Arch Gynecol Obstet (2002) 267:14–18
O R I G I N A L A RT I C L E
Y.E. Erata · B. Kilic · S. Güçlü · U. Saygili · T. Uslu
Risk factors for pelvic surgery
Received: 11 June 2001 / Accepted: 25 September 2001
Abstract One hundred and eighty four women who had
corrective surgery for stress incontinence, genital pro-
lapse or both were compared with two hundred and nine-
ty women who had no surgery for these conditions. Pa-
tients and controls did not differ in terms of age, height,
weight or body mass index. Younger age at first delivery
(20.1±4.1 vs 22.8±4.9, p<0.000) and a smoking history
(33.2% vs 23%, p<0.015) were found as risk factors for
the study group. Women who underwent surgery had
greater gravidity (4.85±2.9 vs 3.87±2.5, p<0.001), great-
er parity (3.03±1.9 vs 2.19±1.3, p<0.000), were less
often nulliparous (2.2% vs 7.9%, p<0.008), less likely to
have had a cesarean delivery (1.1% vs 9%, p<0.001) and
more likely to have had a vaginal delivery (97.3% vs
85.9%, p<0.000) than the control group. The study group
have had larger neonates on average (3800±416 vs
3373±637 gm’s, p<0.000) and had greater use of forceps
or vacuum extractor for at least one delivery (17.9% vs
7.6%, p<0.001). Highly significant relationship was
found between the risk of having corrective surgery and
the number of children born vaginally. Women who had
4 or more vaginal deliveries had 11.7 times more risk of
urinary incontinence or genital prolapse.
Keywords Urinary incontinence · Genital prolapse ·
Risk factors · Epidemiology · Surgery
Introduction
Pelvic organ prolapse and adult urinary incontinence
(UI) are substantial health problems for women in many
countries. In a cohort of the Kaiser permanente North-
Y.E. Erata (✉) · S. Güçlü · U. Saygili · T. Uslu
Dokuz Eylül Üniversitesi,
Tip Fakültesi Kadin Hastaliklari ve Doǧum A.B.D.
35350 İnciralti/ İzmir, Türkei
Fax: ++00902322781581
e-mail: Yakup.erata@deu.edu.tr, Yakup.erata@turk.net
B. Kilic
Department of Public Health, Inciralti, Izmir, Turkey
© Springer-Verlag 2002
west, the lifetime risk of undergoing a single operation
for prolapse or incontinence was about 10%. UI being
the indication for surgery in about 55% of cases [13].
Despite increasing interest in medical literature, the
epidemiological characteristics of women with genital
prolapse and UI are still poorly understood. In particular
very few studies considered risk factors [8, 16]. Factors
which are suggested to contribute to these problems are
parity, advancing age, ethnicity, chronically increased in-
traabdominal pressure, estrogen deficiency, smoking,
connective tissue disorders, neurological injury, and
prior histerectomy [4, 7, 24]. Many of these risk factors
relate to obstetric events.
Historically, obstetric damage to the pelvic floor
could be a catastrophe for women in developing coun-
tries, and sometimes resulted in fistula formation and
genital prolapse [5]. With modern obstetric care these
grave complications are rare; however, obstetric trauma
may still cause an insult to the pelvic floor that, com-
bined with other contributing factors such as obesity and
aging, results in delayed complications of urinary incon-
tinence and pelvic organ prolapse. Several studies have
shown associations between pregnancy, delivery and
stress urinary incontinence but the results are not consis-
tent [9, 12, 15, 25]. Multiparity compared with uniparity
is associated with an increased risk for stress urinary in-
continence in some studies [9, 15] whereas other studies
found no such association [6, 17]. The degree of trauma
is likely to be affected by various condition-events, and
interventions during pregnancy and delivery. Women de-
livered by cesarean seem to have less risk of later stress
urinary incontinence than those delivered vaginally ac-
cording to some studies [26, 27], but not according to
another study [11]. No good data is available regarding
the possible relationships between fetal presentation,
multiple birth, or maternal age at the time of delivery for
later development of genital prolapse and stress urinary
incontinence.
This study was undertaken to expand knowledge of
potential obstetric risk factors involved in the occurrence
of urinary incontinence and pelvic organ prolapse. Pa-
 15
Table 1 Demographic and
descriptive characteristics of Variable Cases n Controls n p
cases and controls
Mean age±SDa [years] 52.0±11.4 184 50.4±6.3 290 0.078
Mean weight±SD [kg] 67.3±8.3 184 67.8±10.4 286 0.621
Mean height±SD [m] 1.61±5.0 181 1.61±5.5 286 0.491
Mean body mass index±SD [kg/m2] 25.9±3.4 181 26.3±4.1 285 0.237
Mean age at first delivery±SD [years] 20.1±4.1 179 22.8±4.9 263 0.000
Mean age at last delivery 27.8±5.1 179 28.4±4.8 260 0.173
a
Smoking [%] 33.2 184 23.0 287 0.015
SD Standard Deviation

Table 2 Obstetrics and delivery characteristics of cases and controls

Variable Cases n Controls n p

Nulliparous [%] 2.2 184 7.9 290 0.008

Mean gravidity±SD [number] 4.85±2.9 184 3.87±2.5 290 0.000
Mean parity±SD [number] 3.03±1.9 184 2.19±1.3 290 0.000
Mean abortus±SD [number] 1.82±2.0 184 1.68±1.9 290 0.453
Mean vaginal delivery±SD [number] 3.01±1.9 184 2.06±1.3 290 0.000
Mean cesarean section±SD [number] 0.02±0.2 184 0.13±0.4 290 0.000
No. with at least 1 cesarean section [%] 1.1 184 9.0 290 0.001
No. with at least 1 vaginal delivery [%] 97.3 184 85.9 290 0.000
Episiotomy [%] 43.5 184 47.9 290 0.343
Perineal tear [%] 7.1 184 9.3 290 0.391
No. with at least 1 delivery with epidural analgesia [%] – 184 1.4 290 0.161
No. with at least 1 delivery with forceps or vacuum [%] 17.9 184 7.6 290 0.001
Mean baby birth weight at first delivery±SD [g] 3800±416 131 3373±637 255 0.000

tients were well suited for this study as many had had
both obstetric care and surgical repair for incontinence or
pelvic organ prolapse at the same institution.
Materials and methods
calculated for measurable variations. Student’s t test or chi-square
is performed as statistical comparisons between two groups. More
than two groups ANOVA or chi square for trend are used. Odds
Ratios and 95% Confidence Intervals are calculated in each group
compared with 0 group or all other subgroups for some variables.
Logistic regression and correlation results are also used for some
situations.

This was a retrospective case control study of women who under-

went surgical treatment for adult urinary incontinence or pelvic
organ prolapse between February 13, 1995, and November 15,
1999 at the hospital of Dokuz Eylul University. The study group
was composed of one hundred and eighty four women who under-
went corrective surgery for urinary incontinence (n=62), pelvic
organ prolapse (n=59) or both (n=63) and whose obstetric history
was obtainable through chart reviews.
Subjects were identified by medical records search (by the ap-
propriate surgical procedure codes). Once identified, a detailed
chart review was performed collecting data that included patients
age, height, weight, smoking history, gravidity, parity, abortuses
and vaginal or cesarean delivery. Spesific delivery data, including
maternal age at delivery, mode of delivery (vaginal, forceps, vacu-
um, cesarean) were also reviewed and entered into a computerized
data base. Neonatal birthweight was not available in all cases
(n=131).
The control group was composed of 290 women. In this group
120 women had gynecologic operations other than corrective sur-
gery for urinary incontinence or prolapse and their obstetric histo-
ry was obtainable through chart reviews. The rest of the control
group (n=170) consisted of women who visited our gynecology
and menopause policlinics and were asked to complete a detailed
questionnaire with information regarding their obstetric, gyneco-
logic and urologic history. Only women who completed the entire
questionnaire and who had not undergone surgical correction of
the study disorders were included in the data analyses. Neonatal
birthweights were not available in all cases in the control group
also (n=255). The study and control groups were analyzed and
compared by demographic, obstetric and delivery characteristics
and several factors affecting urinary incontinence.
In this research all data was analyzed on the computer using
SPSS 8.0 statistical program. Means and standard deviations are
Results
The mean age was 51.0±8.6 years for all women (medi-
an age –50, minimum age 30, maximum age 88). There
was no significance between case and control groups ac-
cording to age groups (linear by linear association). Pa-
tients and controls also did not differ in terms of height,
weight or body mass index. Younger age at first delivery
(20.1±4.1 vs 22.8±4.9, p<0.000) and smoking history
(33.2% vs 23%, p<0.015) were found as risk factors for
the study group (Table 1).
Table 2 summarizes obstetric and delivery character-
istics of both groups. Women who underwent surgery
had greater gravidity (4.85±2.9 vs 3.87±2.5, p<0.000),
greater parity (3.03±1.9 vs 2.19±1.3, p<0.000), were less
often nulliparous (2.2% vs 7.9%, p<0.008), less likely to
have had a cesarean delivery (1.1% vs 9%, p<0.001) and
more likely to have had a vaginal delivery (97.3% vs
85.9%, p<0.000) than the control group. The study
group have had larger neonates on average (3800±416 vs
3373±637 gm’s, p<0.000) and had a greater use of for-
ceps or vacuum extractor for at least one delivery (17.9%
vs 7.6%, p<0.001).
Table 3 summarizes general obstetric data categorized
by surgical indication (incontinence alone, prolapse
alone, both). The distribution of indications for 184 cor-
16
Table 3 Comparision of ob-
stetric characteristics by indica- Variable Incontinence Prolapse Both p
tion for corrective surgery (n=62) (n=59) (n=63)

Mean gravidity±SD [number] 4.55±2.7 5.08±3.1 4.92±2.9 0.574

Mean parity±SD [number] 2.58±1.3 3.19±2.0 3.32±2.2 0.069
Mean abortus±SD [number] 1.97±2.1 1.90±1.9 1.60±2.1 0.572
Mean vaginal delivery±SD [number] 2.56±1.2 3.15±2.0 3.32±2.2 0.068
No. with at least 1 vaginal delivery [%] 96.8 94.9 100 0.076

Table 4 Odds ratios for later

corrective surgery according to Number Vaginal delivery Parity
vaginal delivery and parity
ORa 95% CI ORa 95% CI

0 1.0 – 1.0 –
1 2.48 0.69–9.38 1.99 0.49–8.55
2 4.58 1.64–13.77 3.61 1.14–12.64
OR odds ratio, 3 8.37 2.84–26.44 6.48 1.95–23.72
CI confidence interval 4 or more 11.75 3.84–38.48 9.00 2.64–33.80
a OR is calculated for each
Total 5.89 2.17–17.32 4.62 1.50–15.85
group comparing with 0 group

Table 5 The results of logistic

regression model (n=379) Variable B p OR 95% CI

At least 1 delivery with forceps ar vacuum 0,8209 0,0196 2,27 1,14–4,53

Smoking 0,6816 0,0126 1,98 1,16–3,38
Number of vaginal delivery 0,2471 0,0336 1,28 1,02–1,61
Baby’s birth weight at first delivery 0,0011 0,0000 1,0011 1,0006–1,0016
Mother’s age at first delivery –0,1254 0,0006 0,88 0,82–0,95
Body mass index –0,0669 0,0497 0,94 0,82–0,95
Constant –1,1442 0,4435 – –

rective surgery cases were 33.7%, 32.1% and 34.2%, in-
continence, prolapse and both respectively. According to
analysis of variance (ANOVA) results there is no signifi-
cant relationship between groups. Women who had sur-
gery for either prolapse alone, incontinence alone or for
both prolapse or incontinence did not differ in terms of
having had a vaginal delivery (96.8% incontinence alone
vs 94.9% prolapse alone vs 100% both, p<0.076).
OR’s for having corrective surgery according to the
number of infants delivered by the women vaginally and
parity are shown in Table 4. As shown in the table, there
is a statistically highly significant relationship between
the risk of having corrective surgery and the number of
children born vaginally and parity. (Total-Vaginal deliv-
ery 5.89, 95% CI 2.17, 17.32 – Parity 4.62, 95% CI 1.50,
15.85). Women who had 4 or more vaginal deliveries
had 11.7 times more risk of urinary incontinence or geni-
tal prolapse.
The risk factors were evaluated together by logistic
regression model. Logistic regression results are given in
Table 5. According to this model using forceps or vacu-
um on at least one delivery, smoking, number of vaginal
deliveries and birth weight of baby at first delivery cause
a high risk of corrective surgery.
Discussion
The results of this analysis suggest that women who un-
dergo surgical management of pelvic organ prolapse or
adult urinary incontinence have a different obstetric his-
tory than those who do not have surgical correction.
These differences include gravidity, parity, route of deliv-
ery, maternal age at first delivery, smoking history, mean
birthweight and the use of forceps or vacuum at delivery.
The literature suggests that parity is a factor in both
adult female urinary incontinence [6] and pelvic organ
prolapse [13]. In our study the cesarean section and the
vaginal route for delivery was significantly higher in the
control and surgery groups respectively. In pathogenetics
terms, childbirth can be considered as a cause of damage
to the pelvic connective tissues and nerves, leading to
urogenital prolapse and/or incontinence. Vaginal delivery
may result in significant pelvic floor tissue stretching
and pudental nerve damage, which may then lead to
laxity of the pelvic ligaments [22]. Histochemical and
histological studies of pelvic floor muscle biopsies from
women with urogenital prolapse and stress incontinence
have provided evidence of muscle fiber damage and par-
tial denervation of pelvic floor muscles [10]. It is likely
that denervation of the pelvic floor and muscle fiber
damage are the first steps along a path leading to pro-
lapse and stress incontinence. Denervation may progress

with aging and further denervation is likely to occur with
subsequent deliveries [20]. However not all data is con-
sistent on this issue [18, 21, 22]. For example Smith et
al. [18] found no relationship between pelvic floor den-
ervation in women with prolapse and their obstetric his-
tory. In particular, there was no relationship between the
number of pregnancies and the degree of pelvic floor
denervation.
We found a negative association between stress in-
continence and age at first delivery, but no such associa-
tion with age at last delivery. This finding is in contrast
to a study by Persson et al. [14] and doesn’t support their
suggestion of increasing vulnerability of the pelvic floor
with age in women with no previous delivery.
There is little information on the relationship between
smoking and the risk of UI. In principle it is conceivable
that smoking, that causes coughing, may induce UI. Our
study confirmed this. In a large prospective investigation
of postmenopausal women conducted in the Pitsburgh
area, no relationship emerged between smoking and UI
risk [25].
The impact of various interventions and events during
labor and delivery on the development of stress inconti-
nence, including forceps/vacuum delivery, episiotomy,
spontaneous perineal tear and epidural analgesia, is con-
troversial [2, 3, 6, 17, 23, 27]. We found no association
between the use of episiotomy or spontaneous perineal
tear and later development of stress urinary incontinence
or genital prolapse. We found forceps/vacuum delivery
and high birth weight as predisposing factors leading to
urinary incontinence and genital prolapse. It can be sug-
gested that these two factors are associated with more
severe pelvic floor denervation. Snooks et al. [19] sug-
gested that birth weight is related to pudental nerve dam-
age, implying that the passage through the birth canal is
itself a major factor leading to denervation of pelvic
floor muscle.
In a retrospective study a positive association between
epidural analgesia and later incontinence surgery was
found and the authors suggested that epidural analgesia
might have indirectly promoted stress incontinence by
prolonging the second stage of labor [1]. In our study un-
fortunately no women in the study group had epidural an-
algesia during their labor because in the years that they
delivered their children epidural analgesia was not a com-
mon procedure in obstetric clinics in Turkey. So we are
not able to make comments on this issue in this study.
An association between the number of vaginal deliv-
eries and stress incontinence has been reported previous-
ly [9, 12, 15]. In this study, every birth seems to be very
harmful to the pelvic floor; subsequent deliveries severe-
ly increase the risk for incontinence. The OR’s increased
approximately by two folds for every vaginal birth. Un-
fortunately, we have no information on when inconti-
nence symptoms started, ie, after which birth stress uri-
nary incontinence developed. Thus, it is possible that the
symptoms tended to start after the first birth and the
severity of symptoms increased parallel to increasing
number of vaginal births.
17
We acknowledge two limitations of this study. First
the population was completely white, and our findings
may not be applicable to other ethnic groups. Second the
interval between obstetric events and surgery or comple-
tion of the questionnaire may have resulted in inaccurate
reporting of data in some cases.
Although larger epidemiologic studies are required,
our findings have important implications for clinicians
counseling women regarding potential late complications
of vaginal delivery. These findings enhance our under-
standing of potential pathophysiologic obstetric pro-
cesses involved in occurrence of pelvic organ prolapse
and adult urinary incontinence.
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