This study monitored the symptoms of Pelvic Floor Dysfunction (PFD) during pregnancy and postpartum using the APFQ, a questionnaire that includes four domains: urinary function, bowel function, prolapse, and sexual function. It evaluates the symptoms and quality of life related to each of them. The relationship between anthropometric variables, obstetric history, and questionnaire scores was also analyzed.
During pregnancy, the growing uterus exerts pressure on the bladder and stresses the pelvic floor muscles. Even after childbirth, it may take time for these muscles to recover and return to normal function. In the postpartum group, analysis of the urinary function domain showed that dysfunction symptoms were most severe up to 6 weeks after birth and improved over time. These results align with a previous study of Brazilian postpartum women, which reported a higher frequency of urinary incontinence (UI) symptoms during pregnancy (47%), followed by a decrease at 30 days (6.3%) and 60 days (6.3%) postpartum[[17].
A positive correlation was found between the number of pregnancies and parity with an increase in the APFQ urinary function score, both during pregnancy and postpartum. This finding supports research by Wessel et al., which showed that the prevalence of UI can reach 58% during pregnancy, 31% in nulliparous women, and 42% in multiparous women[[18]. Furthermore, Milsom et al. had previously identified parity as a risk factor for developing UI in the postpartum period[[3].
Regarding bowel function, while no significant difference was found between pregnancy and postpartum periods, it is notable that the mean score for both groups was above zero, indicating symptoms of bowel dysfunction. Investigating bowel dysfunction during pregnancy and postpartum is crucial. Constipation, for example, is common during these periods and can lead to excessive straining during defecation, increasing the risk of hemorrhoids and anal fissures, which in turn worsens bowel dysfunction[[19]. Other studies have highlighted the link between constipation and the development of urinary incontinence[[20, 21], anal incontinence[[20, 22], and pelvic organ prolapse (POP)[[23].
For postpartum women, a negative correlation was found between age and bowel function score, meaning that older women had fewer symptoms of bowel dysfunction. However, intestinal symptoms related to pregnancy and childbirth may not manifest until decades later, which could affect this analysis[[24].
The study did not find significant differences between pregnancy and postpartum periods in the APFQ prolapse domain. Although POP typically appears with advanced age and after menopause[[25], a recent study quantitatively assessed prolapse using the Pelvic Organ Prolapse Quantification system. It showed that the vaginal walls descend from the second to the third trimester of pregnancy and revealed a positive correlation between genital hiatus and symptoms of POP-related dysfunctions[[26]. The literature on prolapse during pregnancy remains controversial, but given the physiological changes and stresses that pelvic organs undergo during pregnancy and childbirth, early investigation allows for timely diagnosis and interventions, which may prevent progression and improve treatment outcomes.
A positive correlation was found between parity and the worsening of prolapse symptoms in pregnant women. A recent study by Sascha et al. identified an odds ratio of 1.06 for prolapse appearance with increased parity[[27]. With each pregnancy, the uterus enlarges as the baby grows, putting pressure on the pelvic floor. Repeated stress from multiple pregnancies can progressively weaken the pelvic floor support structures.
Regarding sexual function, a significant difference was observed in the pregnant group: sexual dysfunction was more prominent in the first and second trimesters compared to the third trimester. Sexuality is influenced by a combination of physical, hormonal, psychological, and social factors. Besides that, some factors differ in each period of pregnancy, which can also impact sexuality – but not exclusively. In the first and second trimesters, women undergo significant bodily changes, such as breast enlargement, fatigue, and morning sickness, which can decrease libido and sexual interest. Additionally, rapid hormonal fluctuations during the early stages of pregnancy can cause mood swings and reduced sex drive. The discovery of pregnancy may also bring concerns about the babyโs health, changes in the relationship with the partner, and the future as a mother, all of which can negatively affect sexual interest[[28,29,30]. As pregnancy progresses and hormones stabilize, some women may experience an improvement in libido.
Understanding these patterns is essential to provide appropriate and sensitive support to pregnant women, addressing issues related to sexuality throughout pregnancy. While this study found that pregnant women in the third trimester experienced less sexual dysfunction than those in the first and second trimesters, it is noteworthy that only 50% of women in the third trimester were sexually active, compared to 76% in the first and second trimesters. This finding is consistent with research by Yeniel and Petri, who observed a tendency for sexual desire to decrease in the third trimester[[31].
Regarding sexual function postpartum, the study showed that women up to 6 weeks after delivery had fewer sexual dysfunction symptoms compared to those between 7 and 24 weeks and beyond 24 weeks postpartum. Postpartum sexual dysfunction can result from a combination of physical, hormonal, emotional, and social factors. After childbirth, hormone levels fluctuate significantly, with a decrease in estrogen and progesterone, which can affect sexual desire and vaginal lubrication, making intercourse less comfortable[[32]. Caring for a newborn can be physically and mentally demanding, which can reduce interest in sex. If the delivery was traumatic or involved complications, pelvic pain or dyspareunia may develop, which can lower sexual desire and delay the resumption of sexual activity[[18]. However, it is important to note that 51% of women were sexually active up to 6 weeks postpartum, 55% between 7 and 24 weeks, and 67% beyond 24 weeks. These findings align with other studies, which report a resumption of sexual activity occurring, on average, 6 to 8 weeks after childbirth, with a gradual increase in frequency after 6 months[[18, 30].
A negative correlation was also found between age and sexual function score, indicating that older women have fewer symptoms of sexual dysfunction. Although this result pertains to postpartum women, previous studies have shown that mature women tend to have better sexual quality[[33,34,35]. This may be related to greater self-awareness, emotional stability, and improved communication with their partners. Given the complexity of sexuality, further research in this area is needed.
A limitation of this study was the loss of participants during follow-up, particularly in the postpartum period. This can be attributed to the challenges of interviewing patients during this time, which involves physical adjustments, hormonal fluctuations, and emotional challenges for new mothers. The instability of daily routines, coupled with the prioritization of the newbornโs needs, made it difficult to contact patients, even by phone.
Another limitation was the exclusion of other risk factors for PFD symptoms. Some variables, such as the babyโs weight, mode of delivery, and difficulty or duration of labor, were not considered in this study, despite their known association with PFD and the prevalence of related symptoms. Future studies should incorporate these variables.
To our knowledge, this is the first study to monitor PFD during pregnancy and postpartum in Brazilian women. Investigating all aspects of PFD (urinary, bowel, prolapse, and sexual) during these periods is essential to ensure womenโs well-being and quality of life. Each PFD domain may require a distinct treatment approach. A comprehensive evaluation facilitates a multidisciplinary approach, involving healthcare providers, physiotherapists, and other specialists, ensuring a personalized and effective treatment plan for each woman.