Postpartum Pelvic Floor Dysfunction

Postpartum pelvic floor dysfunction is a group of problems arising from weakness, injury or abnormal tension of the pelvic floor muscles and their nerves after birth, including urinary and faecal incontinence, prolapse, pelvic pain and painful intercourse. It affects up to 30 to 50 percent of women in the first year after vaginal birth. It matters because it is common, often not reported, and responds to pelvic floor training.

• Risk factors: vaginal birth, instrumental delivery, third or fourth degree tear, large baby, long second stage, obesity, smoking, chronic cough, constipation, older age.
• Most improve in the first 6 months.
• Caesarean section lowers but does not remove the risk.

Women report leaking urine or stool, a sense of heaviness or a bulge in the vagina, pelvic pain, pain with intercourse, and difficulty emptying the bladder or bowel. Examination may show weak or tender pelvic floor muscles.

• Reduced squeeze strength.
• Vaginal bulge with cough or straining.
• Differential diagnosis: stress urinary incontinence, overactive bladder, faecal incontinence, pelvic organ prolapse, anal sphincter defect, vulvodynia, urinary tract infection, constipation, endometriosis.
• Complications: chronic incontinence, prolapse, sexual dysfunction, pelvic pain, depression, social isolation, reduced work and exercise.

The approach is history and focused examination.

• Questionnaire for bladder, bowel, prolapse and sexual symptoms; bladder and bowel diary for 3 days.
• Pelvic examination: perineal scars, tenderness, pelvic floor strength (Oxford scale 0 to 5), prolapse grading (POP-Q), anal tone and squeeze.
• Urine dipstick and culture; residual urine by ultrasound.
• Endo-anal ultrasound or MRI for suspected sphincter or levator ani injury, and urodynamic tests, only if symptoms are complex.

The principle is supervised pelvic floor muscle training for all women with symptoms, plus treatment of the specific problem.

• Supportive: pelvic floor muscle training: 8 to 12 contractions held for 6 to 8 seconds, 3 times daily for at least 3 months, started in the first weeks after birth; weight loss to a body mass index below 25 kg/m2; avoid heavy lifting for 6 weeks; treat constipation and cough; stop smoking; reduce caffeine; gradual return to exercise; biofeedback.
• Pharmacological: lactulose 15 mL oral 12-hourly and ispaghula husk 3.5 g oral 12-hourly for constipation; vaginal oestradiol 10 micrograms tablet at night for 2 weeks then twice weekly for 3 months for vaginal dryness during breastfeeding; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) for pelvic pain; cefalexin 500 mg oral 6-hourly for 5 days for urinary infection.
• Procedures: continence or prolapse pessary; electrical stimulation; trigger point release and physiotherapy for hypertonic muscles; surgery for incontinence or prolapse after 12 months and after childbearing is complete; sphincteroplasty for sphincter defect with persistent symptoms.
• Special groups: women with a third or fourth degree tear need combined anorectal and pelvic floor care and counselling on mode of birth in a later pregnancy.
• Red flags: faecal incontinence, urinary retention, haematuria, constant leakage (fistula), severe pelvic pain, irreducible prolapse, neurological symptoms.
• Follow-up: review at 6 weeks and 3 months; referral to a specialist physiotherapist or urogynaecologist if symptoms persist at 6 months; review before any later birth.