Assessment of lower urinary tract symptoms 6 weeks after delivery and the relationship of pelvic floor muscle function

doi:10.21203/rs.3.rs-4364318/v1

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Assessment of lower urinary tract symptoms 6 weeks after delivery and the relationship of pelvic floor muscle function

https://doi.org/10.21203/rs.3.rs-4364318/v1

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Background

There are few studies of lower urinary tract symptoms (LUTS) in women with different modes of delivery after 42 days. It is doubtful whether the onset of LUTS is related to the decline of pelvic muscle function after delivery.

Methods

This was an observational study conducted at Peking University First Hospital from 2019 to 2022. A total of 2462 women were recruited and interviewed 42 days after delivery using questionnaires, and gynecological physical examinations and pelvic floor muscle screening were performed. A modified Chinese Bristol Female Lower Urinary Tract Symptoms questionnaire was administered. The participants were asked about the presence of individual LUTS and rated the level of bother caused by those symptoms. Descriptive statistics, χ² tests, one-way ANOVA and multivariate logistic regressions were used for data analysis.

Results

The prevalence of any LUTS, storage symptoms, or voiding symptoms was 70.6%, 65.4%, and 23.0%, respectively. Nocturia was the most common symptom (35.4%), followed by frequency (25.6%), urgency (25.3%) and stress urinary incontinence (SUI; 20.8%). Nocturia and frequency were not frequently rated as bothersome (38.0%, 21.5%). Urinary incontinence (UI) was the most frequently reported as severely bothersome (SUI 15.6%, urge urinary incontinence (UUI) 15.3%). Vaginal delivery (VD) and forceps delivery (FD) were strong predictors of LUTS (P < 0.05). Compared with cesarean section (CS), VD, especially FD, was associated with lower surface electromyography (sEMG) activity, including resting baseline and contraction amplitude (P < 0.001).

Conclusions

More than half of women experienced LUTS 42 days after delivery. Nocturia, frequency, urgency, and SUI were the most prevalent LUTS. Straining and UI were most frequently reported as bothersome, while UI caused severe discomfort. VD, especially FD, was more likely to cause pelvic floor muscle or nerve damage and was the strongest predictor of storage LUTS.

Lower urinary tract symptoms (LUTS)

Prevalence

Potential risk factors

Bother

Pelvic floor muscle function

Lower urinary tract symptoms (LUTS) have attracted substantial attention in recent years, partly due to their high prevalence but primarily because of the heightened awareness of their detrimental impact on health-related quality of life ¹. While LUTS are common in women and have a negative impact on quality of life, most women do not seek treatment ^2,3. While numerous effective treatment options for LUTS exist, there is sparse evidence informing optimal bladder health promotion and LUTS prevention strategies. Most primary prevention trials focus purely on one particular symptom. Evidence supports the use of pelvic floor exercise programs for the prevention of urinary incontinence (UI) during pregnancy, but outcomes for other LUTS, such as voiding dysfunction or pain, are unknown ^4–7. Pregnancy and vaginal birth are known risk factors for UI secondary to pelvic floor musculature and nerve injury ^8–11. The postpartum period is a time in which women recover and take on new roles. Some traditional practices are observed to ensure recovery and prevent ill health in later years ¹². UI can be prevented and promoted at this important time. However, there are few data on LUTS in these women. By examining the effects of labor management practices on urological outcomes across this important time, researchers will be well positioned to inform policies and practices governing maternity care.

The aim of this study was to provide estimates of the prevalence and potential risk factors for LUTS and the burden they impose on women with different modes of delivery after afte 6 weeks and the relationship between pelvic floor function and different kinds of LUTS.

2.1. Study design and participants

Beginning in January 2019, we collected data from women who had postpartum reviews at 6 weeks after delivery in outpatient clinics at Peking University First Hospital. The eligibility criteria stipulated postpartum women without urinary incontinence before pregnancy. We excluded women who: (a) were medically diagnosed with cognitive impairments and who could not understand the questions,(b) had parity ≥ 3,(c) with multiple pregnancy,(d) combined with pelvic organ prolapse(Stage 2 or higher),(e) with history of anti-incontinence or pelvic organ prolapse surgery or urinary surgery history;(f) with malignant tumor,(g) with urinary tract infection,(h) do not want to participate. Questionnaires were used to investigate these women. They also underwent a gynecological examination and pelvic floor muscle screening (PFM screening). Ethics committee approval and oral consent were obtained. The participants were asked to complete this questionnaire every year after delivery.

We calculated the sample size according to our previous national study ¹³. We aimed to survey at least 3 different delivery modes. A minimal sample size was calculated to detect a 55.5% prevalence of LUTS, with a 5% estimated error and a 95% confidence interval (CI). Considering a 20% refusal rate, a total of 1367 participants would be required for the LUTS reanalysis according to this formula:

N = Z_α/2² × (π × (1 − π)) / δ² × 3 × (1 + 20%) = 1.96² × (55.5% × (1–55.5%)) / 0.05 ² × 3× (1 + 20%) ≈ 1367.

2.2. Measurements

We used a Chinese version of the International Consultation on Incontinence Questionnaire–Female Lower Urinary Tract Symptoms (ICIQ-FLUTS)¹⁴. This questionnaire included an assessment of 10 types of LUTS: nocturia, daytime frequency, urgency, UUI, SUI, other incontinence, pain or burning, hesitancy, straining, and intermittency. Participants were asked to rate how often individual LUTS were experienced and, if LUTS were experienced, to what degree the symptoms were bothersome. The prevalence of other LUTS was defined by answers other than no. The bother associated with each symptom was evaluated using a scale ranging from 0 (not bothered at all) to 10 (greatly bothered). Bother was also defined by dividing the Likert responses into three groups: minor (scores of 1–4), moderate (scores of 5–7), and severe (scores of 8–10). Information on sociodemographic background, reproductive factors, defecation, and medical conditions was also collected in detail.

2.3. Diagnostic criteria

The definitions in this study were consistent with the standards recommended by the 2002 International Continence Society (ICS) guidelines¹⁵. In our study, nocturia was defined as two or more micturitions per night. Daytime frequency was defined as voiding eight times or more per day. Those who reported UI without symptoms of UUI or SUI were categorized as having other UI. Cesarean section performed after cervical dilation ≥ 1cm were categorized as CS in labor, otherwise, it is defined as CS not in labor.

2.4 Pelvic floor muscle screening (PFM screening)

All participants underwent a gynecological physical examination and PFM screening. The bioelectrical activity of the PFMs was recorded using equipment (Nanjing Medlander Company, China) following the Glazer protocols ¹⁶. The patient was placed in the supine position, and the hips and knees were gently flexed. Two monitoring electrodes were placed on the iliac region, and the other two electrodes were placed on the two sides of the hypogastric region. After the vaginal electrode was placed, participants were asked to perform a series of contraction and relaxation actions according to voice commands. The following surface electromyography (sEMG) signal parameters were recorded: (1) one 60-s rest time (prebaseline): the average mean amplitude (µV) and mean amplitude variability (%); (2) five 2-s phasic (flick) contractions with a 2-s rest time: the average peak amplitude (µV), time before peak (s) and time after peak (s); (3) five 10-s tonic contractions, with a 10-s rest between each: the average mean amplitude (µV) and mean amplitude variability (%); and (4) one 60-s rest time (postbaseline): the average mean amplitude (µV) and mean amplitude variability (%).

2.5. Statistical analysis

We performed χ² tests to compare the prevalence differences between the groups. A multivariable model was set up to assess bother and individual LUTS-related potential risk factors and to estimate odds ratios and 95% CIs; this model was adapted for all factors in the final version. A two-sided P value ≤ 0.05 was considered statistically significant. One-way ANOVA was used with Bonferroni correction. EpiData software was used for data entry and error detection. SPSS v.12.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis.

2.6 Patient and public involvement

Patients were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

As shown in the flowchart (Fig. 1), we enrolled 2900 participants at baseline, data from 2462 (85.1%) participants were ultimately entered into our data analyses. The age distribution ranged from 20 to 46 years, with a mean age of 32.4 years (±3.8 years). Overall, 1274 participants (51.7%) had vaginal deliveries (VDs), 692 (28.1%) women had cesarean section (CS) deliveries (not in labor), 236 women (9.6%) had CS deliveries (in labor), and 260 (10.6%) women had forceps deliveries (FDs). A total of 525 (21.3%) women had delivery histories. Table 1 shows the sociodemographic characteristics of the participants.

3.1. Prevalence of lower urinary tract symptoms

The frequencies of individual LUTS are shown in Table 2. The prevalence of any LUTS was 70.6% and varied with different delivery modes (P< 0.001). Storage symptoms were more prevalent than voiding symptoms (65.4% vs. 23.0%). Storage LUTS were more prevalent in women with VDs and FDs than in those with CS deliveries (70.3% with VDs, 73.5% with FDs, 53.4% with CS deliveries who were in labor and 57.4% with CS deliveries who were not in labor). Nocturia was the most common symptom (35.4%) and varied with different delivery modes (P< 0.001, 34.8% with VDs, 46.5% with FDs, 38.1% with CS deliveries who were in labor and 31.5% with CS deliveries who were not in labor), followed by frequency (25.6%). However, there was no significant difference in frequency between those with VDs and CS deliveries. Urgency (25.3%) and SUI (20.8%) were also prevalent and varied with different delivery modes (P< 0.001). Straining was the least common symptom (6.1%) and varied with different delivery modes (P=0.01) (Table 2).

Women who had VD or FD histories were more susceptible to different storage LUTS, such as frequency (P=0.0019) and UI (P < 0.001), than those with a CS history (Table 2; Fig. 2). However, the difference in voiding symptoms was not notable. Young patients were at high risk for voiding symptoms such as pain/burning (P=0.003), while SUI was most common in women between the ages of 30 and 39 years (22.4%).

3.2. Symptom-specific bother due to lower urinary tract symptoms

The extent to which the study participants were bothered by each urinary symptom is summarized in Table 3 and Fig. 3. Only 6.0–20.2% of participants with bothersome LUTS reported a moderate to severe impact on their quality of life; 1.3–15.6% reported severe bother. Some of the most prevalent symptoms were also reported as the most bothersome, such as UUI (87.3%) and SUI (85.5%). Some of the symptoms that were most likely to be rated as bothersome were not necessarily the most likely to cause moderate or severe bother, such as pain/burning (81.8% vs. 10.7%). UUI was the most likely symptom to cause severe (15.6%) or moderate to severe bother (18.1%), followed by SUI (15.3% and 15.5%, respectively). Nocturia was less likely to be bothersome but the most likely to cause moderate to severe bother (38.0% and 20.2%). Frequency, which caused more moderate or severe bother (21.5% and 17.6%), was the storage symptom that was least commonly reported to be bothersome.

Voiding symptoms were less likely to cause moderate or severe bother than storage symptoms. Straining was the most frequent symptom that caused bother (83.3%). Straining and intermittency were more likely to cause moderate or severe bother (16.0% and 13.8%, respectively) (Table 3, Fig.3).

3.3. Potential risk factors for lower urinary tract symptoms

The risk factors for LUTS according to logistic regression analysis are shown in Tables 4–6 (a-d). VDs and FDs increased the odds of every kind of LUTS. Women who had VDs and FDs were more susceptible to any LUTS and bothersome LUTS than those who had CS deliveries, especially any bothersome LUTS (2.11-fold (95% CI: 1.69-2.63), 2.55-fold (95% CI: 1.86-3.50)), moderate to severely bothersome LUTS (3.17-fold (95% CI: 2.03-4.92), 4.14-fold (95% CI: 2.42-7.07)), any severely bothersome LUTS (4.80-fold (95% CI: 2.22-10.39), 6.65-fold (95% CI: 2.76-16.03)), storage symptoms (1.84- fold (95% CI: 1.48-2.29), 2.18-fold (95% CI: 1.55-3.06)), any UI (2.79-fold (95% CI: 2.16-3.60), 2.89-fold (95% CI: 2.04-4.09)), urgency (1.70-fold (95% CI: 1.32-2.19), 1.76-fold (95% CI: 1.24-2.50)), UUI (3.80-fold (95% CI: 2.54-5.71), 5.10-fold (95% CI: 3.11-8.36)), SUI (2.84-fold (95% CI: 2.13-3.80), 2.68-fold (95% CI: 1.81-3.97)) and MUI (4.00-fold (95% CI: 2.43-6.62), 4.78-fold (95% CI: 2.59-8.83)). A history of VD (VD or FD history) was a strong predictor for both moderate to severely bothersome LUTS and any severely bothersome LUTS and UI (P ≤ 0.05). Participants with a perineal laceration had increased odds of any bothersome LUTS (1.90-fold (95% CI: 1.21-2.98)) and any SUI (2.27-fold (95% CI: 1.33-3.86)) (P ≤ 0.05). Voiding symptoms were less influenced by delivery mode and delivery histories.

3.4 Pelvic floor muscle function

A significant relationship between different delivery modes and PFM values was found (P < 0.001). The CS (not in labor) group had significantly better sEMG parameters than the VD group in terms of the total score (P < 0.001), pretest average mean amplitude (P<0.001), flick contraction average peak amplitude (P < 0.001), flick contraction time after peak (P<0.001), tonic contraction average mean amplitude (CS vs. VD, P < 0.001; CS vs. FD, P=0.002), tonic contraction mean amplitude variability (P < 0.001) and posttesting average mean amplitude (P < 0.001). Women who underwent CS deliveries in labor also showed superior pelvic floor muscle function compared to women who experienced VDs based on the total score (P < 0.001), pretest average mean amplitude (P < 0.001), flash contraction average peak amplitude (P < 0.001), tonic contractions average mean amplitude (P < 0.001), tonic contractions mean amplitude variability (CS vs. VD, P=0.006; CS vs. FD, P=0.002), and posttesting average mean amplitude (P < 0.001). FDs had a more negative impact on PFMs than VDs. The amplitudes of flick and tonic contractions on sEMG were 29.3 (14.2) and 19.1 (10.1), respectively, in the FD group, in which the results showed the significantly lowest amplitude compared with the other groups (P < 0.001). There were also significant differences in the total score (P=0.001) between the VD and FD groups. Whether a woman was in labor before undergoing CS had no obvious effect on the total score, flash contraction average peak amplitude or posttesting average mean amplitude.

In total, 503 women had a delivery history. The total sEMG scores were significantly different among the different groups (P=0.038). Women with a VD history had significantly lower flick contraction average peak amplitude (P=0.015) and pretest and posttest average mean amplitudes (P=0.001 and P=0.009) than women with a CS delivery history (Table 7). We did not find any significant differences between women with or without lateral episiotomies or perineal lacerations.

We reported a higher prevalence in the participants than in adult women in our previous population-based study ¹³. All of the individual LUTS caused bother, and storage symptoms were more likely than voiding symptoms to cause moderate or severe bother, which is consistent with our previous research. A broader view of LUTS showed that potential risk factors include age, race, micturition habits, lifestyle factors, and especially delivery histories^13,17. Childbirth damages pelvic floor function and has different effects on the occurrence of LUTS, which was also confirmed in our results. Overweight, obese and weight gain during pregnancy may contribute to increased LUTS during and after pregnancy ^18,19, but scientific support is lacking. One study reported that weight gain during pregnancy does not seem to be related to LUTS ²⁰, we obtained a similar result.

Only a few studies about pelvic floor function in the early postpartum period according to different modes of delivery have been presented ²¹. Stretching injury of the PFMs, innervating nerves and connective tissue caused by VDs may play important roles in pelvic floor pathologies. VDs, especially instrumental VDs, were the most important factor for changes in PFM variables. In our study, compared with CS deliveries, in VDs, especially FDs, lower sEMG activity were observed. The resting baseline sEMG reflects the resting activity of the PFMs without any voluntary contractions, which is crucial for maintaining the proper postpartum anatomical position of the pelvic organs. A lower resting baseline sEMG might represent lower muscle tone, making women more prone to vaginal laxity and UI. Although some studies reported no significant differences in baseline activity values between pregnant and nulliparous women ²², we confirmed that different modes of delivery affected the pretest and posttest resting baseline sEMG findings. There was a higher resting baseline sEMG after CS deliveries and a lower resting baseline sEMG after FDs in the postpartum period at 6 weeks, which was consistent with other studies ²¹. PFM contractility was also significantly lower in the VD group, especially in the FD group. Our study also showed that in women with VDs, the contractile abilities (flick, tonic) of the PFMs were dramatically decreased. However, Colla et al. found that the strength of PFM contractions seemed to recover spontaneously between 1 and 3 months after delivery ²³. In these studies, the CS group had a higher BMI and older age than the VD group, and these factors could have influenced the results.

For women in the VD group, the contractility, contraction speed and stability of the PFMs were significantly higher than those of women in the FD group. However, a previous study did not show significant differences in strength reduction between spontaneous and instrumental deliveries. The instrumental deliveries group in that study consisted only of women with vacuum-assisted deliveries. Vacuum deliveries have been found to be less traumatic for the pelvic floor musculature than forceps deliveries, which could be one reason for these results ²⁴.

Previous evidence indicated that parity, especially the number of VDs, was associated with damage to the pelvic floor ²⁵. The present study showed that the total sEMG scores were significantly different among the different delivery history groups. We found that compared with women with a history of CS delivery, women with a history of VD delivery had lower contractile abilities (flick) and resting baseline sEMG. A prospective cohort study of parous women estimated the change in PFM strength over time and found that women who delivered all their children by CS had stronger PFMs than those with at least 1 vaginal nonforceps birth or women with at least 1 vaginal FD. Interestingly, the forceps group also showed the greatest improvement in strength over time ²⁶. Although a previous study found no significant differences in PFM strength between women with or without episiotomy ²⁷. Our study showed higher total sEMS scores and more stable tonic contractions in women without episiotomy.

Bladder health in women and girls is poorly understood. It is known that 6weeks after delivery is a very important time for women to recover. Lower urinary tract symptoms (LUTS) and associated conditions comprise a variety of bothersome bladder complaints and should be consideration for medical intervention. Pelvic floor muscular tears across pregnancies, as well as the number of childbirth episodes and associated interventions, may contribute to an accumulated risk for LUTS and poorer bladder health. Women with a VD history had increased odds of storage and bothersome LUTS. VDs, especially FDs, may cause injury to the pelvic muscles, nerves, and connective tissue of the pelvic floor and have a negative impact on bladder control, especially the function of the storage period.

Although SEMG records the electrical activity produced by the recruitment of motor units and not muscle strength itself, some studies indicate that there is good correlation between the number of activated motor units and muscle strength ²⁸. Pregnancy may contribute to reduced PFM strength and endurance²⁹,because of compression, stretching or tearing of the nerves, muscles and connective tissue. In general, muscle contractions increase as the number of activated motor units increases; thus, electrical activity is proportional to the level of strength developed by the muscles, and its changes are considered to represent PFM contractions and relaxations ^21,22. Although we did not find a direct relationship between LUTS and the decline in pelvic floor function, the increased prevalence of LUTS, especially storage symptoms, is closely associated with VDs, especially FDs. The decline in pelvic floor muscle function is also related to VDs or FDs. We speculate that the changes in bladder function during the storage period are related to the changes in postpartum pelvic floor muscle function. Further research is needed to prove this hypothesis and determine whether pelvic floor muscle function training and pelvic floor electrical stimulation can improve LUTS symptoms.

The strengths of our study are the large sample size and the use of a professional questionnaire for urinary symptoms based strictly on criteria in the 2002 ICS guidelines, which also enabled comparisons with the results of other studies.

Our study had some limitations. Our questionnaire did not assess all LUTS, and the observational design is a poor way to ascertain risk factors. Longitudinal studies are needed to better understand the temporal nature and associations of risk factors. The surface EMG results could not directly reflect muscle strength, structure, or anatomical position. Further studies are needed.

This was an observational study of LUTS in women with different modes of delivery after 6 weeks. Of the 70.6% of women who experienced LUTS, nocturia, frequency, urgency, and SUI were the most prevalent symptoms. Straining and UI were most frequently reported as bothersome, while UI caused severe discomfort. Nocturia, frequency, UUI and straining cause more moderate and severe discomfort. The likelihood of any, individual, and bothersome LUTS may involve multiple factors, and VDs, especially FDs, are the strongest predictors, especially for storage symptoms. The reason may be that VDs and FDs are more likely to cause PFM or nerve damage. Lower sEMG activity, including resting baseline and contraction amplitudes, was observed in women with VDs, especially FDs. Further research is needed to determine whether the changes in bladder function during the storage period are related to the changes in postpartum pelvic floor function.

LUTS: Lower urinary tract symptoms

UI: Urinary incontinence

SUI: Stress urinary incontinence

VD: Vaginal delivery

FD: Forceps delivery

CS: Cesarean section

sEMG: Surface electromyography

Ethics approval and consent to participate：The study was approved by the Peking University First Hospital's Ethics Committee (approval number 2022-285-002), approval was obtained from all study participants and the study followed the code of ethics of the Declaration of Helsinki.

Consent for publication: Not applicable.

Availability of data and materials: The datasets analyzed in current study are available from the corresponding author on reasonable request.

Competing interests: All of the authors report no conflicts of interest.

Funding: The Seed fund of Peking University First Hospital (no. 3053750)

Authors' contributions: Lei Zhang: Study design, data collection, paper writing, data statistics: Xiaoxiao Wang: Data collection, paper writing, data statistics; Xinnan Hou: Data collection; Xinrong Zhuang: Data collection, data entry; Yu Wang: Data collection; Xiaoqing Wang: Data collection, paper writing; Ye Lu: Study design, paper editing and supervision.

Acknowledgements: This study received financial support from the Seed fund of Peking University First Hospital (no. 3053750) and approval from the Bristol Urological Institute in England for use of their Female Lower Urinary Tract Symptoms (BFLUTS) questionnaires.

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Tables 1 to 7 are available in the Supplementary Files section

No competing interests reported.

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Assessment of lower urinary tract symptoms 6 weeks after delivery and the relationship of pelvic floor muscle function

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Abstract

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1. Background

2. Methods

2.1. Study design and participants

2.2. Measurements

2.3. Diagnostic criteria

2.4 Pelvic floor muscle screening (PFM screening)

2.5. Statistical analysis

2.6 Patient and public involvement

3. Results

4. Discussion

5. Conclusions

Abbreviations

Declarations

References

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Additional Declarations

Supplementary Files

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