Obstetrics and Pelvic Floor Disorders: Chapter Outline

CHAPTER 16
Obstetrics and
Pelvic Floor
Disorders
W. Thomas Gregory
Baha M. Sibai
changes in the cardiovascular, hematologic, renal, and

Chapter Outline immunologic systems, and anatomic changes in the uterus
and the growing fetus and placenta. There are also anatomic
Introduction and physiologic changes in the lower genitourinary tract and
pelvic floor support. The subsequent process of both labor
Alterations of Pelvic Floor Anatomy and and delivery also impart significant changes, especially to
Physiology in Pregnancy the pelvic floor support.
Pelvic Floor Support To whom are these changes significant? Which woman
Urinary Tract in Pregnancy will evidence the symptoms of pelvic floor disorders (PFDs),
Urinary Tract Conditions during Pregnancy about which this textbook is dedicated? Nearly 100 years
Urinary Retention ago, (in his argument espousing more liberal use of forceps,
Urinary Incontinence it must be pointed out), DeLee wrote:
Asymptomatic Bacteriuria
Labor has been called, and still is believed by many
Acute Cystitis to be, a normal function … and yet it is a decidedly
Acute Pyelonephritis pathologic process. Everything, of course, depends on
Urolithiasis what we define as normal. If a woman falls on a pitch-
Previous Urologic Surgery fork, and drives the handle through her perineum, we call
Impact of Childbirth on Anatomy and that pathologic-abnormal, but if a large baby is driven
Physiology through the pelvic floor, we say that it is natural, and
therefore normal.
Muscular Injury
Injury to Urinary Tract during Delivery This chapter discusses the relevant changes that occur
Postpartum Urinary Retention with pregnancy and following delivery, and how they may
Injury to Anal Canal affect the development of PFDs.
Neurologic Injury
Impact of Childbirth on Specific PFDs Alterations of Pelvic Floor Anatomy
Urinary Incontinence and Physiology in Pregnancy
Fecal Incontinence Pelvic Floor Support
Pelvic Organ Prolapse (POP)
As pointed out in Chapter 2, interactions between the pel-
The Debate about Elective Primary Cesarean vic floor muscles and connective tissue attachments provide
Delivery the support to the pelvic organs. Probably as a result of hor-
Fistulas monal changes, there are significant adaptations to prepare
the pelvic floor and birth passage for the events of labor
Conclusion and delivery. Clinical evidence of this has been observed
using the standardized pelvic organ prolapse (POPQ) sys-
tem. O’Boyle et al. (2002) found that nulliparous pregnant
women were more likely to have mild pelvic organ prolapse
Introduction (POP) than their nulligravid counterparts.
There are many physiologic adaptations a woman undergoes Consistent with the clinical changes noted earlier, molec-
during the course of a routine pregnancy. In most obstet- ular and histologic studies of vaginal tissues have demon-
ric textbooks, much attention is focused on the physiologic strated increased amounts of extracellular matrix material
224
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CHAPTER 16 Obstetrics and Pelvic Floor Disorders 225
in the fibromuscular layers. Collagen becomes less densely reduced ureteral peristalsis compared with the nonpregnant
packed, and smooth muscle cells revert to noncontractile state.
phenotypes (Daucher et al., 2007). The result of these Vesicoureteral reflux is a sporadic, transient occurrence
changes is increased distensibility of the vagina, presumably during pregnancy and has been demonstrated radiologically
to allow for genital stretching during parturition (Alperin in 3.5% of pregnant women. The enlarging uterus displaces
et al., 2010). the ureters laterally, and the intravesical ureters are short-
The advent of genetically engineered knockout mouse ened and enter the bladder perpendicularly rather than
models (LOXL-1 and FBN-5) have provided more insight obliquely. Consequently, the ureterovesical junction is less
for changes in elastin homeostasis during pregnancy, and the efficient in preventing reflux. This increased incidence of
potential that the mechanisms responsible for the regenera- reflux may explain the high incidence of pyelonephritis dur-
tion of the elastic properties of the vagina may be deranged ing pregnancy; however, this association has not been con-
in those animals who develop prolapse as well as other PFD firmed. The transitory nature of vesicoureteral reflux, and
postpartum. the necessary exposure to X-rays for study purposes, hinder
adequate evaluation of the problem. Nevertheless, vesico-
ureteral reflux probably plays only a small role in symptom-
Urinary Tract in Pregnancy
atic or asymptomatic urinary tract infection (UTI).
The kidneys and urinary tract play a major role in maternal Renal blood flow is usually assessed by r-aminohippu-
adaptation to pregnancy. Consequently, observed differ- rate clearance, which measures effective renal plasma flow
ences in function cannot be judged by nonpregnant stan- (ERPF). ERPF increases significantly during pregnancy. It
dards. The renal system increases in size and capacity during reaches a peak increment during the mid trimester of 50% to
pregnancy. Anatomic changes involving the urinary tract 85% and then shows a small decline during the third trimes-
begin during the first trimester of pregnancy and can persist ter. ERPF and glomerular filtration rate (GFR) in pregnancy
up to 16 weeks postpartum. are affected markedly by posture, and are maximal when
The most striking anatomic change in the urinary tract is the pregnant woman lies on her side. Normal pregnancy is
dilation of the ureters (Fig. 16.1). Bilateral dilation of the associated with plasma volume expansion and an increase
calyces, renal pelvis, and ureters can be seen early during in the GFR of 40% to 65% (measured by insulin clearance)
the first trimester and is present in 90% of women during and a decrease in GFR of approximately 15% to 20% late
the late third trimester or early puerperium. The changes during the third trimester. The mechanisms responsible for
are usually more prominent on the right and may persist the increase in GFR, plasma volume, and renal plasma flow
for 3 to 4 months. In 11% of women, ureteral dilation per- rate are unknown.
sists indefinitely (Bailey et al., 1971). In addition, there is Tests of renal function during pregnancy must be inter-
preted in relation to the changes in plasma volume, glomer-
ular filtration, and tubular reabsorption that normally occur
with advancing gestation. Many of the commonly used tests
of function yield lower results in pregnancy than in the non-
pregnant state. Consequently, values that may be regarded
as normal during the nonpregnant state may well indicate
renal dysfunction in pregnancy.
Uric acid, blood urea nitrogen (BUN), and serum creati-
nine levels are crude indices of renal function. In pregnancy,
plasma uric acid usually decreases by 25% beginning during
the first trimester, and increases during the third trimes-
ter. Upper normal limits of plasma uric acid levels are 5 to
5.5 mg/dL during pregnancy. Levels are influenced by race,
multiple gestation, and time of day sampled, with higher
levels in the morning. An indicator of renal filtration, the
BUN normally decreases from nonpregnant levels of 12 mg/
dL (4.3 mmol/L) to 9 mg/dL (3.2 mmol/L), and plasma
creatinine levels decline from a nonpregnant mean value of
0.7 mg/dL (62 mmol/L) to 0.5 mg/dL (44 mmol/L). If the
plasma creatinine level exceeds 0.9 mg/dL or if the BUN is
greater than 14 mg/dL at any stage during pregnancy, renal
dysfunction should be suspected and more detailed investi-
gation should be performed.
Twenty-four-hour creatinine clearance is the best clinical
measurement of GFR. By week 8 of pregnancy, the creati-
nine clearance rate normally increases by 45% and remains
elevated during the second trimester. During the final
weeks of pregnancy, creatinine clearance usually declines to
near-nonpregnant levels.
FIGURE 16.1 Hydronephrosis and hydroureter associated with Urinalysis is essentially unchanged during pregnancy.
pregnancy. However, many variables can affect the results. Normal
226 PART 4 Management of Stress Urinary Incontinence and Pelvic Organ Prolapse
kidneys should be able to concentrate urine to a specific connective tissue. Thus, progesterone probably plays a small
gravity of 1.026 or more, and to dilute urine to a value less role in ureteral dilation during pregnancy.
than 1.005. During pregnancy, posture affects urine concen-
tration and specific gravity. Urinary Tract Conditions during Pregnancy
In addition to the ERPF, the capacity of the urinary tract
increases during pregnancy. Bladder volume during preg- Urinary Retention
nancy increases to 450 to 650 mL, compared with 400 mL Occasionally, the enlarging uterus completely obstructs
in nonpregnant control subjects (Table 16.1). The hydro- both ureters and causes azotemia. Patients usually present
nephrotic ureters can hold as much as 200 mL extra urine; during the early second trimester with a retroverted uterus
however, no changes appear in the contraction patterns on (perhaps incarcerated), flank pain, and minimal signs of
retrograde cystometry. Depending on maternal position, infection. The differential diagnosis includes pyelonephri-
uterine size, and position of the fetus, the functional vol- tis, renal calculi, or papillary necrosis. Serum creatinine
ume of the bladder and ureters is dynamic during the third is elevated (3.8-11.6 mL/dL), but urinary sediment does
trimester. This increased functional volume, coupled with not indicate intrinsic renal disease or prerenal azotemia.
high urine flows (especially with fluid mobilization at night), The diagnosis is confirmed by IVP or renal ultrasound. In
causes polyuria and nocturia in most pregnant women. this case, treatment requires bimanual manipulation of the
The etiology of ureteral and bladder dilation generates uterus out of the sacral hollow. Some have recommended
much discussion. Sharp termination of the ureteral dilation the use of a Smith-Hodge pessary to maintain anteversion
at the pelvic brim seen on intravenous pyelogram (IVP) sug- of the uterus. Other risk factors for obstruction include
gests an obstruction. When a woman is upright or supine, as previous urologic surgery, unilateral absence of a kidney,
during the filming of an IVP, the pregnant uterus compresses polyhydramnios, multiple gestation, and ovarian or uterine
the ureter against the pelvic rim and its overlying iliac ves- neoplasia.
sels. On the left side, the ureter is somewhat protected by Occasionally, third-trimester retention can develop.
the iliac arteries and sigmoid colon and, as a result, is usu- Ultimately, delivery relieves the obstruction, and postpar-
ally less dilated than the right ureter. Although mechani- tum recovery is complete. In cases remote from term, fetal
cal obstruction plays a major role in ureteral dilation during risk from preterm delivery outweighs the risks of urologic
pregnancy, the relative infrequency of ureteral obstruction management. Conservative management for 12 to 24 hours
by large ovarian tumors or fibroids in nonpregnant women is warranted before more aggressive therapy is initiated,
suggests additional factors. In addition, high urine produc- including amniocentesis (in cases with polyhydramnios),
tion, as occurs in diabetes insipidus or pregnancy, is also cystoscopically-placed ureteral stents, or percutaneous
associated with urinary tract dilation. nephrostomy under ultrasound guidance.
In the past, the elevated progesterone levels that accom-
pany pregnancy were thought to cause smooth muscle Urinary Incontinence
relaxation and subsequent hypotonicity and hypomotility As shown in Table 16.1, the symptoms of frequency, noc-
of the ureter—defects that would contribute to ureteral turia, and incontinence all increase during in the first tri-
dilation. Contrary to the latter observation, the large doses mester, and increase during the course of the pregnancy.
of synthetic progesterone used in cancer chemotherapy do Part of this change is a result of the increase in glomerular
not cause ureteral dilation. Measurements of ureteral tone flow described earlier. Stress incontinence is more common
during pregnancy reveal an increase in ureteral tone and than urge incontinence or overactive bladder symptoms,
no decrease in frequency or amplitude of ureteral contrac- but mixed symptoms are common. For those who do have
tions. Histologic study of the ureters of pregnant animals incontinence rather than frequency alone, their quality of
reveals smooth muscle hypertrophy and hyperplasia of the life is affected significantly more. The few urodynamic
Table 16.1 Urologic Symptoms and Measurements in Pregnancy

First Trimester Second Trimester Third Trimester Postpartum
Symptom Frequency
Day ≥7 45% 61% 96% 17%
Night ≥2 22% 39% 64% 6%
Incontinence
Stress 30% 31% 85% 6%
Urge 4% 13% 2% 8%
Hesitancy 24% 28% 22% 9%
Measurement
Urine output (mL) 1917 2020 1820 1475
Bladder capacity (mL) 410 460 272 410
Functional urethral length (mm) 30.3 ± 4.6 35.1 ± 5.1 27.6 ± 3.7
Bladder pressure (cm H2O) 9 ± 3 20 ± 3 9 ± 2
Closure pressure (cm H2O) 61 ± 14 73 ± 18 60 ± 14
Data from Francis WJA: J Obstet Gynaecol Br Commonw 1960;67:353; Iosif et al.: Am J Obstet Gynecol 1980;137:690; Stanton et al.: Br J Obstet
Gynaecol 1980;87:897.
studies that have been done during pregnancy demon- delivered LBW infants. Romero et al. (1989) reviewed 19
strate that bladder capacity increases throughout gestation, studies that related bacteriuria to LBW infants. In these
and functional urethral length and closure pressures may studies, 3619 pregnant women with bacteriuria delivered
increase, but urinary symptoms and urodynamic findings do 400 (11%; range, 4.4%-23%) LBW infants. In these same
not always correlate well. Treatment of incontinence during studies, 31,277 women without bacteriuria delivered 2725
pregnancy is typically pelvic floor rehabilitation. Although (8.7%; range, 3%-13.5%) LBW infants. In 1989, Romero
oxybutynin has been assigned a category B rating during et al. performed a meta-analysis on the relationship between
pregnancy, most providers would not initiate anticholiner- asymptomatic bacteriuria and LBW. Eight randomized clini-
gic treatment as a first-line agent, recognizing that many of cal trials of antibiotic therapy showed a significant reduction
the previously described urinary symptoms will change after in the frequency of LBW after antibiotic therapy (typical
delivery. relative risk (RR) of 0.56, with a 95% confidence interval
(CI) of 0.43-0.73). It is unclear whether the benefit from
Asymptomatic Bacteriuria antibiotics results from a reduction in asymptomatic or
The cohort of women with chronic, episodic asymptomatic symptomatic pyelonephritis, or from beneficial changes in
bacteriuria is identified by routine screening of urine cul- abnormal genital tract flora, which is associated with LBW.
tures at the first prenatal visit. The prevalence of asymp- The association between asymptomatic bacteriuria and
tomatic bacteriuria (two or more cultures at ≥105 cfu/mL) other adverse pregnancy outcomes (hypertension, anemia,
is increased by prior renal or urinary tract disease, diabetes, chronic renal disease, and fetal neuropathology) is con-
sickle cell trait or disease, poor hygiene, high parity, increased troversial, being both supported and refuted by different
age, and lower socioeconomic status. The overall prevalence cohort studies. Between 25% and 50% of pregnant women
varies between 1.9% and 11.8%, with the lowest preva- with asymptomatic bacteriuria have evidence of asymptom-
lence in primiparous patients of the upper socioeconomic atic renal involvement, and these women are twice as likely
class and the highest among indigent multiparas. Although to relapse within 2 weeks after therapy as women with
most women with asymptomatic bacteriuria are identified bladder bacteriuria alone. Asymptomatic renal infection has
shortly after entering prenatal care, approximately 1% to been associated with decreased creatinine clearance, intra-
2% acquires bacteriuria later during pregnancy. uterine growth retardation, and maternal hypertension. On
Because of the more significant concerns of worsening the other hand, Gilstrap et al. (1981b) failed to note a dif-
obstetric outcomes associated with an escalation to acute ference in outcomes between asymptomatic women with
cystitis or pyelonephritis and because the positive predic- and without renal infection, as defined by fluorescent anti-
tive values of culture-independent tests (i.e., dipstick uri- body testing (Table 16.2).
nalysis) drop precipitously with low prevalence, they should A variety of antimicrobial agents and treatment regimens
not be used for diagnosis in the pregnant population. On the have been used to treat asymptomatic bacteriuria during
other hand, the negative predictive value is 98% or more pregnancy. Most community-acquired pathogens associ-
with any of these tests. In a low-risk population, urine test- ated with asymptomatic bacteriuria during pregnancy are
ing for leukocyte esterase and nitrite on a clean-catch, first- sensitive to sulfa drugs (sulfisoxazole, 1 g four times a day
void midstream specimen can supplant urine culture. In (qid) for 7-10 days), nitrofurantoin (100 mg twice daily for
high-risk groups (Box 16.1), a culture should be obtained 7-10 days), or cephalosporins (cephalexin, 500 mg qid for
each trimester. 7-10 days). Ampicillin (500 mg qid for 7-10 days) is a time-
The association between preterm birth and asymptom- honored, safe, and inexpensive therapy; however, there are
atic bacteriuria was first identified by Elder, Kass, and a growing number of resistant Escherichia coli strains (Table
others at Boston City Hospital between 1955 and 1960. 16.3). Other antibiotics should be used. A Cochrane Review
This initial study reported that 32 of 179 (17.8%) patients
with bacteriuria delivered low-birth weight (LBW) infants,
whereas 88 of 1000 (8.8%) patients without bacteriuria Table 16.2 Incidence of Urinary Tract Infection
during Pregnancy
Infection Incidence (%)
Box 16.1 Conditions That Place Patients at
Asymptomatic bacteriuria 2–11
High Risk for Urinary Tract Infections during Acute cystitis 1–4
Pregnancy Acute pyelonephritis 1–2
• Diabetes
• Sickle cell disease or trait
• Urinary tract abnormalities Table 16.3 Microbiology of Urinary Tract
• Müllerian duct abnormalities
Infections in Pregnancy
• Renal disease
• Urolithiasis Organism Percentage
• Hypertensive diseases
Escherichia coli 60-80
• Chronic analgesic use
Klebsiella pneumoniae-Enterobacter 3-5
• Genitourinary group B Streptococcus Proteus sp. 1-5
• History of urinary tract infections Streptococcus faecalis 1-4
• Severe ureteral reflux Group B Streptococcus 4-8
• Urinary infections as a child younger than 4 years old Staphylococcus saprophyticus 1-3
supported the extended treatment duration rather than sin- therapy is initiated as soon as a midstream, clean-catch
gle-dose regimens (Widmer et al., 2011). urine culture has been obtained. A test-of-cure culture
Between 20% and 30% of women who have bacteriuria is obtained within 2 weeks after therapy is complete.
during pregnancy will have bacteriuria on long-term follow- Between 10% and 20% have a positive test-of-cure cul-
up cultures when not pregnant. Radiologic examination at ture, representing a relapse. These women should be
follow-up of women who had bacteriuria during pregnancy retreated with another antibiotic, as determined by bacte-
revealed abnormalities in 316 of 777 women (41%; range, rial sensitivities. After retreatment, these patients should
5%-75%). Chronic pyelonephritis was the most common be placed on suppressive antibiotic therapy. Without sup-
radiologic diagnosis (47% of abnormalities). The incidence pressive therapy, an additional 20% to 30% of women
of bacteriuria during first pregnancies was significantly develop another UTI—a reinfection—during the remain-
greater in women with (47%) than without (27%) renal der of their pregnancies and puerperia. Because of the risk
scarring from childhood urinary infections. Similar control of recurrence, patients with cystitis should be monitored
subjects who had not had childhood urinary infections had intensively, with a urine screen biweekly for nitrite and
an incidence of 2%. leukocyte esterase.
Acute Cystitis Acute Pyelonephritis
Acute cystitis occurs in 1% to 4% of pregnancies. The Acute pyelonephritis is the most common serious medi-
reported frequency is only minimally greater than the fre- cal complication of pregnancy. The modern incidence of
quency of cystitis in sexually active nonpregnant women. pyelonephritis is 1% to 2%. Often, these patients present
Unfortunately, the diagnosis is more difficult to make for prenatal care late during pregnancy with the signs and
during pregnancy. Most pregnant women have urgency, symptoms of pyelonephritis. Only 40% to 67% of cases of
frequency, or suprapubic discomfort. Suprapubic discom- pyelonephritis occur in patients with a known history of
fort in pregnancy often results from pressure from the asymptomatic bacteriuria. Three-fourths of women with
presenting fetal part or early labor. Nevertheless, suprapu- pyelonephritis present in the antepartum period, 5% to
bic discomfort from cystitis is unique, and most women 10% during labor, and 15% to 20% postpartum. Antepartum
with a history of acute cystitis can discriminate accurately pyelonephritis occurs mainly after the first trimester: 10%
between cystitis and pregnancy-related discomfort. The to 20% during the first trimester, 45% to 70% during the
most reliable findings are dysuria and hematuria. Acute second trimester, and 8% to 45% during the third trimester.
dysuria may also result from labial or perivaginal irritation The predominance of pyelonephritis during late pregnancy
from vaginitis, vulvitis, herpes simplex, condylomata acu- and the puerperium likely relates to the partial obstruction
minatum, or genital ulcers. Because of the separate preg- caused by the growing uterus and to trauma or interventions
nancy risks encumbered with these factors, an inspection at birth.
of the vulva and vagina is warranted in patients with acute The diagnosis of acute pyelonephritis is based on clinical
cystitis during pregnancy. presentation: a temperature of 38 °C or more, costover-
Preterm labor and threatening second-trimester loss tebral angle tenderness, and either bacteriuria or pyuria.
often present with signs and symptoms similar to those of Enterobacteriaceae cause a majority of the cases of pyelo-
acute cystitis. As the lower uterine segment expands and nephritis: E. coli, 70% to 80%; Klebsiella-enterobacter spp.,
the presenting fetal part descends, hesitancy, urgency, fre- 5%; Proteus sp., 2% to 4%; and gram-positive organisms
quency, and suprapubic discomfort occur. A bloody vaginal inducing group B Streptococcus, 10%. Blood cultures are
discharge may contaminate and confuse urine testing, and positive in 17% of cases. Infection of the kidney may have
may lead to misdiagnosis of UTI. Pelvic examination is war- an effect on function. Two percent have a serum creatinine
ranted in patients presenting with signs and symptoms of greater than 1.1 mg/dL. This dysfunction is a direct result
lower UTI to rule out preterm labor. of endotoxic injury to both kidneys. After appropriate anti-
The pathophysiology of acute cystitis is more similar biotic treatment, renal function returns to normal by 3 to
to that of asymptomatic bacteriuria than pyelonephri- 8 weeks.
tis. Acute cystitis has sociodemographic and behavioral Endotoxins produced by Enterobacteriaceae have
risk factors similar to those of asymptomatic bacteriuria. adverse consequences on multiple organ systems as well as
Enterobacteriaceae, especially E. coli, are the most com- the kidneys. The injuries include thermoregulatory insta-
mon uropathogens. Acute cystitis is associated with a bility (fever and chills), destruction of blood cells (leuko-
high prevalence of uropathogens in the periurethral flora. cytopenia, thrombocytopenia, anemia), hypercoagulability
E. coli serotypes are associated with more epithelial cell (disseminated intervascular coagulation), endothelial injury
adherence, hence virulence, than fecal strains. Antibody- (adult respiratory distress syndrome), cardiomyopathy
coated bacteria, indicative of renal infection, are pres- (pulmonary edema), and myometrial irritability (preterm
ent in only 5% of acute cystitis, compared with 45% for labor).
asymptomatic bacteriuria and 65% for acute pyelonephri- Overt septic shock or adult respiratory distress syndrome
tis. This difference may result from earlier identification occurs in 1% to 2% of pregnant women with acute pyelo-
and treatment of the patient with these latter condi- nephritis. Clinical clues to the development of these life-
tions because of the intense discomfort that accompanies threatening complications are leukocytopenia (<6000 cells/
cystitis. mL2), hypothermia (≤35 °C), elevated respiratory rate,
Treatment of acute cystitis is similar to that of asymp- and widened pulse pressure. During the late stages, hypo-
tomatic bacteriuria: nitrofurantoin, a cephalosporin, or a thermia, mental confusion, and symptomatic hyperstimu-
sulfonamide. Because these patients are symptomatic, lation of the sympathetic nervous system (cold, clammy
extremities) herald a scenario that often leads to maternal with radiation to the groin or lower abdomen, nausea, and
or fetal death. vomiting. Renal colic is less common after the first trimes-
Most pregnant women with pyelonephritis (and all preg- ter because of ureteral dilation. Likewise, gross hematuria
nant women greater than 24 weeks’ gestation) should be is less common (23%), but microscopic hematuria occurs
hospitalized because of the additional fetal and maternal in 60% to 90% of patients. Bacteriuria may be present in
risks of acute pyelonephritis in pregnancy. Appropriate 80%.
broad spectrum antibiotics should be initiated as soon as The differential diagnosis includes premature labor,
possible after urine and blood cultures are obtained. Antibi- appendicitis, and, most commonly, pyelonephritis. Prema-
otic therapy should be continued until the patient is afebrile ture labor is diagnosed by contractions and cervical dila-
(<37 °C) for more than 24 h. The patient should finish a tion. Urolithiasis is more likely than appendicitis when the
14-day course of antibiotics with oral medication. A test- patient has no fever, the abdominal pain is not localized to
of-cure urine culture should be performed 2 weeks after the right lower quadrant, and no peritoneal signs are pres-
therapy. Reinfection is common in these patients; 20% have ent. The most difficult differentiation is between pyelone-
asymptomatic bacteriuria and 23% have recurrent pyelo- phritis and urolithiasis. Indeed, they may coexist.
nephritis. Frequent surveillance (nitrite/leukocyte esterase IVP is the diagnostic technique of choice. In pregnancy,
testing biweekly) or suppressive antibiotic therapy (nitrofu- the protocol and frequency of IVP are curtailed. The IVP
rantoin, 100 mg every night at bedtime) is warranted. With should be limited to a 20-min film and, if there is delayed
either regimen, the risk of recurrent pyelonephritis is less excretion, a 60-min film. Fluoroscopy is used only in very
than 10%. exceptional circumstances. An IVP is indicated when the
Because many patients are dehydrated as a result of nau- patient has renal colic and gross hematuria, persistent fever
sea and vomiting, careful rehydration is started. The degree or a positive culture after 48 h of parenteral antibiotic ther-
of endothelial damage in the lungs may not be apparent, so apy, persistent nausea and vomiting after 48 h of conserva-
careful attention to fluid intake and output, and vital signs, tive therapy, or evidence of a complete obstruction (e.g.,
especially respiratory rate, is imperative. increasing levels of BUN and serum creatinine).
Endotoxins stimulate cytokine and prostaglandin produc- Transabdominal or transvaginal ultrasound often is the
tion by decidual macrophages and fetal membranes. The first diagnostic choice of radiologists. Their concern is the
ensuing preterm contractions raise concern for preterm birth. 0.4 to 1 rad of radiation the fetus receives with a limited
In the past, preterm labor and delivery were reported to be IVP. There is concern that doses this low may double child-
a common finding in women with pyelonephritis; however, hood cancer rates. Although ultrasound is a good diagnostic
data in 440 cases reported by Hill et al. (2005) found a rate tool for renal abnormalities and ureteral dilation, its sensi-
of only 5%. tivity is 34%, with an 86% specificity for the detection of
The differential diagnosis in patients with persistent an abnormality in the presence of a stone in a symptomatic
fever and costovertebral angle tenderness at 72 h of patient. In one study, renal ultrasound was used as the pri-
therapy includes a resistant organism, urolithiasis, renal mary diagnostic test in 35 of 56 women, but calculi were
abscess, complete ureteral obstruction, or another source detected in only 21 (60%) of these women (Butler et al.,
of infection (e.g., appendicitis or intra-amniotic infec- 2000). IVP is clearly more efficacious for diagnosis of distal
tion). A radiologic evaluation of the urinary tract is war- stones.
ranted after reexamination of the patient and review of Urolithiasis in pregnancy is treated conservatively with
culture and sensitivity reports. Many radiologists have bed rest, hydration, and analgesics. Seventy percent of
undue concern regarding the fetal dangers of IVPs dur- patients pass the stone spontaneously. Urolithiasis during
ing pregnancy and advocate renal ultrasound. A renal pregnancy does not increase the likelihood of abortion, pre-
ultrasound is useful for evaluating renal abscess, but not maturity, or hypertension, but the incidence of symptomatic
for evaluating function or ureteral abnormalities—the urinary tract disease is greater in pregnancies complicated
more common issues associated with antibiotic failure. by a history of urolithiasis (20%-65%), potentially leading
A “one-shot” IVP (no plain film and one 20-min film) is to an increased rate of preterm rupture of membranes. Par-
appropriate. enteral antibiotics (cefazolin 2 g IV q6h) are added to con-
servative management when infection is likely.
Urolithiasis When conservative management is unsuccessful (com-
Urolithiasis occurs in 0.03% to 0.9% of pregnancies, usually plete obstruction, persistent pain, or sepsis), surgical inter-
in the last two trimesters. Between 20% and 40% of women vention is indicated. The choice of procedure depends on
with urolithiasis during pregnancy have a history of stone the size and location of the stone. The usual procedures
disease. Although pregnancy does not appear to increase the include basket extraction or retrograde stent placement at
risk of urolithiasis during any 9-month period in susceptible cystoscopy. Percutaneous nephrostomy under ultrasound
persons, recurrent urolithiasis may indicate primary renal guidance has also been used as a temporizing procedure.
disease (medullary sponge kidney), transport diseases (renal Rarely and with considerably more fetal and maternal mor-
tubular acidosis), or metabolic diseases (hyperparathyroid- bidity, ureterolithotomy, pyelolithotomy/pyelotomy, or par-
ism). The fetal or maternal risk may reflect these systemic tial nephrectomy can be performed.
diseases rather than urolithiasis alone.
Most stones (70%) pass during the second or third tri- Previous Urologic Surgery
mester, with equal distribution between the right and left An increasing number of women are becoming pregnant who
sides. The presentation is more obscure during pregnancy; were born with urinary tract abnormalities that were cor-
the most common signs being severe flank pain (80%) rected surgically. These operations include urinary diversion
procedures (ileal conduit and ureterosigmoidostomy), “Ps”—that is, how the power pushes the passenger through
augmentation cystoplasty, and ureteral reimplantation for the passage. In a classic review, Power (1946) described the
vesicoureteral reflux. The changes in pelvic anatomy caused mechanism by which the fetus negotiates the birth canal
by the enlarging uterus create the potential for infection, and is expelled through the pelvic diaphragm as follows:
obstruction, and trauma at cesarean section.
Pregnancy in patients with a urinary diversion is com- As the flexed fetal head strikes the pelvic floor, the leva-
plicated by premature delivery, 20% to 50%; symptomatic tor ani muscle segments are funneled from behind and
UTIs, 15%; urinary obstruction, 10%; and intestinal obstruc- forward. The ischiococcygeus muscle is the first to receive
tion, 10%. Cesarean delivery should be reserved for obstetric the impact, but the head is often preceded by a dilating
indications. Although less commonly performed, a uretero- wedge of amniotic fluid and membranes that transfers
sigmoidostomy may be an indication to schedule a cesarean most of the pressure onto the front of the pubococcygeus
delivery to preserve the integrity of the anal sphincter. muscle. The anococcygeal raphe is pushed down until it
During the past 20 years, the treatment of patients with becomes vertical. The ischiococcygeus assumes a vertical
abnormal urinary tracts has changed from cutaneous diver- plane and acts as a deflecting surface for the descending
sion to patients who have had a continent internal diver- head, which is deflected downward and forward onto the
sion and augmentation cystoplasty, they may have also iliococcygeus.
undergone vesical neck reconstruction or artificial sphinc- After the resistance of the ischiococcygeus is overcome,
ter placement. This may place the patient at risk for the the head is shunted onto the pubococcygeus segment,
development of incontinence after vaginal delivery. Hill which is stretched anteroposteriorly and peripherally.
et al. (1990) reviewed 15 pregnancies in 15 women after The perineal body is pushed downward as the head is
augmentation cystoplasty. Eight of thirteen were continent propelled along the axis of the pelvic outlet. The recto-
before, during, and after pregnancy. One patient who was vaginal septum fibers are stretched peripherally and
continent before delivery became incontinent after vaginal longitudinally and often torn. As the outlet muscles—the
delivery. Four patients became incontinent during the last bulbocavernosus, ischiocavernosus, transverse perinei,
trimester, but regained continence postpartum. The preg- and periurethral muscles—are dilated, they are converted
nancies were complicated by UTIs (60%), preterm labor into a short muscular tube along the axis of the pelvic
(20%), and urinary obstruction (7%). Five cesarean deliv- outlet. Finally, as the biparietal diameter of the fetal head
eries were performed, three electively for vesical neck or reaches the transverse diameter of the pelvic outlet, the
artificial sphincter construction. One cesarean operation uterovaginal canal is converted into one continuous hia-
was complicated by extensive anterior uterine adhesions. tus. The lateral ligaments of the cervix uteri (endopelvic
Although stretching of the mesentery by the enlarging fascia) are flattened peripherally and stretched vertically.
uterus has the potential risk of vascular compromise, this The vagina is dilated spherically, and the pelvic dia-
complication was not seen in the 15 patients. phragm is changed from an oblique to a vertical plane.
Ureteral reimplantation has been performed routinely
for severe primary vesicoureteral reflux for many years. Much of Power’s description was based on his experi-
Austenfeld and Snow (1988) reviewed 64 pregnancies in ence and conjecture. During the past 15 years, advanced
34 women after ureteroneocystostomy for primary reflux. imaging and computer modeling have added an improved,
The overall infection rate before pregnancy was 48%. Dur- but by no means complete, understanding of the changes
ing pregnancy, 57% experienced a UTI. Pyelonephritis was that occur after labor and delivery (Fig 16.2).
more common during pregnancy (17%) than before preg-
nancy (4%). Of the 64 pregnancies, eight were lost between
9 weeks and 21 weeks, and six were associated with a UTI.
The authors did not report the route of delivery and the dif-
ficulty of cesarean section.
The latter reviews of pregnancies in women with urinary
tract surgery suggest the following obstetric management:
close monitoring for preterm labor (patient education, fre-
quent office visits, frequent pelvic examinations), suppres-
sive antibiotic therapy (nitrofurantoin 100 mg every night at
bedtime), monthly BUN and serum creatinine evaluation,
vigilance for ureteral obstruction, vaginal delivery except
for obstetric indications and patients who have undergone
urinary diversion to the sigmoid and bladder neck/sphinc-
ter surgery, and urologic consultation at cesarean section for
patients with a history of complex urologic surgery, espe-
cially augmentation cystoplasty.
Impact of Childbirth on Anatomy FIGURE 16.2 Sagittal magnetic resonance image of maternal pelvis
and Physiology during stage two of labor. (Reprinted with permission from Bamberg C,
Rademacher G, Güttler F, et al. Human birth observed in real-time open
You may likely have witnessed countless times the miracle magnetic resonance imaging. Am J Obstet Gynecol. 2012; 206:505.
of childbirth and you may also have likely considered the e1-e6.)
The risk of bladder injury is increased among patients with

Muscular Injury
four or more uterine incisions (1.5%) and cesarean hyster-
Lien et al. (2004) used sophisticated imaging and engineer- ectomy (1.7%).
ing techniques to develop a biomechanical model to describe Ureteral injury occurs in 0.09% to 0.6% of cesar-
changes in levator ani muscles as the fetal head descends ean operations and usually occurs in association with late
through the vagina (Fig. 16.3). The medial pubococcygeus
muscle reached an impressive stretch ratio (defined as tissue
length under stretch/original tissue length) of 3.26. Accord-
ing to the authors, this exceeds the greatest stretch ratio
(1.5) seen in passive striated muscle of nonpregnant women
by 217%. Increasing the fetal head diameter by 9% increased
medial pubococcygeus stretch by the same proportion. This
model suggests that the medial muscles of the levator ani
complex have the greatest risk for injury of all the levator ani
muscles during the second stage of labor. This supposition
is supported by magnetic resonance imaging (Fig. 16.4) and
three-dimensional/four-dimensional ultrasound (Fig. 16.5)
studies that reveal abnormalities in this area in 20% to 36% of
primiparous women after vaginal delivery (DeLancey et al.,
2003; Dietz and Lanzarone, 2005).
This evidence, including the observations so well made
by Power, is not a surprising consequence of pregnancy and
delivery. But why do some women go on to have prolapse or
incontinence whereas others are asymptomatic? It has been
demonstrated recently that women with PFDs are more
likely to have the levator ani injuries shown to be acquired
after delivery—certainly a very strong piece of evidence
against injuring this vital structure (Delancey et al., 2007;
Dietz, 2007).
Some of the answers about why some women develop
PFDs and others do not may be also provided by lessons
learned from rodent knockout models. Several investigators
have demonstrated that certain strains of mice are defi-
cient in proteins responsible for collagen and elastin syn-
thesis and homeostasis. Some of these strains will develop
prolapse spontaneously, such as in the fibulin-5 knockout
mouse (Wieslander et al., 2006). However, others, such
as the LOXL-1 knockout mouse (Liu et al., 2006), often
require a traumatic instigating event such as vaginal deliv-
ery to demonstrate the phenotype of prolapse. A defect in
connective tissue homeostasis can worsen tissue damage
that results from injury sustained during delivery resulting
from an inability to repair postpartum. The requirement for
effective repair and regeneration is likely applicable to the
muscular and nervous system injuries that follow pregnancy
and delivery, which generate a significant amount of interest
in using stem cells to aid in that regeneration (Pathi et al.,
2012; White et al., 2010).
Injury to Urinary Tract during Delivery

Injury to the urethra or bladder trigone from prolonged, FIGURE 16.3 Simulated effect of fetal head descent on the levator ani
obstructed labor or difficult operative deliveries is rare in muscles during the second stage of labor. (Top, left) A left lateral view
the developed world, but is still quite common in sub-Saha- shows the fetal head (round) located posteriorly and inferiorly to the
ran Africa, where it remains a scourge. On the other hand, pubic symphysis (PS) in front of the sacrum (S). The sequence of five
the dramatic increase in the United States in cesarean deliv- images at left show the fetal head as it descends 1.1, 2.9, 4.7, 7.9, and
eries from 5% to greater than 30% during the past 30 years 9.9 cm below the ischial spines as the head passes along the curve of
has increased the rates of bladder dome and ureteral injury. Carus (indicated by the transparent, gray, curved tube). The sequence
of five images at right are front left, three-quarter views correspond-
The reported prevalence of injury to the bladder is 0.19% of
ing to those shown at left. (Courtesy, Biomechanics Research Lab, Uni-
primary and 0.6% of repeat cesarean deliveries. Most blad- versity of Michigan, Ann Arbor, MI. Reprinted with permission from Lien
der injuries are associated with postsurgical (cesarean) adhe- K, Mooney B, DeLancey JO, Ashton–Miller JA. Levator ani muscle stretch
sions between the bladder and the lower uterine segment. induced by simulated vaginal birth. Obstet Gynecol 2004; 103:31.)
FIGURE 16.4 Axial and coronal images of a 38-year-old incontinent primiparous woman. The area where the pubovisceral portion of the leva-
tor ani muscle is missing (open arrowhead) between the urethra (U), vagina (V), rectum (R), and obturator internus muscle (OI) is shown. The
vagina protrudes laterally into the defects to lie close to the obturator internus muscle. A, arcuate pubic ligament. (Reprinted with permission
from DeLancey JO, Kearney R, Chou Q, et al. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery.
Obstet Gynecol. 2003; 101:46.)
Postpartum Urinary Retention

second-stage dystocia; deep uterine, cervical, or vaginal lac-
erations; or cesarean hysterectomy. Two-thirds of urinary Postpartum urinary retention occurs in 1.5% to 14% (Yip
tract injuries are identified at the time of surgery. The tech- et al., 2004) of deliveries, depending on the definition. Risk
nique and management of bladder and ureteral injury repair factors include nulliparity, long labor, operative vaginal deliv-
are described in Chapter 29. ery, and the use of regional anesthesia (Yip et al., 2005).
A B
FIGURE 16.5 Axial-rendered volume representation of the puborectalis–pubococcygeus complex on three-dimensional pelvic floor ultrasound
at 38 weeks of gestation (A) and 4 months postpartum (B). Both images were obtained on Valsalva maneuver. The arrows indicate a bilateral
avulsion injury, which was associated with markedly increased pelvic organ descent. (Reprinted with permission from Dietz HP, Lanzarone V.
Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106:707)
The inability to void spontaneously within 6 h after delivery delivery, with one group demonstrating a 10-fold greater
deserves careful attention, such as considering an indwell- risk when the perineal length decreased to less than 2.5 cm
ing catheter or intermittent catheterization for 12 to 48 h. (Deering et al., 2004).
However, the question regarding whether to screen for ele- Methods of reducing the incidence of perineal body
vated postvoid residuals after delivery remains unanswered, trauma have included supporting the perineum manually
in part because of the challenges of defining abnormal resid- during vaginal delivery as well as perineal massage. In a
ual volumes (50-200 mL) and determining a lasting effect Cochrane Review, regular antenatal perineal massage was
in women who void spontaneously, but incompletely, during shown to be an effective intervention, reducing the likeli-
the early postpartum period. hood of perineal laceration or episiotomy by 10% (Beck-
mann and Stock, 2013). There has not been a similar
benefit shown for any of the PFDs (Beckmann and Garrett,
Injury to Anal Canal
2006). In a German randomized trial at four centers, inves-
No documented cases are known of sonographically tigators used an inflatable silicone balloon connected to a
detected anal sphincter disruption following cesarean deliv- hand pump called the EPI-No birth trainer, and found a sig-
ery. However, cesarean delivery after labor onset is not nificant increase in an intact perineum (37.4% versus 25.7%;
entirely protective against postpartum fecal incontinence P = 0.05) (Ruckhäberle et al., 2009).
resulting from some other mechanism, potentially pelvic The plight of the perineal body, and its relationship not
nerve injury. only to the anal sphincter but also to the levator ani complex
Injury to the anal sphincter during childbirth likely has been questioned recently. The untested theory is that the
occurs either as a result of direct disruption of the muscles perineal body is a “fusible link” and it undergoes preferential
or because of injury to the pudendal nerves. The quoted stretching (and/or tearing) that protects against the extreme
incidence of sphincter laceration noted at the time of vagi- stretching believed to occur in the other pelvic floor constitu-
nal delivery ranges from 1% to 24%. The average incidence ents, such as the levator ani attachments to the pubic bone
ranges from 6.5% (0.4%-23.9%) in women with midline (Ashton-Miller and Delancey, 2009). In a potentially relevant
episiotomy, 1.3% (0.5%-2.0%) in women with mediolat- study germane to that question, nulliparous women were
eral episiotomy, and 1.4% (0%-6.4%) in women without randomized to use the EPI-No birth trainer or not. Although
episiotomy. the intervention showed a 50% decrease in sonographically
Because the perineal body anchors not only the super- detected levator ani avulsions, the result was not statistically
ficial perineal space, but also the deeper perineal space significant because the proportions of levator trauma were 6%
and the anorectum itself (Woodman and Graney, 2002), versus 13% (P = 0.19), rendering the sample size with too lit-
it also serves as a barrier between the vagina and rectum. tle power to demonstrate the difference (Shek et al., 2011).
Perineal body length has been reported to be approximately Endoanal ultrasound performed during the first months
3.8 cm–4.6 cm during the third trimester (Dua et al., 2009; postpartum reveals that as many as 35% of primiparous
Rizk and Thomas 2000), and was demonstrated by O’Boyle women and up to 44% of multiparous women have evidence
that the length of the perineal body may actually change of sphincter disruption. Other anal function studies, such
between early and late pregnancy in an adaptive manner as anorectal manometry and anorectal sensation testing,
(O’Boyle et al., 2002). Confirming the logical supposition, have also demonstrated that vaginal delivery has an effect
shorter perineal body length has been shown to be asso- on anal function. Chaliha et al. (2001) showed that, com-
ciated with greater risk of anal sphincter injury at vaginal pared with before delivery, vaginal delivery was associated
Table 16.4 Predictors of Anal Sphincter For example, in a study by Sultan et al. (1994), the pudendal
Disruption after Vaginal Delivery nerve terminal motor latency (PNTML) was not increased
in pregnant nonlaboring women compared with nonpregnant
Risk Factors Adjusted Odds Ratios* women. However, after vaginal delivery, Snooks et al. (1986)
Midline episiotomy 4.9-16.5 found that 42% of women had a prolonged PNTML, but
Nulliparity 2.5-4.0 this eventually recovered in most women by 2 months post-
Operative delivery 2.5-3.5 partum. Single-fiber electromyography (EMG) of the anal
Birth weight ≥4000 g 1.5-2.5 sphincter revealed an increased fiber density 2 months post-
Occipitoposterior presentation 1.2-1.8
partum. These findings were most striking in multiparous
*Numbers represent the minimum and maximum adjusted odds ratios women (suggesting a cumulative effect of vaginal delivery on
reported in the medical literature. the pelvic floor) and women delivered by forceps. No changes
in these parameters were seen in women who had delivered
by cesarean section. Five years after delivery, Snooks et al.
with decreased anal squeeze pressures and resting pres- (1990) reported there was manometric and neurophysiologic
sures, whereas no change in anal sensation was noted. Risk evidence of weakness because of partial denervation of the
factors for both overt and occult sphincter injuries include pelvic floor striated sphincter musculature, with pudendal
forceps, prolonged second stage, large birth weight, mid- neuropathy, which was more marked in those women with
line episiotomy, and occipitoposterior positions. Table 16.4 incontinence. In a prospective study by Allen et al. (1990),
describes the typical adjusted odds ratios for predictors of concentric-needle EMG was performed on the levator ani
anal sphincter disruption on multivariate analyses. In addi- before delivery as well as 2 and 5 days after delivery. After
tion, Richter et al. (2002) reported that vaginal birth after vaginal delivery, the duration of the motor unit potential was
cesarean delivery was an independent risk factor for anal increased, consistent with nerve damage. Eighty percent
sphincter disruption compared with previous vaginal deliv- of the women showed evidence of denervation with sub-
ery (RR, 5.46; 95% CI, 3.69-8.08), after adjusting for pri- sequent reinnervation after vaginal delivery. After elective
miparity, birth weight greater than 4000 g, forceps delivery, cesarean delivery, however, the motor unit potentials were
vacuum delivery, shoulder dystocia, and episiotomy. unchanged. In a more recent study, 12 weeks after a first
Randomized trials have also supported the association routine vaginal delivery, quantitative EMG parameters of the
between episiotomy and anal sphincter disruption. Harrison external anal sphincter demonstrated evidence of denerva-
et al. (1984) randomized 181 primigravid women to routine tion/reinnervation for the inferior hemorrhoidal (pudendal)
mediolateral episiotomy or to restricted use of mediolateral nerve; however, those undergoing cesarean delivery were not
episiotomy. The episiotomy group sustained rectal injury in evaluated (Gregory et al., 2004).
5 of 89 cases (5.6%) compared with no cases of rectal injury Some investigations are questioning whether cesarean
in the restricted group. Sleep et al. (1984) randomized delivery is truly protective. Investigators have found the
1000 women to liberal use of mediolateral episiotomy (51% PNTML to be prolonged after a cesarean delivery performed
of patients) or restricted mediolateral episiotomy (10% of in late labor (cervical dilation, 8 cm or greater), but not in
patients). A liberal policy toward episiotomy resulted in sig- women delivered by cesarean before they reached 8 cm dila-
nificantly more maternal vaginal trauma and more suturing. tion (Fynes et al., 1998; Allen et al., 1990). More recently,
The association between operative delivery and peri- though, South et al., (2009) demonstrated that 30% of pre-
neal trauma has also been studied in a randomized fashion. viously nulliparous women demonstrated EMG evidence of
Yancey et al. (1991) randomly assigned uncomplicated denervation of the levator ani muscles 6 weeks after deliv-
term gestations at 2+ station in occipitoanterior position to ery, including those who underwent cesarean delivery.
routine outlet forceps or to spontaneous delivery. Among
patients delivered by outlet forceps, the incidence of third-
or fourth-degree lacerations was 30 of 165 (18%) versus 12
Impact of Childbirth on Specific PFDs
of 168 (7%) in women who delivered spontaneously. Mid- As outlined earlier, significant anatomic and physiologic
line episiotomy and outlet forceps were the only factors changes occur as a result of pregnancy and delivery. Most of
associated significantly with rectal trauma on multivariate these findings have been made in the belief they are related
analysis. to the onset of PFDs, either immediately after delivery or
Incidentally, defects that appear to be traumatic sphinc- years after. In the following sections, we highlight some
ter injuries on ultrasound may not always be the case. of the evidence about how childbirth, and the method of
Three-dimensional imaging and anatomic studies combined childbirth, affect the risk of developing signs or symptoms
with magnetic resonance imaging have shown that both the of these disorders.
female and male anal sphincters have a variable natural gap
occurring along its anterior length. The natural gap seen on
Urinary Incontinence
ultrasound can be distinguished from a traumatic one by its
anterior uniform hypoechogenicity, smooth and uniform In the large, community-based 2005 to 2006 National
edges, and symmetry. Health and Nutrition Examination Survey, 1961 women
reported PFDs; 6.5% of nulliparous women had urinary
incontinence, but nearly 24% of women who had delivered
Neurologic Injury
more than three children leaked. There was a clear posi-
Earlier studies have suggested that labor and childbirth, but tive relationship between parity and increased prevalence
not pregnancy, are major risk factors for neurologic injury. of urinary incontinence. Nulligravid pregnant women leak
more often than their nonpregnant, nulliparous counter- Conflicting evidence exists about the role of other
parts. Indeed, numerous cross-sectional studies reveal that obstetric variables (besides vaginal delivery) on the develop-
25% to 75% of women report symptoms of stress urinary ment of SUI. Although some studies reported more SUI
incontinence (SUI) during pregnancy. In one of the few with prolonged second stage, increased head circumference,
prospective studies with long-term follow-up, Viktrup et al. increased birth weight, epidural anesthesia, and oxytocin
(1992) found that 32% of 305 primiparas developed SUI use, others did not. In prospective randomized trials, epi-
during pregnancy and 7% after delivery. By 1 year postpar- siotomy did not protect women from developing SUI after
tum, only 3% had SUI. However, in a subsequent follow-up delivery. Episiotomy also does not seem to affect PNTML,
of the same women 5 years later, Viktrup and Lose (2001) urethral closure pressure, or pelvic muscle strength.
reported that 19% of women with no symptoms after the Only one randomized trial has assessed the difference
first delivery had SUI; of women with SUI at 3 months in pelvic floor symptoms after planned elective cesarean
after delivery (most cases of which had resolved by 1 year), delivery or planned vaginal birth: the Term Breech Trial,
92% had SUI 5 years later. In a prospective cohort study conducted by Hannah et al. (2002). Questionnaires were
of 523 women, Burgio et al. (2003) reported that 13% completed 3 months postpartum by 1596 women from
reported urinary incontinence at 12 months postpartum. 110 centers around the world. Although the conclusions
This rate was similar to that at 3 months postpartum, but are limited by the large number of women in the planned
for most women the severity and frequency of leakage were vaginal birth group who, instead, delivered by cesarean, the
less 12 months later. Antepartum incontinence strongly pre- short-term results are of interest. Women in the planned
dicted postpartum incontinence. cesarean delivery group reported less urinary incontinence
Thus, it appears that the symptom of SUI occurs as a than those in the planned vaginal birth group (4.5% versus
natural consequence of pregnancy and delivery, and gen- 7.3%; RR, 0.62; 95% CI, 0.41-0.93). Other outcomes did
erally resolves or declines afterward in severity. Transient not differ. The lower rate of incontinence in this study,
postpartum incontinence, however, may be a marker for compared with others that assessed postpartum urinary
future persistent incontinence. incontinence, may be because women were queried about
Whether pregnancy itself or vaginal delivery is the risk urinary incontinence symptoms only during the week
factor for developing urinary incontinence in the majority before taking the questionnaire. In addition, women from
of women is still unclear. Particularly in younger women, different countries may interpret symptom questionnaires
vaginal delivery roughly doubles a woman’s chance of expe- differently.
riencing urinary incontinence, after adjusting for other
potential causes. Occasional urinary incontinence is com-
Fecal Incontinence
mon but often not bothersome; therefore, it may be more
appropriate to examine the impact of vaginal delivery on In large, prospective cohort studies of pregnant or newly
more clinically significant leakage. In a large Norwegian postpartum women, incontinence to both flatus and stool
population-based study, Rortveit et al. (2003) found that ranged from 6% to 25%. Vaginal delivery by forceps and,
women who delivered vaginally had a 2.2-fold greater risk in some cases, vacuum delivery increased the odds of post-
of moderate or severe urinary incontinence compared with partum fecal incontinence. As discussed previously, midline
those who delivered solely by cesarean (after adjusting for episiotomy is highly associated with sphincter injury but
other risk factors). They concluded that a woman’s risk does not appear, in most studies, to be an independent risk
of moderate or severe incontinence would be decreased, factor for fecal incontinence. Studies assessing the preva-
from about 10% to about 5%, if all her children were deliv- lence of fecal incontinence at various postpartum intervals
ered via cesarean. In a cross-sectional survey of women 5 in women with known sphincter tears reveal prevalence of
to 10 years out from a first delivery, Handa et al. (2011) incontinence of flatus of 17% to 59% and incontinence to
reported that 7% of women who had cesarean deliveries liquid and solid stool of 3% to 27%.
were incontinent, whereas 14% of those who delivered Few studies have been designed to examine the differ-
vaginally only were incontinent. In a prospective cohort ence in fecal incontinence after cesarean versus vaginal
study by Yip et al. (2003), in which women were moni- delivery, and the studies have contradictory findings. In a
tored for 4 years after their first vaginal delivery, the rates prospective study by Fynes et al. (1998), of 234 women
of SUI (defined as two or more episodes of incontinence attending a hospital antepartum clinic in Dublin, none of
occurring in the past month) were 21.1% in those with the 34 women who had a cesarean section reported fecal
and 28.6% in those without a subsequent delivery. Thus, incontinence. Similarly, Abramowitz et al. (2000) reported
one interval delivery did not increase the short-term risk that of 259 women who delivered consecutively at a sin-
of SUI. gle hospital, none of the 31 who delivered by cesarean
Although most studies do demonstrate a link between reported fecal incontinence compared with 13% of pri-
vaginal delivery and urinary incontinence in younger women, miparous women who delivered vaginally. In a large pro-
two facts warrant attention because they help to put the spective study by Chaliha et al. (1999), of 549 nulliparous
debate of the role of “prophylactic” cesarean deliveries into pregnant women, a greater proportion of women reported
perspective. First, in these studies, some women who deliv- fecal urgency after vaginal delivery than after cesarean
ered solely via cesarean also had moderate or severe incon- (7.3% versus 3.1%, respectively). In the Childbirth and
tinence. Second, the protective effect of cesarean delivery Pelvic Symptoms study completed by the Pelvic Floor
and nulliparity on urinary incontinence dissipates by age 50 Disorders Network in 2006, 17% of women who had sus-
to 60, such that older women have the same rate of urinary tained a sphincter tear had fecal incontinence versus 8% of
incontinence regardless of their delivery status. those who had a vaginal delivery without obvious sphincter
involvement (Borello-France et al., 2006). Interestingly, Parity increases the risk for both POP and surgery for
in the cohort of women who had a cesarean delivery, the POP. In women participating in the Women’s Health Ini-
rate of fecal incontinence was no different than the vagi- tiative, those who had borne at least one child were twice
nal delivery group, suggesting that cesarean delivery is not as likely to have uterine prolapse, rectocele, and cystocele
fully protective for the symptom of fecal incontinence, as nulliparous women, after adjusting for age, ethnicity,
even if sphincter injury is spared. body mass index, and other factors. Similarly, in a study of
The impact of delivery type on fecal incontinence appears 487 Swedish women, Samuelsson et al. (1999) reported
to decline with age. In a retrospective study by Nygaard that 31% had some degree of POP on examination; parity
et al. (1997), the reported prevalence of fecal incontinence and age increased the risk of POP, after adjusting for other
30 years after delivery was similar, regardless of delivery variables.
type. Most studies have not examined separately the effect In a British cohort study conducted by Mant et al.
of a third-degree versus a fourth-degree laceration on future (1997) of 17,000 women, parity was the variable related
bowel control. In a retrospective, single-site study by Fenner most strongly to surgery for POP. The risk increased with
et al. (2003), 831 women (29% response rate) completed a each child, but the rate of increase declined after women
bowel questionnaire 6 months after their first delivery. The were delivered of two children. In a case–control study,
incidence of worse bowel control than before pregnancy was Rinne and Kirkinen (1999) found that women younger than
nearly 10 times greater in women with fourth-degree lac- 45 years who underwent surgery for POP had more deliv-
erations (30.8%) compared with women with third-degree eries and heavier babies than age-matched control subjects
lacerations (3.6%). Although this difference may be the operated for benign ovarian tumors.
result of increased participation from women with more In a more recent cohort study out of Johns Hopkins in
symptoms, it is also possible that the greater incidence of which PFDs were compared with route of delivery, Handa
fecal incontinence associated with fourth-degree lacerations et al. (2011) demonstrated in women who were a median
may be the result of the loss of some of the internal anal of 7.4 years out from birth that 13% of the women who had
sphincter muscle. Further study is needed on the role of the spontaneous deliveries had prolapse on examination, but
internal anal sphincter in continence, and the best methods that only 3% of those same women had symptoms of pro-
of repairing this muscle at the time of rupture. lapse on validated questionnaires. Table 16.5 shows more of
Although some degree of fecal incontinence after sphinc- the data for prolapse and other PFDs.
ter disruption is likely related to impaired neurologic con-
trol of continence, separation of the repaired muscles may The Debate about Elective Primary
also play a role. Fitzpatrick et al. (2000) examined 154
women 3 months after primary repair of an anal sphincter
Cesarean Delivery
disruption. One-third had ultrasound evidence of a persis- No chapter about the effect of childbirth on PFDs is com-
tent, large (larger than one quadrant) anal sphincter defect; plete without mention of the ongoing debate about the
this was not influenced by whether the repair was done in role of elective primary cesarean delivery. Certainly, most
an end-to-end manner or an overlapping fashion. serious are concerns about greater mortality associated
with cesarean delivery. It is difficult to tease out morbidity
and mortality related to an elective cesarean delivery done
Pelvic Organ Prolapse (POP)
before labor versus that done not only after active labor, but
Pelvic organ support defects appear to occur during preg- also because of pregnancy complications that increase mor-
nancy but before delivery. O’Boyle et al. (2002) found that bidity. Perhaps more important, minimal information exists
nulligravid pregnant women were more likely to have POP that allows us to judge risk for a woman’s entire reproduc-
than their nulliparous counterparts. tive career; the information that does exist suggests strongly
Table 16.5 Odds of Pelvic Floor Disorders 5-10 years from First Delivery
At Least One
All Cesarean Births Cesarean Delivery
All Births Cesarean before Complete after Complete No Operative At Least One
Pelvic Floor before Active Labor Cervical Dilation Cervical Dilation Vaginal Births Operative Vaginal
Disorder (n = 192) (n = 228) (n = 140) (n = 325) Birth (n = 126)
Stress 1 (Reference) 0.88 (0.4-1.9) 1.30 (0.57-2.95) 2.87 (1.49-5.52) 4.45 (2.14-9.27)
incontinence
Overactive 1 (Reference) 0.74 (0.32-1.73) 1.17 (0.47-2.91) 1.66 (0.80-3.48) 4.89 (2.23-10.74)
bladder
Anal 1 (Reference) 1.12 (0.55-2.29) 1.48 (0.70-3.11) 1.62 (0.85-3.10) 2.22 (1.06-4.64)
incontinence
POP symptom 1 (Reference) 0.72 (0.12-4.42) 0.99 (0.16-6.13) 2.80 (0.73-10.81) 6.83 (1.68-27.80)
POP at or beyond 1 (Reference) 0.53 (0.13-2.27) 0.73 (0.17-3.13) 5.64 (2.16-14.70) 7.50 (2.70-20.87)
hymen
POP, pelvic organ prolapse.

Adapted from Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Munoz A. Pelvic floor disorders 5–10 years after vaginal or cesarean childbirth.
Obstet Gynecol. 2011;118777.
that severe complications increase dramatically after two obvious, extreme example of the trauma to the pelvic floor.
cesarean deliveries. However, nulliparous women also develop PFDs, although
Those in favor of a policy of primary elective cesarean not at as high a rate as parous women. Furthermore, most
support their decision with factors such as patient auton- parous women do not have surgery for PFDs. Both urinary
omy; concern over long-term adverse outcomes thought and fecal incontinence increase with age; indeed, studies of
to be associated with vaginal delivery, particularly PFDs; older nulliparous women find the same or greater rates of
avoidance of the greater morbidity associated with cesarean these disorders, as do studies of younger parous women.
delivery after the onset of labor; prevention of stillbirths The fact that older women have high rates of urinary and
that occur after 39 weeks by delivering preemptively via fecal incontinence does not, however, mean that childbirth
cesarean instead; and a decrease in the incidence of trau- is not one of the causes of these disorders, but that, in
matic birth injuries in neonates. older women, other factors (such as functional impairment,
Conversely, those opposed to allowing women a deliv- medical problems, and even age itself) assume much greater
ery choice cite the increased short-term morbidity, greater importance, thereby minimizing the role of childbirth. In
maternal mortality rate, greater neonatal respiratory com- younger and middle-age women, parity and vaginal delivery
plications, adverse effects on future pregnancies (in terms of remain important risk factors for PFDs. Additional research
both fertility and subsequent complications from repeated is needed to identify the group of women most at risk for
cesarean deliveries), greater cost associated with cesarean PFDs so that preventive efforts may be studied.
delivery, and dubious morality involved in turning a “natu-
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Obstetrics and Pelvic Floor Disorders: Chapter Outline

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Obstetrics and Pelvic Floor Disorders: Chapter Outline

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CHAPTER 16

changes in the cardiovascular, hematologic, renal, and

Table 16.1 Urologic Symptoms and Measurements in Pregnancy

The risk of bladder injury is increased among patients with

Injury to Urinary Tract during Delivery

Postpartum Urinary Retention

POP, pelvic organ prolapse.

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