International Urogynecology Journal

, Volume 26, Issue 12, pp 1719–1723 | Cite as

Can we predict and prevent pelvic floor dysfunction?

Ulf Ulmsten Memorial Lecture 2015
  • Ian MilsomEmail author
Special Contribution


Pelvic floor disorders (PFD) constitute a huge global health problem affecting hundreds of millions of women throughout the world. The prevalence of at least one form of PFD (urinary incontinence [UI], pelvic organ prolapse [POP] or faecal incontinence [FI]) has been reported to be as high as 46 % [1]. In addition, many women may have a combination of PFDs. PFDs have a profound influence on correct well-being and quality of life and prevent many women from participating in recreational and sporting activities [1]. PFDs have also been reported to have a negative influence on sexual function and sexual health parameters [2, 3, 4].

The global costs of PFDs to health care systems and society are enormous [5, 6]. The lifetime risk of undergoing POP surgery alone has been reported to vary between 5 and 19 % [7]. The highest life time risk for POP surgery, 19 %, has been reported from Western Australia [8]. De Boer et al. [9] estimated that 20.2 % of Dutch women would undergo...


Caesarean Section Pelvic Floor Pelvic Organ Prolapse Faecal Incontinence Vaginal Delivery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Adjusted odds ratio


Body mass index


Caesarean section


The Epidemiology of Incontinence in the County of Nord-Trøndelag


Infant birth weight


Magnetic resonance imaging


Obstetric anal sphincter injury


Odds ratio


Pelvic floor disorders


Pelvic organ prolapse


The Relationship of Pregnancy and Delivery with Incontinence and Prolapse Study


Symptomatic pelvic organ prolapse


The Swedish Pregnancy, Obesity and Pelvic Floor Study


Total fertility rate


Urinary incontinence


United Nations


Vaginal delivery


Compliance with ethical standards

Conflicts of interest



  1. 1.
    Milsom I, Altman D, Cartwright R, Lapitan MC, Nelson R, Sillén U, Tikkanen K (2013) Epidemiology of urinary incontinence (UI) and other lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP) and anal (AI) incontinence. In: Abrams P, Cardozo L, Khoury S, Wein A (eds) Incontinence. Health Publications, ParisGoogle Scholar
  2. 2.
    Coyne KS, Sexton CC, Irwin DE, Kopp ZS, Kelleher CJ, Milsom I (2008) The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU Int 101(11):1388–1395CrossRefPubMedGoogle Scholar
  3. 3.
    Cichowski SB, Komesu YM, Dunivan GC, Rogers RG (2013) The association between fecal incontinence and sexual activity and function in women attending a tertiary referral center. Int Urogynecol J 24(9):1489–1494. doi: 10.1007/s00192-013-2044-8 PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Bortolami A, Vanti C, Banchelli F, Guccione AA, Pillastrini P (2015) Relationship between female pelvic floor dysfunction and sexual dysfunction: an observational study. J Sex Med 12(5):1233–1241. doi: 10.1111/jsm.12882 CrossRefPubMedGoogle Scholar
  5. 5.
    Ekelund P, Grimby A, Milsom I (1993) Urinary incontinence: social and financial costs high. BMJ 306:1344PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Moore K, Wagner TH, Subak L, Wagner T, De Wachter S, Dudding TD, Hu T-W (2013) Economics of urinary and faecal incontinence, and prolapse 2012. In: Abrams, Cardozo, Khoury and Wein (eds). Incontinence, 5th edn. Health Publications, Paris, pp 15–107Google Scholar
  7. 7.
    Haya N, Baessler K, Christmann-Schmid C, de Tayrac R, Dietz V, Guldberg R, Mascarenhas T, Nussler E, Ballard E, Ankardal M, Boudemaghe T, Wu JM, Maher CF (2015) Prolapse and continence surgery in countries of the organization for economic cooperation and development in 2012. Am J Obstet Gynecol 212(6):755.e1–755.e27. doi: 10.1016/j.ajog.2015.02.017 CrossRefGoogle Scholar
  8. 8.
    Smith FJ, Holman CD, Moorin RE, Tsokos N (2010) Lifetime risk of undergoing surgery for pelvic organ prolapse. Obstet Gynecol 116(5):1096–1100. doi: 10.1097/AOG.0b013e3181f73729 CrossRefPubMedGoogle Scholar
  9. 9.
    De Boer TA, Slieker-Ten Hove MC, Burger CW, Kluivers KB, Vierhout ME (2011) The prevalence and factors associated with previous surgery for pelvic organ prolapse and/or urinary incontinence in a cross-sectional study in The Netherlands. Eur J Obstet Gynecol Reprod Biol 158(2):343–349. doi: 10.1016/j.ejogrb.2011.04.029 CrossRefPubMedGoogle Scholar
  10. 10.
    Wu JM, Matthews CA, Conover MM, Pate V, Jonsson FM (2014) Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol 123(6):1201–1206. doi: 10.1097/AOG.0000000000000286 PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Milsom I, Ekelund P, Molander U, Arvidsson L, Areskoug B (1993) The influence of age, parity, oral contraception, hysterectomy and menopause on the prevalence of urinary incontinence in women. J Urol 149(6):1459–1462PubMedGoogle Scholar
  12. 12.
    Mant J, Painter R, Vessey M (1997) Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol 104(5):579–585CrossRefPubMedGoogle Scholar
  13. 13.
    DeLancey JO, Kearney R, Chou Q, Speights S, Binno S (2003) The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 101(1):46–53PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Dietz HP, Lanzarone V (2005) Levator trauma after vaginal delivery. Obstet Gynecol 106(4):707–712CrossRefPubMedGoogle Scholar
  15. 15.
    Kearney R, Fitzpatrick M, Brennan S, Behan M, Miller J, Keane D, O'Herlihy C, DeLancey JO (2010) Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery. Int J Gynaecol Obstet 111(1):19–22. doi: 10.1016/j.ijgo.2010.05.019 PubMedCentralCrossRefPubMedGoogle Scholar
  16. 16.
    Dietz HP (2013) Pelvic floor trauma in childbirth. Aust N Z J Obstet Gynaecol 53:220–230CrossRefPubMedGoogle Scholar
  17. 17.
    Parks AG, Swash M, Urich H (1977) Sphincter denervation in anorectal incontinence and rectal prolapse. Gut 18(8):656–665PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    Snooks SJ, Setchell M, Swash M, Henry MM (1984) Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet 2(8402):546–550CrossRefPubMedGoogle Scholar
  19. 19.
    Snooks SJ, Swash M, Mathers SE, Henry MM (1990) Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg 77(12):1358–1360CrossRefPubMedGoogle Scholar
  20. 20.
    Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S, Norwegian EPINCONT Study (2003) Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med 348(10):900–907CrossRefPubMedGoogle Scholar
  21. 21.
    Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM (2006) Parity, mode of delivery, and pelvic floor disorders. Obstet Gynecol 107:1253–1260CrossRefPubMedGoogle Scholar
  22. 22.
    Dolan LM, Hilton P (2010) Obstetric risk factors and pelvic floor dysfunction 20 years after first delivery. Int Urogynecol J 21:535–544CrossRefPubMedGoogle Scholar
  23. 23.
    Leijonhufvud MD, Lundholm C, Cnattinguius S, Granach F, Andolf E, Altman D (2011) Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Am J Obstet Gynecol 204:70e1–70e6CrossRefGoogle Scholar
  24. 24.
    MacArthur C, Glazener C, Lancashire R, Herbison P, Wilson D (2011) Exclusive caesarean delivery and subsequent urinary and faecal incontinence: a 12 year longitudinal study. BJOG 118:1000–1007CrossRefGoogle Scholar
  25. 25.
    Glazener C, Elders A, MacArthur C, Lancashire RJ, Herbison P, Hagen S, Dean N, Toozs-Hobson P, Richardson K, McDonald A, McPherson G, Wilson D (2013) Childbirth and prolapse: long-term associations with the symptoms and objective measurements of pelvic organ prolapse. BJOG 120:161–168CrossRefPubMedGoogle Scholar
  26. 26.
    Gyhagen M, Bullarbo M, Nielsen TF, Milsom I (2013) The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 120(2):144–151. doi: 10.1111/j.1471-0528.2012.03301.x CrossRefPubMedGoogle Scholar
  27. 27.
    Gyhagen M, Bullarbo M, Nielsen TF, Milsom I (2013) Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 120(2):152–160. doi: 10.1111/1471-0528.12020 CrossRefPubMedGoogle Scholar
  28. 28.
    Gyhagen M, Bullarbo M, Nielsen TF, Milsom I (2013) A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women. BJOG 120(12):1548–1555. doi: 10.1111/1471-0528.12367 CrossRefPubMedGoogle Scholar
  29. 29.
    Gyhagen M, Bullarbo M, Nielsen TF, Milsom I (2014) Faecal incontinence 20 years after one birth: a comparison between vaginal delivery and caesarean section. Int Urogynecol J 25:1411–1418CrossRefPubMedGoogle Scholar
  30. 30.
    Gyhagen M, Åkervall S, Milsom I (2015) Clustering of pelvic floor disorders 20 years after one vaginal or one cesarean birth. Int Urogynecol J 26(8):1115–1121. doi: 10.1007/s00192-015-2663-3 CrossRefPubMedGoogle Scholar
  31. 31.
    Koelbl H, Igawa TY, Salvatore S, Laterza RM, Lowry A, Sievert KD, Sultan A (2013) Pathophysiology of urinary incontinence, faecal incontinence and pelvic organ prolapse. In: Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. Health Publications, ParisGoogle Scholar
  32. 32.
    Wilson D, Dornan J, Milsom I, Freeman R (2014) UR-CHOICE—can we provide mothers-to-be with information about the risk of future pelvic floor dysfunction? Int Urogynecol J 25:1449–1452CrossRefPubMedGoogle Scholar
  33. 33.
    Jelovsek JE, Piccorelli A, Barber MD, Tunitsky-Bitton E, Kattan MW (2013) Prediction models for postpartum urinary and fecal incontinence in primiparous women. Female Pelvic Med Reconstr Surg 19(2):110–118. doi: 10.1097/SPV.0b013e31828508f0 CrossRefPubMedGoogle Scholar
  34. 34.
    Changing Childbirth Part 1 (1993) Department of Health Report from the Expert Maternity Group. London: HMSOGoogle Scholar
  35. 35.
    United Nations Children's Fund. Total fertility rate (TFR). 2008 [updated 07/201003/02/2011]. Available from:
  36. 36.
    Gurol-Urganci I, Cromwell D, Edozien L, Mahmood T, Adams E, Richmond D, Templeton A, van der Meulen J (2013) Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 120:1516–1525CrossRefPubMedGoogle Scholar
  37. 37.
    Andrews W, Sultan AH, Thakar R, Jones PW (2006) Occult anal sphincter injuries—myth or reality? BJOG 113:195–200CrossRefPubMedGoogle Scholar
  38. 38.
    Johnson JK, Lindow SW, Duthie GS (2007) The prevalence of occult obstetric anal sphincter injury following childbirth – literature review. J Matern Fetal Neonatal Med 20(7):547–554CrossRefPubMedGoogle Scholar
  39. 39.
    Nygaard I (2005) Should women be offered elective caesarean section in the hope of preserving pelvic floor function? Int Urogynecol J Pelvic Floor Dysfunct 16:253–254CrossRefPubMedGoogle Scholar
  40. 40.
    Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, Carpenter M, Peaceman AM, O'Sullivan MJ, Sibai B, Langer O, Thorp JM, Ramin SM, Mercer BM, National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network (2006) Maternal morbidity associated with multiple repeat Caesarean deliveries. Obstet Gynecol 107:1226–1232CrossRefPubMedGoogle Scholar
  41. 41.
    Hyde MJ, Mostyn A, Modi N, Kemp PR (2012) The health implications of birth by caesarean section. Biol Rev 87(1):229–243CrossRefPubMedGoogle Scholar

Copyright information

© The International Urogynecological Association 2015

Authors and Affiliations

  1. 1.The Department of Obstetrics and GynecologySahlgrenska Academy at Gothenburg UniversityGothenburgSweden

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