By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
Dr. Ghetti reports no financial relationships relevant to this field of study.
SYNOPSIS: Pregnant and postpartum patients lack knowledge about urinary incontinence and prolapse.
SOURCE: Mckay ER, Lundsberg LS, Miller DT, et al. Knowledge of pelvic floor disorders in obstetrics. Female Pelvic Med Reconstr Surg 2019;25:419-425.
The objective of this study was to examine knowledge regarding pelvic disorders, in particular urinary incontinence (UI) and pelvic organ prolapse (POP), among pregnant and postpartum women and to identify the characteristics of subjects who lack knowledge about UI and POP.
This is a cross-sectional, multicenter study of women presenting for prenatal or post-natal care. Subjects were recruited from nine locations with affiliations to three hospitals in Connecticut and were included if they were 18 years of age or older and either pregnant or up to eight weeks postpartum. Women were asked to complete a self-administered survey containing study measures and were excluded if they had completed the survey previously. The primary outcome measure was pelvic floor disorder (PFD) knowledge, which was assessed using the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). This is a 24-item, validated, self-administered questionnaire comprised of two independently scored 12-item subscales. It assesses women’s knowledge about UI and POP, respectively, in the areas of disorder etiology, epidemiology, diagnosis, and treatment. Subjects also completed sociodemographic information and the Pelvic Floor Distress Inventory-20 questionnaire assessing PFD symptoms. The primary outcomes were the percentage of women with a lack of knowledge proficiency, defined as correctly responding to 80% and 50% of the PIKQ UI and POP subscales, respectively. Associations between lack of knowledge and demographic characteristics were explored with univariate and multivariable analyses.
Three hundred ninety-nine subjects completed some portion of the study questionnaires, with 376 and 364 participants completing the UI and POP subscales, respectively. The mean participant age was 28.5 ± 6.0 years. Two-thirds of participants were unmarried (61%) and had delivered at least one child (67%). One-third of women self-identified as white, non-Hispanic (33%). The majority of subjects were pregnant (93.2%) and nearly two-thirds were in the third trimester 64.6% (n = 248). Overall, 39% (n = 151) reported incontinence symptoms, while 4.8% (n = 18) reported seeing or feeling a vaginal bulge. The majority of women showed a lack of knowledge proficiency about UI (74%) and POP (70%). In multivariable analyses, the authors reported that patient characteristics significantly associated with a lack of knowledge proficiency regarding UI include Hispanic race, primiparity, and lower levels of education. For POP, lower level of education was a characteristic significantly associated with lack of knowledge proficiency, while women reporting prior visits to a urologist or urogynecologist and women working in a medical field were more likely to have a higher knowledge proficiency.
Overall, women have poor knowledge regarding PFDs. A prior study by the authors demonstrated that community-dwelling women with a mean age of 49 years (range 19-80+) lacked knowledge proficiency in both UI and POP.1 Seventy-one percent of women lacked UI knowledge and 48% lacked POP knowledge. Chen et al, using the same questionnaire (PIKQ), found a lack of knowledge among women seeking primary care.2,3 In the cohort, 72% lacked knowledge about UI and 54% lacked POP knowledge. The current study finds a persistent lack of knowledge in pregnant and postpartum women; 74% of women lacked UI knowledge and 70% lacked POP knowledge.
Lack of knowledge has been found to be associated with educational status and also with a lack of awareness that PFDs are a medical condition. Mandimika et al found significant racial disparities in pelvic floor knowledge.4 In that study of community-dwelling women attending public events, African-American women were significantly less likely to identify risk factors and treatment options for PFDs when compared to white women.
The patient’s lack of knowledge about PFDs has been associated with lack of seeking care for PFDs.5 Patient knowledge is a barrier to early care, alongside a lack of routine screening by primary physicians. In an email survey of attitudes and knowledge of PFDs among internal medicine and family physicians using a non-validated measure, only half reported screening for UI, and the majority responded that they never screened for POP.6
Increasing patient education and physician screening of PFDs may allow for earlier evaluation and treatment of these conditions. In turn, earlier evaluation may allow patients to benefit earlier from conservative options, and lifelong education and behavioral changes that may not be as efficacious at later stages.
Studies have demonstrated that community-dwelling women have a low knowledge proficiency regarding UI and POP. Similar knowledge deficiencies exist in pregnant and postpartum women. The study by Mckay et al highlights that pregnancy may provide a key educational window to help educate women about PFD symptoms, risks, and treatments. As the main providers of prenatal and postnatal care, we are in the unique role of providing women with education and resources regarding PFDs long before they are plagued by their symptoms.
Unsure where to start? Societies such as the American College of Obstetricians and Gynecologists (https://www.acog.org/Patients/Patient-Education-FAQs-List) and the American Urogynecologic Society (https://www.voicesforpfd.org/resources/fact-sheets-and-downloads/) have developed patient information regarding pelvic floor disorders.
- Mandimika CL, Murk W, Mühlhäuser McPencow A, et al. Knowledge of pelvic floor disorders in a population of community-dwelling women. Am J Obstet Gynecol 2014;210:165.e1-9.
- Shah AD, Massagli MP, Kohli N, et al. A reliable, valid instrument to assess patient knowledge about urinary incontinence and pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1283-1289.
- Chen CCG, Cox JT, Yuan C, et al. Knowledge of pelvic floor disorders in women seeking primary care: A cross-sectional study. BMC Fam Pract 2019;20:doi:10.1186/s12875-019-0958-z.
- Mandimika CL, Murk W, Mcpencow AM, et al. Racial disparities in knowledge of pelvic floor disorders among community-dwelling women. Female Pelvic Med Reconstr Surg 2015;21:287-292.
- Holst K, Wilson PD. The prevalence of female urinary incontinence and reasons for not seeking treatment. N Z Med J 1988;101:756-758.
- Mazloomdoost D, Westermann LB, Crisp CC, et al. Primary care providers’ attitudes, knowledge, and practice patterns regarding pelvic floor disorders. Int Urogynecol J 2017;28:447-453.