Professional Documents
Culture Documents
Disorders
Emily S. Lukacz, MD, Jean M. Lawrence,
and Karl M. Luber, MD
ScD, MPH,
OBJECTIVE: This study aimed to assess the associations between parity, mode of delivery, and pelvic floor disorders.
METHODS: The prevalence of pelvic organ prolapse,
stress urinary incontinence, overactive bladder, and anal
incontinence was assessed in a random sample of women
aged 25 84 years by using the validated Epidemiology of
Prolapse and Incontinence Questionnaire. Women were
categorized as nulliparous, vaginally parous, or only delivered by cesarean. Adjusted odds ratios and 95% confidence intervals (CIs) for each disorder were calculated
with logistic regression, controlling for age, body mass
index, and parity.
RESULTS: In the 4,458 respondents the prevalence of
each disorder was as follows: 7% prolapse, 15% stress
urinary incontinence, 13% overactive bladder, 25% anal
incontinence, and 37% for any one or more pelvic floor
disorders. There were no significant differences in the
prevalence of disorders between the cesarean delivery
and nulliparous groups. The adjusted odds of each disorder increased with vaginal parity compared with cesarean delivery: prolapse 1.82 (95% CI 1.04 3.19), stress
urinary incontinence 1.81 (95% CI 1.252.61), overactive bladder 1.53 (95% CI 1.022.29), anal incontinence
1.72 (95% CI 1.272.35), and any one or more pelvic
floor disorders 1.85 (95% CI 1.422.41). Number-
MD,
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RESULTS
Of the 4,458 (37%) surveys returned, 140 were in
Spanish and 4,318 in English. Racial and ethnic
distributions of the returned samples were representative of the Kaiser Permanente membership: 60%
non-Hispanic white, 20% Hispanic, 10% African
American, 8% Asian-Pacific Islander, 1% Native
American, and 1% other or unknown. There were
insufficient data to categorize 289 women into one of
the birth groups, and 66 surveys had insufficient
information to assess any of the pelvic floor disorders.
Thus, 4,103 subjects were available for analysis (Table
1). Nonresponders were significantly younger than
responders (53 17 versus 57 16 years, P .001).
Nulliparous
(N 787)
Cesarean Delivery
(N 389)
28
72*
37
42
19
2
19
7
3
10
52
10
24
30
45
36
18
1
17
14*
2
12
65*
8
23
33
32
46
20
1
32*
12*
3
15*
57*
9
31*
36*
[3242]
[3747]
[1624]
[15]
[1622]
[59]
[24]
[813]
[4855]
[812]
[2127]
[2733]
(148/404)
(168/404)
(78/404)
(10/404)
(146/776)
(49/747)
(20/742)
(78/748)
(399/773)
(77/767)
(183/767)
(221/742)
[3852]
[2943]
[1324]
[05]
[1321]
[118]
[04]
[916]
[6069]
[511]
[1928]
[2838]
(85/190)
(68/190)
(34/190)
(3/190)
(64/386)
(54/374)
(6/365)
(45/374)
(247/382)
(30/379)
(89/379)
(121/364)
Vaginally Parous
(N 2927)
58.8 15.1 (2584)*
2 (2.7)*
[2629]
(784/2,840)
[7073]
(096/2,921)
[3035]
[4449]
[1822]
[02]
[3034]
[1113]
[23]
[1316]
[5558]
[810]
[3033]
[3438]
(681/2,096)
(974/2,096)
(415/2,096)
(26/2,096)
927/2,911
339/2,787
73/2,679
399/2,751
1,637/2,895
263/2,879
906/2,879
1,014/2,822
n, number of women with the specific pelvic floor disorder; N, total is the number of women with enough data to categorize status of specific
pelvic floor disorder, SD, standard deviation.
Data are expressed as % [95% confidence interval] (n/N), unless otherwise indicated.
* P .05 for differences between cesarean delivery versus nulliparous and vaginally parous versus nulliparous groups.
P .05 for differences between vaginally parous and cesarean delivery groups.
Lukacz et al
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[95% CI]
[35]
[610]
[711]
[1622]
[2430]
(n /N)
(29/774)
(64/771)
(70/773)
(143/766)
(201/750)
4
11
9
16
27
[95% CI]
[27]
[815]
[713]
[1321]
[2231]
(n /N)
(16/386)
(43/387)
(36/381)
(60/365)
(98/369)
8*
18*
15*
28*
42*
[95% CI]
(n /N)
[79]
[1619]
[1416]
[2630]
[4044]
(223/2,883)
(505/2,885)
(427/2,852)
(786/2,823)
(1,153/2,767)
n, number of women with the specific pelvic floor disorder; N, total is the number of women with enough data to categorize status of specific
pelvic floor disorder.
* P .05 for differences between cesarean delivery versus nulliparous and vaginally parous versus nulliparous groups.
P .05 for differences between vaginally parous and cesarean delivery groups.
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Table 3. Crude and Adjusted Odds Ratios With 95% Confidence Intervals for Selected Pelvic Floor
Disorders by Birth Group
Birth Group
Cesarean delivery versus
nulliparous*
Crude OR (CI)
Adjusted OR (CI)
Vaginally parous versus
nulliparous*
Crude OR (CI)
Adjusted OR (CI)
Vaginally parous versus
cesarean delivery*
Crude OR (CI)
Adjusted OR (CI)
Pelvic Organ
Prolapse
Stress Urinary
Incontinence
Overactive
Bladder
Anal
Incontinence
1.72 (0.873.38)
1.61 (0.803.24)
1.38 (0.922.07)
1.26 (0.821.93)
1.05 (0.691.60)
1.00 (0.641.55)
0.86 (0.621.19)
0.84 (0.601.18)
0.99 (0.751.31)
0.92 (0.691.24)
3.33* (2.075.36)
3.21* (1.965.26)
2.34* (1.783.08)
2.26* (1.703.00)
1.77* (1.352.31)
1.46* (1.111.93)
1.68* (1.382.05)
1.53* (1.241.89)
1.95* (1.632.33)
1.76* (1.462.12)
1.94* (1.153.26)
1.82* (1.043.19)
1.70* (1.222.36)
1.81* (1.252.61)
1.69* (1.182.41)
1.53* (1.022.29)
1.96* (1.452.62)
1.72* (1.272.35)
1.98* (1.552.52)
1.85* (1.422.41)
Table 4. Prevalence of Each Pelvic Floor Disorder by Pregnancy Exposure and Cesarean Delivery With
and That Without Labor*
Nulligravid
(N 517)
Gravid-Nulliparous
(N 270)
4 [27] (11/264)
10 [715] (27/262)
11 [715] (29/264)
18 [1524] (50/261)
30 [2536] (76/251)
Unlabored
Labored
Cesarean Delivery Cesarean Delivery
(N 93)
(N 199)
P
.027
.148
.178
.803
.127
1 [06] (1/92)
5 [212] (5/93)
9 [416] (8/92)
17 [1026] (15/90)
22 [1432] (19/88)
7 [411] (13/198)
13 [919] (26/198)
11 [716] (21/193)
16 [1122] (30/185)
31 [2438] (58/189)
P
.043
.065
.678
.925
.116
CI, confidence interval; n, number of women with the specific pelvic floor disorder; N, total is the number of women with enough data to
categorize status of specific pelvic floor disorder; nulligravid, never pregnant; gravid-nulliparous, pregnant but never delivered an infant
weighing more than 2 kg.
* Cesarean delivery unknown 102; 11 women delivered infants weighing less than 2 kg.
Table 5. Crude Odds Ratios for Each Pelvic Floor Disorder by Vaginal Delivery Versus Labored and
Unlabored Cesarean Delivery
Birth Group
Vaginally parous versus
unlabored cesarean delivery
Crude OR (CI)
Adjusted OR (CI)
Vaginally parous versus
labored cesarean delivery
Crude OR (CI)
Adjusted OR (CI)*
Pelvic Organ
Prolapse
Stress Urinary
Incontinence
Overactive
Bladder
Anal
Incontinence
7.63* (1.0655.00)
5.81 (0.8042.04)
3.73* (1.519.24)
3.91* (1.4110.82)
1.85 (0.893.85)
1.72 (0.734.03)
1.93* (1.103.38)
1.53 (0.852.76)
2.59* (1.554.33)
2.26* (1.303.91)
1.19 (0.672.13)
1.18 (0.622.23)
1.40 (0.922.14)
1.63* (1.012.63)
1.44 (0.912.30)
1.24 (0.742.08)
1.99* (1.342.97)
1.88* (1.212.93)
1.61* (1.172.22)
1.56* (1.102.22)
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DISCUSSION
This study examined the contribution of parity and
delivery to the development of patient-reported pelvic floor disorders across a broad age range by using
a well-validated instrument with defined predictive
values. These data indicate that a woman who delivers an infant vaginally has a risk of a pelvic floor
disorder that is higher than a woman who delivers all
infants by cesarean delivery. Based on these data,
parity itself does not increase the odds of developing
a pelvic floor disorder; rather, the labor process and
vaginal birth does. Overall, vaginal delivery increased
the odds of any pelvic floor disorder compared with
cesarean delivery by 85% when controlling for age,
parity, and body mass index. Although development
of pelvic floor disorders may be dependent on multiple risk factors, the attributable risk calculation suggests that vaginal birth confers one third of the burden
in this population.
There are conflicting reports about the influence
of parity, labor, and mode of delivery on the development of pelvic floor disorders. Our results are
consistent with other epidemiological and prospective
studies, which demonstrate vaginal delivery is a risk
for urinary incontinence.5,16,24,25 Rortveit et al16 found
an increased odds (2.4) of moderate or severe stress
incontinence with vaginal delivery compared with
cesarean delivery, with no significant difference in
urge incontinence. We conducted our multivariable
analyses in a similar manner, and our findings differed only in that overactive bladder was 1.5 times
more common in the vaginally parous group than in
the cesarean group. This difference may be reflected
in our definition of overactive bladder, which included urinary urgency and frequency without leakage. In subanalyses of the cesarean group, we found
that labor was associated with a trend toward increased stress urinary incontinence, but labor may not
be entirely responsible for this increased risk because
there remains an increased odds of stress urinary
incontinence when comparing vaginal delivery with
labored cesarean delivery. This is in keeping with the
findings of others that cesarean delivery at any stage
of labor reduced postpartum urinary incontinence.24
Epidemiological studies have not determined the
effect of vaginal delivery on anal incontinence. Our
study found a high prevalence of anal incontinence,
which could be explained by a previous lack of
standard definitions and patient underreporting.26 Alternately, the questionnaire has a positive predictive
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