Anna Marie Ellström Engh

• Siafarikas, Franziska; Benth, Jurate Saltyte; Stær-Jensen, Jette; Reimers, C.; Bø, Kari & Engh, Anna Marie Ellström (2026). Levator hiatus area from 21 weeks' gestation to 8 years after first delivery according to vaginal parity: prospective cohort study with an 8‐year recall extension. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 68(2), p. 273–283. doi: 10.1002/uog.70278. Full text in Research Archive Show summary

  Objectives The first aim was to describe longitudinal changes in levator hiatus area from 21 weeks' gestation in the first pregnancy to 1 and 8 years after first delivery, according to subsequent vaginal parity in women with vaginal delivery or Cesarean section (CS) at first delivery. The second aim was to assess the effect of subsequent vaginal delivery on levator hiatus area after first vaginal delivery. Methods In this prospective cohort study with an 8‐year recall extension, 183 initially nulliparous women underwent three‐ and four‐dimensional transperineal ultrasound examination at 21 weeks' gestation and 1 and 8 years after first delivery. The levator hiatus area at rest, during maximum pelvic floor muscle contraction and during maximum Valsalva maneuver was assessed at each timepoint. Participants with multiple vaginal deliveries (vaginal multiparae), only one vaginal delivery (vaginal primiparae), CS for all deliveries and vaginal birth after CS were compared. The differences between study groups in levator hiatus area over time were assessed using a linear mixed model. Results Overall, vaginal multiparae showed a statistically significant non‐linear increase in levator hiatus area from 21 weeks' gestation to 8 years after first delivery ( P  < 0.001). In contrast, participants who delivered exclusively by CS showed a decrease in levator hiatus area from 21 weeks' gestation to the 8‐year follow‐up. Subsequent vaginal delivery after an initial vaginal delivery did not affect the levator hiatus area during Valsalva maneuver. At the 1‐year and 8‐year follow‐up after the first vaginal delivery, levator hiatus area at rest remained unchanged in vaginal multiparae but decreased in vaginal primiparae. At the 8‐year follow‐up, vaginal multiparae had a larger hiatus area during pelvic floor muscle contraction than did vaginal primiparae. Conclusions In this study, the levator hiatus area was influenced by the mode of the first delivery and by subsequent vaginal deliveries. Overall, the levator hiatus area increased from 21 weeks' gestation to 8 years in participants with at least one vaginal delivery and decreased in those who delivered exclusively by CS. Subsequent vaginal delivery after a first did not seem to affect the levator hiatus area measured during Valsalva maneuver. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

• Gabrielsen, Rakel; Tellum, Tina; Bø, Kari; Engh, Anna Marie Ellström & Tennfjord, Merete Kolberg (2026). Effect of pain management, supervised exercise, and pelvic floor muscle training on sexual function in women with endometriosis: A randomized controlled trial. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. doi: 10.1111/aogs.70318. Full text in Research Archive Show summary

  Abstract Introduction Pelvic and genital pain is a common symptom among women with endometriosis and may negatively affect sexual functioning. Pelvic floor muscle training (PFMT) may improve sexual functioning, but whether this applies to women with endometriosis remains to be explored. This study is a planned secondary analysis in which we aimed to examine how general exercise and PFMT, when added to pain management, affect sexual functioning among women with endometriosis. Material and Methods Planned secondary analysis of a two‐armed, parallel‐group randomized controlled trial with intention‐to‐treat analysis. Women aged 18–45 years with laparoscopically confirmed endometriosis and experiencing pelvic/genital pain were eligible. All participants attended a pain management course. In addition to weekly home training, the exercise group ( n  = 41) participated in weekly supervised general exercise training, including PFMT, for 4 months. The control group ( n  = 40) received no further intervention. Between‐group differences in sexual function were assessed using the total score of the Female Sexual Function Index (FSFI) at the end of the 4‐month intervention and at the 12‐month follow‐up. We also examined differences in the subdomains—desire, arousal, lubrication, orgasm, satisfaction, and pain—at these time points. Clinical Trial registration: NCT05091268. Results Four months post‐intervention, the exercise group showed significantly higher total FSFI scores compared to the control group (mean difference = 3.52, 95% CI 0.49–6.54, p  = 0.023). Significant between‐group differences were also observed for the subdomains lubrication (mean difference = 0.90, 95% CI 0.17–1.63, p  = 0.016) and orgasm (mean difference = 0.81, 95% CI 0.07–1.55, p  = 0.033). No significant between‐group differences were found for desire, arousal, or pain at the end of the 4‐month intervention, or at 12 months follow‐up for any domain. Conclusions The findings suggest that the combined intervention of supervised exercise and PFMT, when added to pain management, may lead to short‐term improvements in sexual function at the end of the 4‐month intervention. Whether this effect is attributable to general exercise, PFMT, or their combination cannot be determined from the present study. However, the findings should be interpreted cautiously due to differences in sexual activity status between groups.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2026). Occurrence of wound infections after perineal tears and perineal assessment in postpartum care: A prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. doi: 10.1111/aogs.70262. Full text in Research Archive Show summary

  Abstract Introduction There is considerable variation in reported perineal wound infection occurrences and limited knowledge of postpartum follow‐up for perineal injuries. The primary aim of this study was to assess the occurrence of symptoms of perineal wound infections and infections requiring medical intervention within the first 30 days postpartum. The secondary aim was to investigate perineal assessment by healthcare providers in postpartum care. Material and Methods This single‐center cohort study was conducted between October 2020 and October 2022. In this analysis, participants with perineal tears and episiotomies following vaginal deliveries were included. Women were contacted via telephone seven to 10 days postpartum and asked about symptoms for infection recommended by the “Surgical Site Infection Surveillance Service.” At 3 months postpartum, participants reported via questionnaire on receiving medical interventions for wound infection and whether a healthcare provider inspected their perineal tear. Results The study sample comprises a total of 748 primi‐ and multiparous women (58.3% primipara, 41.7% multipara). Sixteen participants (2.2%) reported wound infection symptoms. Wound infections requiring medical interventions were identified in seven women (1.1%), all of whom were primipara. This included five cases with an episiotomy and two cases with a second‐degree tear. Half of the participants had their perineal tear inspected during the 6‐week follow‐up visit. Depending on tear category, between 25% and 72% of women who did not undergo an inspection would have preferred one. Conclusions In our population, symptoms of perineal wound infection were 2.2% and infections requiring medical intervention were 1.1%. Half of the participants received a perineal tear inspection at the 6‐week follow‐up visit.

• Macedo, Marthe Dalevoll; Lilleberg, Hanne Sether; Risløkken, Jeanette; Benth, Jurate Saltyte; Engh, Anna Marie Ellström & Siafarikas, Franziska (2025). Prevalence and Risk Factors for Vaginal Flatus From Mid-Pregnancy to 12 Months Postpartum: A Longitudinal Cohort Study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 133(3), p. 487–494. doi: 10.1111/1471-0528.70063. Full text in Research Archive Show summary

  Objective To assess the prevalence of and trend in bothersome vaginal flatus from mid-pregnancy to 12 months postpartum, according to vaginal parity. The secondary objective was to assess differences in pelvic floor anatomy as risk factors for bothersome flatus at 12 months postpartum. Design Longitudinal cohort study. Setting Akershus University Hospital, Norway. Sample 880 women with vaginal births. Methods Participants completed questionnaires in mid-pregnancy, at 3 and 12 months postpartum, and attended a gynaecological examination including ultrasound at 12 months postpartum. Parity was classified as primipara, secundipara, or multipara (no, one, or ≥ 2 previous vaginal births, respectively). A generalised linear mixed model and logistic regression models were used for analysis. Main Outcome Measures Bothersome vaginal flatus, defined as responding “often” or “always” to the question “Are you bothered by sounds caused by air escaping from the vagina?” Results The prevalence of bothersome flatus in mid-pregnancy, at 3 and 12 months postpartum was: primiparas: 0.7%, 4.0%, and 2.5%; secundiparas: 2.3%, 4.4%, and 7.3%; multiparas: 5.4%, 3.0%, and 7.1%, respectively. Compared to primiparas, multiparas had higher odds in pregnancy (OR 14.0, 95% CI 1.8–108.1), and both secundi- and multiparas had higher odds at 12 months postpartum (OR 4.8, 95% CI 1.3–17.6, and OR 6.4, 95% CI 1.1–38.6, respectively). Independent risk factors for bothersome flatus included levator avulsion (aOR 3.6, 95% CI 1.5–8.7), a larger genital hiatus (aOR 2.0, 95% CI 1.2–3.3), and a shorter perineal body (aOR 0.8, 95% CI 0.6–1.0). Conclusion Parity and differences in pelvic floor anatomy affect the odds for bothersome vaginal flatus during the first postpartum year.

• Lilleberg, Hanne Sether; Siafarikas, Franziska; Starck, Marianne; Rotstein, Emilia; Bø, Kari & Engh, Anna Marie Ellström (2025). Perineal Body Anatomy in Primiparas Assessed by Three-Dimensional Endovaginal and Endoanal Ultrasound: A Reliability Study. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-025-06379-5. Full text in Research Archive Show summary

  Abstract Introduction and Hypothesis The integrity of the perineal body (PB) is essential for pelvic floor function. Anatomical deviations in the PB anatomy after childbirth can lead to pelvic floor symptoms, but the reliability of ultrasound assessments for these deviations is unclear. This study evaluates the intra- and inter-rater reliability of detecting deviations in the muscles fusing into the PB and measuring its size using three-dimensional endovaginal (3D EVUS) and endoanal ultrasound (3D EAUS) 1 year postpartum. Methods Forty primiparous women underwent 3D EVUS and 3D EAUS 1 year after birth. The transverse perineal, puboperinealis, and puboanalis muscles were identified where they fuse into the PB. Deviations were defined as discontinuities in or absence of muscle fibers on the right, left, or center. Measurements of PB height, length, and area were taken in the mid-sagittal plane. Intra- and inter-rater reliability for muscle deviations were assessed using percentage agreement and Cohen’s kappa, while PB size measurements were evaluated using the intra-class correlation coefficient. Results Kappa values indicated excellent intra- and inter-rater reliability for the transverse perineal muscle ( κ = 0.881, κ = 0.871) and puboperinealis muscle ( κ = 0.849, κ = 0.810) in 3D EVUS. For the puboanalis muscle, intra-rater reliability was excellent ( κ = 1.00) and inter-rater reliability was good ( κ = 0.658). Similar kappa values were found using 3D EAUS. Percentage agreement for deviations ranged from 90% to 100% for both ultrasound methods. PB measurement also showed good to excellent reliability: 0.76-0.97 for 3D EVUS and 0.90–0.99 for 3D EAUS. Conclusion 3D EVUS and 3D EAUS are reliable methods for assessing PB muscle deviations and its size 1 year postpartum.

• Lilleberg, Hanne Sether; Siafarikas, Franziska; Bø, Kari & Engh, Anna Marie Ellström (2025). Severity of perineal tears and deviations in perineal body anatomy: A three‐dimensional ultrasound study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. doi: 10.1111/aogs.70114. Full text in Research Archive Show summary

  Abstract Introduction Perineal tears are classified into four degrees based on severity. Second‐degree tears, which involve the muscles fusing into the perineal body, but not the anal sphincter, vary in extent and have recently been subcategorized. However, knowledge about their long‐term anatomical impact on the perineal body remains limited, as postpartum evaluation has largely relied on inspection and palpation. This study aimed to examine the association between the severity of perineal tears not affecting the anal sphincter, diagnosed at delivery, and deviations in the muscles fusing into the perineal body, assessed by three‐dimensional ultrasound 1 year after vaginal delivery. Material and Methods This prospective cohort study included 384 primiparous women with vaginal deliveries at Akershus University Hospital, Norway, from January 2021 to July 2022. Perineal tears were classified and sutured according to international standards at delivery. In addition, second‐degree tears were subclassified according to the percentage of the perineal body damage (<50% = 2A, ≥50% = 2B, entire perineal body without anal sphincter = 2C). Women with third‐ or fourth‐degree tears were excluded. One year after delivery, participants underwent three‐dimensional endovaginal and endoanal ultrasound examinations. The transverse perineal, puboperinealis, and puboanalis muscles were examined at their fusion into the perineal body. A deviation was defined as a muscle discontinuity or absence in at least one of the muscles. Results The proportion of women with sonographically detected muscle deviations increased with tear severity: 22% for first‐degree ( n  = 24), 52.7% for 2A ( n  = 29), 60% for 2B ( n  = 21) and 86.2% for 2C ( n  = 25). Among women with episiotomies ( n  = 126), 60.6% had one or more muscle deviations. A higher number of muscles were affected in the 2C tear group compared to 2B and 2A. Conclusion Sonographic deviations in the muscles fusing into the perineal body increase with the severity of perineal tears.

• Gabrielsen, Rakel; Tellum, Tina; Bø, Kari; Engh, Anna Marie Ellström; Frawley, Helena & Tveito, Synne Nedregård [Show all 7 contributors for this article] (2025). Supervised exercise and pelvic floor muscle training eases current pelvic and genital pain but not worst pelvic and genital pain in women with endometriosis: a randomised trial. Journal of Physiotherapy. ISSN 1836-9553. 71(4), p. 246–253. doi: 10.1016/j.jphys.2025.09.012. Full text in Research Archive Show summary

  Question: How much does adding supervised group and independent individual exercise including pelvic floor muscle training (PFMT) to multidisciplinary pain management affect pelvic and genital pain in women with endometriosis? How much does it affect dyspareunia, dysuria, quality of life (with emphasis on psychological distress, including symptoms of depression and anxiety), symptoms of chronic constipation and pelvic floor muscle (PFM) function? Design: A two-armed, parallel-group, randomised controlled trial with concealed allocation, intention-to-treat analysis and blinded assessment of some outcomes. Participants: Women aged 18 to 45 years with laparoscopically confirmed endometriosis experiencing pelvic/genital pain. Intervention: All participants attended a pain management course. The exercise group (n = 41) then performed weekly supervised general exercise training including PFMT for 4 months, and home training two to three times/week. The control group (n = 40) received no further intervention. Outcome measures: Primary outcomes were the change in worst pelvic/genital pain over 1 month and current pelvic/genital pain measured on a numerical rating scale at 4 and 12 months. Secondary outcomes measured at the same time points were: location and concerns related to dyspareunia; presence of dysuria; symptoms of chronic constipation assessed with the Knowles-Eccersley-Scott-Symptom scale; and quality of life with emphasis on psychological distress, including symptoms of depression and anxiety assessed with Hopkins Symptom Checklist-5. PFM function was measured with surface electromyography and manometry at baseline and 4 months. Results: The intervention did not improve worst pelvic/genital pain but it did have a clear benefit on current pelvic/genital pain at the end of the intervention (MD 1.1, 95% CI 0.2 to 2.1). This benefit was still present at the 12-month follow-up (MD 1.5, 95% CI 0.2 to 2.7). The effects on other outcome measures were unclear. Conclusion: Adding supervised group and independent individual exercise including PFMT to pain management did not improve worst pelvic/genital pain but improved current pelvic/genital pain. Effects on other outcomes warrant further investigation.

• Gabrielsen, Rakel; Bø, Kari; Engh, Anna Marie Ellström & Tennfjord, Merete Kolberg (2025). Is Pelvic Floor Muscle Resting Activity Associated with Pelvic and Genital Pain, Dyspareunia, and Pelvic Floor Muscle Contraction? A Cross-Sectional Study of Women with Endometriosis. International Urogynecology Journal. ISSN 0937-3462. 36(11), p. 2277–2285. doi: 10.1007/s00192-025-06190-2. Full text in Research Archive Show summary

  Introduction and Hypothesis A link between pelvic and genital pain, dyspareunia, and increased pelvic floor muscle (PFM) tone is an area of controversy. Additionally, it has been postulated that increased PFM tone can limit the ability to further activate the PFM. We aimed to investigate the association between PFM resting activity and pelvic and genital pain and dyspareunia, and whether there is an association between PFM resting activity and activation during attempts at PFM maximal voluntary contractions (MVCs) in women with endometriosis. Methods This cross-sectional study included 80 women with endometriosis and pelvic and genital pain. An electronic questionnaire included background information, pelvic and genital pain (numeric rating scale 0–10) and questions about location and concerns of dyspareunia. Associations between variables were analyzed using multiple linear regression. PFM resting activity was registered as the mean microvolt (μV) during rest before and between five voluntary MVCs of the PFM. Results Mean age was 29 years (SD 6.2), and 9 (11%) were parous. No significant association between resting activity, pelvic and genital pain or location and concerns of dyspareunia was found. A significant positive association between PFM resting activity and activation during attempts at MVCs of the PFM (β = 0.130, p = 0.009, 95% CI = 0.034–0.229) was found. Conclusion No association was found between PFM resting activity and pelvic and genital pain or location and concerns of dyspareunia. Contrary to the hypothesis, higher PFM resting activity resulted in more activation of the PFM during attempts at MVCs.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2025). The severity of second-degree perineal tears and dyspareunia during one year postpartum: A prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 104(5), p. 968–975. doi: 10.1111/aogs.15084. Full text in Research Archive
• Bø, Kari; Engh, Anna Marie Ellström; Teig, Catherine Joyce & Tennfjord, Merete Kolberg (2025). Do Women with Urinary Incontinence and Pelvic Organ Prolapse Receive Optimal First-Line Treatment? International Urogynecology Journal. ISSN 0937-3462. 36(1), p. 117–123. doi: 10.1007/s00192-024-05990-2. Full text in Research Archive Show summary

  Introduction and Hypothesis: There is scant knowledge on previous pelvic floor muscle training (PFMT) in women with urinary incontinence (UI) and pelvic organ prolapse (POP) referred to hospitals. We hypothesized that women with predominately UI and POP had not received optimal primary care conservative management. Methods: This was a descriptive, cross-sectional survey among women attending a gynecological outpatient’s clinic. The questionnaire included questions about demographics, PFMT dosage, whether ability to contract had been assessed and whether the patients had used precontraction before increase in intra-abdominal pressure (“the knack”). Results: One hundred two women, mean age 52.5 (SD 13.4) years, responded; 37.3% had never been treated previously. There was no statistically significant difference in age, BMI, level of education, parity, time since last birth, SUI, or POP between the women who had been treated conservatively or not before the hospital visit. Thirty-three percent had trained with a physiotherapist and > 35% reported that their ability to contract had not been assessed or were unsure whether it had been assessed; 37% were not able to stop their urine stream; 52% reported that they performed “the knack,” with 15.7% reporting it to be effective. Reasons for not having trained the PFM before visiting the hospital included not being motivated, not knowing how to do PFMT, not being told/advised to do PFMT and not believing PFMT would help. Conclusion: The results of this study indicated that there is a need for improvement within first-line health care service for women with predominately UI and POP.

• Lilleberg, Hanne Sether; Siafarikas, Franziska; Starck, Marianne; Bø, Kari; Rotstein, Emilia & Engh, Anna Marie Ellström (2025). Association Between Sonographic Deviations in the Perineum and Symptoms of a Deficient Perineum in Primiparous Women One Year After Birth: A Prospective Cohort Study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 132(8), p. 1114–1121. doi: 10.1111/1471-0528.18135. Full text in Research Archive Show summary

  Objectives This study aimed to investigate whether primiparous women with sonographic deviations in the muscles fusing into the perineal body reported more symptoms of deficient perineum than women without deviations 1 year after birth. Design Non-consecutive prospective cohort study. Setting Akershus University Hospital, Norway. Population Three hundred and eighty-eight primiparas. Methods Women were examined 1 year after birth using three-dimensional endovaginal and endoanal ultrasound with a high-resolution probe. In the blinded analysis, the transverse perineal, the puboperinealis and the puboanalis muscles were identified where they fuse into the perineal body and assessed for deviations. Symptoms of deficient perineum were evaluated using the ‘Karolinska Symptoms After Perineal Teras Inventory’ (KAPTAIN). Main Outcome Measures Symptoms of a deficient perineum, assessed using two outcomes: the median total score of KAPTAIN and a KAPTAIN score ≥ 8 1 year postpartum. Results Sonographic deviations in one or more of the muscles fusing into the perineal body 1 year after birth were observed in 168 participants (43.3%). Of these, 54 (32.1%) reported a KAPTAIN score ≥ 8. The median KAPTAIN score was 6.0 (IQR 3.0–9.0) in the group with sonographic deviations and 4.0 (IQR 2.0–6.0) in women with a sonographically intact perineum (p > 0.001). The unadjusted and adjusted odds ratio (OR) for reporting a KAPTAIN score ≥ 8 was 2.9 (95% CI 1.7–4.7) and 2.3 (95% CI 1.2–4.2), respectively, when comparing women with sonographic deviations to those with no sonographic deviations. Conclusion Our results indicate that sonographic deviations of the perineal body are associated with symptoms of a deficient perineum in primiparous women 1 year after birth.

• Risløkken, Jeanette; Macedo, Marthe Dalevoll; Bø, Kari; Engh, Anna Marie Ellström & Siafarikas, Franziska (2024). The severity of second-degree perineal tears and perineal pain during three months postpartum: A prospective cohort study. Midwifery. ISSN 0266-6138. 131. doi: 10.1016/j.midw.2024.103930. Full text in Research Archive Show summary

  Background: Second-degree perineal tears are common and can vary widely in the extent of tissue trauma. Therefore, a better understanding of perineal pain based on tissue trauma severity in second-degree tears is needed. Aim: The primary aim of this study was to assess differences in perineal pain according to the severity of perineal tears, with a focus on subcategories of second-degree tears, during the first three months postpartum. The secondary aim was to assess the use of pain medication and breastfeeding patterns according to the severity of the second-degree tears. Methods: In this observational cohort study, nulli- and multiparous women with singleton pregnancies were included during pregnancy. After birth, perineal tears were classified using the latest international classification system. In addition, second-degree tears were subcategorised according to percentage of damage to the perineum (<50 %=2A,>50 % but less than entire perineum=2B, affecting entire perineum, anal sphincter not involved=2C). Perineal pain, use of pain medication and breastfeeding patterns were assessed during a phone interview seven to ten days postpartum and through an electronic questionnaire three months postpartum. Findings: Out of 880 vaginal births, 852 participants completed the phone interview and 715 answered the electronic questionnaire. During the first three months postpartum, women with 2C-tears reported statistically significantly higher pain scores and more frequent use of pain medication compared to women with 2A-tears. There was no statistically significant difference between the number of participants not breastfeeding between second-degree tear subcategories. Conclusion: Women with 2C-tears reported higher perineal pain scores and more use of pain medication compared to those with less severe tears during three months postpartum.

• Tennfjord, Merete Kolberg; Gabrielsen, Rakel; Bø, Kari; Engh, Marie Ellström & Molin, Marianne (2024). Can general exercise training and pelvic floor muscle training be used as an empowering tool among women with endometriosis? Experiences among women with endometriosis participating in the intervention group of a randomized controlled trial. BMC Women's Health. 24. doi: 10.1186/s12905-024-03356-w. Full text in Research Archive Show summary

  Background: The potential benefit of exercise in alleviating symptoms of endometriosis is unclear. Still, exercise may be used to empower women and manage disease symptoms. The purpose of this study was to explore how regular supervised group- and individual exercise training, including pelvic floor muscle training (PFMT), is experienced among women with endometriosis after participating in a randomized controlled trial (RCT). Methods: Among 41 women randomized to exercise training for four months, ten women were interviewed about their experiences with exercise training after participation in the trial. The weekly group training was led by women’s health physiotherapists and included individualized and progressive muscular strength training of large muscle groups and the pelvic floor muscles, in addition to endurance-, flexibility, and relaxation training. An individual training program followed the same principles as the group training and was to be performed 3–5 times per week, depending on the level of intensity. PFMT was recommended daily. The women also received a group pain management course emphasizing exercise training as self-management. Using inductive reflexive thematic analysis, responses to the question “Did participation in the study change your view of exercise as part of the treatment for endometriosis?“ were analyzed. Results: The women brought forward the importance of knowledge about the benefits of exercise to make informed decisions in disease management. Further, the women described how exercise training was perceived as less frightening and manageable when exposed to various intensities, dosages, and types of exercises in a safe and supportive environment. PFMT was especially brought forward as something new and appreciated, and for some of the women, to be performed on days when their bodies could not handle the general exercise training. They also expressed that the supervised exercise brought an extra dimension of belonging through group participation. Conclusions: Individualization and regular supervision seem important to empower women with knowledge about exercise training as self-management and to experience exercise training as safe and non-threatening. Further, creating a sense of belonging through group training may improve social support and build active coping strategies that are essential for disease management of endometriosis.

• Siafarikas, Franziska; Stær-Jensen, Jette; Reimers, Cathrine; Bø, Kari & Engh, Anna Marie Ellström (2024). Levator ani muscle avulsion and subsequent vaginal delivery: 8-year longitudinal follow-up. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 64(1), p. 112–119. doi: 10.1002/uog.27599. Full text in Research Archive Show summary

  Objectives: The aim of this study is to assess the evolution of levator avulsion from 1 year to 8 years after first delivery in women with subsequent vaginal deliveries compared to women without subsequent vaginal deliveries. Further, we aim to assess whether women with full and partial avulsion 8 years after first delivery have larger levator hiatus area and more symptoms of pelvic organ prolapse compared to women with normal levator insertion. Methods: In this single center longitudinal study 195 initially primiparous women were included and underwent transperineal ultrasound 1 year and 8 years after first delivery. Muscle insertion was assessed by tomographic ultrasound imaging in the axial plane. Full levator avulsion was defined as abnormal muscle insertion in all three central slices. Partial levator avulsion was defined as abnormal muscle insertion in one but less than three central slices. Eight years after first delivery levator hiatus area was assessed at rest, during maximum pelvic floor muscle contraction, and maximum Valsalva maneuver. To assess symptoms of pelvic organ prolapse the vaginal symptoms module from the International Consultation on Incontinence Questionnaire was used. Results: At 1 year follow-up, 25 women (12.8%) showed signs of avulsion, 20 women fulfilled sonographic criteria for full avulsion and 5 women fulfilled sonographic criteria for partial avulsion. Eight years after first delivery, 35 (17.9%) women were diagnosed with avulsion, of them 25 women were diagnosed with full avulsion and 10 women were diagnosed with partial avulsion. No women with partial and full avulsion at 1 year improved on their avulsion status at 8-year follow-up. In the subsequent vaginal delivery group, 21 women (14%) were diagnosed with partial and full levator avulsion 1 year after first delivery, and 31 women (20.7%) were diagnosed with partial and full avulsion 8 years after first delivery. Of the 45 women without subsequent vaginal delivery, one woman with partial avulsion 1 year after first delivery was diagnosed as full avulsion at 8-year follow-up. All women with full avulsion at 1-year follow-up were diagnosed as full avulsion at 8 years regardless of subsequent vaginal delivery. At 8-year follow-up women with full avulsion had statistically significant larger levator hiatus area compared to women with normal muscle insertion. Vaginal symptoms scores ranged between 5.5 (SD 5.7) and 6.0 (SD 4.0) and vaginal symptom quality of life scores ranged between 0.9 (SD 1.4) and 1.5 (SD 2.2) and did not differ statistically significantly between women with normal muscle insertion and women with partial and full avulsion at 8-year follow-up. Conclusion: More avulsions 8 years after first delivery compared to one year after first delivery were found in women with subsequent vaginal delivery. Except one primipara, none of the women without subsequent vaginal delivery changed on their levator status from 1 to 8 years after first delivery. Larger levator hiatus area was found in women with full avulsion compared to women with normal muscle insertion at 8-year follow-up. Vaginal symptoms scores were low and did not differ between women with normal muscle insertion, partial and full avulsion at 8-year follow-up.

• Skaug, Kristina Lindquist; Engh, Anna Marie Ellström & Bø, Kari (2024). Pelvic floor muscle training in female functional fitness exercisers: An assessor-blinded randomised controlled trial. British Journal of Sports Medicine. ISSN 0306-3674. 58(9), p. 486–493. doi: 10.1136/bjsports-2023-107365. Full text in Research Archive Show summary

  Objective: Stress urinary incontinence (SUI) is common among females during functional fitness training, such as CrossFit. The aim of this study was to assess the effect of pelvic floor muscle training (PFMT) on SUI in female functional fitness exercisers. Methods: This was an assessor-blinded randomised controlled trial with a PFMT group (n=22) and a control group (n=25). The PFMT group followed a 16-week home-training programme with 3 sets of 8–12 maximum pelvic floor muscle (PFM) contractions daily and weekly follow-up/reminders by phone. The primary outcome was change in a total score of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI-SF). The secondary outcomes were perceived change of symptoms of SUI, change of PFM strength measured by vaginal manometry and symptoms of anal incontinence (AI) and pelvic organ prolapse (POP). Results: 47 women, mean age of 33.5 years (SD: 8.1), participated. At 16 weeks, there was a mean difference between groups of −1.4 (95% CI: −2.6 to −0.2) in the change of the ICIQ-UI-SF score in favour of the PFMT group. The PFMT group completed a mean of 70% (SD: 23) of the prescribed protocol. 64% in the PFMT group versus 8% in the control group reported improved symptoms of SUI (p＜0.001, relative risk: 7.96, 95% CI, 2.03 to 31.19). There were no group differences in the change of PFM strength or AI/POP symptoms. Conclusion: A 16-week home-training programme of the PFM led to improvements in SUI in female functional fitness exercisers. However, PFM strength and AI and POP symptoms did not improve significantly in the PFMT group compared with the control group.

• Rimstad, Kjersti; Oversand, Sissel Hegdahl; Engh, Anna Marie Ellström & Svenningsen, Rune (2024). Effectiveness and Safety of Shorter Incontinence Slings. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-024-05971-5. Full text in Research Archive Show summary

  Introduction and Hypothesis Traditional slings, tension-free vaginal tape obturator inside-out (TVT-O) and tension-free vaginal tape (TVT), have well-documented continence outcomes but can cause serious complications. This study was aimed at evaluating whether slings with less synthetic material, Ajust™ and TVT-O Abbrevo™ (TVT-A), have comparable 6– to 12-month failure and complication rates, including risk of prolonged postoperative pain, compared with traditional slings. Methods A registry study from the Norwegian Female Incontinence Registry (NFIR) including 611 Ajust™, 2,772 TVT-A, and 18,612 traditional slings was carried out. Preoperative, surgical, and 6– to 12-month follow-up data from the period 2009–2021 were used. Objective failure was defined as ≥ 1-g leakage on standardized cough-jump stress test. Subjective failure was defined as stress index-score ≥ 3 on a validated questionnaire. Prolonged postoperative pain was defined as lasting > 3 months. Results At first follow-up after 6–12 months, the groups differed significantly. Objective failure rates were as follows: Ajust™ 15.4%, TVT-A 13.5%, and traditional slings 7.3%, p < 0.01. Subjective failure rates were as follows: Ajust™ 23.4%, TVT-A 23.8%, and traditional slings 18.8%, p < 0.01. Shorter slings had fewer overall complications (Ajust™ 4.9% vs TVT-A 6.5% vs traditional slings 9.3%, p < 0.01), but did not have less prolonged postoperative pain (TVT-A: 1.4% vs Ajust™ 0.8% vs traditional slings 0.7%, p < 0.01 < 0.01). All presented outcomes remained significant after adjusting for differences at baseline. Conclusions Shorter slings have inferior subjective and objective continence outcomes at 6–12 months, but fewer overall complications except for prolonged postoperative pain.

• Macedo, Marthe Dalevoll; Risløkken, Jeanette; Rotstein, Emilia; Benth, Jurate Saltyte; Engh, Anna Marie Ellström & Siafarikas, Franziska (2024). Pelvic floor symptoms according to the severity of second-degree perineal tears within 12 months post-partum: A longitudinal prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 103(7), p. 1366–1376. doi: 10.1111/aogs.14854. Full text in Research Archive Show summary

  Introduction Second-degree perineal tears following vaginal birth are common and presumed to be of little clinical importance. However, the extent of damage to the perineal body varies widely, and there is reason to believe that larger second-degree tears may be associated with more pelvic floor symptoms, compared to lesser form. Therefore, the aim of this study was to assess differences in pelvic floor symptoms according to the severity of second-degree perineal tears up to 12 months post-partum, stratified by parity. Material and Methods This was a prospective cohort study conducted at Akershus University Hospital, a tertiary referral hospital in Norway. The study sample consisted of 409 primiparas and 394 multiparas with vaginal births. Perineal tears were classified using the classification system recommended by the Royal College of Obstetricians and Gynecologists. Further, second-degree tears were subclassified as 2A, 2B, or 2C, depending on the percentage of damage to the perineal body. Episiotomies were analyzed as a separate group. Pelvic floor symptoms were assessed using the Karolinska Symptoms After Perineal Tear Inventory (KAPTAIN). A linear mixed model was estimated to assess the trend in pelvic floor symptom scores according to perineal tear category and stratified by parity. The primary and secondary outcome measures were the mean sum scores of the KAPTAIN-Inventory, measured in pregnancy (at 18 weeks of gestation), at 3- and 12 months post-partum, and the reported impact of genital discomfort on quality of life measured in pregnancy and at 12 months post-partum. Results There were no significant differences in pelvic floor symptom scores over time, or at any timepoint, between no tear, first-degree tear, or second-degree tear subcategories, for primi-, and multiparas. Pelvic floor symptoms increased from pregnancy to 3 months post-partum and remained higher at 12 months post-partum compared to pregnancy in all perineal tear categories. Compared to primiparas, multiparas reported a significantly higher impact of genital discomfort on quality of life in pregnancy and at 12 months post-partum. Conclusions There were no statistically significant differences in pelvic floor symptoms according to the severity of second-degree perineal tears.

• Macedo, Marthe Dalevoll; Risløkken, Jeanette; Halle, Tuva Kristine Toresdatter; Engh, Anna Marie Ellström & Siafarikas, Franziska (2024). Occurrence and risk factors for second-degree perineal tears: A prospective cohort study using a detailed classification system. Birth. ISSN 0730-7659. 51(3), p. 602–611. doi: 10.1111/birt.12817. Full text in Research Archive Show summary

  Background The amount of tissue trauma within second-degree perineal tears varies widely. Therefore, subcategorization of second-degree tears and a better understanding of their occurrence and risk factors are needed. The aim of this study was to assess the occurrence of perineal tears when second-degree tears were subcategorized. Furthermore, we aimed to assess the association between variables related to perineal anatomy and other potential risk factors, with second-degree tear subcategories. Methods This prospective cohort study included 880 primiparous and multiparous women giving birth to one child vaginally. Perineal tears were categorized using the classification system recommended by the Royal College of Obstetricians and Gynaecologists. In addition, second-degree tears were subcategorized as 2A, 2B, or 2C according to the percentage of damage to the perineal body. Selected variables related to perineal anatomy were as follows: length of genital hiatus; perineal body length; and previous perineal trauma. Risk factors for second-degree tear subcategories were analyzed using a multinominal regression model. Results Perineal tears occurred as follows: first-degree: 35.6% (n = 313), 2A: 16.3% (n = 143), 2B: 9.1% (n = 80), 2C: 6.6% (n = 58), and third- or fourth-degree: 1.6% (n = 14). In total, 169/880 participants underwent an episiotomy. When episiotomies were excluded, the risk for 2B, or 2C tears increased with smaller genital hiatus, larger perineal body, previous perineal trauma, primiparity, higher gestational age, instrumental vaginal delivery and fetal presentation other than occiput anterior. Conclusion The occurrence of second-degree tear subcategories was 16.3% for 2A tears, 9.1% for 2B tears, and 6.6% for 2C tears. Factors related to perineal anatomy increased the odds for experiencing a second-degree tear in a more severe subcategory.

• Skaug, Kristina Lindquist; Engh, Anna Marie Ellström & Bø, Kari (2023). Acute Effect of Heavy Weightlifting on the Pelvic Floor Muscles in Strength-Trained Women: An Experimental Crossover Study. Medicine & Science in Sports & Exercise. ISSN 0195-9131. 56(1), p. 37–43. doi: 10.1249/MSS.0000000000003275. Full text in Research Archive Show summary

  Introduction/Purpose: Heavy lifting may produce strain on the pelvic floor muscles (PFM) due to high increases in intraabdominal pressure, but knowledge of the impact of weightlifting on the PFM is lacking. Therefore, this study aimed to investigate acute effects of heavy weightlifting on the PFM in strength-trained women and whether general strength in whole-body exercises correlated to PFM strength. Methods: Forty-seven nulliparous women between 18-35 years who regularly performed weightlifting and were able to lift their own body weight x 1.2 in back squat and 1.5 in deadlift were included in this experimental crossover study. They participated in baseline evaluations (questionnaire/measurements of background characteristics and pelvic floor disorders, 1 repetition maximum (1RM) tests in back squat and deadlift) and one test day where they were randomized to start with 60 minutes of weightlifting (4 sets of 4 repetitions at 75-85% of 1RM in back squat and deadlift) or seated rest of 60 minutes. Vaginal pressure measurements of PFM resting pressure, strength, and endurance and sEMG-measurements of PFM resting activity were performed before/after weightlifting and rest. Results: No statistically significant differences were found when comparing the change in PFM resting pressure, strength, endurance, and resting activity after heavy weightlifting and rest. There were no statistically significant correlations between PFM strength and maximum (1RM) or relative strength (1RM/bodyweight) in either back squat or deadlift. Conclusions: Our results imply that heavy weightlifting is well tolerated by the PFM in short-term among young, nulliparous, and strength-trained women. Strength in whole-body exercises was not correlated to PFM strength.

• Gluppe, Sandra L.; Engh, Anna Marie Ellström & Bø, Kari (2023). Curl-up exercises improve abdominal muscle strength without worsening inter-recti distance in women with diastasis recti abdominis postpartum: a randomised controlled trial. Journal of Physiotherapy. ISSN 1836-9553. 69(3), p. 160–167. doi: 10.1016/j.jphys.2023.05.017. Full text in Research Archive Show summary

  Question: What is the effect of a 12-week, home-based, abdominal exercise program containing head lifts and abdominal curl-ups on inter-recti distance (IRD) in women with diastasis recti abdominis (DRA) 6 to 12 months postpartum? What is the effect of the program on: observed abdominal movement during a curl-up; global perceived change; rectus abdominis thickness; abdominal muscle strength and endurance; pelvic floor disorders; and low back, pelvic girdle and abdominal pain? Design: This was a two-arm, parallel-group, randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. Participants: Seventy primiparous or multiparous women 6 to 12 months postpartum, having a single or multiple pregnancy following any mode of delivery, with a diagnosis of DRA (IRD > 28 mm at rest or > 25 mm during a curl-up). Intervention: The experimental group was prescribed a 12-week standardised exercise program including head lifts, abdominal curl-ups and twisted abdominal curl-ups 5 days a week. The control group received no intervention. Outcome measures: The primary outcome measure was change in IRD measured with ultrasonography. Secondary outcomes were: observed abdominal movement during a curl-up; global perceived change; rectus abdominis thickness; abdominal muscle strength and endurance; pelvic floor disorders; and low back, pelvic girdle and abdominal pain. Results: The exercise program did not improve or worsen IRD (eg, MD 1 mm at rest 2 cm above the umbilicus, 95% CI –1 to 4). The program improved rectus abdominis thickness (MD 0.7 mm, 95% CI 0.1 to 1.3) and strength (MD 9 Nm, 95% CI 3 to 16) at 10 deg; its effects on other secondary outcomes were trivial or unclear. Conclusion: An exercise program containing curl-ups for women with DRA did not worsen IRD or change the severity of pelvic floor disorders or low back, pelvic girdle or abdominal pain, but it did increase abdominal muscle strength and thickness.

• Kleven, Anne Grethe; Miaskowski, Christine; Torstveit, Ann Helen; Ritchie, Christine Seel; Engh, Marie Ellström & Andersen, Elin [Show all 7 contributors for this article] (2023). Quality of life of older gynecologic oncology patients at the initiation of chemotherapy. Nursing Open. 10(10), p. 6749–6757. doi: 10.1002/nop2.1921. Full text in Research Archive Show summary

  Aim To evaluate older gynecologic oncology patients' quality of life (QOL) at the initiation of chemotherapy and compare their QOL scores with a female age-matched general population (GP) sample. Design Cross-sectional. Methods Older (n = 122) gynecologic oncology patients completed the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) that evaluates global health and five functional scales (range from 0 to 100). Differences in QOL scores between our sample and the GP were evaluated using one-sample t-tests and effect sizes were calculated using Cohen's d. Results Patients' mean age was 70.7 years (±6.6). Mean scores for the function scales ranged from 58.5 (±31.1) for role function to 86.1 (±17.0) for cognitive function. Compared to the GP, our sample reported significantly lower scores for global health status, social, role and physical functioning, and a significantly higher score for cognitive functioning. No differences were found in emotional functioning scores.

• J., Catherine Teig; Bond, Malcolm J.; Grotle, Margreth; Kjøllesdal, Møyfrid; Saga, Susan & Småstuen, Milada Cvancarova [Show all 8 contributors for this article] (2023). A novel method for the translation and cross-cultural adaptation of health-related quality of life patient-reported outcome measurements. Health and Quality of Life Outcomes. 21(1). doi: 10.1186/s12955-023-02089-y. Full text in Research Archive Show summary

  Background This paper presents a novel methodology for translation and cross-cultural adaptation of health-related quality-of-life patient-reported outcome measures, incorporating the Delphi method. Specifically, we describe the process of translating the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 from English to Norwegian using this method. Methods The multistep translation method combined the European Organization for Research and Treatment of Cancer Quality of Life guidelines, an Expert Panel review, and the Delphi method. It comprised two independent forward- and back-translations. While the bilingual pelvic floor Expert Panel ensured rigorous cross-checking and effective cross-cultural adaptation, the addition of the Delphi method (comprising the attributes of anonymity, controlled feedback, and statistical group response) further established consensus on translated items. Outcomes The application of the Delphi method in the Expert Panel phase proved adequate in producing comprehensible intermediate Norwegian versions ready for pilot testing. The Expert Panel reviewed the comments made by patients completing the instruments and offered advice to allow final translated versions to be produced and tested for measurement properties. This iterative approach, internal logic, and anonymity between rounds improved the evaluations that the panel members provided, which in turn enhanced the final translated Patient Reported Outcome Measures (PROMs). Conclusions To our knowledge, this work represents the first demonstration of the application of an Expert Panel review incorporating a Delphi method to assess health-related quality-of-life instruments. The controlled feedback approach, iterative nature, internal logic, and anonymity of the Delphi consensus method appeared to ensure a good cross-cultural adaptation of these PROMs.

• Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska; Engh, Anna Marie Ellström & Bø, Kari (2022). Postpartum pelvic floor muscle training, levator ani avulsion and levator hiatus area: a randomized trial. International Urogynecology Journal. ISSN 0937-3462. 34(2), p. 1–11. doi: 10.1007/s00192-022-05406-z. Full text in Research Archive Show summary

  Introduction and hypothesis Vaginal delivery may lead to tearing of the levator ani (LA) muscle from its bony insertions (complete LA avulsion) and increased levator hiatus (LH) area, both risk factors for pelvic foor dysfunctions. Early active rehabilitation is standard treatment after musculo-skeletal injury. We hypothesized that pelvic foor muscle training (PFMT) early postpartum would reduce the presence of LA avulsions and reduce LH area. Methods We carried out a planned secondary analysis from a randomized controlled study. Primiparous women (n=175) giving birth vaginally were included 6 weeks postpartum, stratifed on complete LA avulsion, and thereafter randomized to PFMT or control. The training participants (n=87) attended a supervised PFMT class once a week and performed home-based PFMT daily for 16 weeks. The control participants (n=88) received no intervention. Presence of complete LA avulsion, LH area at rest, maximal contraction, and maximal Valsalva maneuver were assessed by transperineal ultrasound. Betweengroup comparisons were analyzed by analysis of covariance for continuous data, and relative risk (RR) for categorical data. Results Six months postpartum, the number of women who had complete LA avulsion was reduced from 27 to 14 within the PFMT group (44% reduction) and from 28 to 17 within the control group (39% reduction). The between-group diference was not signifcant, RR 0.85 (95% CI 0.53 to 1.37). Further, no signifcant between-group diferences were found for LH area at rest, during contraction, or Valsalva. Conclusions Supervised PFMT class combined with home exercise early postpartum did not reduce the presence of complete LA avulsion or LH area more than natural remission.

• Torstveit, Ann Helen; Miaskowski, Christine; Løyland, Borghild; Grov, Ellen Karine; Ritchie, Christine Seel & Paul, Steven M [Show all 8 contributors for this article] (2022). Characteristics associated with decrements in objective measures of physical function in older patients with cancer during chemotherapy. Supportive Care in Cancer. ISSN 0941-4355. 30(12), p. 10031–10041. doi: 10.1007/s00520-022-07416-5. Full text in Research Archive Show summary

  Purpose Study purposes were to evaluate for inter-individual variability in the trajectories of three objective measures of physical function (PF) in older patients receiving chemotherapy (n=112) and determine which characteristics were associated with worse PF.<p> <p>Methods Balance, gait speed, and chair-stand test were evaluated at initiation and 1, 3, 6, 9, and 12 months following chemotherapy. Hierarchical linear modeling was used to assess inter-individual variability in the trajectories of the three tests. Demographic, clinical, and symptom characteristics, and levels of cognitive function associated with initial levels and changes over time in each of the tests were determined. <p>Results Gait speed and chair-stand tests improved over time. Balance declined until month 6, then increased. Characteristics associated with decreases in balance scores at initiation of chemotherapy were lower level of education and lower Karnofsky Performance Status (KPS) score. For initial levels of poorer gait speed, older age, poorer Trail Making Test B (TMTB), and worse Attentional Function Index scores were the associated characteristics. Lower KPS scores, higher body mass index, and poorer TMTB scores were associated with poorer chair-stand times at initiation of chemotherapy. Worse trajectories of chair-stand times were associated with poorer chair-stand time at enrollment. Characteristic associated with lower initial levels and improved trajectories of balance was older age at enrollment. <p>Conclusions Determination of characteristics associated with decrements in balance, gait speed, and chair-stand can assist clinicians to identify older oncology patients at risk for decrements in PF. Interventions to maintain and improve PF need to be implemented with higher risk patients.

• Siafarikas, Franziska; Halle, Tuva Kristine Toresdatter; Benth, Jurate Saltyte; Stær-Jensen, Jette; Reimers, Cathrine & Bø, Kari [Show all 7 contributors for this article] (2022). Pelvic floor symptoms from first pregnancy up to 8 years after the first delivery: a longitudinal study. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 227(4), p. 613.e1–613.e15. doi: 10.1016/j.ajog.2022.06.020. Full text in Research Archive Show summary

  Background: Despite the strong association between vaginal childbirth and pelvic floor dysfunction, genetic factors, pregnancy, advancing age, and lifestyle also play a role. The pelvic floor undergoes substantial changes during pregnancy which may contribute to pelvic floor dysfunction. On the other hand, these changes may be favorable to allow for vaginal delivery. However, there is a lack of studies assessing pelvic floor symptoms over time according to delivery mode, which includes women prior to delivery. Objective: The aim of this study was to describe urinary incontinence, vaginal symptoms, and bowel control symptoms from 21 weeks of gestation in the first pregnancy and up to 8 years after the first delivery, stratified by delivery mode. Study design: This is a longitudinal observational cohort study. 300 nulliparous women were recruited during their first pregnancy. Pelvic floor symptoms were assessed at 21 and 37 weeks of gestation, and 6 weeks, 6 months, 12 months and 8 years after first delivery using the International Consultation on Incontinence Questionnaire (ICIQ) modules: the urinary incontinence sum score; the weighted vaginal symptom sum score; the vaginal-associated quality of life score; the bowel control sum score; and the bowel-associated quality of life sum score. Delivery mode at first delivery defined delivery groups as: normal vaginal, operative vaginal and cesarean delivery. A linear mixed model analysis was used to assess symptom scores over time and to assess the differences in symptom scores between the delivery groups. Results: Of the 300 women included in the study, of which 193 attended the 8-year follow-up. Pelvic floor symptoms differed in women with vaginal and cesarean delivery. The symptom scores showed a non-linear statistically significant trend. In women, who delivered vaginally, there was an increase of urinary incontinence and vaginal symptom scores already during pregnancy. In women, who later delivered by cesarean, there was a decrease of symptoms scores during pregnancy, and overall lower symptom scores compared to women with vaginal delivery until 12 months after first delivery. Pelvic floor symptoms scores increased from 12 months to 8 years after the first delivery and exceeded pregnancy levels in all delivery groups, however overall symptom scores were low. Differences between delivery groups were not statistically significant. Conclusion: Pelvic floor symptoms differed in women with vaginal and cesarean delivery from the first pregnancy up to 8 years after the first delivery. These differences were recognizable already prior to first delivery.

• Bø, Kari; Næss, Karoline; Stær-Jensen, Jette; Siafarikas, Franziska; Engh, Anna Marie Ellström & Hilde, Gunvor (2022). Recovery of pelvic floor muscle strength and endurance 6 and 12 months postpartum in primiparous women—a prospective cohort study. International Urogynecology Journal. ISSN 0937-3462. 33(12), p. 3455–3464. doi: 10.1007/s00192-022-05334-y. Full text in Research Archive Show summary

  Introduction and hypothesis: To date there has been scant knowledge on the natural recovery of the pelvic floor muscles (PFMs) after childbirth. The aims of the present study were to investigate whether PFM variables at 6 and 12 months postpartum had returned to mid-pregnancy levels and assess risk factors for reduced recovery at 12 months postpartum. Methods: This was a prospective cohort study following 235 nulliparous pregnant women from mid-pregnancy to 12 months postpartum. Vaginal resting pressure (VRP), PFM strength and endurance were assessed by manometry at 22 weeks, 6 and 12 months postpartum. Multiple linear regression was used to address factors influencing PFM variables beyond birth mode. Results: Cesarean section was protective for change in PFM variables. From mid-pregnancy to 12 months postpartum there was a 20% reduction in VRP (p<0.001) and a 7.5 % reduction in PFM strength (p=0.007), and an increase of 9% in PFM endurance (p=0.002) in the normal vaginal birth. The instrumental vaginal group had a decline in VRP of 21% (p<0.001) and PFM strength of 15% (p=0.011), but no significant change in PFM endurance. Higher BMI at 12 months postpartum, longer second stage of labor, and major tears of the levator ani muscle had a negative influence on the PFM recovery beyond delivery mode. Conclusions: At 12 months postpartum following vaginal delivery, the PFMs are not fully recovered compared with mid-pregnancy values. More follow-up physical therapy may be warranted in the postpartum period, especially for women with complicated vaginal births and higher BMI.

• Gluppe, Sandra L.; Engh, Anna Marie Ellström & Bø, Kari (2022). Primiparous women’s knowledge of diastasis recti abdominis, concerns about abdominal appearance, treatments, and perceived abdominal muscle strength 6–8 months postpartum. A cross sectional comparison study. BMC Women's Health. 22, p. 1–11. doi: 10.1186/s12905-022-02009-0. Full text in Research Archive Show summary

  Background: Diastasis recti abdominis (DRA) is a prevalent condition in the postpartum period. To date, there is scant knowledge on how DRA influences physical, mental, and emotional health. This study investigates primiparous women`s knowledge about DRA, concerns about abdominal appearance, and perceived abdominal muscle strength, comparing women with and without reported DRA. Methods: This was a cross-sectional comparison study. Data were collected by a web-based questionnaire, mainly through social media in Norway. To be included in the study women had to be primiparous 6–8 months postpartum. The questionnaire contained questions regarding women`s knowledge about DRA, perceived protrusion, received treatment, concerns with abdominal appearance and muscle strength. Abdominal body image was measured through the shape concern questions from The Eating Disorder Examination questionnaire (EDE-Q 6.0). Demographic and other descriptive variables are presented as means with standard deviations (SD) or as frequencies with percentages. Chi-square test of independence and independent sample t-tests were used to compare differences between women with and without abdominal protrusion for categorical and continuous variables, respectively. Results: Our sample consisted of 460 women. Knowledge about DRA was reported by 415/440 (94.3%) women. A total of 73.3% reported to have been worried during pregnancy about abdominal appearance postpartum. Mean degree of concern about present abdominal appearance was 5.5/10 (SD 2.4). Almost 80% experienced weaker abdominal muscles than pre-pregnancy. Ninety-six women (20.9%) reported a protrusion along the midline of their abdomen. Significantly more women with protrusion reported weaker abdominal muscles than women without protrusion. The most frequent treatment women with protrusion reported were exercises for the abdominal muscles (92.6%). Mean score on the EDE-Q, shape concern questions, was higher in women with reported protrusion (mean score: 2.37 (SD 1.6) than women without protrusion (mean score: 2.14 (SD 1.4), p = 0.175. Conclusion: Primiparous women are concerned about abdominal appearance both during pregnancy and after birth. Those reporting abdominal protrusion are less satisfied with their abdominal appearance and they report weaker abdominal muscles than women without protrusion. This study may contribute to improved knowledge about women`s health concerns, and assessment of DRA should be part of routine follow-up of postpartum women.

• Macedo, Marthe Dalevoll; Engh, Anna Marie Ellström & Siafarikas, Franziska (2022). Detailed classification of second-degree perineal tears in the delivery ward: an inter-rater agreement study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 101(8), p. 880–888. doi: 10.1111/aogs.14369. Full text in Research Archive Show summary

  Introduction Second-degree perineal tears can vary widely as to the extent of trauma, which may be relevant for women's pelvic floor health postpartum. However, the short- and long-term consequences of second-degree perineal tears are poorly understood, likely due to the lack of a detailed classification system. Such a classification system for second-degree tears has been suggested but the inter-rater agreement has not yet been assessed. The aim of this study was to assess the inter-rater agreement of the already established classification system for perineal tears recommended by the Royal College of Obstetricians and Gynaecologists (RCOG classification) among midwives. Further, we aimed to assess the inter-rater agreement of a classification system that provides three sub-categories for second-degree perineal tears. Material and methods This was an inter-rater agreement study, conducted at Akershus University Hospital in Norway from 31 August to 29 November 2020. All midwives working in the delivery ward participated in the study. Midwives classified the integrity of the perineum of all women delivering vaginally within the study period. During the first month of the study, tears were classified by two midwives who were blinded to each other's findings, and the agreement of the RCOG classification was assessed. The following month, the detailed classification system was introduced to the midwifery staff. The last month, perineal tears were classified by two midwives using the detailed classification system, and the agreement was assessed. Inter-rater agreement was measured using Fleiss multirater kappa (k) and Kendall's coefficient of concordance (KCCw). Results The inter-rater agreement for the RCOG classification was good to very good, with k = 0.705 (95% confidence interval [CI] 0.62–0.79, P < 0.001), KCCw = 0.928 (P < 0.001). The inter-rater agreement for the detailed classification system was good to very good, with k = 0.748 (95% CI 0.67–0.83, P < 0.001), KCCw = 0.956 (P < 0.001). Conclusions The inter-rater agreement among midwives using both the RCOG classification and the detailed classification system among midwives was good to very good. The detailed classification system provides additional information about the extent of tissue trauma in second-degree tears, warranted for future research on women's pelvic floor health postpartum.

• Gluppe, Sandra L.; Engh, Anna Marie Ellström & Bø, Kari (2021). What is the evidence for abdominal and pelvic floor muscle training to treat diastasis recti abdominis postpartum? A systematic review with meta-analysis. Brazilian Journal of Physical Therapy (BJPT). ISSN 1413-3555. 25(6), p. 664–675. doi: 10.1016/j.bjpt.2021.06.006. Full text in Research Archive Show summary

  Background: Diastasis recti abdominis (DRA) affects a significant number of women in the post- partum period. Objective: To systematically review whether abdominal and pelvic floor muscle (PFM) exercise programs are effective in the treatment of DRA postpartum. Methods: Electronic search was conducted from inception to March 2020. Randomized controlled tri- als (RCT) or pilot RCTs that compared abdominal training, PFM training, or a combination of both in at least one arm of the trial were included. The primary outcome was presence of DRA (numbers/per- centage) or inter-recti distance (IRD) change. GRADE was used to rate the overall quality of evidence. Pooled effect sizes were expressed as mean difference (MD) with 95% confidence intervals (CI). Results: Seven RCTs totaling 381 women were included. Two studies comparing transversus abdominis (TrA) training with minimal intervention provided data to be included in a meta-analy- sis. The results provided very low level quality evidence that TrA training reduced IRD (MD = - 0.63 cm, 95% confidence interval: -1.25, -0.01, I2 = 0%). Two studies included curl-up exercises as part of their intervention. Level of evidence based on single trials of high risk of bias show very low evidence that curl-up training is more effective than minimal intervention for treating DRA. Similarly, analyses based on single trials provided low to very low quality evidence that PFM training is not more effective than minimal intervention for treating DRA. Conclusion: There is currently very low-quality scientific evidence to recommend specific exer- cise programs in the treatment of DRA postpartum

• Skaug, Kristina Lindquist; Engh, Marie Ellström; Frawley, Helena C. & Bø, Kari (2021). Urinary and anal incontinence among female gymnasts and cheerleaders—bother and associated factors. A cross-sectional study. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-021-04696-z. Full text in Research Archive Show summary

  Introduction and hypothesis: Artistic gymnastics, team gymnastics and cheerleading are sports including high-impact activities. It is presumed that the athletes' pelvic floor must be functioning well to prevent urinary (UI) and anal incontinence (AI) during sports. The aim of this study was to investigate the prevalence and risk factors for UI and AI in female artistic gymnasts, team gymnasts and cheerleaders; the influence of UI and AI on daily living and sport performance; and the athletes' knowledge about the pelvic floor muscles (PFM). Methods: All female athletes ≥ 12 years of age competing in ≥ 1 National Championship in artistic gymnastics, team gymnastics or cheerleading in 2018/2019 were invited. International Consensus on Incontinence Questionnaires were used to assess the prevalence/bother of UI and AI. Results: Among the 319 gymnasts and cheerleaders who participated, the prevalence of UI and AI was 67% and 84%, respectively. Age, training ≥ 4 days/week and straining to void were significantly associated with stress urinary incontinence (SUI) and years of training with AI. Eighty-three percent of athletes with SUI reported a negative effect on sports performance, 22% would occasionally avoid training or specific exercises because of leakage, and 28% used pads for protection. Forty-one percent of the athletes had never heard about the PFM, and 74% reported an interest in PFM training to prevent/treat UI or AI. Conclusions: UI and AI were prevalent in female gymnasts and cheerleaders, and SUI negatively influenced sport performance. The athletes' knowledge about the PFM was limited.

• Forsse, David Erik; Barbero, Mark Lewis B Barbero; Werner, Henrica Maria Johanna; Woie, Kathrine; Nordskar, Nina Jebens & Nilsen, Elisabeth Berge [Show all 14 contributors for this article] (2021). Longitudinal effects of adjuvant chemotherapy and lymph node staging on patient-reported outcomes in endometrial cancer survivors: a prospective cohort study. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 226(1), p. 90.e1–90.e20. doi: 10.1016/j.ajog.2021.08.011. Full text in Research Archive Show summary

  Background Most patients with endometrial cancer with localized disease are effectively treated and survive for a long time. The primary treatment is hysterectomy, to which surgical staging procedures may be added to assess the need for adjuvant therapy. Longitudinal data on patient-reported outcomes comparing different levels of primary treatment are lacking, especially when adjuvant radiotherapy is omitted. Objective We assessed the impact of lymphadenectomy and adjuvant chemotherapy on patient-reported symptoms, function, and quality of life. We hypothesized that these treatment modalities would substantially affect patient-reported outcomes at follow-up. Study Design We prospectively included patients with endometrial cancer enrolled in the ongoing MoMaTEC2 study (ClinicalTrials.gov Identifier: NCT02543710). Patients were asked to complete the patient-reported outcome questionnaires European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire EN24 preoperatively and at 1 and 2 years of follow-up. Functional domains and symptoms were analyzed for the whole cohort and by treatment received. To assess the effect of the individual treatment modifications, we used mixed regression models. Results Baseline data were available for 448 patients. Of these patients, 339 and 219 had reached 1-year follow-up and 2-year follow-up, respectively. Treatment included hysterectomy (plus bilateral salpingo-oophorectomy) alone (n=177), hysterectomy and lymph node staging without adjuvant therapy (n=133), or adjuvant chemotherapy irrespective of staging procedure (n=138). Overall, patients reported improved global health status and quality of life (+9 units; P<.001), increased emotional and social functioning, and increased sexual interest and activity (P<.001 for all) from baseline to year 1, and these outcomes remained stable at year 2. Means of functional scales and quality of life were similar to age- and sex-weighted reference cohorts. Mean tingling and numbness and lymphedema increased after treatment. The group who received adjuvant chemotherapy had a larger mean reduction in physical functioning (−6 vs +2; P=.002) at year 1, more neuropathy (+30 vs +5; P<.001; year 1) at years 1 and 2, and more lymphedema at year 1 (+11 vs +2; P=.007) than the group treated with hysterectomy and salpingo-oophorectomy only. In patients not receiving adjuvant chemotherapy, patient-reported outcomes were similar regardless of lymph node staging procedures. Adjuvant chemotherapy independently increased fatigue, lymphedema, and neuropathy in mixed regression models. Conclusion Patients with endometrial cancer receiving adjuvant chemotherapy reported significantly reduced functioning and more symptoms up to 2 years after treatment. For patients treated by surgery alone, surgical staging did not seem to affect the quality of life or symptoms to a measurable degree at follow-up. Therefore, subjecting patients to lymph node removal to tailor adjuvant therapy seems justified from the patient’s viewpoint; however, efforts should increase to find alternatives to traditional chemotherapy.

• Gluppe, Sandra L.; Engh, Marie Ellström & Bø, Kari (2021). Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis. Physiotherapy. ISSN 0031-9406. 111, p. 57–65. doi: 10.1016/j.physio.2021.01.008. Full text in Research Archive Show summary

  Objective: To investigate whether women with diastasis recti abdominis (DRA) have weaker abdominal muscles and higher prevalence of pelvic floor disorders (PFD), low back, pelvic girdle and abdominal pain than women without DRA. Design: Cross sectional study of women with and without DRA. Setting: University study. Participants: Seventy-two parity and age matched women with and without DRA. Main outcome measures: Maximal abdominal muscle strength and endurance were assessed with a dynamometer and with a curl-up test. Women reported whether they experienced PFD, low back pain, pelvic girdle pain or abdominal pain. Those experiencing PFD or pain completed the Pelvic Floor Distress Inventory-short form 20 (PFDI-20), the Oswestry Disability Index (ODI), the Pelvic Girdle Questionnaire (PGQ) or questions about abdominal pain, respectively. Results: Maximal abdominal strength standing with 30° hip flexion was significantly lower in women with DRA (mean difference −12.9 Nm, 95%CI: −24.4 to −1.5; P = 0.028), but adjusted analyses showed no significant difference (mean difference −11.9 Nm, 95%CI: −26.5 to 2.6; P = 0.106). Adjusted analyses showed significant higher prevalence of abdominal pain in women with DRA (OR: 0.02, 95%CI: 0.00 to 0.61, P = 0.026). There was no difference between the groups in PFD, low back and pelvic girdle pain. Conclusion: Women with DRA tend to have weaker abdominal muscles and higher prevalence of abdominal pain, but no higher prevalence of PFD, low back or pelvic girdle pain than women without DRA.

• Gyhagen, Maria; Engh, Anna Marie Ellström; Husslein, Heinrich; Koelbl, Heinz; Nilsson, Ida E. K. & Schulz, Jane [Show all 8 contributors for this article] (2021). Temporal trends in obstetric anal sphincter injury from the first vaginal delivery in Austria, Canada, Norway, and Sweden. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 100(11), p. 1969–1976. doi: 10.1111/aogs.14244. Full text in Research Archive Show summary

  Introduction Obstetric anal sphincter injuries (OASI) are severe complications that can cause considerable short- and long-term morbidity. Austria, Canada, Norway, and Sweden have similar socio-economic characteristics, and all four countries have access to national birth registers. In this study, we hypothesized that the incidence of OASI should be very similar for different obstetric scenarios in these four countries. Therefore, the aim was to compare the incidence of OASI in these four countries in primiparous women, with spontaneous or instrumental delivery (vacuum or forceps), and in women with a first vaginal birth after cesarean section (VBAC). Material and methods Aggregated data on 1 933 930 vaginally delivered primiparous women and women with VBAC were retrieved from the birth registers gathered in Austria, Canada, Norway, and Sweden. The annual rate of OASI (ICD-10 codes O70.2–O70.3) was presented as the percentage of women with a spontaneous delivery, vacuum or forceps delivery, and a VBAC during the period 2004–2016. Results The incidence of OASI varied considerably between countries and over time. Canada and Sweden had the highest rates, and Austria and Norway the lowest. In Norway, the rate of OASI decreased consistently for all types of deliveries after introducing a perineal protection program in 2004 (p < 0.001). During vacuum delivery, the incidence of OASI varied between countries from 4.1% to 15.5% across the study period. In Canada and Norway, the rate of OASI after a forceps delivery was similar in 2004 at ~20% and with differing trajectories to 24.3% (β 0.49) and 6.2% (β −1.15) (trend, all p < 0.001) in 2016. Conclusions This comparative register study suggests that there may be considerable potential for lowering the incidence of OASI. The perineal protection program implemented by Norway has been successful. Each country should critically, without prejudice, analyze their current clinical practices and rate of OASI and consider the best preventive strategy.

• Skaug, Kristina Lindquist; Engh, Marie Ellström; Frawley, Helena & Bø, Kari (2020). Prevalence of Pelvic Floor Dysfunction, Bother, and Risk Factors and Knowledge of the Pelvic Floor Muscles in Norwegian Male and Female Powerlifters and Olympic Weightlifters. Journal of Strength and Conditioning Research. ISSN 1064-8011. 36(10), p. 2800–2807. doi: 10.1519/JSC.0000000000003919. Full text in Research Archive Show summary

  Strenuous exercise has been suggested as a risk factor of pelvic floor dysfunction (PFD). Powerlifters and Olympic weightlifters compete with high external loads. To date, knowledge of PFD in these athletes has been sparse. The aim of this study was to investigate prevalence, risk factors, and bother of PFD in powerlifters and Olympic weightlifters and their knowledge of the pelvic floor muscles (PFM). All athletes aged ≥18 years competing in ≥1 National Championship in powerlifting or Olympic weightlifting in 2018/2019 were invited. The International Consensus on Incontinence Questionnaires were used to assess PFD. One hundred eighty women and 204 men participated. The prevalence of urinary incontinence (UI), anal incontinence (AI), and pelvic organ prolapse in women was 50.0, 80.0, and 23.3%, respectively. Stress UI (SUI) was reported by 41.7% of the women and 87.8% reported a negative influence on sport performance. The prevalence of UI and AI in men was 9.3 and 61.8%. In women, increasing body mass index was significantly associated with SUI (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 1.01–1.17) and international level of competition (OR: 3.27, 95% CI: 1.32–8.07) and weightlifting ≥4 d·wk−1 (OR: 0.26, 95% CI: 0.08–0.86) with AI. In men, increasing age (OR: 1.03, 95% CI: 1.00–1.07) and frequently straining to void (OR: 4.84, 95% CI: 1.02–22.94) were significantly associated with AI. Forty-three percent of the women and 74% of the men did not know why and 44.4 and 72.5% how to train the PFM. In conclusion, the prevalence of PFD was high, and the athletes had limited knowledge of the PFM.

• Halle, Tuva Kristine Toresdatter; Stær-Jensen, Jette; Hilde, Gunvor; Bø, Kari; Engh, Marie Ellström & Siafarikas, Franziska (2020). Change in prevalence of major levator ani muscle defects from 6 weeks to 1 year postpartum, and maternal and obstetric risk factors: A longitudinal ultrasound study. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 99(10), p. 1403–1410. doi: 10.1111/aogs.13878. Full text in Research Archive Show summary

  Introduction: The present study aimed first to investigate the change in prevalence of major levator ani muscle (LAM) defects, also called avulsions, from 6 weeks to 1 year postpartum, and second to assess maternal and obstetric risk factors for having persistent major LAM defects/avulsions at 1 year postpartum. Material and methods: This is a secondary analysis of data from a prospective cohort study including 300 nulliparous women at 17-19 weeks of gestation. Major LAM defects were diagnosed at 6 weeks and 1 year postpartum using transperineal ultrasonography. We defined persistent major LAM defects as a defect diagnosed both at 6 weeks and 1 year postpartum. Maternal and obstetric data were obtained from the hospital's electronic birth records. Pelvic floor muscle function was measured vaginally by manometer at 21 weeks of gestation. The main outcome measurement was change in prevalence of major LAM defects. Maternal and obstetric risk factors for having persistent major LAM defect were also assessed. Results: Prevalence of major LAM defects was 19.4% at 6 weeks and 10.4% at 1 year postpartum. No new major LAM defects were diagnosed at 1 year postpartum. Persisting major LAM defects were associated with longer second stage of labor (median 74.5 minutes vs median 48.0 minutes, P = .012) and higher neonatal birthweight (mean difference of 232.3 g, 95% confidence interval [CI] 21.5-443.1). Vacuum delivery was independently associated with persistent major LAM defects, adjusted OR 3.0 (95% CI 1.0-9.0). Conclusions: There was a 50% reduction of sonographically diagnosed major LAM defects from 6 weeks to 1 year postpartum. This finding suggests that assessment of the major LAM 6 weeks postpartum may be too early to diagnose defects/avulsions. Long second stage of labor, high neonatal birthweight and vacuum delivery were associated with persistent major LAM defects/avulsions.

• Gluppe, Sandra L.; Engh, Marie Ellström & Bø, Kari (2020). Immediate Effect of Abdominal and Pelvic Floor Muscle Exercises on Interrecti Distance in Women With Diastasis Recti Abdominis Who Were Parous. Physical Therapy. ISSN 0031-9023. 100(8), p. 1372–1383. doi: 10.1093/ptj/pzaa070. Full text in Research Archive Show summary

  Objective: There is a lack of consensus on which abdominal or pelvic floor muscle (PFM) exercises to recommend for the treatment of diastasis recti abdominis (DRA). The objective of this study was to investigate the immediate effect of abdominal and PFM exercises on interrecti distance (IRD) in women with DRA who are parous. Methods: In this cross-sectional study, 38 women who were parous, with a mean age of 36.2 years (SD = 5.2), diagnosed with DRA participated. IRD was assessed with 2-dimensional real-time ultrasonography during rest and during 8 randomly ordered different exercises. A paired t test was used to compare the IRD at rest with the IRD recorded during each exercise as well as the differences between exercises. Means with 95% CI are reported. Results: Head lift and twisted curl-up exercises significantly decreased the IRD both above and below the umbilicus. Above the umbilicus, the mean IRD difference from rest during head lift was 10 mm (95% CI = 7 to 13.2), whereas during twisted curl-up it was 9.4 mm (95% CI = 6.3 to 12.5). Below the umbilicus, the corresponding values were 6.1 mm (95% CI = 3.2 to 8.9) and 3.5 mm (95% CI = 0.5 to 6.4), respectively, but PFM contraction, maximal in-drawing, and PFM contraction + maximal in-drawing increased the IRD (mean difference = −2.8 mm [95% CI = −5.2 to 0.5], −4.7 mm [95% CI = −7.2 to −2.1], and − 5.0 mm [95% CI = −7.9 to −2.1], respectively). Conclusions: Head lift and twisted curl-up exercises decreased the IRD both above and below the umbilicus, whereas maximal in-drawing and PFM contraction exercises only increased the IRD below the umbilicus. A randomized controlled trial is needed to investigate whether head lift and twisted curl-up exercises are effective in permanently narrowing the IRD. Impact: To date there is scant scientific knowledge of which exercises to recommend in the treatment of DRA. In-drawing and PFM contraction leads to an acute increase in IRD, while head lift and twisted curl-up leads to an acute decrease in IRD in postpartum women. There is a need for high-quality randomized controlled trials to investigate if there is a long-term reduction in IRD by doing these exercises over time. The acute IRD increase and decrease during the different exercises is also present in a sample of women with larger separations.

• Tennfjord, Merete Kolberg; Engh, Marie Ellström & Bø, Kari (2020). The Influence of Early Exercise Postpartum on Pelvic Floor Muscle Function and Prevalence of Pelvic Floor Dysfunction 12 Months Postpartum. Physical Therapy. ISSN 0031-9023. 100(9), p. 1681–1689. doi: 10.1093/ptj/pzaa084. Full text in Research Archive Show summary

  Objective: There is limited knowledge on how exercise impacts the pelvic floor muscles (PFM) and prevalence of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) postpartum. The purpose of this study was to investigate whether early onset of general exercise postpartum negatively affects the PFM and/or increases the risk of SUI and POP 12 months postpartum. Methods: This study used a prospective cohort design. At 6 weeks postpartum, 57 women classified as exercisers (exercising ≥3 times at ≥30 min/week) were compared with 120 nonexercisers (mean age = 29 y, SD = 4.3). Manometry was used to measure vaginal resting pressure (VRP), PFM strength, and PFM endurance, and symptoms of SUI and POP were assessed using questionnaires. Data were presented as standardized beta coefficients (B) and odds ratios (OR). Results: No differences were found between exercisers (n = 57) and nonexercisers (n = 120) at 6 weeks postpartum on VRP (B = −0.04 [95% CI = −3.4 to 2.1]), PFM strength (B = 0.03 [95% CI = −4.7 to 7.4]), PFM endurance (B = −0.02 [95% CI = −59 to 46]), or symptoms of SUI (OR = 0.51 [95% CI = 0.25 to 1.1]) or POP (OR = 0.62 [95% CI = 0.26 to 1.5]) measured at 12 months postpartum. Adjusting for covariates, women with body mass index between 25 and 29.9 and > 30 were more likely to report SUI 12 months postpartum (OR = 2.2 [95% CI = 1.0 to 4.7] and OR = 3.3 [95% CI = 1.2 to 9.4], respectively). Women with physically strenuous occupations were more likely to report POP 12 months postpartum (OR = 3.0 [95%CI: 1.2 to 7.3]). Conclusions: This study suggests that regular exercise 6 weeks postpartum has no negative effect on PFM function or on SUI or POP. Being overweight, however, was associated with more SUI, and women with physically strenuous occupations reported more POP. Impact: Results from this study suggest that first time mothers should be encouraged to start general exercise within the first 6 weeks after giving birth. Women at risk for PFD should be advised accordingly and potentially modifiable risk factors should be addressed prior to delivery.

• Reimers, Cathrine; Siafarikas, Franziska; Stær-Jensen, Jette; Småstuen, Milada Cvancarova; Bø, Kari & Engh, Marie Ellström (2018). Risk factors for anatomic pelvic organ prolapse at 6 weeks postpartum: a prospective observational study. International Urogynecology Journal. ISSN 0937-3462. doi: 10.1007/s00192-018-3650-2. Full text in Research Archive Show summary

  Introduction and hypothesis: The objective was to identify risk factors for postpartum anatomic pelvic organ prolapse (aPOP) by comparing women with and without aPOP at 6 weeks postpartum with regard to pelvic floor measurements antepartum and obstetrical characteristics. Methods: We carried out a prospective observational cohort study including nulliparous pregnant women in a Norwegian university hospital. Participants underwent clinical examinations, including pelvic organ prolapse quantification system (POP-Q) and transperineal ultrasound at gestational week 21 and at 6 weeks postpartum. Background and obstetrical information was obtained from an electronic questionnaire and from the patient’s electronic medical file respectively. Associations were estimated using logistic regression analyses. The dependent variable was aPOP, defined as POP-Q stage ≥2 at 6 weeks postpartum. Independent variables were mid-pregnancy measurements of selected POP-Q variables and levator hiatus area (LHarea), delivery route, and the presence of major levator ani muscle (LAM) injuries at 6 weeks postpartum. Results: A larger LHarea, a more distensible LAM, a longer distance from the meatus urethra to the anus (Gh + Pb) and a more caudal position of the anterior vaginal wall (Ba) at mid-pregnancy were risk factors for aPOP at 6 weeks postpartum, whereas delivery route and the presence of major LAM injuries were not. Conclusion: Prelabor differences in the pelvic floor rather than obstetrical events were risk factors for aPOP at 6 weeks postpartum.

• Gluppe, Sandra L.; Hilde, Gunvor; Tennfjord, Merete Kolberg; Engh, Marie Ellström & Bø, Kari (2018). Effect of a Postpartum Training Program on Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Physical Therapy. ISSN 0031-9023. 98(4), p. 260–268. doi: 10.1093/ptj/pzy008. Full text in Research Archive Show summary

  Objective: The objective was to evaluate the effect of a postpartum training program on prevalence of diastasis recti abdominis. Design: The design was a secondary analysis of an assessor-masked randomized controlled trial. Methods: One hundred and seventy-five primiparous women (mean age 29.8±4.1) were randomized to an exercise or control group. The interrectus distance was palpated using finger widths with a cut-off point for diastasis as ≥ 2 finger widths. Measures were taken 4.5 above, at, and 4.5 cm below the umbilicus. The 4-month intervention started 6-weeks postpartum and consisted of a weekly, supervised exercise class focusing on strength training of the pelvic floor muscles. In addition, the women were asked to perform daily pelvic floor muscle training at home. The control group received no intervention. Analyses were based on intention-to-treat. Mantel-Haenszel (relative risk ratio) and Chi Square test for independence were used to evaluate between-group differences on categorical data. P value was set to <.05. Results: At 6weeks postpartum, 55.2% and 54.5% of the participants were diagnosed with diastasis in the intervention and control groups, respectively. No significant differences between groups in prevalence were found at baseline (RR: 1.01 [0.77-1.32]), at 6 months (RR: 0.99 [0.71, 1.38]), or at 12 months postpartum (RR: 1.04 [0.73, 1.49]). Limitations: The interrecti distance was palpated using finger widths and the sample included women with and without diastasis. Conclusions: A weekly, postpartum, supervised exercise program, including strength training of the pelvic floor and abdominal muscles, in addition to daily home training of the pelvic floor muscles, did not reduce prevalence of diastasis.

• Bø, Kari; Engh, Marie Ellström & Hilde, Gunvor (2018). Regular Exercisers Have Stronger Pelvic Floor Muscles than Non-Regular Exercisers at Midpregnancy. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 218(4), p. 427.e1–427.e5. doi: 10.1016/j.ajog.2017.12.220. Full text in Research Archive Show summary

  Background: Today, all healthy pregnant women are encouraged to be physically active throughout pregnancy, with recommendations to participate in at least 30 min of aerobic activity on most days of the week, in addition to perform strength training of the major muscle groups 2-3 days per week, and also pelvic floor muscle training. There is, however, an ongoing debate whether general physical activity enhances or declines pelvic floor muscle function. Objectives: To compare vaginal resting pressure, pelvic floor muscle strength and endurance in regular exercisers (exercise ≥ 30 minutes ≥ 3 times per week) and non-exercisers at mid-pregnancy. Furthermore, to assess whether regular general exercise or pelvic floor muscle strength was associated with urinary incontinence. Study design: This was a cross-sectional study at mean gestational week 20.9 (± 1.4) including 218 nulliparous pregnant women, mean age 28.6 years (range 19-40) and pre-pregnancy body mass index 23.9 kg/m2 (SD 4.0). Vaginal resting pressure, pelvic floor muscle strength and pelvic floor muscle endurance were measured by a high precision pressure transducer connected to a vaginal balloon. International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form was used to assess urinary incontinence. Differences between groups were analyzed using Independent Sample T-test. Linear regression analysis was conducted to adjust for pre-pregnancy body mass index, age, smoking during pregnancy and regular pelvic floor muscle training during pregnancy. P-value was set to ≤ 0.05. Results: Regular exercisers had statistically significant stronger ( mean 6.4 cm H2O (95% CI: 1.7, 11.2)) and more enduring ( mean 39.9 cm H2Osec (95% CI: 42.2, 75.7)) pelvic floor muscles. Only pelvic floor muscle strength remained statistically significant, when adjusting for possible confounders. Pelvic floor muscle strength and not regular general exercise was associated with urinary continence (adjusted B: -6.4 (95% CI: -11.5, -1.4)). Conclusion: Regular exercisers at mid pregnancy have stronger pelvic floor muscles than their sedentary counterparts. However, pelvic floor muscle strength and not regular general exercise was associated with urinary incontinence. There is a need for additional studies in elite athletes and women performing more strenuous exercise regimens.

• J., Catherine Teig; Grotle, Margreth; Bond, Malcolm J.; Prinsen, Cecilia A.C.; Engh, Marie Ellström & Småstuen, Milada C [Show all 8 contributors for this article] (2017). Norwegian translation, and validation, of the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7). International Urogynecology Journal. ISSN 0937-3462. Published ahead of print, p. 1–13. doi: 10.1007/s00192-016-3209-z. Full text in Research Archive
• Tennfjord, Merete Kolberg; Engh, Marie Ellström & Bø, Kari (2017). Role of physical therapy in the treatment of female dysfunction. In Costantini, Elisabetta; Villari, Donata & Filocamo, Maria Teresa (Ed.), Female sexual function and dysfunction. Springer. ISSN 9783319417141. p. 189–204. doi: 10.1007/978-3-319-41716-5_17. Full text in Research Archive
• Reimers, Cathrine; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Bø, Kari & Engh, Marie Ellström (2017). Association between vaginal bulge and anatomical pelvic organ prolapse during pregnancy and postpartum: an observational study. International Urogynecology Journal. ISSN 0937-3462. 29(3), p. 441–448. doi: 10.1007/s00192-017-3407-3. Full text in Research Archive Show summary

  Introduction and hypothesis: Pelvic organ prolapse (POP) is defined as the coexistence of anatomical POP and relevant symptoms. Vaginal bulge is the symptom most closely associated with the anatomical condition in nonpregnant women. Even if childbearing is a major risk factor for the development of POP, there is scant knowledge on the prevalence of specific POP symptoms, and how these symptoms relate to anatomical POP during pregnancy and postpartum. The aim of this study was to explore whether vaginal bulge symptoms were associated with anatomical POP in pregnancy and postpartum, and to present the prevalence of vaginal bulge symptoms throughout this period. Methods: A prospective observational study was carried out following 300 nulliparous pregnant women with repeat assessments from mid-pregnancy until 1 year postpartum. Symptoms of vaginal bulge defined as the sensation of a vaginal bulge inside and/or outside the vagina were assessed by electronic questionnaires. Anatomical POP defined as pelvic organ prolapse quantification system (POP-Q) stage ≥2 has been presented in a previous publication and showed a range of 1–9%. The association between the symptom vaginal bulge and anatomical POP at the various visits was analyzed using Fisher’s exact test. Results: Prevalence of vaginal bulge ranged between 16 and 23%. At 6 weeks postpartum the symptom was associated with anatomical POP; otherwise, these two features were unrelated. Conclusions: The symptom vaginal bulge was barely associated with anatomical POP, and cannot identify anatomical POP in pregnancy or postpartum.

• Tennfjord, Merete Kolberg; Engh, Marie Ellström & Bø, Kari (2017). An intra- and interrater reliability and agreement study of vaginal resting pressure, pelvic floor muscle strength, and muscular endurance using a manometer. International Urogynecology Journal. ISSN 0937-3462. 28, p. 1507–1514. doi: 10.1007/s00192-017-3290-y. Full text in Research Archive Show summary

  INTRODUCTION AND HYPOTHESIS: Manometry is commonly used to assess pelvic floor muscle (PFM) function. Aims of the study were to assess intra- and interrater reliability and agreement of vaginal resting pressure, PFM strength, and muscular endurance using a high-precision pressure transducer. METHODS: A convenient sample of 23 women was included. The participants were tested twice by two examiners on day 1 and retested after 1 week by one examiner. Vaginal resting pressure, PFM strength, and muscular endurance were measured by manometer (Camtech AS). Intraclass correlation coefficient (ICC) and Bland-Altman plots were used to analyze reliability and agreement respectively. Results are presented with mean differences (bias) and minimal detectable change. RESULTS: Twenty participants completed the tests (mean age 55.8 years [27-71], mean parity 1.7 [range 0-3], and mean body mass index 23.7 [range 18.4-27.2, SD 2.4]). ICC values were very good (ICC >0.90) for all measurements. Considerable intervariation of scores, and outliers were seen for measurements representing the highest values. Agreement with mean differences (bias) and minimal detectable change for the intrarater assessment was for vaginal resting pressure: -2.44 ± 8.7 cmH2O, for PFM strength -0.22 ± 7.6 cmH2O, and for muscular endurance 0.75 ± 59.5 cmH2O/s. The interrater agreement for vaginal resting pressure was: 1.36 ± 9.0 cmH2O, for PFM strength 2.24 ± 9.0 cmH2O, and for muscular endurance 15.89 ± 69.7 cmH2O/s. CONCLUSIONS: Manometry (Camtech AS) seems less accurate for the strongest women. In clinical practice, significant improvement in PFM variables needs to exceed the minimal detectable change to be above the error of measurement.

• Bø, Kari; Hilde, Gunvor; Tennfjord, Merete Kolberg & Engh, Marie Ellström (2017). Does Episiotomy Influence Vaginal Resting Pressure, Pelvic Floor Muscle Strength and Endurance, and Prevalence of Urinary Inc ontinence 6 Weeks Postpartum? Neurourology and Urodynamics. ISSN 0733-2467. 36(3), p. 683–686. doi: 10.1002/nau.22995. Full text in Research Archive Show summary

  Aims: The aim of the present study was to compare vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength and endurance, and prevalence of urinary incontinence (UI) at 6 weeks postpartum, in women with and without lateral or mediolateral episiotomy. Methods: Two hundred and thirty-eight nulliparous pregnant women, mean age 28.5 years (SD 4.2) and pre-pregnancy BMI 23.8 (SD 4.0) participated in the study. Lateral or mediolateral episiotomy was only performed for indications such as fetal distress or imminent risk of severe perineal tear. At 6 weeks postpartum, a vaginal balloon connected to a high precision pressure transducer was used to measure VRP (cm H2O), PFM strength (cm H2O), and endurance (cm H2O sec). All women completed the International Classification of Urinary Incontinence Short Form (ICIQ-UI-SF) by means of an electronic questionnaire. Results: No statistically significant differences were found in VRP (mean difference 0.0 cm H2O, 95%CI: −2.1 to 2.1), PFM strength (mean difference 1.3 cm H2O, 95%CI: −1.9 to 4.6), or PFM endurance (mean difference 12.1 cm H2O sec, 95%CI: −11.0 to 35.1) between women with or without episiotomy. No significant differences were found in prevalence of UI (37.5% vs. 46.6%) or SUI (23.6% vs. 35.6%), between women with or without episiotomy, respectively. Conclusions: PFM function and/or prevalence of post-partum UI were not affected by a lateral or mediolateral episiotomy.

• Njølstad, Tormund Salvesen; Werner, Henrica Maria Johanna; Marcickiewicz, Janusz; Tingulstad, Solveig; Staff, Anne Cathrine & Oddenes, Klaus [Show all 14 contributors for this article] (2017). Late-week surgical treatment of endometrial cancer is associated with worse long-term outcome: Results from a prospective, multicenter study. PLOS ONE. 12(8:e0182223), p. 1–12. doi: 10.1371/journal.pone.0182223. Full text in Research Archive Show summary

  Surgery is the cornerstone in primary endometrial cancer treatment, and with curative intent it constitutes total hysterectomy and bilateral salpingo-oopherectomy. In addition, lymphadenectomy is performed in selected patients dependent on a preoperative risk assessment. Recent reports from the surgical approach to esophageal cancer reveal worse outcome when esophagectomy is performed later in the week. On this basis, we set out to explore weekday of surgery in relation to long-term outcome in 1302 endometrial cancer patients prospectively included in the MoMaTEC multicenter study. Day of surgery was dichotomized as early-week (Monday-Tuesday) or late-week (Wednesday-Friday), and evaluated as a discrete variable. Adjusted for patient age, Body Mass Index (BMI), FIGO stage, and histology, surgery performed later in the week was associated with 50.9% increased risk of all-cause death (p = 0.029). Among high-stage patients (FIGO stage III and IV), 5-year disease-specific survival proportions were 53.0% for early-week operated vs. 40.2% for late-week operated (p = 0.005 for difference). In multivariate survival analysis of high-stage patients, late-week surgery correlated with an increased risk of disease-specific death by 88.7% and all-cause death by 76.4% (p<0.017). Evaluating only patients who underwent lymphadenectomy, the adverse prognostic effect of being operated late-week remained for both disease-specific and all-cause death (HR 2.151 and HR 1.912, p = 0.004). Whether surgery was performed early- or late-week was not influenced by patient age, BMI, preoperative histology risk classification, FIGO stage or postoperative histology (all p>0.05). In conclusion, endometrial cancer surgery conducted late-week is associated with worse long-term outcome. Our findings are most evident among patients with higher FIGO stages, and patients who underwent more extensive surgical procedure (lymphadenectomy). With support from other studies, our results suggest that high-risk patients may benefit from surgery earlier in the week.

• Sperstad, Jorun Bakken; Tennfjord, Merete Kolberg; Hilde, Gunvor; Engh, Marie Ellström & Bø, Kari (2016). Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. British Journal of Sports Medicine. ISSN 0306-3674. 50(17), p. 1092–1096. doi: 10.1136/bjsports-2016-096065. Full text in Research Archive Show summary

  Background/aim: Diastasis recti abdominis (DRA) is defined as a separation of the 2 muscle bellies of rectus abdominis. To date there is scant knowledge on prevalence, risk factors, and consequences of the condition. The present study aimed to investigate the prevalence of DRA during pregnancy and post partum, presence of possible risk factors, and the occurrence of lumbopelvic pain among women with and without DRA. Methods: This prospective cohort study followed 300 first-time pregnant women from pregnancy till 12 months post partum. Data were collected by electronic questionnaire and clinical examinations. DRA was defined as a palpated separation of ≥2 fingerbreadths either 4.5 cm above, at or 4.5 cm below the umbilicus. Women with and without DRA were compared with independent samples Student's t-test and χ2/Fisher exact test, and OR with significance level >0.05. Results: Prevalence of DRA was 33.1%, 60.0%, 45.4%, and 32.6% at gestation week 21, 6 weeks, 6 months and 12 months post partum, respectively. No difference in risk factors was found when comparing women with and without DRA. OR showed a greater likelihood for DRA among women reporting heavy lifting ≥20 times weekly (OR 2.18 95% CI 1.05 to 4.52). There was no difference in reported lumbopelvic pain (p=0.10) in women with and without DRA. Conclusions: Prevalence of mild DRA was high both during pregnancy and after childbirth. Women with and without DRA reported the same amount of lumbopelvic pain 12 months post partum.

• Altman, Daniel; Mikkola, Tomi S.; Bek, Karl Möller; Rahkola-Soisalo, Päivi; Gunnarsson, Jonas & Engh, Marie Ellström [Show all 7 contributors for this article] (2016). Pelvic organ prolapse repair using the Uphold™ Vaginal Support System: a 1-year multicenter study. International Urogynecology Journal. ISSN 0937-3462. 27(9), p. 1337–1345. doi: 10.1007/s00192-016-2973-0. Full text in Research Archive
• Tennfjord, Merete Kolberg; Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Engh, Marie Ellström & Bø, Kari (2016). Effect of postpartum pelvic floor muscle training on vaginal symptoms and sexual dysfunction—secondary analysis of a randomised trial. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(4), p. 634–642. doi: 10.1111/1471-0528.13823. Full text in Research Archive Show summary

  Objective: Evaluate effect of pelvic floor muscle training (PFMT) on vaginal symptoms and sexual matters, dyspareunia and coital incontinence in primiparous women stratified by major or no defects of the levator ani muscle. Design: Randomised controlled trial (RCT). Setting: Akershus University Hospital, Norway. Sample: About 175 primiparous women with a singleton vaginal delivery. Methods: Two-armed assessor blinded parallel group RCT from 6 weeks to 6 months postpartum comparing effect of PFMT versus control. Main outcome measures: International Consultation on Incontinence Modular Questionnaire—vaginal symptoms questionnaire (ICIQ-VS) and ICIQ sexual matters module (ICIQ-FLUTSsex). Results: Overall, analysis (n = 175) showed no difference between training and control groups in women having vaginal symptoms or symptoms related to sexual dysfunction 6 months postpartum. The majority of women (88%) had intercourse and there was no difference between groups. Unadjusted subgroup analysis of women with a major defect of the levator ani muscle (n = 55) showed that women in the training group had 45% less risk of having the symptom ‘vagina feels loose or lax’ compared with the control group (relative risk 0.55, 95% confidence interval 0.31, 0.95; P = 0.03). Conclusions: Unadjusted analysis showed that in women with major defect of the levator ani muscle, significantly fewer in the training group had the symptom ‘vagina feels loose or lax’ compared with the control group. No difference was found between groups for symptoms related to sexual dysfunction. More studies are needed to explore effect of PFMT on vaginal symptoms and sexual dysfunction.

• Bø, Kari; Hilde, Gunvor; Tennfjord, Merete Kolberg; Sperstad, Jorun Bakken & Engh, Marie Ellström (2016). Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: Prospective cohort study. Neurourology and Urodynamics. ISSN 0733-2467. 36(3), p. 716–721. doi: 10.1002/nau.23005. Full text in Research Archive
• Reimers, Cathrine; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Benth, Jurate Saltyte; Bø, Kari & Engh, Marie Ellström (2016). Change in pelvic organ support during pregnancy and the first year postpartum: a longitudinal study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 123(5), p. 821–829. doi: 10.1111/1471-0528.13432. Full text in Research Archive Show summary

  Objective: To describe changes in pelvic organ support from mid pregnancy until 1 year postpartum among nulliparous pregnant women, and to examine whether delivery route affects changes in pelvic organ support. Design: Prospective cohort study. Setting: Akershus University Hospital in Norway. Population: A cohort of 300 nulliparous pregnant women included at mid-pregnancy. Methods: Pelvic organ support assessed at 21 and 37 weeks of gestation, and again at 6 weeks, 6 months, and 12 months postpartum, by the use of the Pelvic Organ Prolapse Quantification (POP-Q) system. Linear mixed model was used to assess longitudinal change in pelvic organ support. Main outcome measures: Prevalence of anatomic POP. Change in POP-Q variables over time and between delivery groups. Results: The prevalence of anatomic POP ranged from 0 to 10%. Vaginal POP-Q points made a cranial shift from mid to late pregnancy, a caudal shift following delivery, and again a cranial shift after 6 weeks postpartum. Postpartum change was present following both vaginal and caesarean deliveries, but was more pronounced following vaginal delivery. The perineal body and genital hiatus became longer from mid to late pregnancy, and shortened after 6 weeks postpartum. At 12 months postpartum all POP-Q points, except cervix, had recovered to baseline in the vaginal delivery group. Conclusions: The prevalence of anatomic POP was low in this cohort. There was change in pelvic organ support both during pregnancy and following vaginal as well as caesarean delivery. The short-term ability to recover was good after the first pregnancy and delivery.

• Brækken, Ingeborg Hoff; Majida, Memona; Engh, Marie Ellström & Bø, Kari (2015). Can pelvic floor muscle training improve sexual function in women with pelvic organ prolapse? A randomized controlled trial. Journal of Sexual Medicine. ISSN 1743-6095. 12(2), p. 470–480. doi: 10.1111/jsm.12746. Full text in Research Archive Show summary

  Introduction: Pelvic floor muscle training (PFMT) has level 1 evidence of reducing the size and symptoms associated with pelvic organ prolapse (POP). There is scant knowledge, however, regarding whether PFMT has an effect on sexual function. Aim: The aim of the trial was to evaluate the effect of PFMT on sexual function in women with POP. Methods: In this randomized controlled trial, 50 women were randomized to an intervention group (6 months of PFMT and lifestyle advice) and 59 women were randomized to a control group (lifestyle advice only). Main Outcome Measures: Participants completed a validated POP-specific questionnaire to describe frequency and bother of prolapse, bladder, bowel, and sexual symptoms and answered a semi-structured interview. Results: No significant change in number of women being sexually active was reported. There were no significant differences between groups regarding change in satisfaction with frequency of intercourse. Interview data revealed that 19 (39%) of women in the PFMT group experienced improved sexual function vs. two (5%) in the control group (P < 0.01). Specific improvements reported by some of the women were increased control, strength and awareness of the pelvic floor, improved self-confidence, sensation of a “tighter” vagina, improved libido and orgasms, resolution of pain with intercourse, and heightened sexual gratification for partners. Women who described improved sexual function demonstrated the greatest increases in pelvic floor muscle (PFM) strength (mean 16 ± 10 cmH20) and endurance (mean 150 ± 140 cmH20s) (P < 0.01). Conclusion: PFMT can improve sexual function in some women.Women reporting improvement in sexual function demonstrated the greatest increase in PFM strength and endurance.

• Siafarikas, Franziska; Stær-Jensen, Jette Elisabeth; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellström (2015). The levator ani muscle during pregnancy and major levator ani muscle defects diagnosed postpartum: a three- and four-dimensional transperineal ultrasound study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 122(8), p. 1083–1091. doi: 10.1111/1471-0528.13332. Full text in Research Archive Show summary

  Objective: To investigate associations between levator hiatus area and levator ani muscle function during pregnancy and major levator ani muscle defects postpartum. Design: Observational prospective cohort study. Setting: University hospital, Norway. Sample: A cohort of 234 nulliparous women at 21 and 37 weeks of gestation, and at 6 weeks postpartum. Methods: Ultrasound measurements of the levator hiatus at rest, during pelvic floor muscle contraction, and during the Valsalva manoeuvre were taken at 21 and 37 weeks of gestation. Levator ani muscle function was estimated as the percentage changes in levator ani muscle length from rest to contraction, and the level of muscle stretch during the Valsalva manoeuvre. Major levator ani muscle defects were diagnosed at 6 weeks postpartum using tomographic ultrasound imaging. Main outcome measures: Associations between ultrasound measurements antepartum and major levator ani muscle defects postpartum. Results: Women with major levator ani muscle defects postpartum had significantly smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid-pregnancy (mean difference 1.03 cm2, 95% CI 0.31–1.76; 2.92 cm2, 95% CI 1.77–4.07), and at 37 weeks of gestation (mean difference 1.47 cm2, 95% CI 0.62–2.32; 2.84 cm2, 95% CI 0.88–4.80), than women without such defects. They also had significantly less shortening of the levator ani muscle during contraction at 37 weeks of gestation. Conclusions: Smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid and late pregnancy, and less shortening of the levator ani muscle during contraction at 37 weeks of gestation, are associated with major levator ani muscle defects postpartum.

• Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Hilde, Gunvor; Benth, Jurate Saltyte; Bø, Kari & Engh, Marie Ellström (2015). Postpartum Recovery of Levator Hiatus and Bladder Neck Mobility in Relation to Pregnancy. Obstetrics and Gynecology. ISSN 0029-7844. 125(3), p. 531–539. doi: 10.1097/AOG.0000000000000645. Full text in Research Archive
• Bø, Kari; Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Tennfjord, Merete Kolberg & Engh, Marie Ellström (2015). Does general exercise training before and during pregnancy influence the pelvic floor “opening” and delivery outcome? A 3D/4D ultrasound study following nulliparous pregnant women from mid-pregnancy to childbirth. British Journal of Sports Medicine. ISSN 0306-3674. 49(3), p. 196–199. doi: 10.1136/bjsports-2014-093548. Full text in Research Archive Show summary

  Background: It has been suggested that women who are regular exercisers have a tighter pelvic floor and thereby have more difficulty during childbirth than non-exercising women. We investigated whether women exercising before and during pregnancy have a narrower levator hiatus (LH) area than their sedentary counterparts. We also studied whether regular exercise at gestational week 37 influences delivery outcome. Methods: Cohort study of 274 nulliparous pregnant women assessed at mid-pregnancy and gestational week 37 by three-dimensional/four-dimensional transperineal ultrasonography of the LH area. Exercisers were defined as those exercising ≥30 min three times per week and non-exercisers as not exercising. Exercise data were collected via electronic questionnaire at mean gestational weeks 21 and 37. Labour and delivery outcomes were collected from the women's electronic medical birth records. Differences between exercisers and non-exercisers were analysed using independent sample t test or χ2 test. p Value was set to ≤0.05. Results: At gestational week 37, exercisers had a significantly larger LH area than non-exercisers at rest and during PFM contraction (mean difference −1.6 cm2 (95% CI −3.0 to −0.3), p=0.02 and −1.1 cm2 (95% CI −2.0 to −0.1), p=0.04, respectively). No significant differences were found between exercisers and non-exercisers at week 37 in any labour or delivery outcomes. Conclusions: The results of the present study do not support the hypothesis that women exercising regularly before or during pregnancy have a narrower LH area or more complicated childbirths than non-exercising women.

• Tennfjord, Merete Kolberg; Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Engh, Marie Ellström & Bø, Kari (2015). Coital incontinence and vaginal symptoms and the relationship to pelvic floor muscle function in primiparous women at 12 months postpartum: A cross-sectional study. Journal of Sexual Medicine. ISSN 1743-6095. 12(4), p. 994–1003. doi: 10.1111/jsm.12836. Full text in Research Archive
• Bø, Kari; Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Tennfjord, Merete Kolberg & Engh, Marie Ellström (2015). Postpartum pelvic floor muscle training and pelvic organ prolapse - A randomized trial of primiparous women. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 212(1), p. 38e1–38e7. doi: 10.1016/j.ajog.2014.06.049. Full text in Research Archive Show summary

  Objective: Pelvic organ prolapse (POP) is a common and distressing condition. The aim of the present study was to evaluate the effect of pelvic floor muscle training (PFMT) on prevention and treatment of symptoms and signs of POP in primiparous postpartum women. Study design: This was a parallel group assessor blind randomized controlled trial. One hundred and seventy-five primiparous postpartum women, mean age 29.8 years (SD 4.1), stratified on major levator ani defects or no defect diagnosed by 3/4D ultrasound, participated in a four month PFMT program starting at 6-8 weeks postpartum or control. All participants had thorough individual instruction and assessment of ability to perform correct pelvic floor muscle contractions. The PFMT group followed a supervised, weekly group training program and performed 3 sets of 8-12 daily maximal contractions at home. Main outcome was POP stage II or greater assessed by POP quantification (POP-Q) and bladder neck position assessed by 3/4 D transperineal ultrasonography. Secondary outcome was symptoms of vaginal bulge using International Consultation on Incontinence vaginal symptoms questionnaire (ICIQ-vag). Results: Ninety-six percent of the intervention group adhered to ≥ 80% of both group and home training sessions. At post-intervention there was no significant risk difference in POP (RR: 1.62 (95% CI: 0.55, 4.75), bladder neck position or symptoms of vaginal bulging. Conclusion: No effect was found of postpartum PFMT on POP in primiparous women. More RCTs are needed before strong conclusions can be drawn on the effect of PFMT on POP in the this particular population.

• Tennfjord, Merete Kolberg; Hilde, Gunvor; Stær-Jensen, Jette; Engh, Marie Ellstrøm & Bø, Kari (2014). Dyspareunia and pelvic floor muscle function before and during pregnancy and after childbirth. International Urogynecology Journal. ISSN 0937-3462. 25(9), p. 1227–1235. doi: 10.1007/s00192-014-2373-2. Full text in Research Archive Show summary

  Introduction and hypothesis: There is limited knowledge on dyspareunia during pregnancy and postpartum and the role of the pelvic floor muscles (PFM) in women with dyspareunia. Aims of the study were to investigate the presence of dyspareunia before and during pregnancy and postpartum, and to compare vaginal resting pressure (VRP), PFM strength, and endurance between women with and those without dyspareunia. It was hypothesized that there is no difference in PFM variables between women with and those without dyspareunia. Methods: Three hundred nulliparous women participated in this prospective cohort and answered questions about dyspareunia and the level of bother at gestational weeks 22 and 37, 6 and 12 months postpartum, and retrospectively prior to their pregnancies using ICIQ-FLUTSsex. PFM variables were assessed by manometer at gestational week 22, and 6 and 12 months postpartum. Comparisons between groups were analyzed using independent samples t test. Results: Twenty-eight and 30 % of the women reported dyspareunia at pre-pregnancy and at gestational week 22 respectively. At gestational week 37, and 6 and 12 months postpartum, the percentages were 40, 45, and 33 respectively. No difference in PFM variables was found between women with and those without dyspareunia. Level of bother was higher postpartum than before and during pregnancy. Conclusions: Symptoms of dyspareunia were common at all time points. No link could be made between PFM function and dyspareunia. Women suffering from dyspareunia postpartum reported it as being bothersome. Our findings suggest that women should be asked about symptoms of dyspareunia related to pregnancy, and that future research should aim for preventative and therapeutic strategies.

• Bø, Kari; Hilde, Gunvor; Tennfjord, Merete Kolberg; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska & Engh, Marie Ellstrøm (2014). Pelvic floor muscle variables and levator hiatus dimensions: a 3/4D transperineal ultrasound cross-sectional study on 300 nulliparous pregnant women. International Urogynecology Journal. ISSN 0937-3462. 25(10), p. 1357–1361. doi: 10.1007/s00192-014-2408-8. Full text in Research Archive Show summary

  Introduction and hypothesis: The aims of the present study were to investigate the correlation among vaginal resting pressure and pelvic floor muscle (PFM) strength and endurance, and the correlation between the same variables and levator hiatus (LH) dimensions in nulliparous pregnant women. Methods: This was a cross-sectional study of 300 nulliparous pregnant women, mean age 28.7 years (SD 4.3) and prepregnancy BMI 23.9 kg/m2 (SD 3.9), assessed at mean gestational week 20.8 (±1.4). Vaginal resting pressure and PFM strength and endurance were measured using a high precision pressure transducer connected to a vaginal balloon. LH dimensions (transverse and anterior–posterior diameters_ and LH area were assessed using 3/4D transperineal ultrasound in the axial plane of minimal hiatal dimensions using render mode. The Pearson correlation was used to analyze correlations among vaginal resting pressure and PFM strength and endurance, and between PFM variables and LH dimensions. Level of significance was set at 0.05. Results: Pelvic floormuscle strength and vaginal resting pressure were significantly, but weakly correlated (r=0.198, p<0.001). PFM strength and endurance showed a strong correlation (r=0.929, p<0.001). High vaginal resting pressure was moderately correlated with a small LH area at rest (r=−0.451, p<0.001), but there was no significant correlation neither between PFM strength and LH area at rest (r=−0.012, p=0.84) nor between muscle endurance and LH area at rest (r=−0.014, p=0.81). A strong PFM contraction correlated moderately with reduction of the LH area (r=−0.367, p<0.001). Conclusions: Pelvic floor muscle strength and endurance are strongly correlated, butdo not correlate with a smaller LH area at rest.

• Siafarikas, Franziska; Stær-Jensen, Jette; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellstrøm (2014). Levator hiatus dimensions in late pregnancy and the process of labor : a 3- and 4-dimensional transperineal ultrasound study. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 210(5), p. 484.e1–484.e7. doi: 10.1016/j.ajog.2014.02.021. Full text in Research Archive Show summary

  Objective: The objectives of the investigation were to study the association between levator hiatus dimensions in late pregnancy and both the length of second stage of labor and also the delivery mode in women delivering their first child. Study Design: In this cohort study, 231 nulliparous women were examined with 3- and 4-dimensional transperineal ultrasonography at 37 weeks of gestation. The anteroposterior, transverse diameter, and the area of levator hiatus were measured at rest, during levator ani muscle contraction, and during Valsalva maneuver. The second stage of labor was divided into passive and active second stage and delivery modes into normal vaginal or instrumental deliveries. Spearman correlation coefficient, independent-sample t test, and standard logistic regression were used for analysis. Results: Larger levator hiatus dimensions at rest and during contraction at 37 weeks of gestation correlated with a shorter duration of the active second stage in women with normal vaginal delivery (Spearman correlation coefficient, –0.13 to –0.35, P ≤ .08). Women having normal vaginal deliveries had significantly larger transverse diameter at rest, during contraction, and during Valsalva maneuver compared with women having instrumental deliveries (mean difference, 0.29; 95% confidence interval (CI), 0.16–0.41; mean difference, 0.33; 95% CI, 0.21–0.44 and mean difference, 0.24; 95% CI, 0.06–0.42; P < .05). The same was true for the levator hiatus area at rest and during contraction (mean difference, 1.22; 95% CI, 0.37–2.07 and mean difference, 0.84; 95% CI, 0.22–1.46; P < .01). These estimates were unchanged by adjustments in the logistic regression analysis. Conclusion: Larger levator hiatus dimensions in late pregnancy had a significant association with a shorter active second stage of labor and normal vaginal delivery.

• Brækken, Ingeborg Hoff; Majida, Memona; Engh, Marie Ellstrøm & Bø, Kari (2014). Are pelvic floor muscle thickness and size of levator hiatus associated with pelvic floor muscle strength, endurance and vaginal resting pressure in women with pelvic organ prolapse stages I-III? A cross sectional 3D ultrasound study. Neurourology and Urodynamics. ISSN 0733-2467. 33(1), p. 115–120. doi: 10.1002/nau.22384. Full text in Research Archive Show summary

  Aims: To investigate if pelvic floor muscle (PFM) thickness and area of levator hiatus (LH) are associated with manometry measured PFM function in 109 women with pelvic organ prolapse (POP) stages I–III. Methods: In this cross-sectional study pubovisceral muscle thickness and LH area were assessed with three-dimensional transperineal ultrasound at rest and analyzed in the axial plane. PFM function was assessed with manometry and included strength, endurance, and vaginal resting pressure. Relationships were investigated using univariate linear logistic regressions models, Pearson product-moment correlation coefficient and hierarchical multiple regression. Results: The mean age was 49 (SD 12). There was a significant positive moderate association between muscle thickness and PFM strength (r = 0.49, P < 0.001) and endurance (r = .45, P < 0.001). A moderate negative association was found between LH area and vaginal resting pressure (r = −0.46, P < 0.001), strength (r = −0.41, P < 0.001) and endurance (r = −0.40, P < 0.001). Multivariate analyses included PFM strength, endurance, vaginal resting pressure, age, parity, BMI and socioeconomic status. Muscle thickness was best explained by PFM strength and LH area was best explained by vaginal resting pressure. However, PFM function explained only 20.0% and 26.4% of the variance in muscle thickness and LH area after controlling for age, parity, BMI, and socioeconomic status. Conclusion: There are moderate associations between measurements using ultrasound and manometry in POP women. Thicker muscles and smaller LH were associated with higher strength and endurance. Smaller LH was additionally associated with higher vaginal resting pressure. Ultrasound and manometry measure different aspects of the PFM and cannot be used interchangeably

• Stær-Jensen, Jette; Richter, Franziska; Hilde, Gunvor; Brækken, Ingeborg Hoff; Bø, Kari & Engh, Marie Ellstrøm (2013). Pelvic Floor Muscle Injuries 6 Weeks Post Partum-An Intra- and Inter-Rater Study. Neurourology and Urodynamics. ISSN 0733-2467. 32(7), p. 993–997. doi: 10.1002/nau.22337. Full text in Research Archive
• Bø, Kari; Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska & Engh, Marie Ellstrøm (2013). Too tight to give birth? Assessment of pelvic floor muscle function in 277 nulliparous pregnant women. International Urogynecology Journal. ISSN 0937-3462. 24(12), p. 2065–2070. doi: 10.1007/s00192-013-2133-8. Full text in Research Archive Show summary

  Introduction and hypothesis Theoretically, tight or strong pelvic floor muscles may impair the progress of labor and lead to instrumental deliveries. We aimed to investigate whether vaginal resting pressure, pelvic floor muscle strength, or endurance at midpregnancy affect delivery outcome. Methods This was a prospective cohort study of women giving birth at a university hospital. Vaginal resting pressure, pelvic floor muscle strength, and endurance in 300 nulliparous pregnant women were assessed at mean gestational week 20.8 (±1.4) using a high precision pressure transducer connected to a vaginal balloon. Delivery outcome measures [acute cesarean section, prolonged second stage of labor (> 2 h), instrumental vaginal delivery (vacuum and forceps), episiotomy, and thirdand fourth-degree perineal tear) were retrieved from the hospital’s electronic birth records. Results Twenty-three women were lost to follow-up, mostly because they gave birth at another hospital. Women with prolonged second stage had significantly higher resting pressure than women with second stage less than 2 h; the mean difference was 4.4 cmH2O [95 % confidence interval (CI) 1.2–7.6], p<0.01, adjusted odds ratio 1.049 (95 % CI 1.011– 1.089, p=0.012). Vaginal resting pressure did not affect other delivery outcomes. Pelvic floor muscle strength and endurance similarly were not associated with any delivery outcomes. Conclusions While midpregnancy vaginal resting pressure is associated with prolonged second stage of labor, neither vaginal resting pressure nor pelvic floor muscle strength or endurance are associated with operative delivery or perineal tears. Strong pelvic floor muscles are not disadvantageous for vaginal delivery.

• Werner, Henrica Maria Johanna; Trovik, Jone; Marcickiewicz, Janusz; Tingulstad, Solveig; Staff, Anne Cathrine & Engh, Marie Ellstrøm [Show all 12 contributors for this article] (2013). A discordant histological risk classification in preoperative and operative biopsy in endometrial cancer is reflected in metastatic risk and prognosis. European Journal of Cancer. ISSN 0959-8049. 49(3), p. 625–632. doi: 10.1016/j.ejca.2012.09.006. Full text in Research Archive
• Hilde, Gunvor; Stær-Jensen, Jette; Richter, Franziska; Engh, Marie Ellstrøm; Brækken, Ingeborg Hoff & Bø, Kari (2013). Impact of childbirth and mode of delivery on vaginal resting pressure and on pelvic floor muscle strength and endurance. American Journal of Obstetrics and Gynecology. ISSN 0002-9378. 208(1), p. e1–e7. doi: 10.1016/j.ajog.2012.10.878. Full text in Research Archive Show summary

  Objective: We sought to study impact of delivery mode on vaginal resting pressure (VRP) and on pelvic floor muscle (PFM) strength and endurance, and whether these measurements differed in women with and without urinary incontinence. Study Design: We conducted a cohort study following 277 nulliparous women from midpregnancy to 6 weeks postpartum. Manometer was used for PFM measurements; differences were analyzed by t test (within groups) and analysis of variance (between groups). Results: Only VRP changed significantly (10% reduction, P = .001) after emergency cesarean section. After normal and instrumental vaginal delivery, VRP was reduced by 29% and 30%; PFM strength by 54% and 66%; and endurance by 53% and 65%, respectively. Significant differences for all PFM measures (P < .001) were found when comparing cesarean vs normal and instrumental vaginal delivery, respectively. Urinary continent women at both time points had significantly higher PFM strength and endurance than incontinent counterparts (P < .05). Conclusion: Pronounced reductions in VRP and in PFM strength and endurance were found after vaginal delivery. Continent women were stronger than incontinent counterparts.

• Stær-Jensen, Jette; Siafarikas, Franziska; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellstrøm (2013). Ultrasonographic Evaluation of Pelvic Organ Support During Pregnancy. Obstetrics and Gynecology. ISSN 0029-7844. 122(2-2), p. 329–336. doi: 10.1097/AOG.0b013e318299f62c. Full text in Research Archive Show summary

  OBJECTIVE: To investigate whether pregnancy affects levator hiatus dimensions and the position and mobility of the bladder neck and the levator ani muscle in nulliparous pregnant women. METHODS: In the present study, 274 nulliparous pregnant women were examined at 21 weeks and 37 weeks of gestation using three-dimensional and four-dimensional transperineal ultrasonography at rest, during contraction, and during Valsalva maneuver. Levator hiatus dimensions were the anteroposterior diameter, the transverse diameter, and the area measured in rendered images. Positions of the bladder neck and levator plate were analyzed in the midsagittal plane, and mobility was calculated as displacement of the bladder neck or levator plate from rest to contraction or from rest to Valsalva. RESULTS: A significant increase for all levator hiatus dimension measurements was found from 21 weeks to 37 weeks of gestation. The most marked change was found for levator hiatus area at rest and during Valsalva maneuver, in which the mean area was increased by 17.1% (11.7–13.7 cm2) and 21.4% (15.4–18.7 cm2), respectively. Bladder neck mobility changed significantly during pregnancy. The most marked change was seen from rest to contraction (mean –14 mm, standard deviation 0.4). CONCLUSIONS: An increase of all hiatal dimensions as well as bladder neck mobility was found from 21 weeks to 37 weeks of gestation in nulliparous pregnant women. The findings indicate that the changes in pelvic organ support are not solely caused by delivery, but also by physiologic changes during pregnancy.

• Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska; Gjestland, Kristin; Engh, Marie Ellstrøm & Bø, Kari (2013). How well can pelvic floor muscles with major defects contract? A cross-sectional comparative study 6 weeks after delivery using transperineal 3D/4D ultrasound and manometer. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 120(11), p. 1423–1429. doi: 10.1111/1471-0528.12321. Full text in Research Archive
• Siafarikas, Franziska; Stær-Jensen, Jette; Brækken, Ingeborg Hoff; Bø, Kari & Engh, Marie Ellstrøm (2013). Learning process for performing and analyzing 3D/4D transperineal ultrasound imaging and interobserver reliability study. Ultrasound in Obstetrics and Gynecology. ISSN 0960-7692. 41(3), p. 312–317. doi: 10.1002/uog.11192. Full text in Research Archive Show summary

  Objectives: To evaluate the learning process for acquiring three- and four-dimensional (3D/4D) transperineal ultrasound volumes of the levator hiatus (LH) dimensions at rest, during pelvic floor muscle (PFM) contraction and on Valsalva maneuver, and for analyzing the ultrasound volumes, as well as to perform an interobserver reliability study between two independent ultrasound examiners. Methods: This was a prospective study including 22 women. We monitored the learning process of an inexperienced examiner (IE) performing 3D/4D transperineal ultrasonography and analyzing the volumes. The examination included acquiring volumes during three PFM contractions and three Valsalva maneuvers. LH dimensions were determined in the axial plane. The learning process was documented by estimating agreement between the IE and an experienced examiner (E) using the intraclass correlation coefficient. Agreement was calculated in blocks of 10 ultrasound examinations and analyzed volumes. After the learning process was complete the interobserver reliability for the technique was calculated between these two independent examiners. Results: For offline analysis of the first 10 ultrasound volumes obtained by E, good to very good agreement between E and IE was achieved for all LH measurements except for the left and right levator–urethra gap and pubic arc. For the next 10 analyzed volumes, agreement improved for all LH measurements. Volumes that had been obtained by IE and E were then re-evaluated by IE, and good to very good agreement was found for all LH measurements indicating consistency in volume acquisition. The interobserver reliability study showed excellent ICC values (ICC, 0.81–0.97) for all LH measurements except the pubic arc (ICC = 0.67). Conclusion: 3D/4D transperineal ultrasound is a reliable technique that can be learned in a short period of time

• Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska; Engh, Marie Ellstrøm & Bø, Kari (2013). Postpartum Pelvic Floor Muscle Training and Urinary Incontinence: A Randomized Controlled Trial. Obstetrics and Gynecology. ISSN 0029-7844. 122(6), p. 1231–1238. doi: 10.1097/AOG.0000000000000012. Full text in Research Archive Show summary

  OBJECTIVE: To evaluate whether postpartum pelvic floor muscle training decrease prevalence of any urinary incontinence (UI) in primiparous women with and without UI at inclusion (mixed population) and further to perform stratified analyses on women with and without major levator ani muscle defects. METHODS: A two-armed assessor-blinded randomized controlled trial including primiparous women 6 weeks after vaginal delivery was conducted. Participants were stratified on major levator ani muscle defects, verified by transperineal ultrasonography, and thereafter randomly allocated to training or control. All participants were taught to contract the pelvic floor muscles. The control participants received no further intervention, whereas training participants attended a weekly supervised pelvic floor muscle training class and performed daily home exercise for 16 weeks. Primary outcome was self-reported UI analyzed by relative risk. RESULTS: We included 175 women, 55 with major levator ani muscle defects and 120 without. Prevalence of UI at baseline was 39.1% in the training group (n=87) and 50% among those in the control group (n=88). Fifteen women (8.6%) were lost to follow-up. At 6 months after delivery (postintervention), 34.5% and 38.6% reported UI in the training and control groups, respectively. Relative risk analysis of UI gave a nonsignificant effect size of 0.89 (95% confidence interval [CI] 0.60–1.32). Results were similar for the stratum with and without major levator ani muscle defects, 0.89 (95% CI 0.51–1.56) and 0.90 (95% CI 0.53–1.52), respectively. CONCLUSIONS: Postpartum pelvic floor training did not decrease UI prevalence 6 months after delivery in primiparous women. Stratified analysis on women with and without major levator ani muscle defects showed similar nonsignificant results.

• Hilde, Gunvor; Stær-Jensen, Jette; Engh, Marie Ellstrøm; Brækken, Ingeborg Hoff & Bø, Kari (2012). Continence and pelvic floor status in nulliparous women at midterm pregnancy. International Urogynecology Journal. ISSN 0937-3462. 23(9), p. 1257–1263. doi: 10.1007/s00192-012-1716-0. Full text in Research Archive Show summary

  Introduction and hypothesis: A Cochrane review recommends antenatal pelvic floor muscle training (PFMT) in urinary incontinence (UI) prevention. The aim of the study was to investigate nulliparous pregnant women’s knowledge about and practising of PFMT, their pelvic floor muscle (PFM) function, and ability to contract correctly. It was hypothesized that continent women had higher PFM strength and endurance than women with UI. Methods: Three hundred nulliparous women at gestational week 18–22 were included in a cross-sectional study. Vaginal resting pressure, maximum voluntary contraction, and PFM endurance were measured by manometer. UI was assessed by International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI-SF). Comparisons of PFM function in continent women and women with UI were analyzed using independent-samples t test. Mean differences with 95 % confidence interval (CI) are presented. Results: Of 300 women, 89 % had heard of PFMT at mid pregnancy, and 35 % performed PFMT once or more a week. After thorough instruction 4 % were unable to contract correctly. Thirty-five percent reported UI, of whom 48 % performed PFMT once or more a week. Continent women had significantly higher PFM strength and endurance when compared with women having UI, with mean differences of 6.6 cmH2O (CI 2.3–10.8, p = 0.003), and 41.5 cmH2Osec (CI 9.8–73.1, p = 0.010), respectively. No difference was found for vaginal resting pressure (p = 0.054). Conclusions: Most nulliparous pregnant women knew about PFMT. Thirty-five percent performed PFMT once or more a week. Incontinent nulliparous pregnant women had weaker PFM than their continent counterparts. More emphasis on information regarding PFM function and PFMT is warranted during pregnancy.

• Majida, Memona; Brækken, Ingeborg Hoff; Bø, Kari & Engh, Marie Ellstrøm (2012). Levator hiatus dimensions and pelvic floor function in women with and without major defects of the pubovisceral muscle. International Urogynecology Journal. ISSN 0937-3462. 23(6), p. 707–714. doi: 10.1007/s00192-011-1652-4. Full text in Research Archive Show summary

  Introduction and hypothesis: The aim of present study was to compare pelvic floor morphology and function in women with and without major defects of the pubovisceral muscle. Methods: One hundred fifty-seven women with pelvic organ prolapse participated in this cross-sectional study. Participants answered a symptom questionnaire and underwent clinical and three- and four-dimensional transperineal ultrasound examination. Pelvic floor muscle maximum voluntary contraction (MVC), endurance, and resting vaginal pressure were registered with a vaginal balloon catheter. Offline analyses were performed for the presence of major pubovisceral muscle defects (PVMD) and hiatal dimensions. Results: The levator hiatus dimensions at rest and contraction were significantly larger in women with than without major PVMD. Mean differences in levator hiatus area between women with and without major PVMD were: rest 1.9 cm2 95% confidence intervals (CI) 0.21–3.7, P = 0.028 and contraction 2.75 cm2 95% CI 1.0–4.5, P =0.002; and Valsalva maneuver mean difference was 0.82 cm2 95% CI 2.18–3.83, P = 0.543. Women with major PVMD had lower MVC and endurance measurements as compared with women without major PVMD, but the differences were not statistically significant. Conclusions: Women with major pubovisceral muscle defects have larger hiatal dimensions at rest and at contraction than women without PVMD. We were unable to prove the corresponding relationship for hiatal dimensions on Valsalva.

• Engh, Marie Ellstrøm & Hauso, Wenche (2012). Vaginal hysterectomy, an outpatient procedure. Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 91(11), p. 1293–1299. doi: 10.1111/j.1600-0412.2012.01502.x. Full text in Research Archive
• Bø, Kari; Majida, Memona & Engh, Marie Ellstrøm (2012). Does a ring pessary in situ influence the pelvic floor muscle function of women with pelvic organ prolapse when tested in supine? International Urogynecology Journal. ISSN 0937-3462. 23(5), p. 573–577. doi: 10.1007/s00192-011-1598-6. Full text in Research Archive Show summary

  Introduction and hypothesis: It has been suggested that repositioning pelvic organ prolapse (POP) by pessary support may improve pelvic floor muscle (PFM) function. The aim of the present study was to compare vaginal resting pressure and maximal voluntary contraction (MVC) of the PFM measured with and without a ring pessary in situ. Methods: This was a short-term experimental study with women acting as their own controls. Twenty-two women with POP quantified II–IV were included. Vaginal resting pressure and MVC was measured with a manometer (Camtech AS) in supine position. Difference between measurements with and without the ring pessary was analyzed by paired sample t test and Wilcoxon signed rank test. Significance level was <0.05. Results: There was a statistically significant difference in measurement of vaginal resting pressure (p<0.01) but not of MVC (p=<0.68) with the ring pessary in situ. Conclusions: Measurement of PFM strength can be done without repositioning the prolapse.

• Engh, Marie Ellstrøm; Ekeryd, Ann; Magnusson, Åsa; Olsson, Ingegerd; Otterlind, Lena & Tobiasson, Gun (2011). Can de novo stress incontinence after anterior wall repair be predicted? Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 90(5), p. 488–493. doi: 10.1111/j.1600-0412.2011.01087.x. Full text in Research Archive
• Majida, Memona; Brækken, Ingeborg Hoff; Bø, Kari; Saltyte-Benth, Jurate & Engh, Marie Ellstrøm (2011). Anterior but not posterior compartment prolapse is associated with levator hiatus area: a three- and four-dimensional transperineal ultrasound study. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 118(3), p. 329–337. doi: 10.1111/j.1471-0528.2010.02784.x. Full text in Research Archive Show summary

  Objectives: Many women seeking help for pelvic organ prolapse (POP) have a clinically significant descent in more than one vaginal compartment, and there is often a discrepancy between subjective symptoms and objective findings. We examined the association between the size of the levator hiatus using transperineal three-dimensional (3D) ultrasound and both the degree and anatomical site(s) of POP, and symptoms of pelvic organ dysfunction. Design: Cross-sectional study. Setting: Gynaecology Department, University Hospital. Population: A total of 157 women with (POP) stage 0–IV with or without symptoms, recruited by community gynaecologists. Methods: All women answered the symptom questionnaire. They underwent a clinical examination with grading of the prolapse and a 3D/4D transperineal ultrasound. The ultrasound volumes were analysed offline using the software 4D View (GE, Zipf, Austria). Main outcome measures: Area of the levator hiatus at rest and on Valsalva manoeuvre. Results: Clinically significant prolapse in the anterior but not in the posterior compartment was positively associated with area of the levator hiatus (P < 0.001). This was also true for women with POP in two compartments. No independent association between area of the levator hiatus and symptoms of pelvic floor dysfunction was found. Conclusions: Our data suggest that accessing the axial plane to evaluate the size of the levator hiatus is indicated in women who have clinically significant POP including the anterior vaginal compartment. The size of the levator hiatus did not explain the discrepancy between subjective and objective findings in women with POP.

• Altman, Daniel; Väyrynen, Tapio; Engh, Marie Ellstrøm; Axelsen, Susanne & Falconer, Christian (2011). Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. New England Journal of Medicine. ISSN 0028-4793. 364(19), p. 1826–1836. doi: 10.1056/nejmoa1009521. Full text in Research Archive

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• Gabrielsen, Rakel; Engh, Anna Marie Ellström; Bø, Kari & Tennfjord, Merete Kolberg (2023). Spectrum of symptoms among women suffering endometriosis and the relationship with physical activity and exercise. Full text in Research Archive
• Tennfjord, Merete Kolberg; Engh, Marie Ellström & Bø, Kari (2019). Does early onset of exercise training postpartum negatively affect pelvic floor muscle function and prevalence of pelvic floor dysfunction 12 months postpartum? Full text in Research Archive Show summary

  Background: There is scant knowledge whether early onset of postpartum general physical activity/ exercise training affect the pelvic floor muscles and increase the risk of SUI and POP. Aim: To investigate how general exercise training six weeks postpartum impact on the PFM and symptoms of SUI and POP 12 months postpartum. Method: In this prospective cohort study, at six weeks postpartum, 70 primiparous women characterised as regular exercisers (≥3 times ≥30 min/week) were compared to 97 non-exercisers. Mean age 29 (SD 4.3). Twelve months postpartum vaginal resting pressure (VRP), PFM strength and PFM endurance were measured by vaginal manometer and symptoms of SUI and POP were assessed by questionnaire (ICIQ). Results: Twelve months postpartum no differences were found between exercisers (n=70) and non-exercisers (n=97) performed six weeks postpartum on VRP (B: -0.04 (95%CI: -3.39, 2.07), PFM strength (B: 0.06, 95%CI: -3.66, 8.04), PFM endurance (B: 0.03, 95%CI: -39.17, 61,45) or symptoms of SUI (OR: 0.35 , 95%CI: 0.41, 1.62) or POP (OR: 1.23, 95%CI: 0.29, 1.42). After adjusting the findings for possible covariates having SUI at mid-pregnancy and BMI >30 were associated with increased risk of having SUI 12 months postpartum: OR=16.46, (95%CI: 2.62, 15.85) and OR=4.59, (95%CI: 1.11, 11.30), respectively. Having POP at mid-pregnancy was associated with increased risk of having POP 12 months postpartum (OR=10.16, 95%CI: 1.87, 13.83). Conclusion: Starting regular, general exercise training six weeks postpartum does not negatively influence the PFM or PFD 12 months postpartum.

• Tennfjord, Merete Kolberg; Engh, Marie Ellström & Bø, Kari (2019). General exercise training six weeks postpartum did not influence pelvic floor muscle function or pelvic floor dysfunction at 12 months postpartum: a prospective cohort study. Full text in Research Archive Show summary

  Background: There is scant knowledge whether early onset of postpartum general physical activity/ exercise training affect the pelvic floor muscles and increase the risk of SUI and POP. Aim: To investigate how general exercise training six weeks postpartum impact on the PFM and symptoms of SUI and POP 12 months postpartum. Method: In this prospective cohort study, at six weeks postpartum, 70 primiparous women characterised as regular exercisers (≥3 times ≥30 min/week) were compared to 97 non-exercisers. Mean age 29 (SD 4.3). Twelve months postpartum vaginal resting pressure (VRP), PFM strength and PFM endurance were measured by vaginal manometer and symptoms of SUI and POP were assessed by questionnaire (ICIQ). Results: Twelve months postpartum no differences were found between exercisers (n=70) and non-exercisers (n=97) performed six weeks postpartum on VRP (B: -0.04 (95%CI: -3.39, 2.07), PFM strength (B: 0.06, 95%CI: -3.66, 8.04), PFM endurance (B: 0.03, 95%CI: -39.17, 61,45) or symptoms of SUI (OR: 0.35 , 95%CI: 0.41, 1.62) or POP (OR: 1.23, 95%CI: 0.29, 1.42). After adjusting the findings for possible covariates having SUI at mid-pregnancy and BMI >30 were associated with increased risk of having SUI 12 months postpartum: OR=16.46, (95%CI: 2.62, 15.85) and OR=4.59, (95%CI: 1.11, 11.30), respectively. Having POP at mid-pregnancy was associated with increased risk of having POP 12 months postpartum (OR=10.16, 95%CI: 1.87, 13.83). Conclusion: Starting regular, general exercise training six weeks postpartum does not negatively influence the PFM or PFD 12 months postpartum.

• Reimers, Cathrine; Stær-Jensen, Jette; Siafarikas, Franziska; Bø, Kari & Engh, Marie Ellström (2018). Correction to: Association between vaginal bulge and anatomical pelvic organ prolapse during pregnancy and postpartum: an observational study. International Urogynecology Journal. ISSN 0937-3462. 29(3), p. 449–449. doi: 10.1007/s00192-018-3564-z. Full text in Research Archive
• Tennfjord, Merete Kolberg; Bø, Kari & Engh, Marie Ellström (2017). Målemetoder innen utredning og behandling av bekkenbunnsplager. Full text in Research Archive
• Tennfjord, Merete Kolberg; Bø, Kari & Engh, Marie Ellström (2017). Physical activity and pelvic floor muscle function in primiparous women 12 months postpartum-a cross-sectional study. Full text in Research Archive Show summary

  Background: Urinary incontinence (UI) during physical activity is common, with prevalence rates ranging from 15% in noncompetitive exercisers up to 80% in elite athletes. There is scant knowledge on the impact of physical activity on pelvic floor muscle (PFM) function and UI postpartum. One hypothesis is that strenuous physical activity may overload, stretch and weaken the pelvic floor. Purpose: Assess the relationship between frequency and type of physical activity in primiparous women 12 months postpartum on PFM function and prevalence of UI. Methods: One hundred seventy-seven primiparous women, mean age 28.7 years (SD 4.3) participated. Outcomes were prevalence of UI categorized as yes/no measured by ICIQ-UI Short Form and vaginal resting pressure, PFM strength and endurance measured by manometer (Camtech AS, Sandvika, Norway). Exposure was frequency and type of physical activity; brisk walking, low impact exercise (swimming, bicycling, training in fitness centres, low impact aerobic classes, prenatal aerobic classes, dancing, skiing, horseback riding, other) and high impact exercise (jogging, ball games, high impact aerobic classes). Frequency of physical activity was categorized into never and exercising ≥30 min 3 times per week, while type of activity was categorized into brisk walking only and low -and high impact exercises ≥30 min 3 times per week. Results were analyzed using Independent sample t-test and Chi-Square test. P-value was set to <0.05. Results: Twelve months postpartum, there was no difference between those exercising ≥30 min 3 times per week (n=75) versus those never exercising (n=52) for vaginal resting pressure (mean difference: -0.8 cmH2O, 95%CI 2.61, 4.18), PFM strength (mean difference: 2.9 cmH2O, 95%CI -9.88, 4.06) or endurance (mean difference: 22.1 cmH2Osec, 95%CI -82.69, 38.48). Due to only two women performing high impact exercises only, low -and high impact exercises were grouped into those exercising ≥30 min 3 times per week for the analysis on type of exercise. No difference in vaginal resting pressure (mean difference: 0.3 cmH2O, 95%CI -4.54, 3.78), PFM strength (mean difference: 7.2 cmH2O, 95%CI -16.89, 2.60) or endurance (mean difference: 44.2 cmH2Osec, 95%CI -129.54, 40.95) was found between those exercising low –and high impact exercises ≥30 min 3 times per week (n=65) versus brisk walking only (n=22). No difference was found for women with and without on frequency (p=0.45) or type of exercise (p=0.81), respectively. Conclusions: Twelve months postpartum there was no difference in prevalence of UI or PFM function in women exercising ≥30 min 3 times per week versus never exercising and between different types of physical activities. Our results may be biased by few women reporting high impact exercises and that women having UI may refrain from exercising. Future studies should investigate physical activity prior to and during pregnancy in relation to birth trauma and pelvic floor dysfunction. Implications: Results from this study indicate that general physical activity 12 months postpartum has no negative influence on PFM function or UI. However, due to possible confounding factors more research is needed before recommendations on frequency and type of exercise are given in this group of women.

• Tennfjord, Merete Kolberg; Bø, Kari & Engh, Marie Ellström (2016). An intra –and inter-rater reliability study of the measurement of pelvic floor muscle function using manometry. Full text in Research Archive Show summary

  Interpretation of results We found that the use of manometry in the assessment of vaginal resting pressure, PFM strength and endurance showed very good agreement from test one to test two by the same assessor and also between assessors. There were no systematic differences in any of the measurements, but visual inspection of the data and outliers showed a slight tendency towards greater differences for the highest scores of PFM strength and endurance. Concluding message Manometry is a reliable method to assess all parameters of PFM function. Thorough practice and standardisation of the procedure, instructions to the patient, recording and analysing the measurements are of importance.

• Tennfjord, Merete Kolberg; Bø, Kari & Engh, Marie Ellström (2016). Målemetoder i klinisk praksis. Full text in Research Archive
• Tennfjord, Merete Kolberg; Bø, Kari; Engh, Marie Ellström; Hilde, Gunvor; Stær-Jensen, Jette & Siafarikas, Franziska (2015). EFFEKT AV BEKKENBUNNSTRENING ETTER FØDSEL FOR VAGINALE SYMPTOMER OG SEKSUELL DYSFUNKSJON- EN RANDOMISERT KONTROLLERT STUDIE. Full text in Research Archive Show summary

  Innledning Bekkenbunnstrening er førsteledds behandling for stress inkontinens og underlivs prolaps. Det er ingen konsensus for behandling av andre vaginale symptomer eller seksuelle forhold hos førstegangsfødende kvinner etter fødsel. Målsetting var å undersøke om bekkenbunnstrening kan redusere vaginale symptomer og forbedre seksuelle forhold hos førstegangsfødende kvinner etter fødsel. Metode Et hundre sytti-fem kvinner, gjennomsnitt alder 29.8 år (SD 4.1) ble inkludert i en 2 armet blindet randomisert kontrollert studie som startet 6 uker etter fødsel. Kvinnene ble stratifisert på skade av levator ani muskelen eller ikke skade verifisert av ultralyd. Alle deltakere ble instruert i riktig bekkenbunnssammentrekning. Treningsgruppen mottok veiledet, ukentlig gruppe trening og gjorde hjemme øvelser i 16 uker, mens kontroll gruppen fikk ingen videre oppfølging. Utfallet var selv-rapporterte vaginale symptomer og seksuelle forhold undersøkt med International Consultation on Incontinence Modular Questionnaire (ICIQ) vaginal symptoms questionnaire. Resultater ble analysert som intention to treat og rapportert som relativ risk. Resultat Det var ingen forskjell mellom gruppene i forhold til de som ikke hadde samleie ved 6 måneder etter fødsel. I den totale gruppen var det ingen forskjell mellom gruppene for vaginale symptomer eller seksuelle forhold. I stratum med skade på levator ani muskelen var det i treningsgruppen signifikant færre som følte at skjeden var for “slapp” sammenlignet med kontrollgruppen 10/27 (37%) versus 19/28 (67.9%), (RR 0.55, 95%KI 0.31, 0.95, p=0.03). Diskusjon og konklusjon I tillegg til at bekkenbunnstrening er anbefalt som førsteledds behandling for stress inkontinens og underlivsprolaps, kan disse resultatene brukes som motivasjon for bekkenbunnstrening for andre typer symptomer som følelsen av å ha for “slapp skjede” hos kvinner med skade på levator ani muskelen.

• Planke, Catherine; Martini, A; Engh, Marie Ellström; Øresland, Tom; Cvancarova, M & Grotle, M [Show all 8 contributors for this article] (2015). TRANSLATION AND VALIDATION OF CONDITION-SPECIFIC QUALITY OF LIFE QUESTIONNAIRES FOR WOMEN WITH PELVIC ORGAN PROLAPSE IN THE NORWEGIAN CONTEXT. Full text in Research Archive
• Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Siafarikas, Franziska; Gjestland, Kristin; Engh, Marie Ellström & Bø, Kari (2014). Authors' reply: How well can pelvic floor muscles with major defects contract? A cross- sectional comparative study six weeks post partum using transperineal 3D/4D ultrasound and manometer. BJOG: An International Journal of Obstetrics and Gynaecology. ISSN 1470-0328. 121(9), p. 1174–1175. doi: 10.1111/1471-0528.12596. Full text in Research Archive
• Tennfjord, Merete Kolberg; Bø, Kari; Engh, Marie Ellström; Hilde, Gunvor; Stær-Jensen, Jette & Siafarikas, Franziska (2013). COITAL INCONTINENCE DURING PREGNANCY AND POSTPARTUM AND ASSOCIATIONS WITH PELVIC FLOOR MUSCLES. Full text in Research Archive Show summary

  Objective: The aim of this study was to investigate the presence of coital incontinence (CI) before pregnancy, at gestational week 21 and 37, 6 -and 12 months postpartum and associations with other symptoms of urinary incontinence (UI). Further, to compare women with CI to women with no UI in relation to vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength and endurance. Background: CI is urinary leakage with sexual intercourse (1). It has been suggested that CI is linked with stress urinary incontinence (SUI) and that a weak PFM may be one cause of the condition (2). There is scant knowledge on VRP, PFM strength and endurance in relation to CI in pregnancy and the postpartum period. Methods: Three hundred nulliparous pregnant women were included in this prospective cohort study. Mean age at inclusion was 28.7 years (SD 4.3) and mean pre-pregnancy body mass index 23.9 kg/m2 (SD 3.9). At 6 weeks postpartum 71 women were recruited to a parallel ongoing randomized controlled trial and excluded from the cohort. International Consultation on Incontinence Modular Questionnaire, sexual matters module (ICIQ Flutsex) was used for data collection on the presence of CI and the perceived impact of CI on sexual life. Participants were assessed as having CI if they responded having one or more episodes of leakage during intercourse the last 3 months prior to pregnancy and the last 4 weeks at gestational week 21 and 37, 6 -and 12 months postpartum. Questions regarding pre-gestational CI were asked retrospectively at week 21. Presence of UI and type of UI was assessed by answers given for “when does urine leak?” in ICIQ-Urinary Incontinence Short Form (ICIQ UI SF). VRP, PFM strength and endurance were measured at gestational week 21, 6 –and 12 months postpartum with a vaginal balloon catheter connected to a high precision pressure transducer in combination with visual observation (3). Background variables are reported as means and SD and descriptive variables as frequencies. Between groups comparisons were analysed with Mann-Whitney U Test. P-values <0.05 were considered significant. Results: Three(1%) of the 299 women having sexual intercourse reported CI prior to pregnancy, 2(0.7% ) of 284 at gestational week 21, 2(0.9%) of 227 at gestational week 37, 6(3.4%) of 179 at 6 months and 3(1.7%) of 179 at 12 months postpartum. UI was present in 46 of 300(15%) at pre-pregnancy, 104 of 300(35%) at gestational week 21, 139 of 277(50%) at gestational week 37, 68 of 196(35%) at 6 months postpartum and in 71 of 178(40%) at 12 months postpartum. Among the 13 women reporting CI once or more; 5 women complained of SUI, 2 of urgency urinary incontinence and 2 of mixed urinary incontinence. Four reported CI only, with no symptoms of other types of UI. Mean level of bother was 5.6(SD 5.1) pre-pregnancy, 1.5(SD 2.1) at gestational week 21, 4.5(SD 2.1) at gestational week 37, 3.8(SD 2.0) at 6 months postpartum and 4.5(SD 0.7) at 12 months postpartum. VRP was statistically significantly lower in women with CI at gestational week 21 compared to continent women. PFM strength and endurance showed no statistically significant difference between the groups Conclusions: In women delivering their first child CI was a rare but moderately bothersome condition. CI often co-exists with other symptoms of UI. There was no difference in PFM strength and endurance

• Altman, D; Bek, Moller K.; Mikkola, T.; Gunnarsson, J.; Engh, Marie Ellstrøm & Falconer, C (2013). INTRA- AND PERIOPERATIVE MORBIDITY FOLLOWING PELVIC ORGAN PROLAPSE REPAIR USING A TRANSVAGINAL SUTURE CAPTURING MESH DEVICE COMPARED TO TROCAR GUIDED TRANSVAGINAL MESH AND TRADITIONAL COLPORRAPHY. Neurourology and Urodynamics. ISSN 0733-2467. 32(6), p. 873–874. Full text in Research Archive
• Staer-Jensen, J.; Siafarikas, Franziska; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellstrøm (2013). DO MAJOR DEFECTS OF THE LEVATOR ANI MUSCLE HEAL WITHIN THE FIRST 6 MONTHS POSTPARTUM? Neurourology and Urodynamics. ISSN 0733-2467. 32(6), p. 650–651. Full text in Research Archive
• Reimers, Cathrine; Stær-Jensen, Jette; Siafarikas, Franziska; Benth, Jurate Saltyte; Bø, Kari & Engh, Marie Ellstrøm (2013). Pelvic organ support assessed during pregnancy and post partum; a cohort study following 229 nulliparous pregnant women from mid-pregnsncy until one year post portum using pop q. Neurourology and Urodynamics. ISSN 0733-2467. 32(6), p. 809–811. Full text in Research Archive
• Stær-Jensen, Jette; Siafarikas, Franziska; Hilde, Gunvor; Bø, Kari & Engh, Marie Ellström (2013). Ultrasonographic Evaluation of Pelvic Organ Support During Pregnancy EDITORIAL COMMENT. Obstetrical and Gynecological Survey. ISSN 0029-7828. 68(11), p. 735–736. Full text in Research Archive
• Bø, Kari; Hilde, Gunvor; Tennfjord, M.K.; Jensen, Johan Skog; Siafarikas, Franziska & Engh, Marie Ellstrøm (2013). RANDOMIZED CONTROLLED TRIAL OF PELVIC FLOOR MUSCLE TRAINING TO PREVENT AND TREAT PELVIC ORGAN PROLAPSE IN POSTPARTUM PRIMIPAROUS WOMEN. Neurourology and Urodynamics. ISSN 0733-2467. 32(6), p. 806–807. Full text in Research Archive
• Engh, Marie Ellstrøm (2012). Meshes in pelvic floor reconstructive surgery - are there any indications? Acta Obstetricia et Gynecologica Scandinavica. ISSN 0001-6349. 91, p. 33–33. Full text in Research Archive
• Tennfjord, Merete Kolberg; Bø, Kari; Engh, Marie Ellström; Hilde, Gunvor; Siafarikas, Franziska & Stær-Jensen, Jette (2012). DYSPAREUNIA IN RELATION TO PELVIC FLOOR MUSCLE FUNCTION - A LONGITUDINAL STUDY FROM PREGESTATION TO SIX MONTHS POSTPARTUM. Full text in Research Archive Show summary

  Objective: The aim of the present study was to investigate the presence of dyspareunia from pregestation to six months postpartum. Further, to study dyspareunia in relation to pelvic floor muscle (PFM) function. Background: To date there is scant knowledge on female sexual dysfunction (FSD) in relation to PFM function. Dyspareunia is pain or discomfort related to sexual intercourse (1), and is an area of controversy with respect to prevalence, underlying causes and treatment (2). Methods: Three hundred nulliparous pregnant women, mean age at inclusion 28.7 (range 19-40, SD 4.3) and prepregnancy BMI 23.9 (SD 3.9) were included in this prospective cohort study. Inclusion criteria: ability to speak and understand the native speaking language. Exclusion criteria: multiple pregnancies or premature birth <32w. Ongoing exclusion criteria: previous miscarriage after week 16, still birth and serious illness of mother or child. International Consultation on Incontinence Modular Questionnaire, sexual matters module (ICIQ-FLUTSex) were used to collect data regarding the presence of dypareunia and the perceived impact of dyspareunia on sexual life, on a scale ranging from 0-10. Zero being no impact and 10 major impact. Dyspareunia was defined as one or more episodes of pain during intercourse the last 3 months before the pregnancy and the last 4 weeks at gestational week 22 and 37, 6 weeks- and 6 months postpartum. Questions regarding pregestational dyspareunia were asked retrospectively. Vaginal resting pressure (VRP), maximum voluntary contraction (MVC) and PFM endurance were measured at gestational week 22, 6 weeks- and 6 months postpartum with fiberoptic pressure transducer connected to a vaginal balloon catheter (camtech AS) in combination with visual observation. The method is assessed to be reliable and valid (3). Background variables are reported as means with range and SD and descriptive variables as frequencies. VRP, MVC and PFM endurance are reported as means and SD. Between groups comparisons were analysed with Independent Samples T-Test. P-values < 0.05 were considered significant. Results: Women not having sexual intercourse were 15 (5 %) at gestational week 22, 50 (18 %) at gestational week 37, 182 (65 %) at 6 weeks- and 20 (10 %) at 6 months postpartum. 83 (27.7 %) of the 299 women having sexual intercourse reported dyspareunia during the last 3 months before pregnancy, 87 (30.5% ) of 285 at gestational week 22, 94 (41 %) of 227 at gestational week 37, 52 (52.5 %) of 99 at 6 weeks- and 81 (44.7 %) of 181 at 6 months postpartum. Mean perceived impact of dyspareunia was 3.4 (SD 2.5) prepregnancy, 3.5 (SD 2.3) at gestational week 22, 4.0 (SD 2.5) at gestational week 37, 4.7 (SD 2.9) at 6 weeks- and 4.5 (SD 2.9) at 6 months postpartum. There were no statistically significant differences in VRP, MVC and PFM endurance in women with and without dyspareunia at gestational week 22, 6 weeks- and 6 months postpartum. Conclusions: To our knowledge this is the first longitudinal study on dyspareunia following first time pregnant mothers from gestational week 22 to 6 months postpartum, including clinical assessment of PFM function. The prevalence of dyspareunia was high even before pregnancy, rose during pregnancy and was 45 % at 6 months postpartum. There was no difference in VRP, MVC or PFM endurance in women with and without dyspareunia

• Majida, Memona; Brækken, Ingeborg Hoff; Bø, Kari & Engh, Marie Ellstrøm (2011). MAJOR DEFECTS OF THE PUBOVISCERAL MUSCLE, LEVATOR HIATUS DIMENSIONS AND PELVIC FLOOR FUNCTION, A THREE AND FOUR DIMENSIONAL TRANSPERINEAL STUDY. Neurourology and Urodynamics. ISSN 0733-2467. 30(6), p. 1035–1036. Full text in Research Archive
• Hilde, Gunvor; Stær-Jensen, Jette Elisabeth; Brækken, Ingeborg Hoff; Engh, Marie Ellstrøm & Bø, Kari (2011). IMPACT OF CHILDBIRTH AND MODE OF DELIVERY ON PELVIC FLOOR MUSCLE STRENGTH: A COMPARATIVE PROSPECTIVE STUDY. Neurourology and Urodynamics. ISSN 0733-2467. 30(6), p. 942–944. Full text in Research Archive
• Majida, Memona; Brækken, Ingeborg Hoff; Bø, Kari & Engh, Marie Ellstrøm (2011). Sammenlikning av levator hiatus dimensjoner og bekkenbunns funksjon hos kvinner med og uten skade av puboviseralmuskelen, et tre og fire-dimensjonal transperineal ultralydstudium. Gynekologen. ISSN 0805-2158. 24(3), p. 38–38. Full text in Research Archive
• Stær-Jensen, Jette Elisabeth; Engh, Marie Ellström & Bø, Kari (2015). Pelvic floor changes during pregnancy and after delivery assessed by ultrasound. Akademika forlag. ISSN 9788283330663. Full text in Research Archive
• Majida, Memona; Engh, Marie Ellstrøm & Bø, Kari (2012). Three and four dimensional perineal ultrasound in the assessment of the pelvic floor muscle and and pelvic organ descent. Akademika forlag. ISSN 9788282645546. Full text in Research Archive

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