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INTRODUCTION: Obstetric anal sphincter injury is an important risk factor for postpartum fecal incontinence but few studies have reported fecal incontinence occurring, even during pregnancy. The first objective of this study was to examine the prevalence of fecal incontinence, obstructed defecation and vaginal bulging early and late in pregnancy and postpartum. The second objective was to assess the association between symptoms in pregnancy, delivery characteristics, and bowel and vaginal bulging symptoms at 1 year postpartum.

MATERIAL AND METHODS: This prospective cohort study was conducted between October 2014 and October 2017, including 898 nulliparous women enrolled with the maternity healthcare service in Örebro County, Sweden. The women responded to questionnaires regarding pelvic floor dysfunction in early and late pregnancy and at 8 weeks and 1 year postpartum. The data were analyzed using random effect logistic models estimating odds ratios (ORs) and generalized linear models estimating relative risks, with 95% confidence intervals (CIs).

RESULTS: At 1 year postpartum, the prevalence of fecal incontinence, obstructed defecation and vaginal bulging was 6% (40/694), 28% (197/699) and 8% (56/695), respectively. Among women with vaginal delivery, the risk of fecal incontinence and vaginal bulging increased significantly both in late pregnancy, with ORs of 3.4 (95% CI 1.5-7.7) and 3.6 (95% CI 1.6-8.1), respectively, and at 1 year postpartum, with ORs of 5.0 (95% CI 2.1-11.5) and 8.3 (95% CI 3.8-18.1), respectively, compared with early pregnancy. Among all women, factors associated with increased prevalence of fecal incontinence 1 year postpartum were fecal incontinence during pregnancy (adjusted relative risk [aRR] 7.4; 95% CI 4.1-13.3), obstructed defecation during pregnancy (aRR 2.0; 95% CI 1.1-3.9) and concurrent obstructed defecation (aRR 2.4; 95% CI 1.3-4.5).

CONCLUSIONS: This prospective study shows an increased risk of fecal incontinence by late pregnancy, suggesting that the pregnancy itself may be involved in the development of postpartum fecal incontinence. Obstructed defecation during pregnancy and postpartum was found to be associated with increased risk of fecal incontinence postpartum, indicating that postpartum fecal incontinence may be a result of incomplete bowel emptying.

INTRODUCTION AND HYPOTHESIS: The aim of this prospective study was to examine the impact of sociodemographic, pregnancy and obstetric characteristics on sexual function 12 months postpartum in primiparous women. We hypothesized that sexual function would decrease after childbirth.

METHODS: Between 1 October 2014 and 1 October 2017, all nulliparous women in early pregnancy registering for maternity health care in Region Örebro County, Sweden, were invited to participate in this prospective study. A total of 958 women were included. Sexual activity and function were measured at early pregnancy, 8 weeks postpartum and 12 months postpartum using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The associations between sociodemographic, pregnancy and obstetric characteristics and sexual activity and function from early pregnancy to 12 months postpartum were examined using linear and logistic models based on generalized estimating equations.

RESULTS: We found that the prevalence of sexually active women decreased from 98.0% in early pregnancy to 66.7% at 8 weeks postpartum, but increased to 90.0% at 12 months postpartum. Age ≥ 35 years, second-degree perineal tear and current breastfeeding were statistically significant risk factors for sexual inactivity at 12 months postpartum. Poor self-reported health in early pregnancy was statistically significantly associated with decreased sexual function at 12 months postpartum.

CONCLUSIONS: A majority of women resumed sexual activity at 8 weeks postpartum and most women at 12 months postpartum; the decrease in sexual function at 12 months postpartum was small and few risk factors were observed.

BACKGROUND: Many women experience urgency (UUI) and mixed (MUI) urinary incontinence but commonly hesitate to seek care. Treatment access and self-management for these conditions can be supported through eHealth approaches.

OBJECTIVE: This study aimed to investigate the efficacy of the mobile app Tät II for self-management of UUI and MUI in women.

METHODS: This randomized controlled trial included women ≥18 years old with UUI or MUI and ≥2 leakages per week. Those with red-flag symptoms were excluded. Participants were recruited via analog and digital advertisements and screened for initial selection through a web-based questionnaire. Data were collected using another questionnaire and a 2-day bladder diary. A telephone interview confirmed the symptom diagnosis. Participants were randomized (1:1) to receive access to a treatment app (including pelvic floor muscle training, bladder training, psychoeducation, lifestyle advice, tailored advice, exercise log, reinforcement messages, and reminders) or an information app (control group), with no external treatment guidance provided. The primary outcome was incontinence symptoms at the 15-week follow-up, measured using the International Consultation on Incontinence Questionnaire (ICIQ)-Urinary Incontinence Short Form (ICIQ-UI SF). Urgency symptoms were assessed using the ICIQ-Overactive Bladder Module (ICIQ-OAB) and quality of life using the ICIQ-Lower Urinary Tract Symptoms Quality of Life Module (ICIQ-LUTSqol). Incontinence episode frequency (IEF) was calculated per bladder diary entries. Improvement was measured using the Patient's Global Impression of Improvement. All outcomes were self-reported. Cure was defined as no leakages per the bladder diary. Intention-to-treat analysis was performed.

RESULTS: Between April 2017 and March 2018, 123 women (mean age 58.3, SD 9.6 years) were randomized to the treatment (n=60, 2 lost to follow-up) or information (n=63) group. Of these, 35 (28%) women had UUI, and 88 (72%) had MUI. Mean ICIQ-UI SF score at follow-up was lower in the treatment group than in the information group (estimated difference -3.1, 95% CI -4.8 to -1.3). The estimated between-group difference was -1.8 (95% CI -2.8 to -0.99) for mean ICIQ-OAB score and -6.3 (95% CI -10.5 to -2.1) for the mean ICIQ-LUTSqol score at follow-up. IEF reduction from baseline to follow-up was greater in the treatment group (-10.5, IQR -17.5 to -3.5) than in the information group (P<.001). Improvement was reported by 87% (52/60) of treatment group participants and by 30% (19/63) of information group participants. The cure rate was 32% in the treatment group, and 6% in the information group (odds ratio 5.4, 95% CI 1.9-15.6; P=.002). About 67% (40/60) of the treatment group participants used the app more than thrice a week.

CONCLUSIONS: The treatment app was effective for improving urgency and mixed incontinence in women. When self-management is appropriate, this app may be a good alternative to pharmacological treatment or other conservative management, thus increasing access to care.

TRIAL REGISTRATION: ClinicalTrials.gov NCT03097549; https://clinicaltrials.gov/ct2/show/NCT03097549.

INTRODUCTION: Few prospective studies have examined the effect of pregnancy and childbirth on stress and urgency urinary incontinence separately. The aim of the present study was to assess the extent to which pregnancy, vaginal delivery, and vaginal delivery characteristics affect the risk of significant stress and urgency incontinence 1 year after delivery.

MATERIAL AND METHODS: We conducted a prospective cohort study of 670 nulliparous women from early pregnancy to 1 year partum. The women were recruited at maternity health care service in Region Örebro County, Sweden, between October 1, 2014 and October 1, 2017 and completed questionnaires in early and late pregnancy and at 8 weeks and 1 year postpartum. Primary outcome measures were significant stress and urgency incontinence at 1 year postpartum in women who reported being continent before pregnancy. Generalized linear models were used.

RESULTS: Stress and urgency incontinence commencing before pregnancy were reported by 4% and 3% of women, respectively, in the first questionnaire in early pregnancy, and these women were excluded from subsequent analysis. Stress and urgency incontinence were reported by 21% and 8%, respectively, at 1 year postpartum, in women not reporting incontinence before pregnancy. Stress incontinence during pregnancy increased the risk of stress incontinence postpartum (risk ratio [RR] 2.48, 95% CI 1.86-3.3). Urgency incontinence during pregnancy increased the risk of urgency incontinence postpartum (RR 4.07, 95% CI 2.1-7.89). Vaginal delivery increased the risk of stress incontinence postpartum (adjusted RR 2.63, 95% CI 1.39-5.01) but not of urgency incontinence. This effect of vaginal delivery on stress incontinence was similar irrespective of incontinence status during pregnancy. The population-attributable fraction of stress incontinence associated with vaginal delivery was 0.58 (95% CI 0.23-0.77).

CONCLUSIONS: This study shows essentially different risk factors for stress and urgency incontinence, supporting stress incontinence as being the subtype mostly associated with pregnancy and childbirth, and urgency incontinence as being more stable over time. At a population level, vaginal delivery was the major risk factor for stress incontinence, followed by reporting stress incontinence during pregnancy.

Background: The aim of this study was to estimate the incidence of second-degree perineal tears, obstetric anal sphincter injuries (OASI), and high vaginal tears in primiparous women, and to examine how sociodemographic and pregnancy characteristics, hereditary factors, obstetric management and the delivery process are associated with the incidence of these tears.

Methods: All nulliparous women registering at the maternity health care in Region Örebro County, Sweden, in early pregnancy between 1 October 2014 and 1 October 2017 were invited to participate in a prospective cohort study. Data on maternal and obstetric characteristics were extracted from questionnaires completed in early and late pregnancy, from a study-specific delivery protocol, and from the obstetric record system. These data were analyzed using unadjusted and adjusted multinomial and logistic regression models.

Results:  A total of 644 women were included in the study sample. Fetal weight exceeding 4000 g and vacuum extraction were found to be independent risk factors for both second-degree perineal tears (aOR 2.22 (95% CI: 1.17, 4.22) and 2.41 (95% CI: 1.24, 4.68) respectively) and OASI (aOR 6.02 (95% CI: 2.32, 15.6) and 3.91 (95% CI: 1.32, 11.6) respectively). Post-term delivery significantly increased the risk for second-degree perineal tear (aOR 2.44 (95% CI: 1.03, 5.77), whereas, maternal birth positions with reduced sacrum flexibility significantly decreased the risk of second-degree perineal tear (aOR 0.53 (95% CI 0.32, 0.90)). Heredity of pelvic floor dysfunction and/or connective tissue deficiency, induced labor, vacuum extraction and fetal head circumference exceeding 35 cm were independent risk factors for high vaginal tears (aOR 2.32 (95% CI 1.09, 4.97), 3.16 (95% CI 1.31, 7.62), 2.53 (95% CI: 1.07, 5.98) and 3.07 (95% CI 1.5, 6.3) respectively).

Conclusion: The present study corroborates previous findings of vacuum extraction and fetal weight exceeding 4000 g as risk factors of OASI. We found that vacuum extraction is a risk factor for second-degree tear, and vacuum extraction, fetal head circumference exceeding 35 cm and heredity of pelvic floor dysfunction and/or connective tissue deficiency were associated with increased risk of high vaginal tears. These findings have not been documented previously and should be confirmed by additional studies.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to develop a new protocol for documentation of perineal lacerations and to validate the latter against the most common obstetric record system in Sweden. The hypothesis was that the new protocol would render more complete data on perineal lacerations than the current documentation method.

METHODS: A protocol for documentation of perineal lacerations was developed to be sufficiently comprehensive to serve research purposes. All women delivering their first child vaginally from 13 October 2015 to 1 February 2016 at Örebro University Hospital were eligible for the validation study. Perineal lacerations were documented using the protocol in parallel with the regular obstetric record system (ObstetriX). Cross tabulations were used to compare the coverage regarding perineal lacerations between the two documentation methods. McNemar's test was used to evaluate systematic differences between the methods.

RESULTS: A total of 187 women were included. The coverage of documentation regarding perineal laceration was significantly higher (p < 0.001) in the new protocol (89%) compared with ObstetriX (18%). Incidence of second-degree perineal tears was 26% according to the new protocol and 11% according to ObstetriX. The incidence of third-degree perineal tears A, B, and C was 2.7%, 2.1%, and 2.1%, respectively, according to the new protocol, and 3.2%, 2.7%, and 1.1% according to ObstetriX.

CONCLUSIONS: This validation study of a new documentation protocol showed that it delivered significantly more comprehensive information regarding perineal lacerations than the most common obstetric record system in Sweden.