Keywords

1 Introduction

Whereas Chap. 10 looked at the sexual aspects of the pelvic floor (PF) in healthy pregnancy and postpartum, this chapter will address how various PF disorders influence sexuality. The chapter will successively pay attention to urinary problems, defecation problems, pelvic organ prolapse, and pelvic girdle pain and how they relate to sexuality. We start with the pregnancy-related situations and then the postpartum situations.

2 Pelvic Floor Disturbances/Disorders During Pregnancy

2.1 Introduction

PF disorders are common during pregnancy. The increased intra-abdominal pressure and the relaxation of the PF connective tissues can disturb micturition and defecation and cause pelvic organ prolapse [1]. Those are embarrassing complaints that decrease quality of life, including sexual life. The range of disturbances goes from a slight inconvenience to severe disorders. Factors such as shame in the woman and her partner influence the degree of impact on sexuality and sexual well-being, just as the importance they attach to sexuality.

2.2 Urinary Disorders During Pregnancy

Both pregnancy and childbirth are risk factors for developing urinary incontinence.

Stress urinary incontinence (SUI) is the involuntary loss of urine on effort or physical exertion. SUI can already develop before childbirth and happens in 38% of nulliparous [pregnant] women [2]. With the potential damage caused by delivery added, SUI occurs in 42% of multiparous women [3].

Urgency urinary incontinence (UUI or urine leakage at urgencyFootnote 1) also increases during pregnancy but less frequently.

The amount of urine loss differs. Whereas some women lose some drops, the bladder empties entirely in others. It can be experienced as embarrassing, diminishes the woman’s self-esteem and self-worth, and impairs her sexuality.

SUI and UUI can also happen during sexuality, with SUI occurring relatively more frequently during penetration and UUI relatively more frequently at orgasm. The last, called ‘climacturia’, is especially disturbing during cunnilingus (oral sex to the woman’s genitalia), a standard part of the sexual script for couples in many parts of the globe.

Urinary tract infections (UTI) affect up to 10% of pregnant women. Although some people consider sexual intercourse to cause recurrent UTIs, (un-)hygienic measures and dysfunctional voiding seem more relevant. Some women appear to avoid sexuality to prevent UTIs with dysuria and the continuous urge to void as additional reasons to abstain from penetrative sex.

2.2.1 Treatment Aspects

During pregnancy, urinary incontinence (UI) is associated with an underactive pelvic floor, and is a risk factor for developing postpartum UI. So the woman should train her PF muscles (PFMT as described in Chap. 10), focusing on contraction (increasing strength and endurance), relaxation and coordination. The most important aspect of PFMT is learning to squeeze the PF muscles when the abdominal pressure increases and consciously relax them when no contraction is needed. A correct function and good awareness of the PF will allow penetration and intensify sexual feelings.

In case of recurrent urinary tract infections, adequate toilet technique needs attention.

With a completely relaxed PF, voiding can take place spontaneously without pressing. The woman should also take time to empty the bladder completely.

2.3 Defecation Disorders During Pregnancy

In pregnancy, defecation disorders include anal incontinence, involuntary loss of faeces or flatus, and constipation. Anal incontinence and constipation are highly distressing and negatively impact sexuality.

Although pregnant women rarely report the involuntary loss of solid or liquid faeces (out of shame?), the research found incidences between 2% and 9.5% [4]. Involuntary loss of flatus (‘flatal incontinence’) affects 12–35% of pregnant women and is especially embarrassing during intercourse. As a result, some women seem to avoid sexuality, others avoid genital contact, and nearly all abstain from receptive oral sex.

The causes of constipation during pregnancy are manifold. In constipation, defecation is infrequent or incomplete, or there is a need for frequent straining or digital assistance to defecate. The relaxation of the connective tissues of the bowels increases the ‘colon transit time’, increasingly solidifying the stool. The woman then strains to defecate, which can cause haemorrhoids and painful and incomplete evacuation. Oral anaemia-related iron supplementation can aggravate this process.

Constipation can cause abdominal pain, reduced appetite, and reduced well-being, negatively affecting sexuality. In addition, the rectum filled with faeces can cause an unpleasant sensation of urgency during sex.

2.3.1 Treatment Aspects

In case of anal or flatal incontinence, PFMT (pelvic floor muscle training) is recommended (as described in Chap. 10). In case of constipation, osmotic laxatives can soften the stool. Furthermore the position during a bowel movement is important.

For proper defecation, the position is essential. The knees should be placed higher than the hips. In this ‘squatting’ position, the PF (especially the puborectal muscles) relaxes and enhances free passage (Fig. 16.1).

Fig. 16.1
A schematic diagram of a person sitting on a western toilet. The feet are placed on a small stool. The thighs and lower legs are bent to form an inverted V shape.

Position for easily passing stool. (Illustration by Corine Adamse)

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2.4 Pelvic Organ Prolapse During Pregnancy

Pelvic organ prolapse (POP) is the descent of the anterior vaginal wall, posterior vaginal wall, uterus, or combinations. Since the connective tissues relax and the intra-abdominal pressure increases, one may expect a descent of the pelvic organs during pregnancy. In contrast, there is a cranial shift from the pelvic organs from mid- to late pregnancy [5]. So, a pelvic organ prolapse is not expected in the primigravid woman. Pregnant women, however, report a heavy, dragging sensation in the vaginal area. Most probably, circulatory changes, particularly reduced venous backflow with perivaginal varicose and venous congestion, are responsible for this heavy sensation. Combined with the increased vaginal blood circulation of sexual arousal, this can increase the feeling of prolapse. In some women, that might be a reason to avoid sexual activities. The decreased function of the pelvic floor muscles might be another part of the explanation for the ‘prolapse sensation’.

Be aware that in threatening premature labour, the woman can also experience the sensation of prolapse.

2.4.1 Treatment Aspects

Without other signs of threatening premature labour, it seems relevant to reassure pregnant women that the sensation of prolapse is just part of the pregnancy and that sexual activities, including penetration, will not worsen this condition. On the other hand, the woman could diminish the sensations by limiting her standing time to decrease the pressure on the lower belly.

Improving the PF function will create better support for the pelvic organs and be, in that way, effective. Training of the PF muscles, performed in the supine position, will activate the muscle pump and relieves by diminishing the venous congestion.

2.5 Pregnancy-Related Pelvic Girdle Pain (or Pregnancy-Related Low Back Pain)

The definition of pelvic girdle pain (PGP) is: pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joint. The pain may radiate in the posterior thigh and occur in the symphysis [6]. It generally develops during pregnancy or the first 3 weeks postpartum. PGP affects up to 45% of pregnant women and causes multiple limitations in daily life activities [7]. Musculoskeletal pain can limit sexual activities as well [8].

Furthermore, PGP can be considered a motor control impairment of the lumbar spine and the pelvis, leading to several compensation strategies. One of those compensation strategies is using the pelvic floor muscles to improve motor control. Many women unconsiously develop an overactive pelvic floor. Such PF muscle overactivity can cause dyspareunia [9].

2.5.1 Treatment Aspects

Counselling, explaining the pain, and training to improve motor control of the lumbar spine and the pelvis can reduce this pain and be sufficient to resume sexual activities. Here, it can be helpful to recommend trying adapted positions for penetrative sex, for instance, the man on his side and the woman on her back with knees bent and vagina towards the penis (position A) (Fig. 16.2a). The woman’s pelvis is spared in this position, just as in the ‘scissors position’ (position B). When advising couples on such pelvis-sparing positions for penetration, it is necessary to be very concrete and detailed to minimize any hesitation to implement these tips at home because of doubts about the ‘How?’. Here, hand-out illustrations can be beneficial.

Fig. 16.2
A set of 2 schematic diagrams of sexual positions. a. Both legs of the man are placed between the thighs and the lower leg of the woman who is in the supine position. b. The man's legs are placed between the woman's left thigh who is in the supine position and her right leg is placed above the man's left leg.

Sexual positions to be recommended in Pelvic Girdle Pain. Position A: woman supine, man on his side, penis towards the vagina. Position B: sciccors position. (Illustration by Corine Adamse)

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3 Pelvic Floor Disturbances/Disorders in the Postpartum Period

3.1 Introduction

Pregnancy and vaginal birth are the most common risk factors for postpartum PF disorders: stress urinary incontinence, overactive bladder syndrome, pelvic organ prolapse, and anal incontinence [1]. This might sound like pathologizing birth. However, HCPs tend to underestimate the rates of obstetric (anal) injury, and in most textbooks, levator ani avulsion is not even mentioned. In an Australian study with 483 patients, only 33–40% of primiparous women achieved an atraumatic normal vaginal birth [10].

These disorders develop by various combinations of damaged PF muscles, damaged PF nerves, and damaged connective tissues, all potentially influencing sexuality. This part will first address perineal pain, vaginal laxity, and overactive pelvic floor, followed by urinary incontinence, anal incontinence, pelvic organ prolapse, and pelvic girdle pain.

3.2 Perineal Pain

Perineal pain can happen because of episiotomy, lacerations, or (over)stretching of the perineum. Nine out of ten women report this pain, with a third of the women experiencing moderate-to-severe pain and one in seven women still suffering 9 weeks after childbirth [11]. Perineal pain can limit daily life activities. It can also impair sexual life and sexual pleasure with, especially in couples with poor communication, the risk that dyspareunia develops into long-standing sexual and relationship problems.

3.3 Vaginal Laxity

One of the effects of childbirth PF injuries is a reduced strength of the PF muscles. When the strength has decreased too much, the woman cannot close the genital hiatus sufficiently. This symptom is called vaginal laxity. With such laxity, there is no or little friction between the penis and the vagina during penetration. This laxity diminishes sexual pleasure for both partners. Furthermore, it can cause vaginal noise or ‘vaginal flatus’ during intercourse, which is embarrassing for most people. Because of the entrance’s insufficient closure, air enters the vagina and is noisily pushed out by the intercourse movements. Though laxity does not physically hurt, it means, for some couples, a serious sexual disorder needing counselling with practical recommendations on how to avoid vaginal flatus during penetrative sex.

Couples could try another position. Unfortunately, literature does not offer solution of ‘noise-free’ positions. One could try minimally moving the penis after penetration and use other stimulation like kissing, caressing the breasts, stimulating the clitoris, or whatever a couple prefers. Some couples use loud music and orchestrate penetration on the beats of the music.

Vaginal laxity is frequently linked to an avulsion of the levator ani muscle, meaning that the muscle is partly (and sometimes wholly) torn away from the pubic bone. In a multicentre study on women with first deliveries, the prevalence of levator ani avulsion was 18.8% (with 8% in spontaneous, 29% in vacuum-assisted, and 51% in forceps–assisted delivery) [12].

3.3.1 Treatment Aspects

PFMT, creating a kind of hypertrophy of the puborectal and pubococcygeus muscle, will decrease the cross-sectional area of the genital hiatus and thus improve the closure of the genital hiatus and increase the friction between the vaginal wall and the penis with a more intense sexual sensation [13].

3.4 Overactive Pelvic Floor

Overactivity is the opposite of laxity. The PF has an increased tone and is not able to relax when needed. This can be caused by perineal pain and fear of (urinary or anal) incontinence or prolapse. The overactivity causes the PF nods and closes the vagina, resulting in a short and narrow vagina, as described in Chap. 10. The consequences are difficulties in penetrating, dyspareunia, and the risk of developing a vicious circle of ‘dyspareunia → no desire → dyspareunia’.

3.4.1 Treatment Aspects

PFMT should focus on relaxation and coordination. In perineal pain, the woman needs reassurance that squeezing the PF will not cause harm. On the contrary, alternately, maximum squeezing and complete relaxation of the PF will decrease the pain. Especially here, be aware of the risk of developing long-standing vicious circles of pain, poor sexual pleasure, and relationship problems. Having couples avoid all potentially painful sexual activities is often considered an excellent start to treatment and a way of preventing the development of more permanent pain associations [11].

3.5 Urinary Incontinence

Urinary incontinence affects up to a third of women in the first 3 months after childbirth. Unfortunately, 1 year after birth, that has barely changed.

Urinary incontinence is a burdensome condition affecting the quality of life, often causing shame and loss of one’s self-perceived sexual appeal.

Vaginal birth is particularly associated with stress urinary incontinence (SUI). It is caused by injuries to the PF muscles (reduced strength), connective tissues (weakened support of the bladder neck), and the pudendal nerve. SUI limits all ‘abdominal pressure increasing’ activities like coughing, running, jumping, bending, and carrying the baby. During sex, it occurs with pressure on the belly and when the penetrating penis pushes against the bladder. So urinary incontinence can affect personal, work, and leisure activities.

There is no difference between vaginal and caesarean delivery regarding urgency urinary incontinence [14].

Urinary incontinence can also lead to coital incontinence (as described in Chap. 10), diminishing sexual activity in some couples.

3.5.1 Treatment Aspects

Part of these injuries will heal but not recover completely. Well-functioning PF muscles can partly compensate for this damage [15].

They can improve the closure of the urethra.

To close the urethra optimally, a contraction of the diaphragm pelvis and the urogenital diaphragm, in particular the external urinary sphincter, is required. Actually, the external urethral sphincter is not really a sphincter, but a horseshoe-shaped muscle that closes the urethra by pressing it against the fascia. 

The closure of the urethra should be emphasised. With your palpating finger against the bladder neck, ask the woman to contract her PF. A proper contraction will lift the urethra ventralward (‘bladder neck elevation’).

Following the advice given in Chap. 10, (healthy) women can expect improvement by PFMT after 6 weeks. Recovery of the pelvic floor muscles will take more time in the breastfeeding woman because of her low oestrogen levels.

Practical aspects: empty the bladder before sexual activity.

Adjust urine production to desired sexuality (food that makes the urine smell, timing, the diuretic effect of caffeine, et cetera).

3.6 Anal Incontinence

Anal incontinence is a rather embarrassing condition, more bothersome and burdensome than urinary incontinence. After vaginal childbirth, 14% of women suffer from anal incontinence [16].

Anal incontinence is associated with third- and fourth-degree anal sphincter tears [17]. Women with anal sphincter tears often have injuries to the perineal muscles (pubovaginalis, puborectalis) and the pudendal nerve as well. Like urinary incontinence, anal incontinence limits all ‘abdominal pressure increasing’ activities. With a sphincter tear, women have less resumption of sexual activities [18]. Because of the extent of the injury, there can be a decrease in sensations during sexual activities. Fear of losing stool or gas does neither make a woman feel feminine nor attractive.

3.6.1 Treatment Aspects

Practical aspects: Work with quality and timing of food intake and defecation training towards regular daily bowel movements. With such regularity, the rectum will be empty for the rest of the day, and one will not lose stool. Training of strength and coordination of both the anal sphincter and the puborectal muscle is vital to maintain anal continence. Both aspects will improve sexuality as well.

3.7 Pelvic Organ Prolapse

Over her lifetime, pelvic organ prolapse (POP) affects 50% of all women who have had at least one vaginal birth [19]. Women with prolapse experience various pelvic floor symptoms depending on the localization and prolapse stage. The most apparent sign of POP is a bulge descending into the vagina. This bulge can be the descending bladder, uterus, or rectum. Sometimes, the vagina seems blocked by the bulge. However, during sexual activities, the bulge can easily be pushed aside.

Damage to the PF muscles and connective tissues causes the prolapse. Sometimes the pudendal nerve is damaged as well. Many women with POP cannot sufficiently close the genital hiatus. During childbirth, the PF muscles, specifically the pubovaginal and puborectal muscles, have to stretch with a factor of 3–4. Since striated muscles cannot stretch more than a factor of 1.5, it is not surprising that these PF muscles get injured during childbirth. Such an overstretching can result in a partial or complete avulsion of the levator ani muscle or traumatic overstretching. Levator ani muscle avulsion is not reversible and has a 13–36% incidence [20]. After a first vaginal birth, the next vaginal deliveries are unlikely to cause avulsion [12].

An open or insufficiently closed genital hiatus can lead to vaginal noise or ‘vaginal flatus’ and low friction between the vagina and the penis [21]. POP affects the quality of life, particularly the woman’s self-image or self-esteem. Mechanically, sexual intercourse is, in general, not impaired. In other words: penetration stays possible.

3.7.1 Treatment Aspects

For sexual contact and intercourse, the couple can choose positions in which gravity does not push the prolapse into the vulva, which makes penetration easier. In urogenital prolapse, training of the PF muscles (PFMT) is the first treatment option. Another frequently used strategy is a pessary [3]. PFMT will improve the closure of the hiatus and will increase the friction between the vagina and the penis creating a more intense sexual sensation [22]. The levator ani, bulbospongiosus, and ischiocavernosus muscles are important in sexuality by clasping what enters the vagina, increasing the clitoral circulation, and experiencing orgasm contractions.

If PFMT, a pessary, or the combination does not yield effect, the next option is surgery, aiming to repair the disturbed anatomical structures.

3.8 Pelvic Girdle Pain (PGP)

Though postpartum PGP prevalence decreases, it still affects a quarter of women 1 year postpartum [9]. Pelvic girdle pain (formerly sometimes called pelvic instability) is usually caused by impaired motor control of the lumbar spine and the pelvis.

Since the PF muscles connect the pelvic bones and can increase the abdominal pressure, they can give an increased feeling of motor control. When experiencing a lack of motor control, the woman will unconsciously compensate for this with her pelvic floor. Though that will partly contribute to the stiffness of the predominantly bony pelvic ring, it does not lead to optimal motor control. As a result, the PF muscles gradually become overactive without improving the pain. Then, a vicious circle can develop with the pain stimulating the PF muscles to keep trying improved motor control. The overactive pelvic floor impedes sexual reflexes and nods and closes the vagina. Sexual well-being is thus harder to attain.

3.8.1 Treatment Aspects

Teach proper techniques to improve motor control without excessively squeezing the PF. After achieving effective motor control, one should learn PF relaxation. See also Chap. 10 or refer to a PF physiotherapist. As in prepartum PGP, being aware of specific positions for penetrative sex is valuable.

4 Conclusion

Sexual disorders related to pregnancy and childbirth can be due to PF disorders and dysfunctions. Women need more information about their PF muscles and their changes during pregnancy and after birth [23]. Increasing PF muscle awareness and improving PF muscle function can contribute to more satisfying sex. Though sexuality will always be different after childbirth, it does not mean that a woman cannot enjoy sex anymore. On the contrary, the woman who, in the course of the pregnancy, becomes more aware of her pelvic floor and learns how to use those muscles as ‘love muscles’ can benefit tremendously.