Impact of vaginal parity and aging on the architectural design of pelvic floor muscles

Abstract

Background: Vaginal delivery and aging are key risk factors for pelvic floor muscle dysfunction, which is a critical component of pelvic floor disorders. However, alterations in the pelvic floor muscle intrinsic structure that lead to muscle dysfunction because of childbirth and aging remain elusive.

Objectives: The purpose of this study was to determine the impact of vaginal deliveries and aging on human cadaveric pelvic floor muscle architecture, which is the strongest predictor of active muscle function.

Study design: Coccygeus, iliococcygeus, and pubovisceralis were obtained from younger donors who were ≤51 years old, vaginally nulliparous (n = 5) and vaginally parous (n = 6) and older donors who were >51 years old, vaginally nulliparous (n = 6) and vaginally parous (n = 6), all of whom had no history of pelvic floor disorders. Architectural parameters, which are predictive of muscle's excursion and force-generating capacity, were determined with the use of validated methods. Intramuscular collagen content was quantified by hydroxyproline assay. Main effects of parity and aging and the interactions were determined with the use of 2-way analysis of variance, with Tukey's post-hoc testing and a significance level of .05.

Results: The mean age of younger and older donors differed by approximately 40 years (P = .001) but was similar between nulliparous and parous donors within each age group (P > .9). The median parity was 2 (range, 1-3) in younger and older vaginally parous groups (P = .7). The main impact of parity was increased fiber length in the more proximal coccygeus (P = .03) and iliococcygeus (P = .04). Aging changes manifested as decreased physiologic cross-sectional area across all pelvic floor muscles (P < .05), which substantially exceeded the age-related decline in muscle mass. The physiologic cross-sectional area was lower in younger vaginally parous, compared with younger vaginally nulliparous, pelvic floor muscles; however, the differences did not reach statistical significance. Pelvic floor muscle collagen content was not altered by parity but increased dramatically with aging (P < .05).

Conclusions: Increased fiber length in more proximal pelvic floor muscles likely represents an adaptive response to the chronically increased load placed on these muscles by the displaced apical structures, presumably as a consequence of vaginal delivery. In younger specimens, a consistent trend towards decrease in force-generating capacity of all pelvic floor muscles in the parous group suggests a potential mechanism for clinically identified pelvic floor muscle weakness in vaginally parous women. The substantial decrease in predicted muscle force production and fibrosis with aging represent likely mechanisms for the pelvic floor muscle dysfunction in older women.

Keywords: aging; architecture; pelvic floor muscle; vaginal delivery.

Figure 1

Representative photograph of in situ pelvic floor muscles from a younger donor (superior view) with superimposed boundaries of coccygeus (C, red), iliococcygeus (IC, blue), and pubovisceralis (PV, yellow). ATFP: arcus tendinious fascia pelvis; IS: ischial spine; Ano-C Raphe: ano-coccygeal raphe.

Figure 2

Scatter plot of normalized fiber length and physiological cross-sectional area (PCSA) of coccygeus (C), iliococcygeus (IC), and pubovisceralis (PV) muscles. YVN: younger vaginally nulliparous; YVP: younger vaginally nulliparous; OVN: older vaginally nulliparous; OVP: older vaginally parous

Figure 3

Changes in normalized fiber length (L_fn) of the pelvic floor muscles with vaginal parity and aging ^*P values derived from Tukey’s pairwise comparisons, following two-way analysis of variance with significance level set to 5%. VN: vaginally nulliparous; VP: vaginally parous

Figure 4

Changes in physiological cross-sectional area (PCSA) of the pelvic floor muscles with vaginal parity and aging ^*P values derived from Tukey’s pairwise comparisons, following two-way analysis of variance with significance level set to 5%. VN: vaginally nulliparous; VP: vaginally parous

Figure 5

Effects of vaginal parity and aging on the pelvic floor muscles’ sarcomere length (L_s) ^*P values derived from Tukey’s pairwise comparisons, following two-way analysis of variance with significance level set to 5%. VN: vaginally nulliparous; VP: vaginally parous

Figure 6

Effects of vaginal parity and aging on the pelvic floor muscles’ mass ^*P values derived from Tukey’s pairwise comparisons, following two-way analysis of variance with significance level set to 5%. VN: vaginally nulliparous; VP: vaginally parous