Covid-19, pelvic health, and women’s voices: A descriptive study

Objective: To examine how the pandemic affected women with pelvic dysfunction. Methods: A Survey Monkey™ online questionnaire on how the pandemic and Covid-19 infection affected women’s pelvic problems, exercise, and weight. A free text box captured their comments. Results: Six hundred and forty-seven women took part. Bladder control 265 (41%), prolapse 240 (37%), pelvic pain 40 (6%), sexual dysfunction 27 (4%), faecal incontinence 19 (3%) and other symptoms 56 (9%) were women’s main pelvic problems. Symptoms were unchanged for 331 (51%), worse for 243 (38%), and improved for 60 (10%). Weight was gained by 290 (45%), unchanged by 243 (38%), and lost by 114 (17%). Exercise levels were unchanged, worse, or better in 33% each. Access to medical appointments and date for surgery were difficult for 235 (36.5%) and 38 (6%) women respectively. Sixty-six (10.3%) women reported Covid-19 infection: the distribution of pelvic problems and changes through the pandemic, weight and exercise patterns, and difficulty accessing a date for surgery or healthcare were similar to those not contracting infection. Sexual dysfunction was the main new or worsening problem, featuring 13 women (18%). Seventy women — 16 postnatal, and 54 with a pre-existing pelvic problem commented. Five core themes were identified. Difficulty accessing healthcare review, mental health impact and physiotherapy services especially affected delivered women: lifestyle alterations and conservative treatment tools were prominent in women with a pre-existing problem. Conclusions: Pelvic floor dysfunction adversely affected women’s mental health in the pandemic through limiting their ability to exercise. Furthermore, the pandemic exposed the fact that female pelvic health services are not readily available to those in need: many women particularly postnatally received no care. Sexual dysfunction was a feature of recovery from Covid infection in this study.


Introduction
There are reports of the effects of the Covid-19 Pandemic on gynaecology/urogynaecology services [1], but limited information on how the lives of women with pelvic symptoms have been impacted. The female pelvic floor is acutely and often critically affected by pregnancy and delivery, and postnatal care has been highlighted as a potential casualty of the pandemic [2]. Access to much healthcare was also seriously reduced: in the effort to reduce viral transmission, acute care became largely preoccupied with Covid-19 infection. The nature and volume of women's activities day-to-day changed with increases in childcare, home-schooling, and working from home [3]. Alterations in body weight [4] and recreational exercise levels [5] were also reported. As each of these factors can impact pelvic floor health, we aimed to examine how women with pelvic dysfunction were affected by the pandemic. * Corresponding author.

Methods
A Survey Monkey™ questionnaire, designed to capture women's pelvic issue, exercise, and weight through the pandemic, was developed. A free text box inviting women to comment was included. A history of Covid-19 infection, and its impact on continence and sexual function was sought using a previously developed tool [6]: this included a question on whether their problem was new or worse since contracting Covid-19. The questionnaire link was available from May 28 to July 16, 2021, on the EVB™ (support garments) website, and shared over social media by MASIC (Mothers with Anal Sphincter in Childbirth), PELVICROAR (Pelvic, Obstetric and Gynaecological Physiotherapy collaboration) and EVB™ over Facebook, Instagram, and Twitter. Qualitative methods were used to analyse free-text comments. Common themes were identified using the three stages of familiarisation [7]: pattern recognition [8], and reviewing, defining, and naming themes [9]. Data analysis was mainly undertaken by the lead author. As the main themes began to emerge and the data was continuously reexamined, team discussions led to ongoing review of the data and the identification of sub-themes until all relevant content was exhausted.
As this was an opt-in survey using the Survey Monkey tool, ethical approval was not required; however, the principles of confidentiality were applied and all data anonymised. In addition, principles of data collection/storage were honoured (Data Protection Act, 2018).
We present the distribution and changes through the pandemic for both the Covid infection and non-infected groups in main complaints, weight, and exercise levels in Tables 1 and 2.

Thematic analysis of comments
Seventy women commented in the free text box, from which 2 groups were identified: 54 women with a pre-existing pelvic issue, and 16 who delivered a baby in the period preceding and during the pandemic. Five core themes were identified: difficulty accessing health care review, pelvic health physiotherapy services, conservative measures for pelvic symptoms, mental health impact, and lifestyle alterations. Table 3 illustrates the number of women in the two groups who commented on these themes.

Accessing healthcare review
Women recently delivered were particularly affected. Access to physiotherapy was mentioned most frequently, but doctors and midwives also featured. Some tried and failed to see any healthcare professional, and one third of this group accessed care privately. Avoidance of physical contact by staff caused distress and frustration. '

Pelvic health physiotherapy services
Almost all recently delivered women commented on the lack of access to physiotherapist services during or after pregnancy, and only two had a face-to-face appointment through the hospital system. Some had a telephone consultation, one had advice mailed to her, but the majority who sought this service were unsuccessful, resulting in several accessing care privately. '

Other conservative measures used
For symptom alleviation recently delivered women only referenced physiotherapy. However, those with pre-existing pelvic problems familiar with or using other measures, rated their experiences positively. Almost half mentioned recreational exercise: women regularly ran, walked, and engaged in sports. Many commented on the beneficial influence of exercise on their pelvic floor function.

Lifestyle alterations
During the pandemic travel restrictions and particularly lockdown changed people's lives and restricted exercise opportunities. Only one recently delivered woman commented.
'I had a baby in lockdown and developed an anterior prolapse, the NHS physio team couldn't see me face to face ... Additionally, specialised classes for pelvic restoration were virtual. . . I used to swim a lot which would have been perfect for my recovery but pools were shut. I'm not sharing this to complain, just to acknowledge it was hard to recover due to the pandemic and whilst many have suffered worse health issues, postnatal health, physical and mental, has definitely been challenging. . . I have struggled with my symptoms' In the group of women not recently delivered almost one in three commented on the impact of lifestyle changes on their pelvic problem. Negative comments mainly concerned increased workload e.g., home schooling, childcare, and cooking, and several mentioned 'juggling'. Positive comments focused on more time for weight loss and exercise with less commuting.  Table 3 Numbers of women with a preexisting pelvic problem or who recently delivered, and commented on five core themes.

Women who commented n = 70 Theme Pre-existing problem 54
Recently delivered 16 Healthcare access n = Physiotherapy Gynaecology GP Midwife

Main findings
Apart from being somewhat less likely to gain weight and to exercise during the pandemic which is unsurprising given the impact of infection, the survey found little difference between women who contracted Covid-19, and those who did not. Although sexual dysfunction was not listed as a primary complaint by respondents recovered from Covid infection, it featured either de novo or as a worsening problem in these women. This has not been previously reported, though decreased sexual activity has been observed in studies during the pandemic [10]. Covid-19 is known to be linked to de novo overactive bladder symptoms, thought due to the inflammatory effect of increased urinary cytokines [11,12] and possibly other pelvic organs also undergo similar inflammatory change.
Pregnancy with vaginal delivery is the single greatest factor in pelvic floor pathology, and the postnatal women's comments underline both their vulnerability, and the multidisciplinary requirements of maternity services. Women with longstanding pelvic symptoms tended to have seen a physiotherapist and had established tools for symptom relief, while recently delivered women's needs were acute and largely unmet. This is in the setting where women recognise the importance of the service, and little or no pelvic floor education is known to disadvantage them in the long term [13]. There also was poor access to other healthcare professionals postnatally: the ensuing lack of support had a clear effect on these women's mental health, at a time when anxiety/depression affects 10%-15% within the first 12 months [2,14]. While loss of face-to-face contact and personal avoidance by frontline healthcare staff were valid measures to reduce viral transmission, the change in body language was experienced as a lack of compassion [15,16] and caused distress. Telephone contact was simply not an adequate substitute for in-person care for these women, as reported elsewhere [2].
Pelvic floor muscle training is first-line treatment for both stress incontinence and genital prolapse [17], and many respondents with a longstanding pelvic issue referred to formal physiotherapy, home core strengthening through online classes, pelvic floor exercises, Kegels or a vaginal trainer. A number used vaginal pessaries or EVB™ shorts for support. Three women had specifically declined an offer of surgery, favouring conservative methods in the first instance. The moratorium on mesh surgery has curtailed surgical interventions, and bedavailability has been reduced by the pandemic. The Cumberlege report [18] reminds us to explore less invasive treatments where available, but plans for a national strategy for Women's Health [19], which recognised the deficits in pelvic health care, have been put on hold during the pandemic. Respondents were surprised to find access to pelvic health therapist difficult, given the number of women who have a vaginal delivery and go on to develop a pelvic floor issue.
Three women used the phrase 'juggling' in relation to their responsibilities during the pandemic. During lockdown, the UK Household Longitudinal Study [20], found women spent more time on unpaid care work than men, and mothers more than fathers changed their employment schedule because of increased childcare commitments. They also found that women who spent long hours on housework and childcare reported increased levels of psychological distress. Our respondents had a more mixed experience of being at home: several used the time gained through not commuting to work as an opportunity for additional exercise, and the enhanced sense of control translated into better wellbeing. Presumably those with small children who could not attend school or creche were impacted more negatively, and several mothers viewed exercise as a critical outlet. That pregnant or delivered women were not as cognisant of lifestyle changes is unsurprising, being less likely to participate in sport.
The tendency overall was towards weight-gain in our respondents: curtailment of movement, particularly with national lockdowns, was partly responsible. Increased sedentariness contributes to increased BMI and has been linked to adverse changes in mental health, particularly in women [21]. Psychological distress is a feature of the pandemic worldwide and the uncertainty and isolation associated with Covid-19, as factors triggering factors in mental health problems, may be a driving factor behind this distress [22].

Strengths
The qualitative data captured through the free text box is the main strength of this study. Through 'telling your story' subjects are free to report what is important to them in their own words. The part played by women's voices in delivery of obstetric and gynaecological care has been recognised [23]. Qualitative methods help us to ''enter the world of its participants'' [24] and free text response is a rich source of data suitable for content, thematic and narrative analysis [25].

Limitations
Because this research was conducted through the internet, there is a recognised bias towards younger, more computer-literate respondents, and the EVB™ website attracts women who exercise and enjoy sport. Further, as the prerequisite for participation in the survey was a pelvic 'condition', the findings are not generalisable to women in general.

Interpretation
Worldwide, the pandemic has seen nonurgent/quality-of life care such as urogynaecology [1,26] severely curtailed. In June 2020, the RCOG published a framework for care in response to COVID-19 [23] detailing the withdrawal of much elective care over previous months and anticipating the frustration and suffering as waiting lists grew. Commenting that urogynaecology had probably suffered the greatest reduction in activity they noted it would likely be the last service to be reinstated. This study confirms these predictions, capturing the suffering by women with pelvic dysfunction resulting from reduced access to healthcare in the pandemic.
The number of respondents referring to the positive effects of exercise on mental wellbeing was notable. There is mounting evidence suggesting that exercise and physical activity interventions affect physical and mental-health outcomes positively [27] and increasing calls for healthcare providers to formally prescribe exercise [28]

Conclusion
Healthcare continues to face uncertainty in the aftermath of Covid-19, and the paucity of services for pelvic health dysfunction has been further exposed by the pandemic. Our survey underlines the importance women ascribe to exercise for their pelvic floor health: it also emphasises the role of exercise in stress relief and how pelvic floor dysfunction can adversely affect mental health through limiting exercise. There have been calls for enhanced care and support for women postnatally [2] and our study shows that pelvic health is an important component of this. The finding of sexual dysfunction as part of recovery from Covid-19 infection merits further exploration.

Declaration of competing interest
One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.cont.2022.100012. Maire Milner reports administrative support was provided by EVB Sport Shorts Ltd. Maire Milner is medical advisor to EVB™ which she conducts on a pro bono basis.