Pelvic floor dysfunction after childbirth : symptoms, diagnosis, treatment

Abstract

Vaginal delivery is a trauma to the levator ani muscles, the perineal muscles, and the anal sphincter complex (1-3). A levator ani deficiency cannot be surgically remedied and increases the risk of pelvic floor dysfunction later in life (4-6). Contrarily, an injury to the perineal body can be sutured directly following vaginal birth, however, perineal trauma may in the aftermath result in a deficient perineum. There is a lack of knowledge regarding the natural history of recovery after vaginal childbirth, which symptoms are reported, and how high the prevalence of persistent symptoms is. Thus, there is a need for improved tools to identify and diagnose women displaying symptoms of deficiencies in either level of the pelvic floor and develop refined treatment options, with the ultimate goal of improved quality of life. Therefore, the overall aim of this thesis was to explore the symptoms, diagnostics, and possible surgical treatment associated with a deficient perineum and concomitant levator ani muscle defects.

Study I was a prospective cohort study investigating symptoms in non-instrumentally delivered primiparas with no more than a second-degree perineal tear, one year after delivery. In total, 410 women completed an inventory of questions encompassing fecal incontinence, bowel emptying difficulties, and sexual dysfunction. The results showed that symptoms from the posterior compartment were common irrespective of the extent of the perineal tear. In conclusion, these symptoms must be considered and addressed in all women after vaginal delivery.

Study II was an observational study to evaluate how consistently different raters can assess levator ani defects using the Levator Ani Deficiency (LAD) score system in a subsample of primiparas from study I. In addition, rates of LAD in this low-risk subsample were estimated. By using two different endovaginal probes, three-dimensional ultrasound volumes of 141 women were assessed on two occasions. Correlations of scores and categories within and between raters and probes were calculated using Kendall’s tau-b coefficient. Overall, intra- and interrater, and -probe correlations were very high with correlations for intrarater comparisons of >0.79 and interrater comparisons of >0.78. However, the rate of LAD in this low-risk subsample was, as expected, low, 13-15% had scores correlating to a moderate or severe injury. In conclusion, the LAD scoring system can be reproduced consistently.

Study III was a mixed methods study to construct and initially validate an inventory to estimate symptoms of a deficient perineum. The preliminary inventory was tested on 170 patients diagnosed with a deficient perineum and results were compared to 54 primiparous women one year after elective caesarian section and 338 nulliparous women. Results showed that the final 11-item inventory, the 'Karolinska Symptoms After Perineal Tear Inventory' (KAPTAIN) could discern patients with symptoms such as an acquired sensation of wide vagina, vaginal flatulence, and bowel emptying difficulties, from the two control groups with high sensitivity (100%) and specificity (87–91%) when using a cut-off of 8 points out of a maximum score of 33 points. To conclude, the KAPTAIN inventory can detect symptomatic women with high accuracy and might be used to identify women in need of further support and investigation after vaginal birth.

Study IV was a follow-up study one year after standardized perineal reconstructive surgery of 131 patients with long-term symptoms of a deficient perineum. Patients with symptoms e.g., an acquired sensation of wide vagina, and a confirmed perineal body defect, completed the KAPTAIN inventory preoperatively and at one-year follow-up. All patients were examined with 3D ultrasound to evaluate concomitant LAD. The hypothesis that the primary outcome “sensation of wide vagina” would not improve as much in patients with LAD as in patients with an intact levator ani muscle was rejected. There was an overall significant score reduction after surgery for the whole group. In conclusion, a standardized perineal reconstruction can alleviate symptoms of a deficient perineum independent of LAD.