Regular Exercisers Have Stronger Pelvic Floor Muscles than Non-Regular Exercisers at Midpregnancy

Background: Today all healthy pregnant women are encouraged to be physically active throughout pregnancy, with recommendations to participate in at least 30 minutes of aerobic activity on most days of the week in addition to performing strength training of the major muscle groups 2–3 days per week and also pelvic floor muscle training. There is, however, an ongoing debate whether general physical activity enhances or declines pelvic floor muscle function. Objectives: The objectives of the study were to compare vaginal resting pressure, pelvic floor muscle strength, and endurance in regular exercisers (exercise ≥30 minutes 3 or more times per week) and nonexercisers at midpregnancy. Furthermore, another objective was to assess whether regular general exercise or pelvic floor muscle strength was associated with urinary incontinence. Study Design: This was a cross-sectional study at mean gestational week 20.9 (±1.4) including 218 nulliparous pregnant women, with a mean age of 28.6 years (range, 19–40 years) and prepregnancy body mass index of 23.9 kg/m2 (SD, 4.0). Vaginal resting pressure, pelvic floor muscle strength, and pelvic floor muscle endurance were measured by a high-precision pressure transducer connected to a vaginal balloon. The International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form was used to assess urinary incontinence. Differences between groups were analyzed using an independent-sample Student t test. Linear regression analysis was conducted to adjust for prepregnancy body mass index, age, smoking during pregnancy, and regular pelvic floor muscle training during pregnancy. The significance value was set to P ≤ .05. Results: Regular exercisers had statistically significant stronger (mean 6.4 cm H2O [95% confidence interval, 1.7–11.2]) and more enduring (mean 39.9 cm H2Osec [95% confidence interval, 42.2–75.7]) pelvic floor muscles. Only pelvic floor muscle strength remained statistically significant, when adjusting for possible confounders. Pelvic floor muscle strength and not regular general exercise was associated with urinary continence (adjusted B, –6.4 [95% confidence interval, –11.5 to –1.4]). Conclusion: Regular exercisers at midpregnancy have stronger pelvic floor muscles than their sedentary counterparts. However, pelvic floor muscle strength and not regular general exercise was associated with urinary incontinence. There is a need for additional studies in elite athletes and women performing more strenuous exercise regimens

The Influence of Early Exercise Postpartum on Pelvic Floor Muscle Function and Prevalence of Pelvic Floor Dysfunction 12 Months Postpartum

Objective: There is limited knowledge on how exercise impacts the pelvic floor muscles (PFM) and prevalence of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) postpartum. The purpose of this study was to investigate whether early onset of general exercise postpartum negatively affects the PFM and/or increases the risk of SUI and POP 12 months postpartum. Methods: This study used a prospective cohort design. At 6 weeks postpartum, 57 women classified as exercisers (exercising ≥3 times at ≥30 min/week) were compared with 120 nonexercisers (mean age = 29 y, SD = 4.3). Manometry was used to measure vaginal resting pressure (VRP), PFM strength, and PFM endurance, and symptoms of SUI and POP were assessed using questionnaires. Data were presented as standardized beta coefficients (B) and odds ratios (OR). Results: No differences were found between exercisers (n = 57) and nonexercisers (n = 120) at 6 weeks postpartum on VRP (B = −0.04 [95% CI = −3.4 to 2.1]), PFM strength (B = 0.03 [95% CI = −4.7 to 7.4]), PFM endurance (B = −0.02 [95% CI = −59 to 46]), or symptoms of SUI (OR = 0.51 [95% CI = 0.25 to 1.1]) or POP (OR = 0.62 [95% CI = 0.26 to 1.5]) measured at 12 months postpartum. Adjusting for covariates, women with body mass index between 25 and 29.9 and > 30 were more likely to report SUI 12 months postpartum (OR = 2.2 [95% CI = 1.0 to 4.7] and OR = 3.3 [95% CI = 1.2 to 9.4], respectively). Women with physically strenuous occupations were more likely to report POP 12 months postpartum (OR = 3.0 [95%CI: 1.2 to 7.3]). Conclusions: This study suggests that regular exercise 6 weeks postpartum has no negative effect on PFM function or on SUI or POP. Being overweight, however, was associated with more SUI, and women with physically strenuous occupations reported more POP. Impact: Results from this study suggest that first time mothers should be encouraged to start general exercise within the first 6 weeks after giving birth. Women at risk for PFD should be advised accordingly and potentially modifiable risk factors should be addressed prior to delivery

An intra- and interrater reliability and agreement study of vaginal resting pressure, pelvic floor muscle strength, and muscular endurance using a manometer

Introduction and hypothesis Manometry is commonly used to assess pelvic floor muscle (PFM) function. Aims of the study were to assess intra- and interrater reliability and agreement of vaginal resting pressure, PFM strength, and muscular endurance using a high-precision pressure transducer. Methods A convenient sample of 23 women was included. The participants were tested twice by two examiners on day 1 and retested after 1 week by one examiner. Vaginal resting pressure, PFM strength, and muscular endurance were measured by manometer (Camtech AS). Intraclass correlation coefficient (ICC) and Bland–Altman plots were used to analyze reliability and agreement respectively. Results are presented with mean differences (bias) and minimal detectable change. Results Twenty participants completed the tests (mean age 55.8 years [27–71], mean parity 1.7 [range 0–3], and mean body mass index 23.7 [range 18.4–27.2, SD 2.4]). ICC values were very good (ICC >0.90) for all measurements. Considerable intervariation of scores, and outliers were seen for measurements representing the highest values. Agreement with mean differences (bias) and minimal detectable change for the intrarater assessment was for vaginal resting pressure: −2.44 ± 8.7 cmH2O, for PFM strength −0.22 ± 7.6 cmH2O, and for muscular endurance 0.75 ± 59.5 cmH2O/s. The interrater agreement for vaginal resting pressure was: 1.36 ± 9.0 cmH2O, for PFM strength 2.24 ± 9.0 cmH2O, and for muscular endurance 15.89 ± 69.7 cmH2O/s. Conclusions Manometry (Camtech AS) seems less accurate for the strongest women. In clinical practice, significant improvement in PFM variables needs to exceed the minimal detectable change to be above the error of measurement

The Influence of Early Exercise Postpartum on Pelvic Floor Muscle Function and Prevalence of Pelvic Floor Dysfunction 12 Months Postpartum

Objective: There is limited knowledge on how exercise impacts the pelvic floor muscles (PFM) and prevalence of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) postpartum. The purpose of this study was to investigate whether early onset of general exercise postpartum negatively affects the PFM and/or increases the risk of SUI and POP 12 months postpartum. Methods: This study used a prospective cohort design. At 6 weeks postpartum, 57 women classified as exercisers (exercising ≥3 times at ≥30 min/week) were compared with 120 nonexercisers (mean age = 29 y, SD = 4.3). Manometry was used to measure vaginal resting pressure (VRP), PFM strength, and PFM endurance, and symptoms of SUI and POP were assessed using questionnaires. Data were presented as standardized beta coefficients (B) and odds ratios (OR). Results: No differences were found between exercisers (n = 57) and nonexercisers (n = 120) at 6 weeks postpartum on VRP (B = −0.04 [95% CI = −3.4 to 2.1]), PFM strength (B = 0.03 [95% CI = −4.7 to 7.4]), PFM endurance (B = −0.02 [95% CI = −59 to 46]), or symptoms of SUI (OR = 0.51 [95% CI = 0.25 to 1.1]) or POP (OR = 0.62 [95% CI = 0.26 to 1.5]) measured at 12 months postpartum. Adjusting for covariates, women with body mass index between 25 and 29.9 and > 30 were more likely to report SUI 12 months postpartum (OR = 2.2 [95% CI = 1.0 to 4.7] and OR = 3.3 [95% CI = 1.2 to 9.4], respectively). Women with physically strenuous occupations were more likely to report POP 12 months postpartum (OR = 3.0 [95%CI: 1.2 to 7.3]). Conclusions: This study suggests that regular exercise 6 weeks postpartum has no negative effect on PFM function or on SUI or POP. Being overweight, however, was associated with more SUI, and women with physically strenuous occupations reported more POP. Impact: Results from this study suggest that first time mothers should be encouraged to start general exercise within the first 6 weeks after giving birth. Women at risk for PFD should be advised accordingly and potentially modifiable risk factors should be addressed prior to delivery

Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain

Background/aim: Diastasis recti abdominis (DRA) is defined as a separation of the 2 muscle bellies of rectus abdominis. To date there is scant knowledge on prevalence, risk factors, and consequences of the condition. The present study aimed to investigate the prevalence of DRA during pregnancy and post partum, presence of possible risk factors, and the occurrence of lumbopelvic pain among women with and without DRA. Methods: This prospective cohort study followed 300 first-time pregnant women from pregnancy till 12 months post partum. Data were collected by electronic questionnaire and clinical examinations. DRA was defined as a palpated separation of ≥2 fingerbreadths either 4.5 cm above, at or 4.5 cm below the umbilicus. Women with and without DRA were compared with independent samples Student's t-test and χ2/Fisher exact test, and OR with significance level >0.05. Results: Prevalence of DRA was 33.1%, 60.0%, 45.4%, and 32.6% at gestation week 21, 6 weeks, 6 months and 12 months post partum, respectively. No difference in risk factors was found when comparing women with and without DRA. OR showed a greater likelihood for DRA among women reporting heavy lifting ≥20 times weekly (OR 2.18 95% CI 1.05 to 4.52). There was no difference in reported lumbopelvic pain (p=0.10) in women with and without DRA. Conclusions: Prevalence of mild DRA was high both during pregnancy and after childbirth. Women with and without DRA reported the same amount of lumbopelvic pain 12 months post partum

What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum?: A systematic review with meta-analysis

Background: Diastasis recti abdominis (DRA) affects a significant number of women in the postpartum period. Objective: To systematically review whether abdominal and pelvic floor muscle (PFM) exercise programs are effective in the treatment of DRA postpartum. Methods: Electronic search was conducted from inception to March 2020. Randomized controlled trials (RCT) or pilot RCTs that compared abdominal training, PFM training, or a combination of both in at least one arm of the trial were included. The primary outcome was presence of DRA (numbers/percentage) or inter-recti distance (IRD) change. GRADE was used to rate the overall quality of evidence. Pooled effect sizes were expressed as mean difference (MD) with 95% confidence intervals (CI). Results: Seven RCTs totaling 381 women were included. Two studies comparing transversus abdominis (TrA) training with minimal intervention provided data to be included in a meta-analysis. The results provided very low level quality evidence that TrA training reduced IRD (MD = -0.63 cm, 95% confidence interval: -1.25, -0.01, I2 = 0%). Two studies included curl-up exercises as part of their intervention. Level of evidence based on single trials of high risk of bias show very low evidence that curl-up training is more effective than minimal intervention for treating DRA. Similarly, analyses based on single trials provided low to very low quality evidence that PFM training is not more effective than minimal intervention for treating DRA. Conclusion: There is currently very low-quality scientific evidence to recommend specific exercise programs in the treatment of DRA postpartum

What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis

Background: Diastasis recti abdominis (DRA) affects a significant number of women in the postpartum period. Objective: To systematically review whether abdominal and pelvic floor muscle (PFM) exercise programs are effective in the treatment of DRA postpartum. Methods: Electronic search was conducted from inception to March 2020. Randomized controlled trials (RCT) or pilot RCTs that compared abdominal training, PFM training, or a combination of both in at least one arm of the trial were included. The primary outcome was presence of DRA (numbers/percentage) or inter-recti distance (IRD) change. GRADE was used to rate the overall quality of evidence. Pooled effect sizes were expressed as mean difference (MD) with 95% confidence intervals (CI). Results: Seven RCTs totaling 381 women were included. Two studies comparing transversus abdominis (TrA) training with minimal intervention provided data to be included in a meta-analysis. The results provided very low level quality evidence that TrA training reduced IRD (MD = -0.63 cm, 95% confidence interval: -1.25, -0.01, I2 = 0%). Two studies included curl-up exercises as part of their intervention. Level of evidence based on single trials of high risk of bias show very low evidence that curl-up training is more effective than minimal intervention for treating DRA. Similarly, analyses based on single trials provided low to very low quality evidence that PFM training is not more effective than minimal intervention for treating DRA. Conclusion: There is currently very low-quality scientific evidence to recommend specific exercise programs in the treatment of DRA postpartum

Recovery of pelvic floor muscle strength and endurance 6 and 12 months postpartum in primiparous women: A prospective cohort study

Introduction and hypothesis: To date there has been scant knowledge on the natural recovery of the pelvic floor muscles (PFMs) after childbirth. The aims of the present study were to investigate whether PFM variables at 6 and 12 months postpartum had returned to mid-pregnancy levels and assess risk factors for reduced recovery at 12 months postpartum. Methods: This was a prospective cohort study following 235 nulliparous pregnant women from mid-pregnancy to 12 months postpartum. Vaginal resting pressure (VRP), PFM strength and endurance were assessed by manometry at 22 weeks, 6 and 12 months postpartum. Multiple linear regression was used to address factors influencing PFM variables beyond birth mode. Results: Cesarean section was protective for change in PFM variables. From mid-pregnancy to 12 months postpartum there was a 20% reduction in VRP (p<0.001) and a 7.5 % reduction in PFM strength (p=0.007), and an increase of 9% in PFM endurance (p=0.002) in the normal vaginal birth. The instrumental vaginal group had a decline in VRP of 21% (p<0.001) and PFM strength of 15% (p=0.011), but no significant change in PFM endurance. Higher BMI at 12 months postpartum, longer second stage of labor, and major tears of the levator ani muscle had a negative influence on the PFM recovery beyond delivery mode. Conclusions: At 12 months postpartum following vaginal delivery, the PFMs are not fully recovered compared with mid-pregnancy values. More follow-up physical therapy may be warranted in the postpartum period, especially for women with complicated vaginal births and higher BMI

Risk factors for anatomic pelvic organ prolapse at 6 weeks postpartum: a prospective observational study

Introduction and hypothesis: The objective was to identify risk factors for postpartum anatomic pelvic organ prolapse (aPOP) by comparing women with and without aPOP at 6 weeks postpartum with regard to pelvic floor measurements antepartum and obstetrical characteristics. Methods: We carried out a prospective observational cohort study including nulliparous pregnant women in a Norwegian university hospital. Participants underwent clinical examinations, including pelvic organ prolapse quantification system (POP-Q) and transperineal ultrasound at gestational week 21 and at 6 weeks postpartum. Background and obstetrical information was obtained from an electronic questionnaire and from the patient’s electronic medical file respectively. Associations were estimated using logistic regression analyses. The dependent variable was aPOP, defined as POP-Q stage ≥2 at 6 weeks postpartum. Independent variables were mid-pregnancy measurements of selected POP-Q variables and levator hiatus area (LHarea), delivery route, and the presence of major levator ani muscle (LAM) injuries at 6 weeks postpartum. Results: A larger LHarea, a more distensible LAM, a longer distance from the meatus urethra to the anus (Gh + Pb) and a more caudal position of the anterior vaginal wall (Ba) at mid-pregnancy were risk factors for aPOP at 6 weeks postpartum, whereas delivery route and the presence of major LAM injuries were not. Conclusion: Prelabor differences in the pelvic floor rather than obstetrical events were risk factors for aPOP at 6 weeks postpartum

Risk factors for anatomic pelvic organ prolapse at 6 weeks postpartum: a prospective observational study

Introduction and hypothesis: The objective was to identify risk factors for postpartum anatomic pelvic organ prolapse (aPOP) by comparing women with and without aPOP at 6 weeks postpartum with regard to pelvic floor measurements antepartum and obstetrical characteristics. Methods: We carried out a prospective observational cohort study including nulliparous pregnant women in a Norwegian university hospital. Participants underwent clinical examinations, including pelvic organ prolapse quantification system (POP-Q) and transperineal ultrasound at gestational week 21 and at 6 weeks postpartum. Background and obstetrical information was obtained from an electronic questionnaire and from the patient’s electronic medical file respectively. Associations were estimated using logistic regression analyses. The dependent variable was aPOP, defined as POP-Q stage ≥2 at 6 weeks postpartum. Independent variables were mid-pregnancy measurements of selected POP-Q variables and levator hiatus area (LHarea), delivery route, and the presence of major levator ani muscle (LAM) injuries at 6 weeks postpartum. Results: A larger LHarea, a more distensible LAM, a longer distance from the meatus urethra to the anus (Gh + Pb) and a more caudal position of the anterior vaginal wall (Ba) at mid-pregnancy were risk factors for aPOP at 6 weeks postpartum, whereas delivery route and the presence of major LAM injuries were not. Conclusion: Prelabor differences in the pelvic floor rather than obstetrical events were risk factors for aPOP at 6 weeks postpartum