care does not highlight any risk factors for pelvic-floor dysfunction.
Discussion of Management
What should be the approach to a woman with this condition?
When a patient has evidence of postpartum pelvic-floor relaxation, an important part of her initial care is reassuring her that most cases resolve within weeks or months after delivery. In the 19th century, Velpeau observed, "The descent of the womb, which is pretty often met with in the early periods of a confinement, in women who make improper exertions, scarcely requires anything after the reduction except rest and a horizontal posture; it is allowable only to add some astringent or syptic lotions, the use of small rags moistened with red wine."30 Studies indicate that 60 percent of women will recover some pudendal-nerve function; moreover, unilateral injury may be compensated for by reinnervation from the contralateral nerve. These factors likely lead to the improvement in pelvic support and continence that is often seen in the initial months after delivery.31,32
Conservative Management
When this patient presented at six weeks post partum, I initially recommended a pessary for relief of the prolapse and instructed her in Kegel exercises to strengthen the levator ani. Conservative management of pelvic-floor relaxation with a pessary may afford symptomatic relief and does not appear to have deleterious effects. In fact, if pelvic-floor descent is resulting in stretching of the pudendal nerve, pessary use may relieve traction neuropathy and lead to improved levator ani function.23
Kegel exercises have been shown to reduce postpartum stress incontinence, but not fecal incontinence or prolapse, when practiced by primiparous women after giving birth.33,34 A randomized, controlled trial35 showed that weekly, 20-minute sessions of group training in Kegel exercises decreased the number of episodes of incontinence by 50 percent, regardless of the type of incontinence. At six months, 88 percent of the women who had the training reported some degree of improvement, further demonstrating this method to be a highly effective, low-cost, low-effort, first-line intervention in the management of pelvic-floor dysfunction. Sixty-six percent of the women who had initial improvement with Kegel exercises were found to have continued improvement at a 10-year follow-up assessment.36
Despite conservative measures, however, this patient's prolapse problems worsened over time, which caused her considerable distress.
Surgical Management
The next issue to consider in this patient is the potential of surgical management for her condition. The type of operation will depend on her plans for future childbearing. What are the options for a woman with symptomatic pelvic-floor dysfunction who has not completed childbearing? Long-term, conservative management with a pessary is not optimal treatment for pelvic-organ prolapse in a young patient. Uterine suspensions have been performed with varying degrees of success, and subsequent pregnancies have been described. A survey of urogynecologists showed that 59 percent of respondents would perform a uterine suspension for a patient with stress incontinence before the completion of childbearing, with most recommending cesarean delivery for any future pregnancies.29
The patient under discussion had completed her childbearing and desired surgical correction. Because of her voiding symptoms, preoperative urodynamic testing was undertaken to confirm that there was no detrusor dysfunction, as well as to rule out occult stress incontinence, which can be present in up to 25 percent of patients with pelvic-organ prolapse. I performed a total vaginal hysterectomy with anterior and posterior colporrhaphy and uterosacral-ligament fixation of the vaginal vault (Figure 3). She did well postoperatively and has had complete resolution of her symptoms.
Figure 3. Photograph of the Perineum after Surgery.
The uterus has been removed, and the cystocele and rectocele have been repaired.
Prevention of Pelvic-Floor Dysfunction
This patient and many others, as well as many health care providers, may well ask: Why do providers allow vaginal births to happen at all? Clearly, there is good evidence to link vaginal delivery with the development of fecal incontinence, which is a potentially devastating condition but one that occurs rarely. The role of vaginal delivery in the development of urinary incontinence and symptomatic uterine prolapse is less clear. Against any protective effects of cesarean section, one must balance the risks of this procedure, which may include infection, thromboembolic events, hemorrhage, cystotomy, placenta previa, and placenta accreta. Many women who have had one cesarean delivery will choose or be advised to have cesarean delivery for any subsequent pregnancies; morbidity rises dramatically with the increasing number of such deliveries. Nonetheless, a survey found that 31 percent of female obstetricians would elect a cesarean delivery for their own uncomplicated pregnancy, with 80 percent citing fear of pelvic-floor injury as the reason.37
Since cesarean delivery is not without risk and since the incidence of pelvic-floor dysfunction in women undergoing cesarean delivery is not zero, further study to identify women most at risk for permanent pelvic-floor dysfunction would facilitate informed decision making. Until large trials support the abandonment of any one obstetric intervention and the adoption of another, however, providers need to continue thoughtful practice and attempt to do no harm.20
Dr. Arlan F. Fuller (Obstetrics and Gynecology): Are these problems more common among women who have had episiotomies?
Dr. Berkowitz: Since the 1980s, critical evaluations of routine episiotomy have shown that this practice is not protective of the pelvic floor, as was claimed in the 1920s, when its routine use was first advocated. The association between routine episiotomy and the increased incidence of severe obstetrical lacerations has been well described; the procedure does not protect the muscle strength of the pelvic floor and may weaken it.38,39,40
A Physician: How do you answer when a pregnant woman in your care asks for an elective primary cesarean section?
Dr. Berkowitz: I first need to understand the reason she is making the request. The data do not suggest that choosing to deliver by cesarean section will be wholly protective against pelvic-floor relaxation or urinary incontinence. Giving her access to this information may influence her decision to undergo surgery, if she has asked for that reason alone. The risk of anal dysfunction after vaginal birth is more difficult to counter with data, although I would certainly emphasize to her that this devastating injury is quite rare. It is also worth evaluating the specific clinical scenario: a 37-year-old woman who would like one or two children may not face the same obstetrical risks as a 22-year-old woman who wants a larger family. Of paramount importance to the discussion are the implications of elective repeated cesarean sections, which will probably place the patient at far greater risk for complications than will a potential procedure for stress incontinence sometime down the road.
Dr. Fuller: Are there ethnic or genetic risk factors for uterine prolapse?
Dr. Berkowitz: There are no defined ethnic predispositions.12,41 Neither the presence of a family history of incontinence, prolapse, or collagen disorders nor the presence of abdominal striae, hernias, varicose veins, or joint hyperextensibility was found to have predictive value.14
Dr. Michael F. Greene (Obstetrics and Gynecology): What is the chance that 20 or 30 years after total vaginal hysterectomy with repairs a patient such as this will have incontinence or vaginal vault prolapse?
Dr. Berkowitz: The risk of recurrence of prolapse is about 10 to 15 percent.42,43
Dr. May Wakamatsu (Obstetrics and Gynecology): Given the data, why are episiotomies still performed?
Dr. Greene: Generally, an episiotomy is performed because in the estimation of the provider, after assessing the anatomy, the length of the perineal body, and other factors, there will be more extensive and severe laceration in the absence of an episiotomy than if one is performed. To date, trials that have compared routine episiotomy and selective episiotomy have clearly demonstrated that routine episiotomy is associated with a higher incidence of third- and fourth-degree lacerations. However, episiotomy in selected cases for appropriate indications is clearly not proscribed.
Anatomical Diagnosis
Uterine prolapse, cystocele, and rectocele.
Source Information
From the Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School.
References
MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000;107:1460-1470.
Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-506.
Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 2000;183:277-285.
Abrams P, Blaivas JG, Stanton SL, Andersen JT. The standardisation of terminology of lower urinary tract function. Scand J Urol Nephrol Suppl 1988;114:5-19.
Herzog AR, Fultz NH. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990;38:273-281.
Allen RE, Hosker GL, Smith ARB, Warrell DW. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 1990;97:770-779.
Chen BH, Wen Y, Li H, Polan ML. Collagen metabolism and turnover in women with stress urinary incontinence and pelvic prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:80-87.
Goh JTW. Biomechanical properties of prolapsed vaginal tissue in pre- and postmenopausal women. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:76-79.
Gilpin SA, Gosling JA, Smith ARB, Warrell DW. The pathogenesis of genitourinary prolapse and stress incontinence of urine: a histological and histochemical study. Br J Obstet Gynaecol 1989;96:15-23.
Faundes A, Guarisi T, Pinto-Neto AM. The risk of urinary incontinence of parous women who delivered only by cesarean section. Int J Gynaecol Obstet 2001;72:41-46.
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-17.
Sze EHM, Sherard GB III, Dolezal JM. Pregnancy, labor, delivery, and pelvic organ prolapse. Obstet Gynecol 2002;100:981-986.
Dietz HP, Haylen BT, Vancaillie TG. Female pelvic organ prolapse and voiding function. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:284-288.
Chaliha C, Kalia V, Stanton SL, Monga A, Sultan AH. Antenatal prediction of postpartum urinary and fecal incontinence. Obstet Gynecol 1999;94:689-694.
Chaliha C, Bland JM, Monga A, Stanton SL, Sultan AH. Pregnancy, childbirth, and delivery: a urodynamic viewpoint. BJOG 2000;107:1354-1359.
Thorp JM Jr, Norton PA, Wall LL, Kuller JA, Eucker B, Wells E. Urinary incontinence in pregnancy and the puerperium: a prospective study. Am J Obstet Gynecol 1999;181:266-273.
Viktrup L, Lose G, Rolff M, Barfoed K. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol 1992;79:945-949.
Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol 1996;103:154-161.
Iosif CS, Ingemarsson I. Prevalence of stress incontinence among women delivered by elective cesarian section. Int J Gynaecol Obstet 1982;20:87-89.
Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med 2003;348:900-907.
Buchsbaum GM, Chin M, Glantz C, Guzick D. Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol 1997;76:324-331.
Faltin DL, Sangalli MR, Curtin F, Morabia A, Weil A. Prevalence of anal incontinence and other anorectal symptoms in women. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:117-121.
Snooks SJ, Swash M, Mathers SE, Henry MM. Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg 1990;77:1358-1360.
Tetzschner T, Sorensen M, Jonsson L, Lose G, Christiansen J. Delivery and pudendal nerve function. Acta Obstet Gynecol Scand 1997;76:324-331.
Kammerer-Doak DN, Wesol AB, Rogers RG, Dominguez CE, Dorin MH. A prospective cohort study of women after primary repair of obstetric anal sphincter laceration. Am J Obstet Gynecol 1999;181:1317-1322.
Eason E, Labrecque M, Wells G, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol 2000;95:464-471.
Foldspang A, Mommsen S, Djurhuus JC. Prevalent urinary incontinence as a correlate of pregnancy, vaginal childbirth, and obstetric techniques. Am J Public Health 1999;89:209-212.
Foldspang A, Mommsen S, Lam GW, Elving L. Parity as a correlate of adult female urinary incontinence prevalence. J Epidemiol Community Health 1992;46:595-600.
Davila GW, Ghoniem GM, Kapoor DS, Contreras-Ortiz O. Pelvic floor dysfunction management practice patterns: a survey of members of the International Urogynecological Association. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:319-325.
Velpeau AALM. An elementary treatise on midwifery: or principles of tokology and embryology. Philadelphia: J. Grigg, 1831.
Snooks SJ, Setchell M, Swash M, Henry MM. Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet 1984;2:546-550.
Peschers UM, Schaer GN, DeLancey JOL, Schuessler B. Levator ani function before and after childbirth. Br J Obstet Gynaecol 1997;104:1004-1008.
Meyer L, Hohlfeld P, Achtari C, De Grandi P. Pelvic floor education after vaginal delivery. Obstet Gynecol 2001;97:673-677.
Sampselle CM, Miler JM, Mims BL, DeLancey JOL, Ashton-Miller JA, Antonakos CL. Effect of pelvic muscle exercise on transient incontinence during pregnancy and after birth. Obstet Gynecol 1998;91:406-412.
Subak LL, Quesenberry CP, Posner SF, Cattolica E, Soghikian K. The effect of behavioral therapy on urinary incontinence: a randomized controlled trial. Obstet Gynecol 2002;100:72-78.
Cammu H, Van Nylen M, Amy JJ. A 10-year follow-up after Kegel pelvic floor muscle exercises for genuine stress incontinence. BJU Int 2000;85:655-658.
Al-Mufti R, McCarthy A, Fisk NM. Obstetricians' personal choice and mode of delivery. Lancet 1996;347:544-544.
Combs CA, Robertson PA, Laros RK Jr. Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries. Am J Obstet Gynecol 1990;163:100-104.
Shiono P, Klebanoff MA, Carey JC. Midline episiotomies: more harm than good? Obstet Gynecol 1990;75:765-770.
Rockner G, Jonasson A, Olund A. The effect of mediolateral episiotomy at delivery on pelvic floor muscle strength evaluated with vaginal cones. Acta Obstet Gynecol Scand 1991;70:51-54.
Sampselle CM, Harlow SD, Skurnick J, Brubaker L, Bondarenko I. Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women. Obstet Gynecol 2002;100:1230-1238.
Sze EHM, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997;89:466-475.
Lovatsis D, Drutz HP. Safety and efficacy of sacrospinous vault suspension. Int Urogynecol J Pelvic Floor Dysfunct 2002;13:308-313.(Lori R. Berkowitz, M.D.)