Dear Editor,

We are grateful to Dr. Dietz for his response to our recent article. Although there is a vast body of literature and data regarding pelvic floor injury and vaginal delivery, the specific mechanism responsible for the damage to the pelvic floor is not completely known. The fact is that there are women who have delivered many children vaginally without pelvic floor injury and others who after the first vaginal delivery have remarkable damage to the pelvic floor. There are many causes and risk factors for pelvic floor injury, but their significance is not entirely understood. Our paper is a clinical opinion based on our experience and knowledge. We chose to review articles that support our thought process and practice. The reason we did not cite the articles mentioned by Dr. Dietz [1, 2] is simply that they appeared after our article was submitted for publication.

We never intended to imply that our group was the first to publish regarding pelvic floor injury and vaginal delivery. Our work supports the concepts presented, and all points were clearly referenced. It is appropriate to mention that Dr. Sultan was a pioneer in the field of pelvic floor disorders in association with vaginal deliveries [3]. There is no doubt regarding the vast contribution Dr. Dietz and other researchers have made to the study of pelvic floor health. In no way did we intend to slight him or his research or anyone else.