Symptom Phenotypes of Patients Presenting to the Postpartum Urogynecology Clinic

Objectives: The postpartum perineal clinics provide care to patients with anal sphincter and perineal injuries. We aim to describe the symptom distribution of patients presenting to a comprehensive postpartum urogynecology (PPU) clinic that addresses all postpartum pelvic floor issues.

Methods: This retrospective cohort study includes postpartum patients seen at PPU from its establishment in 2016 to 2023. PPU referrals, presenting symptoms, and demographics (age, race, gravida, para, mode of delivery, usage of vacuum/forceps, smoking) were tabulated. All patients completed PFDI, POPDI, FSFI, and underwent a 3D Endovaginal Ultrasound.

Results: 229 patients were seen from 2016 to 2023. Establishing referrals was slow until 2022 with only 100 patients seen. 163/229 patients were white (71.5%), with 58/229 (25.6%) with operative vaginal delivery. Although the major appointment reason was 55/229 (24.1%) obstetric anal sphincter injury, there were less frequent presentations, such as 8/229 (3.4%) patients with vaginal cysts, and 1/229 (0.4%) patient with rectovaginal fistula.
When categorizing based on symptoms, 84/229 (38.5%) had obstetric anal sphincter injury, among which 52/84 (62%) presented with complaints of vaginal bulge or prolapse.
75/229 (34.4%) had pelvic floor weakness, among which 27/75 (36%) vaginal pressure, 24/75 (32%) stress urinary incontinence, 23/75 (30.7%) dyspareunia or inability to have intercourse, and 21/75 (28%) patients with pain and discomfort.
8/229 (3.5%) had urinary urgency, or 4/229 (1.8%) had defecatory dysfunction such as fecal urgency or incontinence and splinting (Fig. 1).
Of note, 39/229 (17.03%) of patients presented with more than one symptom.
84/229 (36.6%) patients with Ultrasound documented EAS or LAM injury or both were offered surgical management, of which 53/84 (63%) patients proceeded with surgery, and 31/84 (36.9%) waited to be scheduled for surgery.
60/229 (26.6%) patients were managed with physical therapy, and 14/229 (6.1%) with expectant management with symptom improvement.

Conclusions: A comprehensive postpartum urogynecology clinic offers more than perineal care. The most common patient symptom phenotypes were feeling of vaginal bulge, vaginal pressure, and pain. 28% of patients who presented with perineal symptoms had documented LAM injury. Further investigations of postpartum pelvic floor symptoms with pelvic floor ultrasound can assign a proper diagnosis.