Risk Factors of Pelvic Floor Dysfunction in Postpartum Period: a Cross-Section Study

doi:10.21203/rs.3.rs-2567990/v1

Introduction: Pelvic floor dysfunction (PFD) is most commonly dysfunctions in women, it has been reported to affect 23% to 49% of women according to an epidemiological report. PFDs have many consequences, such as pain, embarrassment, social isolation, and a decreased quality of life (QOL). Thus, this study aims to understand which factors are associated with the development of postpartum pelvic floor dysfunction and determine the degree of such dysfunctions to provide theoretical and data support for clinical diagnosis and treatment of this disorder.

Method: Puerperal women were recruited between September to November of 2021 by an online survey platform called WenjuanXing. And the demographic characteristics and PFDs related questionnaire were be collected and analyzed. Multivariate logistic regression analyses were conducted to identify the risk factors of postpartum PFDs in postpartum women.

Result: A total of 1226 participants were included, the incidence of urinary incontinence (UI), pelvic organ prolapse (POP) and anal incontinence (AI) was 79.6%, 70.7% and 67.4%, respectively. Multivariate logistic regression analyses shown that body mass index (BMI) more than 28 (OR: 2.591, 95% CI: 1.016-6.607), gestational diabetes (OR: 1.541, 95% CI: 1.011-2.348, P=0.044), prenatal incontinence (OR: 2.63, 95% CI: 0.405-0.982), vaginal delivery (OR: 1.521, 95% CI: 0.35-0.774), episiotomy (OR: 1.595, 95% CI: 1.093-2.326) were the risk factors of postpartum UI. BMI more than 28 (OR: 2.337, 95% CI: 1.086-5.029), smoking in pregnancy (OR: 1.434, 95% CI: 0.241-0.78), vaginal delivery (OR: 1.663, 95% CI: 0.473-0.93) were the risk factors of the POP, however, BMI less than 18.5(OR: 546, 95% CI: 0.337-0.885) was considered as a protective factor for POP in statistical methods. BMI less than 18.5 (OR: 0.555, 95% CI: 0.344-0.895) was only the protective factor of Colorectal-Anal Distress Inventory (CRADI).

Conclusion: According to our data, we conclude that the BMI >28, gestational diabetes, prenatal incontinence, vaginal delivery, and episiotomy are risk factors for postpartum UI. In addition to the above risk factors, smoking has also been found to be a risk factor for POP. However, we found no risk factors for AI. Additionally, we found that BMI <18.5 is a protective factor of AI and POP.

Health sciences/Risk factors

Health sciences/Urology/Urogenital diseases/Urinary incontinence

pelvic floor dysfunction

risk factor

postpartum women

urinary incontinence

pelvic organ prolapse

BMI

vaginal delivery

Pelvic floor dysfunctions (PFDs) is most commonly dysfunctions in women, and it includes various diseases, such as urinary incontinence (UI), pelvic organ prolapse (POP), anal incontinence (AI), sexual dysfunction, overactive bladders, and other symptoms related to the lower urinary tract and defecation [1, 2]. PFDs have been reported to affect 23% to 49% of women according to an epidemiological report [1]. The prevalence of PFDs increases with age and childbirth, and according to a recent study, 40%-91% of patients who have their first child report at least one or more symptoms of PFDs [2]. The patients who have PFDs, 10% have UI, 30% have anal incontinence, 30-76% POP [3], and 2-25% AI [4, 5]. PFDs and pelvic floor damage have many consequences, such as pain and a decreased quality of life (QOL), in these symptoms, AI due to embarrassment, social isolation, loss of employment, deterioration of intimate relationships, and depression [4]. POP might reduced workforce productivity, increased costs and raised financial burden upon health care systems [3], and UI will bring the distress, anxiety, loss of self-esteem, and thus affect a woman’s social, cultural, physical, psychological, marital, domestic, and sexual well-being [6].

In previous studies, researchers have discovered that certain risk factors are associated with PFDs. It is significant to note that many factors before, during, and after birth can influence the development of postpartum dysfunction. Examples include prenatal urinary incontinence, smoking during pregnancy, gestational diabetes, age, body mass index (BMI), delivery method, number of deliveries, estrogen levels, head circumference and weight of the newborn, etc [7-9]. It is, therefore, highly significant in this context to identify and understand the risk factors for postpartum PFD. This has profound effects on women's ability to function after childbirth. Recent, studies identified several risk factors contributing to PFDs, but the results of existing studies are still inadequate in terms of sample size and control and selection of risk factors and need to be supported by high-quality, large-sample data [2]. It should be noted that, to a certain extent, the current research on the risk factors of postpartum pelvic floor dysfunction focuses more on a particular prenatal or postpartum aspect and does not consider factors throughout the entire pregnancy cycle. In addition, postpartum women have been studied extensively in Europe and the United States for risk factors associated with PFD. However, due to differences in dietary habits, postpartum rehabilitation, and puerperium care of Chinese women. this may lead to different factors influencing postpartum PFD. As a result, the present study intends to comprehensively examine the impact of individual elements in all three stages of the pregnancy and delivery cycle, including the prenatal, pregnancy, and postpartum stages in Chinese women. Ultimately, this study conduct an electronic questionnaire survey among postpartum women to understand which factors are associated with the development of postpartum PFD and determine the degree of such dysfunction to Helps identify Chinese postpartum women at high risk for PFD in a timely manner, so that prevention and treatment strategies can be implemented as early as possible to reduce the burden of dysfunction in Chinese postpartum women.

Study design and Participants

This was a population-based, retrospective cross-sectional study. The patients was recruited at Sichuan Jinxin Women & Children Hospital, Chengdu between September to November of 2021. Women will be asked to complete questionnaires online, through a weblink they receive by email and WeChat (a popular social application in China). An online survey platform called WenjuanXing was used to generate the weblink for the questionnaire. The inclusion criteria of women were: at least 18 years of age, with a singleton pregnancy. The exclusion criteria was: the age more than 50 years old. In this study, we total recruited 1358 participants,132 were excluded from the analysis due to the incomplete or anomalous of questionnaires, and finally returned 1226 questionnaires, with a response rate of 90.27%.

Ethics approval and consent to participate

The feasibility of the study has been endorsed by the ethics committee of Chengdu Sport University (2022(45)). All the procedures of the study follow the Helsinki declaration for human procedures and experiments. Before subjects complete the questionnaire, the aim of the study and the procedure was described for participants, and signed informed consent was obtained for each participants for study participation. Meanwhile, we maintained anonymity by utilizing codes for identification; and no participant was harmed during the study.

Measurements

In this research, we prepared two questionnaires to collect information about women:

Women who met the inclusion criteria were asked to complete an electronic questionnaire to assess demographic characteristics including age, weight, height, body mass index (BMI) and educational background. Additionally, this questionnaire collects medical and obstetric history including protestation, pregnancy and postpartum.
As a questionnaire, the Pelvic Floor Distress Inventory (PFDI) can be used by clinicians and researchers to evaluate the amount of pain and discomfort associated with the lower urinary tract, lower digestive tract, and quality-of-life symptoms related to dysfunctions of the pelvic floor in women who suffer from PFDs [1, 10]. The questionnaire was translated into Chinese and shown to have satisfactory reliability and validity[11]. The PFDI consists of 46 questions divided into three scales, the Urinary Distress Inventory (UDI), the Pelvic Organ Prolapse Distress Inventory (POPDI), and the Colorectal-Anal Distress Inventory (CRADI). The validity and reliability of this test have been demonstrated. The PFDI-20 is a short form of the PFDI composed of 20 questions, divided into three subscales, each of which evaluates these symptoms: UDI-6, CRADI-8, and POPDI-6 [10]. It will be beneficial in a clinical research study or in any situation where it is essential to reduce the burden on participants or reduce costs. The PFDI-20 was shown to be psychologically valid and reliable in non-pregnant as well as in pregnant patients. Participants can answer either yes or no to questionnaire items. ‘No’ is given a value of ‘0’, whereas ‘yes’ will be followed by a ranking of the level of bothering on a scale between 1 and 4 (1= ‘not at all’, 2= ‘somewhat’, 3= ‘moderately’, and 4= ‘quite a bit’). The Scale Score is the mean value of all questions answered per scale multiplied by 25. Each scale (urinary distress, colorectal anal distress, and pelvic organ prolapse) may receive a maximum score of 100. The Summary Score is the sum of all three Scale Scores (range 0-300).

Statistical analysis

All collected data were calculated with SPSS X8. The continuous normally distributed variables were used as the mean and standard deviation (SD) to explain. The chi-squared test was used for formal differences between groups about dichotomous outcomes, while the t-test was used for continuous outcomes. Prevalence of self-reported PFDs and related bother were described in terms of proportions (%) and frequencies (n) for all women and stratified by mode of delivery (vaginal delivery and cesarean section). Then maternal characteristics and other obstetric outcomes with pelvic floor dysfunction stratified by the different symptoms were then examined using multiple logistic regression. The variable assignment in multivariate logistic regression was presented in (Table 1). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for estimation. p≤0.05 was considered to indicate statistical significance.

Table 1 The variable assignment in multivariate logistic regression

Factors	Variables	Assignment
POP	Y₁	Yes=1, No=2
AI	Y₂	Yes=1, No=2
UI	Y₃	Yes=1, No=2
BMI(kg/m2)	X₁	<18.5=3, 18.5-23.9=4, 24.0-27.9=2, ≥28=1
BMI before pregnancy(kg/m2)	X₂	<18.5=3, 18.5-23.9=4, 24.0-27.9=2, ≥28=1
Pregnancy weeks	X₃	28-32w=1, 33-37w=2, >42w=3, 38-42w=4
Pregnancy weight gain(kg)	X₄	≥20=1,<20=2
Pre-pregnancy pelvic floor muscle training	X₅	Yes=1, No=2
Accidental Pregnancy	X₆	Yes=1, No=2
Number of pregnancies	X₇	Three and more times=1, Twice=2, Once=3
Gestational diabetes	X₈	Yes=1, No=2
Smoking in pregnancy	X₉	Yes=1, No=2
Pelvic floor muscle training during pregnancy	X₁₀	Yes=1, No=2
Abortion history	X₁₁	Yes=1, No=2
Prenatal incontinence	X₁₂	Yes=1, No=2
Delivery method	X₁₄	Vaginal deliver=1, Cesarean sectiony=2,
Number of deliveries	X₁₅	Three and more times=1, Twice=2, Once=3
Post-operative infection	X₁₆	Yes=1, No=2
Episiotomy	X₁₇	Yes=1, No=2
Postpartum pelvic floor treatment	X₁₈	Yes=1, No=2
Postpartum constipation	X₁₉	Yes=1, No=2
Postpartum urinary incontinence	X₂₀	Yes=1, No=2
Birthweight(kg)	X₂₁	<1.5=1, 1.5-2.5=2, ≥4,0=3, 2.6-3.9=4

The total participants’ clinical characteristics and pelvic floor dysfunction situation have shown in (Table 2). The continuous variables: BMI was 22.38 ±2.80 kg/m^2,and birth weight was 3.37 ±1.12 kg. Before the pregnancy, their BMI was 20.85 ±2.48 kg/m². In these patients, their pregnancy weeks were 14.11 ±6.01, and pregnancy weight gain was 38.89 ±1.89 kg.

The questionnaires are the significant index in PFDs. The score of POPDI-6 was 8.82 ±9.94, CRADI-8 was 8.39 ±10.56, UDI-6 was 14.52 ±14.33, and PFDsI-20 was 31.74 ±27.23. In categorical variables: 31-35 years were the most age (46.6%), and 26-30 years was the second age (35.2%). 54.2% of women (665) have Bachelor's degree in the education level. Notably, the number he vaginal delivery women (74.4%) was more than the Cesarean delivery patients (25.6%). There are 67.3% primiparas (825) and only 2.3% of women (28) have three and more babies. The questionnaire data were divided into symptomatic and asymptomatic.

This study shows that the incidence rate of PFDs was 94.5%, the result is substantially large than previous reports, we guess that may be because of the smaller sample size. Therefore, the prevalence of all three symptoms in our study was higher than in previous studies. We describe the results of incidence of the three symptoms, which shows the highest incidence was urinary distress symptom (79.6%) (Table 3).

This results show details of the multiple logistic regression analysis results. The results demonstrated, BMI more than 28 (OR: 2.337, 95% CI: 1.086-5.029, p=0.03), smoking in pregnancy (OR: 1.434, 95% CI: 0.241-0.78, p=0.005), vaginal delivery (OR: 1.663, 95% CI: 0.473-0.93 , p=0.017) were the risk factors of the POP, however, BMI less than 18.5(OR: 0.546, 95% CI: 0.337-0.885, p=0.014) was considered as a protective factor for POP in statistical methods (Table 4). According to our results, BMI less than 18.5 (OR: 0.555, 95% CI:0.344-0.895, p=0.016) was only the influence factor of CRAD (Table 5). There were a number of risk factors of UI including BMI more than 28(OR: 2.591, 95% CI: 1.016-6.607, p=0.046), gestational diabetes (OR: 1.541, 95% CI: 1.011-2.348, p=0.044), prenatal incontinence(OR:2.63, 95% CI: 0.405-0.982, p=0.041), vaginal delivery(OR: 1.521, 95% CI: 0.35-0.774, p=0.001), episiotomy(OR: 1.595, 95% CI: 1.093-2.326, p=0.015) (Table 6).

Table 2 Clinical characteristics of study participants

Characteristics	Data(n=1226)
Height(m)	1.60±0.05
Weight(kg)	58.08±8.36
BMI(kg/m²)	22.38±2.80
Height before pregnancy(m)	1.60±0.05
Weight before pregnancy(kg)	53.98±7.27
BMI before pregnancy(kg/m2)	20.85±2.48
Pregnancy weeks	14.11±6.01
Pregnancy weight gain(kg)	38.89±1.89
Birthweight(kg)	3.37±1.12
POPDI-6	8.82±9.94
CRADI-8	8.39±10.56
UDI-6	14.52±14.33
PFDsI-20	31.74±27.23
Age(years)
18-25	36(2.9%)
26-30	431(35.2%)
31-35	571(46.6%)
36-40	139(11.3%)
41-45	33(2.7%)
46-50	16(1.3%)
BMI(kg/m2)
＞28	54(4.4%)
24-27.9	308(25.1%)
＜18.5	75(6.1%)
18.5-23.9	789(64.4%)
BMI before pregnancy(kg/m2)
＞28	11(0.9%)
24-27.9	124(10.1%)
＜18.5	208(17%)
18.5-23.9	883(72%)
Education level
High school or below	79(6.4%)
Junior college	224(18.3%)
Bachelor's degree	665(54.2%)
Master's degree or above	258(21%)
Number of pregnancies
Once	665(53.5%)
Twice	175(14.3%)
Third and more times	396(32.3%)
Mode of delivery
Vaginal delivery	912(74.4%)
Cesarean delivery	314(25.6%)
Number of deliveries
Once	825(67.3%)
Twice	373(30.4%)
Third and more times	28(2.3%)

Table 3 Frequency of symptomatic women with pelvic floor dysfunction (%)

	PFDs	POPDI	CRADI	UDI
Asymptomatic	5.5	29.5	32.7	20.4
Symptomatic	94.5	70.5	67.3	79.6

Table 4 Multiple logistic regression for the risk factors influencing POPDI

	POPDI
	P-value	OR	95%CI
Age	0.426	1.07	0.906-1.263
Education level	0.609	0.955	0.8-1.139
BMI(kg/m2)	1
＞28	0.03*	2.337	1.086-5.029
24-27.9	0.596	0.925	0.694-1.233
＜18.5	0.014*	0.546	0.337-0.885
18.5-23.9	1
BMI before pregnancy(kg/m2)
＞28	0.992	1.008	0.232-4.383
24-27.9	0.682	1.103	0.69-1.762
＜18.5	0.072	0.684	0.452-1.034
18.5-23.9	1
Pregnancy weeks
28-32 weeks	0.548	1.361	0.497-3.724
33-37 weeks	0.904	0.976	0.658-1.447
>42 weeks	0.933	0.908	0.096-8.582
38-42 weeks	1
Pregnancy weight gain(kg)
≥20	0.888	1.021	0.765-1.364
<20	1
Pre-pregnancy pelvic floor muscle training(yes or no)	0.167	0.628	0.324-1.215
Accidental Pregnancy(yes or no)	0.86	1.027	0.767-1.375
Number of pregnancies
Third and more times	0.127	0.681	0.416-1.116
Twice	0.37	0.729	0.365-1.455
Once	1
Gestational diabetes(yes or no)	0.733	1.064	0.745-1.518
Smoking in pregnancy(yes or no)	0.005**	1.434	0.241-0.78
Pelvic floor muscle training during pregnancy(yes or no)	0.459	1.198	0.743-1.929
Abortion(yes or no)	0.215	1.276	0.868-1.874
Prenatal incontinence(yes or no)	0.29	0.836	0.6-1.165
Delivery method
Vaginal delivery	0.017*	1.663	0.473-0.93
Cesarean delivery	1
Number of deliveries
Third and more times	0.132	2.133	0.796-5.716
Twice	0.805	1.063	0.654-1.729
Once	1
Post-operative infection(yes or no)	0.637	1.184	0.587-2.389
Episiotomy(yes or no)	0.121	1.273	0.938-1.728
Birthweight(kg)
＜1.5	0.751	0.881	0.403-1.926
1.5-2.5	0.954	1.014	0.636-1.616
＞4	0.657	0.913	0.61-1.366
2.5-4	1

*P < 0.05, **P < 0.01, ***P < 0.001,

Table 5 Multiple logistic regression for the risk factors influencing CRADI

	CRADI
	P-value	OR	95%CI
Age	0.19	1.121	0.945-1.329
Education level	0.764	0.972	0.809-1.168
BMI(kg/m2)
＞28	0.114	1.701	0.88-3.286
24-27.9	0.626	1.073	0.808-1.424
＜18.5	0.016*	0.555	0.344-0.895
18.5-23.9	1
BMI before pregnancy(kg/m2)
＞28	0.839	1.162	0.273-4.94
24-27.9	0.392	0.802	0.484-1.329
＜18.5	0.992	1.002	0.671-1.498
18.5-23.9	1
Pregnancy weeks
28-32 weeks	0.555	0.722	0.244-2.132
33-37 weeks	0.548	0.881	0.583-1.332
>42 weeks	0.668	1.639	0.171-15.675
38-42 weeks
Pregnancy weight gain(kg)
≥20	0.431	0.888	0.66-1.194
<20	1
Pre-pregnancy pelvic floor muscle training(yes or no)	0.228	0.659	0.335-1.298
Accidental Pregnancy(yes or no)	0.841	0.97	0.717-1.311
Number of pregnancies
Third and more times	0.238	0.736	0.443-1.224
Twice	0.415	0.742	0.362-1.522
Once	1
Gestational diabetes(yes or no)	0.983	1.004	0.694-1.452
Smoking in pregnancy(yes or no)	0.544	0.845	0.491-1.455
Pelvic floor muscle training during pregnancy(yes or no)	0.478	0.834	0.505-1.378
Abortion history(yes or no)	0.787	0.946	0.632-1.415
Prenatal incontinence(yes or no)	0.323	0.844	0.602-1.182
Delivery method
Vaginal delivery	0.165	1.29	0.9-1.848
Cesarean delivery	1
Number of deliveries
Third and more times	0.474	1.455	0.521-4.065
Twice	0.812	0.942	0.573-1.547
Once	1
Post-operative infection(yes or no)	0.113	0.519	0.23-1.168
Episiotomy(yes or no)	0.748	1.052	0.774-1.429
Birthweight(kg)
＜1.5	0.236	1.628	0.727-3.645
1.5-2.5	0.085	0.631	0.374-1.066
＞4	0.308	1.23	0.826-1.833
2.5-4	1

*P < 0.05, **P < 0.01, ***P < 0.001

Table 6 Multiple logistic regression for the risk factors influencing UDI

	UDI
	P-value	OR	95%CI
Age	0.167	0.862	0.698-1.064
Education level	0.129	0.848	0.685-1.049
BMI(kg/m2)
＞28	0.046*	2.591	1.016-6.607
24-27.9	0.373	1.164	0.833-1.628
＜18.5	0.052	0.598	0.355-1.005
18.5-23.9	1
BMI before pregnancy(kg/m2)
＞28	0.998	0.7851	0.652-1.23
24-27.9	0.96	1.015	0.569-1.809
＜18.5	0.635	1.12	0.7-1.793
18.5-23.9	1
Pregnancy weeks
28-32 weeks	0.855	1.121	0.33-3.81
33-37 weeks	0.664	0.901	0.563-1.443
>42 weeks	0.532	0.1043	0.663-1.043
38-42 weeks	1
Pregnancy weight gain(kg)
≥20	0.895	1.024	0.721-1.454
<20	1
Pre-pregnancy pelvic floor muscle training(yes or no)	0.314	0.674	0.312-1.453
Accidental Pregnancy(yes or no)	0.744	1.06	0.747-1.505
Number of pregnancies
Third and more times	0.45	0.79	0.429-1.456
Twice	0.48	1.363	0.577-3.218
Once	1
Gestational diabetes(yes or no)	0.044*	1.541	1.011-2.348
Smoking in pregnancy(yes or no)	0.272	0.705	0.378-1.315
Pelvic floor muscle training during pregnancy(yes or no)	0.917	1.03	0.589-1.8
Abortion history(yes or no)	0.136	0.686	0.418-1.126
Prenatal incontinence(yes or no)	0.041*	2.63	0.405-0.982
Delivery method
Vaginal delivery	0.001**	1.521	0.35-0.774
Cesarean delivery	1
Number of deliveries
Third and more times	0.545	0.687	0.204-2.317
Twice	0.434	0.784	0.426-1.442
Once	1
Post-operative infection(yes or no)	0.381	0.663	0.265-1.662
Episiotomy(yes or no)	0.015*	1.595	1.093-2.326
Birthweight(kg)
＜1.5	0.11	0.402	0.132-1.229
1.5-2.5	0.822	0.936	0.526-1.665
＞4	0.153	1.407	0.881-2.249
2.5-4	1

*P < 0.05, **P < 0.01, ***P < 0.001

Currently, most studies of PFDs risk factors are meta-analyses and a limited number of clinical studies. The relationship between individual risk factors and PFDs has been reported, however, no study has yet analyzed different influencing factors for the different trimesters. This present study conducted a retrospective analysis of different risk factors at three stages of pregnancy, prenatal, and postnatal life.

The prevalence of postpartum UI in this study was 79.6%, the highest in PFDs. Based on our results, we found several factors that influenced UI, such as BMI >28, gestational diabetes, prenatal incontinence, vaginal delivery, and episiotomy. BMI greater than 28, which was considered as obesity, has also been reported as a risk factor in other studies. Obesity caused excessive intra-abdominal pressure loading on the pelvic floor (including the pubic area and nerves), leading to excessive laxity of the fascia around the pelvis, and resulting in prolapse of the intrapelvic organs [12, 13]. In the pregnancy stage, our study found that gestational diabetes significantly influenced the processing of UI [7]. Type 2 diabetes may result in lower muscle strength and muscle mass, abnormal lipid deposition, and high collagen levels in patient tissues [14]. During pregnancy, gestational diabetes is characterized by gestational hyperglycemia (GH). It was proved that both short-term severe and long-term mild diabetes has detrimental effects on urethral muscle in pregnant rats [15]. A recent study found serum relaxin-2, a serum marker of diabetes was significantly elevated in order to regulate blood sugar levels in diabetes patients. Nevertheless, the concentration of serum relaxin-2 was significantly lower in pregnant women with gestational diabetes, and these women also showed a reduction in their pelvic floor muscle strength. These results suggest that serum relaxin-2 may be beneficial for postpartum UI patients with gestational diabetes [16]. In this study, prenatal incontinence was identified as a risk factor for UI. An increase in the weight of the uterus causes increased pressure on the bladder, stimulating it and reducing its volume, which in turn increases the incidence of UI in pregnant women [8]. A previous study has found that women who experienced urine leakage during pregnancy had a higher risk of developing postpartum incontinence than those who did not [17-20]. Furthermore, pregnant women who experienced urine leakage symptoms during pregnancy are twice as likely to experience urine leakage again within 15 years of delivery as those without urine leakage symptoms during pregnancy [8, 17-20]. In pregnancy, the increased weight of the uterus presses on the bladder, stimulating it and reducing its volume, which in turn leads to an increase in urination during pregnancy. Several studies have identified vaginal delivery as a short- and long-term risk factor for postpartum UI [7, 8, 21, 22]. Meanwhile, vaginal delivery is more likely to impair the pelvic floor structures, leading to pelvic floor muscles (PFMs) weakness. Additionally, it resulted in urethral sphincter incompetence and ultimately led to UI. Furthermore, lateral episiotomy during the delivery results in PFMs rupture and other complications. According to our study, women who have undergone episiotomy were more likely to suffer from postpartum UI [6]. As a result, the effect of different modes of delivery on UI is inconsistently understood. It has been demonstrated in other studies that instrument-assisted vaginal delivery (for example, forceps delivery) substantially increases the risk of UI.

In our study, POP was identified as another most common symptom, with 70.7% of cases. All currently known risk factors for POP result in pelvic floor fascia injury and thus leading to POP [23]. According to the findings of this study, there were differences and similarities in the risk factors between POP and UI. The consistent risk factors with UI were BMI >28 and vaginal delivery. Interestingly, in our study, we found that BMI <18.5 was a protective factor (p=0.014, OR=0.546) for POP, which has not been reported in previous studies. Compared with obese women, those who have lower BMI, have a lower risk of POP. Subjects in the previous study are mostly from Europe and America, it was found that the prevalence of obesity in women is generally above 20% in 18 European countries and the US women have the highest incidence of obesity at 39.5% [24]. Meanwhile, the occurrence rate of the POP stage has been reported between 18-56% in 3-6 months after delivery in (Postpartum pelvic floor muscle training and pelvic organ prolapse. In contrast, according to a cross-sectional study based on one million adults in China, the prevalence of obesity in women was found to be 15.8% [25], and the prevalence of POP has been reported about 84.25% in puerperal women [26]. Consequently, we analyze this might be associated with racial differences. Although BMI <18.5 has negative effects on health of female, however, our study found it plays a protective role for POP and UI in Chinese women.

Besides, different from the risk factors of UI, we found smoking during pregnancy significant influence of POP (p=0.005). Smoking is one of the risk factor for chronic respiratory diseases, and may increase intra-abdominal pressure (e.g. coughing). Smoking may cause irritation of the pelvic floor muscles and increase the risk of POP development [27]. The evidence suggests that estrogen levels and a family genetic history are also risk factors for POP [12].

The incidence of AI in our study was 67.4%, in this study, we haven’t found risk factors associated with it. Our results found that BMI <18.5 was the protective factor (p=0.016, OR=0.555) for AI, and it was consistent with POP. Additionally, AI was associated with several risk factors in previous studies. These include obesity, number of births, age, UI, hormonal stimulation, neonatal head circumference, anal penetrative intercourse and levator ani muscle injury [28-30]. During delivery, stretching and compression of the pubic nerve and its regional branches due to the factors described above are the most common causes of AI. The abscess may also lead to permanent damage and scarring of the pubic nerve due to repeated longitudinal strains and denervation of the sphincter, leaving the anus unable to be controlled by the body [31].

There were still some shortcomings in this research method. Estrogen levels were not included as a risk factor due to trial conditions. According to previous studies, this may be an influential factor of PFD in postpartum women. Second, the questionnaire was answered by the nurse managers of the hospital maternity wards, which might have led to response bias, confusion bias and selection bias. Future research needs to reduce this error methodologically.

PFDs are most commonly dysfunction after delivery, it has caused serious negative effects on the daily life of puerperal women. This study found that the incidence of UI, POP and AI was 79.6%, 70.7% and 67.4%, respectively, this is similar to the results of previous studies. According to our data, we conclude that the BMI >28, gestational diabetes, prenatal incontinence, vaginal delivery, and episiotomy are risk factors for postpartum UI. In addition to the above risk factors, smoking has also been found to be a risk factor for POP. However, we found no risk factors for AI. Additionally, we found that BMI <18.5 is a protective factor of AI and POP. This result needs to be further explored large-sample and high-quality studies. These data can be used to generate risk prediction models and provide reference for prevention and treatment strategies for postpartum PFD patients.

PFD: pelvic floor dysfunction; UI: urinary incontinence; POP: pelvic organ prolapse; AI: anal incontinence; QOL: quality of life; BMI: body mass index; PFDI: Pelvic Floor Distress Inventory; UDI: Urinary Distress Inventory; POPDI: Pelvic Organ Prolapse Distress Inventory; CRADI: Colorectal-Anal Distress Inventory; SD: standard deviation; ORs: Odds ratios; CIs: confidence intervals; GH: gestational hyperglycemia; PFMs: plevic floor muscles.

Acknowledgments

Not applicable.

Authors’ contributions

MJW contributed to oversight and leadership responsibility for the research activity planning. XYJ and JG contributed to write the initial draft. BRY contributed to the data collection and YZW contributed to analyze the study data. All authors contributed to manuscript revision, read, and approved the submitted version.

Funding

This work was supported by Sichuan Maternal and Child Health Association (21FX016) and was also funded by Institute of Sports Medicine Key Laboratory of Sichuan Province, grant number 2022-A065.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study protocol has been verified and approved by the ethical committee of Chengdu Sport University ([2022] No.45). Written informed consent was obtained from all patients.

Consent for publication

Not applicable.

Conflicts of interests

None of the authors have any commercial association or other conflicts of interest regarding the manuscript.

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No competing interests reported.

Risk Factors of Pelvic Floor Dysfunction in Postpartum Period: a Cross-Section Study

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Abstract

Introduction

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Discussion

Conclusion

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