Living with the consequences of symptomatic pelvic organ prolapse following vaginal childbirth—a partner’s perspective

We are grateful to Dr. Leong and Dr. Rogers for their valuable feedback and insightful comments (1) on our article titled “Bearing the burden of spill-over effects: Living with a woman affected by symptomatic pelvic organ prolapse after vaginal birth-from a partner’s perspective” (2).

The discourse on pelvic organ prolapse (POP) and its impact on the daily lives of women and their partners is critical, given its high prevalence among women after vaginal childbirth (3,4). In Sweden, as many as one in five women undergo surgery for symptomatic POP (sPOP), incontinence, or improperly healed birth injuries (3). It is known that symptoms of POP typically appear decades after vaginal birth. Still, early onset may occur due to severe obstetric trauma to the pelvic floor’s supporting structures during vaginal birth (5). One such trauma is an injury to the levator ani muscle, which affects 10–30% of first-time mothers (6).

Despite its high prevalence, postpartum sPOP has largely been a silent issue and an understudied condition. Mirskaya et al.’s study is part of a project aimed at increasing knowledge of sPOP following vaginal birth from the perspectives of women, their partners, and healthcare providers (2,7).

This study revealed that women’s sPOP severely restricted family life, affecting both current dynamics and future prospects. Partners often ended up caring for both the newborn and the mother without adequate healthcare support, leading to feelings of powerlessness and loneliness. This burden of the women’s sPOP affected partners’ health behaviors, intimate relationships, and psychological well-being, putting couples’ relationships at risk and, in some cases, nearly leading to breakdowns. Additionally, the lack of preparedness for post-birth pelvic floor complications, trivialization of sPOP by healthcare professionals, and limited treatment options added distress to the already strained situation (2).

Leong and Rogers (1) highlight the main results of our research, largely supporting our conclusions and clinical implications, including the importance of prenatal individualized pelvic floor dysfunction risk assessment and the implementation of preventive strategies. They also agree that women and partners should be informed about the potential risk of sPOP following obstetric trauma. If birth trauma occurs, the women and partners must receive adequate support and management postpartum.

Leong and Rogers (1), while primarily supporting our results, make several remarks that need to be addressed. Thus, in the commentary, it is noted that we did not investigate the effect of concomitant pelvic floor disorders (PFDs) such as urinary incontinence (UI) and fecal incontinence (FI) on the partners, which, according to the commentary, made it difficult to determine if the burdensome experiences of partners following childbirth was the result of solely POP and not confounded by coexisting PFDs (1).

In response to the notice, it is worth mentioning that, while we did not check if women had UI, we knew that none of the 13 women whose partners were interviewed had obstetric anal sphincter injuries (OASIs), which minimizes the risk for FI. Moreover, all women met the inclusion criteria: they had been diagnosed with sPOP after vaginal birth and had self-reported symptoms of POP. In the information letters for both partners and women, it was clearly stated that the study aimed to explore what it means to live with a woman with sPOP after vaginal birth from the partner’s perspective. In addition, seven women reported levator ani avulsion, one reported partial levator ani injury, and none mentioned UI, which minimizes the probability that they had bothersome symptoms of it. Thus, in the targeted women, the symptoms of POP may coexist with symptoms of levator ani injury rather than with FI or/and UI (which, of course, cannot be excluded entirely). These women may also constitute a subgroup with more severe birth-related pelvic floor traumas affecting muscular fascia, muscles, and ligaments at all three levels of vaginal support (4). As we mentioned in the discussion, the limited information on obstetric trauma and the fact that we did not have the medical records are the study’s weaknesses. However, it is worth noting that the important difference between UI and levator ani injury is the possible cure (2). While UI can be managed by physical therapy or surgically, levator ani avulsion reconstruction is only in its infancy (8). Our study showed that the lack of treatment options largely contributed to partners’ frustration (2). However, we agree with the authors that it could be interesting to explore how UI and FI contribute to the partners’ experiences following birth trauma.

Another critique is that the sample recruited for our study did not represent the general population. Indeed, qualitative studies aim to explore and provide deeper insights into real-world problems, and it is not the goal of qualitative research to be generalized like quantitative studies (9). It would be interesting to conduct extensive quantitative research with a representative population sample and investigate the impact of sPOP on a family’s relationship dynamic, socioeconomic status, lifestyle, family planning, and health.

Further, Leong and Rogers (1) note that the high prevalence of postpartum blues complicates determining whether the core category of ‘facing a new restricted life’ is only due to sPOP. The partners in our study made it clear that sPOP and levator ani injuries triggered women’s depressive symptoms. This unexpected and unknown condition led to distorted body image, intense grief, and anxiety (2). The link between the onset of sPOP and other PFDs after vaginal birth and psychological trauma was observed in previous studies (8,10). Professionals must be aware of the real impact of PFDs on the quality of life and psychological health of new mothers and their partners.

We can all agree that unexpected complications following childbirth, such as sPOP, can have severe consequences for the woman’s health and well-being, which also impacts her partner. Therefore, raising awareness and increasing knowledge about sPOP is crucial for prevention, improving healthcare response, and enabling effective treatment. We deeply appreciate the thoughtful comments and suggestions by Dr. Leong and Dr. Rogers.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-36/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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