Hypothesis / aims of study
Pregnancy and childbirth are major risk factors for pelvic floor dysfunction (PFD), including urinary incontinence (UI)(1) and anal incontinence (AI) (2). We hypothesized that women referred to a specialized perineal clinic due to obstetric risk factors or early postpartum symptoms would show a high prevalence of PFD at 6 months postpartum, and that identifiable clinical and ultrasound parameters would be independently associated with each type of dysfunction. The aim of this study was to determine the prevalence of UI, AI and defecatory urgency at 6 months postpartum in this selected cohort and to analyze predisposing factors associated with each condition.
Study design, materials and methods
This was an observational cohort study including women referred to a specialized perineal clinic at a tertiary university hospital between 2022 and 2025. Referral at 8 to 12 weeks postpartum was indicated in cases of instrumental delivery, primiparity with a macrosomic newborn, obstetric anal sphincter injury (OASIS) diagnosed intrapartum, levator ani muscle (LAM) injury diagnosed intrapartum or during the postpartum physical examination, and PFD symptoms during early postpartum.
Women with LAM injury and or OASIS, or with significant persistent symptoms at 6 months postpartum despite pelvic floor muscle training, underwent clinical and urogynecological ultrasound assessment by a urogynecologist and pelvic floor physiotherapist. UI was defined as ICIQ-UI-SF score greater than 5, AI as St Mark’s score greater than 0, and fecal urgency as inability to defer defecation for more than 15 minutes. Demographic variables, obstetric history, delivery characteristics, pelvic floor muscle strength measured by Oxford score and ultrasound parameters including urethral hypermobility, urethrocele, levator ani muscle (LAM) avulsion or ballooning and anal sphincter defects were recorded. Bivariate analyses were performed to identify independent predisposing factors.
Results
A total of 336 women were included. Mean maternal age was 36.0 years (SD 4.8) and mean body mass index was 23.1 kg per m2 (SD 3.9). Spontaneous vaginal delivery occurred in 57.7 percent, mean neonatal birthweight was 3333 g (SD 471), and 32.3% underwent episiotomy.
At 6 months postpartum, 29.7% of women had UI, and 11.9% reported moderate to severe symptoms. Independent predisposing factors for UI were higher maternal age, UI during pregnancy, higher ICIQ-UI-SF score at 8 to 12 weeks, urethral hypermobility, urethrocele at rest and ultrasound ballooning.
AI was present in 26.2% and fecal urgency in 11%. Higher maternal age, lower Oxford score, previous OASIS before the index delivery and residual anal sphincter defect on ultrasound were independently associated with AI and or fecal urgency.
Interpretation of results
In this high-risk postpartum population, UI and AI prevalence at 6 months was substantial. Both early clinical symptoms and objective ultrasound findings were strongly associated with later dysfunction, suggesting that combined clinical and imaging assessment improves risk stratification.
Concluding message
Women referred to a perineal clinic after childbirth show a high burden of UI and AI at 6 months postpartum. Maternal age, symptoms during pregnancy and the immediate postpartum period, and pelvic floor muscle weakness were identified as predisposing factors based on clinical presentation and physical examination. On ultrasound assessment, urethral hypermobility and ballooning were associated with a higher risk of UI, whereas sonographic evidence of anal sphincter injury—following either the current or a previous delivery—was associated with AI and fecal urgency.
These findings support the need for specific screening and referral pathways to perineal clinics and early postpartum rehabilitation in order to prevent the chronicity of UI and AI, as well as the routine use of ultrasound in selected postpartum women to classify lesions suspected intrapartum or in the immediate postpartum.