The association between pelvic floor deficiency and urinary incontinence: a retrospective study

The association between pelvic floor deficiency and urinary incontinence: a retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The association between pelvic floor deficiency and urinary incontinence: a retrospective study Yu Wang, Yan Zhuo, Jianqi Fang, Jinming Shen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7356888/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Objective This study aimed to examine the association between pelvic floor deficiency and urinary incontinence. Methods We reviewed records from 2,745 women who visited our hospital between December 2019 and June 2022. Pelvic floor 4-dimension ultrasound was performed to screen the pelvic floor structural deficiency of postpartum women. Linear regression and generalized addictive model were used to analyse the relationship between urinary incontinence and pelvic floor parameters. In addition, population-attributable fraction value for UI were calculated for cystocele, urethral funnel separately and for the combinations of them. Results The bladder neck position (at rest), bladder neck position (at Valsalva), cystocele, and urethral funnel were risk factors for urinary incontinence after adjusting for additional confounding factors (BMI, age, education, gestational diabetes mellitus, abortion, neonatal weight, delivery mode, gestational weight gain, delivery mode, gravidity, parity) (OR: 0.695, 95% CI: 0.533–0.905; OR: 0.883, 95% CI: 0.805–0.969; OR: 1.255, 95% CI: 1.037–1.518; OR: 1.862, 95% CI: 1.556–2.228). The population-attributable fraction value for cystocele and urethral funnel were 4.7% and 8.0%, and the combined value was 12.7%. Conclusions Deficiency of anterior compartment including cystocele and urethral funnel, increases the risk of urinary incontinence. ultrasound urethral funnel cystocele risk factors urinary incontinence Figures Figure 1 Figure 2 Figure 3 Introduction Urinary incontinence (UI) is defined as the involuntary leakage of urine under any circumstances ( 1 ). Its prevalence is approximately 10–20%, with higher rates (21%-30%) among postpartum women ( 2 , 3 ). Risk factors were reported including vaginal delivery, high BMI, smoking, chronic cough, diabetes, UI during pregnancy, and older age ( 4 – 6 ). UI often causes embarrassment, leading to reduced social engagement and strong associations with anxiety, depression, and lower quality of life ( 7 ). Despite its impact, few women seek medical help, either due to embarrassment or lack of awareness ( 8 – 10 ). While the exact mechanisms remain unclear, pelvic floor structural defects are known to play a significant role in its development. Ultrasound has been increasingly used in recent years to assess pelvic floor structures, with studies confirming its reliability ( 11 , 12 ). The Pelvic Organ Prolapse Quantification (POP-Q) system evaluates the pelvic compartments indirectly through vaginal wall measurements so that its accuracy can vary depending on the examiner’s judgment ( 13 , 14 ). In contrast, 4D pelvic floor ultrasound provides more precise measurements of organ displacement across all three pelvic compartments. It also allows assessment of additional parameters, such as urethral funnel, levator avulsion and hiatal area, offering a more comprehensive evaluation of pelvic floor function ( 15 ). While studies have reported the relationship between pelvic organ prolapse (POP) and UI, it remains unclear whether defects in all three pelvic compartments contribute equally ( 16 ). Large-scale studies on this question are still lacking. Since cesarean delivery rarely causes levator ani muscle injury, this study focused exclusively on vaginal delivery patients. The aim of this study was to investigate the relationship between pelvic floor structural defects and UI using 4D pelvic floor ultrasound. Materials and methods Participants This retrospective study analyzed 2,745 women who received care at Fujian Maternity and Child Health Hospital between December 2019 and June 2022. Trained hospital staff collected comprehensive maternal and obstetric data, including height, weight, age, BMI, education level, neonatal birth weight, gestational weight gain, history of gestational diabetes mellitus, abortion, gravidity, parity, and delivery mode, with all information stored in the electronic medical record system. UI status was assessed using the Chinese version of the Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) (17). This validated self-report instrument, which has received Grade-A recommendation from the International Continence Society for evaluating UI-related quality of life, has demonstrated excellent reliability in previous Chinese validation studies (18, 19). Eligibility criteria included: vaginal delivery of a live birth, postpartum evaluation within 8 weeks of delivery. Exclusion criteria included: active vaginal bleeding, history of pelvic surgery, Inability to perform Valsalva maneuver. This study was approved by the Ethics Committee of Fujian Maternity and Child Health Hospital (No. 2022KYLLR03045) and were in accordance with the Helsinki declaration. No informed consent was obtained from the patients because the retrospective nature of this study. Assessment of Pelvic floor 4D ultrasound All ultrasound examinations were performed by the lead investigator (Y.W.), a specialist with over 15 years of clinical experience in ultrasonic imaging, using a Mindray Resona 8s 3D ultrasound system (Mindray, Shenzhen, China) with a D8-2U transducer placed on the perineum in the mid-sagittal plane at an 85-degree sweep angle. To ensure diagnostic accuracy, all scans were independently reviewed by a second author (Y.Z.). Participants underwent imaging during three functional states (resting phase, Valsalva maneuver, and pelvic floor muscle contraction), with up to three attempts allowed for both Valsalva maneuvers and pelvic floor muscle contraction, and the most effective effort selected for analysis. Tomographic ultrasound imaging was used to assessed the integrity of levator ani muscle . The volumes were obtained at maximal pelvic floor muscle contraction from 5mm below to 12.5mm above the plane of minimal hiatal dimensions with a 2.5 mm slice intervals. Levator avulsion was defined as the continuity of the levator echo is interrupted in three or more consecutive fault planes. Key measurements included urethral rotation angle (difference between urethral tilt angles at rest and during Valsalva) and bladder neck descent (vertical displacement of bladder neck from rest to Valsalva). Pelvic organ prolapse was assessed using established ultrasound criteria: cystocele (bladder neck descent ≥0 mm below symphysis pubis), uterine prolapse (cervical descent ≥0 mm), rectocele (rectal ampulla descent ≥15 mm), and proctocele (posterior vaginal wall extrusion > 0 mm from the reference line parallel to the anal canal extending from the ventral internal anal sphincter), with negative values indicating organ position below the symphysis pubis inferior margin. Sample size calculation According to the guideline of events per variable, approximately 103 UI cases per independent variable was included in the final model, which meets accepted standards for logistic regression (20). Statistical analysis All statistical analyses were performed using SPSS software (Version 26.0) and R software (Version 4.4.3). Categorical data are shown as numbers and percentages [n (%)], and continuous data as means with standard deviations (SD). We used both univariate and multivariate logistic regression to examine the relationship between pelvic floor measurements and UI. Generalized additive models (GAMs) were further used analyse the non-linear relationship between bladder neck position (at rest and Valsalva) and bladder neck descent and UI, and inflection points were also calculated. The population-attributable fraction (PAF) for UI was calculated separately for each risk factor and for combinations of factors. All calculations for combined factors and PAF estimates were based on adjusted models. A p-value less than 0.05 (two-tailed test) was considered statistically significant. Results Basic characteristics of the study population After excluding 1,717 participants with incomplete data and 555 participants who had undergone cesarean delivery, our final analysis included 2,745 individuals. The key demographic characteristics of the study population are summarized in Table 1. Association between pelvic floor parameters and UI Our results indicated that bladder neck position (at Valsalva), bladder neck descent, cystocele, and urethral funnel were risk factors of UI (OR 0.823, 95% CI: 0.753-.899; OR 1.175, 95% CI: 1.077-1.281; OR 1.388, 95% CI: 1.154-1.669; OR 1.985, 95% CI: 1.664-2.368). Moreover, the effects of bladder neck position (at rest), bladder neck position (at Valsalva), cystocele, and urethral funnel were statistically significant after adjusting for additional confounding factors (BMI, age, education, gestational diabetes mellitus, abortion, neonatal weight, delivery mode, gestational weight gain, delivery mode, gravidity, parity) (OR: 0.695, 95% CI: 0.533-0.905; OR: 0.883, 95% CI: 0.805-0.969; OR: 1.255, 95% CI: 1.037-1.518; OR: 1.862, 95% CI: 1.556-2.228) (Table 2). The non-linear association between bladder neck position (at rest), bladder neck position (at Valsalva), bladder neck descent and UI, and the inflection point analysis of bladder neck position (at rest), bladder neck descent and UI Both bladder neck position (at rest) and bladder neck descent exhibited U-shaped associations with UI, with identified inflection points at 2.54 and 3.02, respectively (Table 3). Notably, when values exceeded these thresholds, higher bladder neck position (at rest) showed a protective effect against UI (OR: 0.544, 95% CI: 0.358-0.829), while greater bladder neck descent became a risk factor (OR: 1.265, 95% CI: 1.041-1.538) (Figure 1 and Figure 2). These findings strongly support the use of a two-piece-wise linear regression model for optimal data fitting. In contrast, bladder neck position (at Valsalva) showed a different pattern, despite having an inflection point at -0.83, its relationship with UI approximated a downward-sloping linear trend (Figure 3). Interaction between cystocele, u rethral funnel and UI Participants who had cystocele, urethral funnel had the highest risk of UI (adjusted OR 2.078, 95 % CI 1.630-2.650, and the PAF for the two factors were 4.7% and 8.0% respectively and 12.7% in combination accounted for 22.63 % of UI. In addition, the PAF value of the combination declined to 9.6% in the sensitivity analyses (Table 4 and Table 5). Discussion Our study found a significantly higher prevalence of UI (44.92%) in the early postpartum period compared to the 9.5% reported by Zhu et al ( 21 ), which is not surprising given the well-established impact of vaginal delivery on pelvic floor integrity ( 22 ). To reduce UI incidence, two key strategies were recommended: first, controlling gestational weight gain to minimize macrosomia risk and implementing proper perineal protection during the second stage of labor ( 23 ). Second, performing regular Kegel exercises during pregnancy and postpartum as a simple yet effective preventive measure ( 24 ). Our findings demonstrate a particularly strong association between UI and anterior compartment defects, consistent with previous studies identifying cystocele, urethral hypermobility, and urethral funneling as key risk factors ( 25 , 26 ). Urethral funnel are resulting from intrinsic sphincter deficiency impairs urethral closure mechanisms and leading to UI ( 27 ). The exact mechanism by which cystocele contributes to UI remains unclear, but surgical evidence strongly implicates anterior compartment defects as the most critical factor ( 28 ). Procedures correcting only middle/posterior compartment prolapse often result in de novo UI, while concurrent anterior repair prevents this complication ( 29 , 30 ). Both bladder neck position (at rest) and bladder neck descent exhibited U-shaped associations with UI. Overall, higher bladder neck position (at rest) and smaller bladder neck descent appear protective against UI. The relationship between bladder neck position (V) and UI incidence showed a nearly linear pattern, supporting the use of the pubic symphysis inferior margin as the reference point for defining cystocele. When the bladder neck position (V) fell below − 0.83 cm, UI incidence essentially reached a plateau. Wu Manli et al. proposed defining cystocele as 1.00 cm for Chinese women ( 31 ), which closely matches our findings and suggests this threshold may be most effective for predicting UI. However, sensitivity analysis indicated that using the pubic symphysis inferior margin as the reference point provided better combined predictive value (12.7%). Interestingly, our study failed to find any significant association between hiatal area, levator avulsion and UI. Theoretically, the levator ani muscle provides dynamic urethral support through its connection to the endopelvic fascia of the anterior vaginal wall ( 32 ). This anatomical connection should theoretically elevate the bladder neck and prevent urine leakage. However, our findings, consistent with previous meta-analyses, could not demonstrate any relationship between levator avulsion and UI. Similarly, while hiatal ballooning may indicate reduced pelvic floor muscle contractility, our data showed no correlation between hiatal area and UI ( 33 ). These unexpected findings suggest that the levator ani muscle's role in UI may be less significant than traditionally assumed, warranting further investigation into alternative mechanisms of UI pathogenesis. Several limitations should be acknowledged in our study. First, the exclusive inclusion of vaginally delivered postpartum women limits the generalizability of our findings to other female populations. Second, the lack of differentiation between various types of urinary incontinence might have introduced bias in assessing the levator avulsion-UI relationship. Finally, due to the retrospective nature of this study, potential confounding effects from unmeasured variables cannot be excluded. Conclusions Deficiency of anterior compartment including cystocele and urethral funnel, increases the risk of urinary incontinence. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of Fujian Maternity and Child Health Hospital (No. 2022KYLLR03045) and were in accordance with the Helsinki declaration. No informed consent was obtained from the patients because the retrospective nature of this study. The Ethics Committee of Fujian Maternity and Child Health Hospital has waived the informed consent procedure for the study. Administrative permissions for the data were acquired by the authors for research purposes. Informed Consent Statement Informed consent was obtained from all subjects. Availability of data and materials The data that support the findings of this study are available from the corresponding author upon reasonable request. Competing interests The authors declare that there is no conflict of interest regarding the publication of this article. Funding This study was funded by the fujian provincial natural science foundation of China (2024J011047) and the fujian provincial health technology project (2024TG013). Authors' contributions J.F. developed the project; Y.W. and Y.Z. collected the data; J.S. and Y.W. supervised the project; Y.W. and Y.Z. managed the data; J.F. and J.S. wrote the manuscript; J.F. and J.S. analysed the data; J.F. and J.S. edited the manuscript Acknowledgements Not applicable. Authors' information Yu Wang, Department of ultrasound, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350000, People's Republic of China. Fujian Key Laboratory of Women and Children’s Critical Diseases Research [Fujian Maternity and Child Health Hospital (Fujian Women and Children’s Hospital)], Fuzhou, Fujian 350000, People's Republic of China. . Email: [email protected] Yan Zhuo, Department of ultrasound, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350000, People's Republic of China. Email: [email protected] Jianqi Fang, Department of women’s health care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350000, People’s Republic of China. Email: [email protected] Jinming Shen. Department of Rehabilitation, Fujian University of Traditional Chinese Medicine, People's Republic of China, Fuzhou, Fujian 350000, People's Republic of China. Email: [email protected] References Bo K, Frawley HC, Haylen BT, Abramov Y, Almeida FG, Berghmans B, et al. 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Morphological changes after pelvic floor muscle training measured by 3-dimensional ultrasonography: a randomized controlled trial. Obstet gynecol. 2010;115(2 Pt 1):317-24. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 08 May, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviewers agreed at journal 19 Mar, 2026 Reviews received at journal 07 Sep, 2025 Reviewers agreed at journal 30 Aug, 2025 Reviewers invited by journal 27 Aug, 2025 Editor invited by journal 18 Aug, 2025 Editor assigned by journal 14 Aug, 2025 Submission checks completed at journal 14 Aug, 2025 First submitted to journal 12 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7356888","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":507858933,"identity":"a50d3d99-f895-4053-8095-424baf608e9a","order_by":0,"name":"Yu Wang","email":"","orcid":"","institution":"Fujian Maternity and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Wang","suffix":""},{"id":507858936,"identity":"b8b9f9df-124d-40d0-b82a-f9bdafb23ab4","order_by":1,"name":"Yan Zhuo","email":"","orcid":"","institution":"Fujian Maternity and Child Health Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Zhuo","suffix":""},{"id":507858937,"identity":"18f02f1d-c3a0-46b6-9d69-60d44dbbe8e0","order_by":2,"name":"Jianqi Fang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIie3RLQvCQBjA8RuDrZyuPkP0M5wMxpLiRzmEpTEEo8EDYVGrfgtN1sGhS2I1zmYwbFgXfA7EYNgWDfcPdxfuB/dCiE73h9kCB2A4mGZaABk0E5p+icW3QLyW5LMcbkkrYl/kI5iN4m5GSxFUjAtbnva1hMZhAGw6d2XnINwECQ3DWx0Zk8hnwEy+l51j7oqKC6B+LaHOU5ElEnoXoA7WSCDycmBSEUOA1Yo8fXzkjO+kNVR38ZKmu1An8l5QLfj6Ku8rPFh/Y8tzLcGsHqgpxd/ExSRp2K4yy+JDjEI9oU6n0+l+egNin0tD2IxUQwAAAABJRU5ErkJggg==","orcid":"","institution":"Fujian Maternity and Child Health Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jianqi","middleName":"","lastName":"Fang","suffix":""},{"id":507858938,"identity":"55df1ba0-36b1-463c-9fdc-7e356bcb47c4","order_by":3,"name":"Jinming Shen","email":"","orcid":"","institution":"Fujian University of Traditional Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jinming","middleName":"","lastName":"Shen","suffix":""}],"badges":[],"createdAt":"2025-08-12 14:38:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7356888/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7356888/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90794998,"identity":"56d44ece-1225-4f5f-88a1-6f752a1b6006","added_by":"auto","created_at":"2025-09-08 08:49:37","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":224036,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between UI Incidence and bladder neck position (at rest)\u003c/p\u003e","description":"","filename":"Figure1RelationshipbetweenUIIncidenceandbladderneckpositionatrest.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7356888/v1/26220f54c5e290d5703b0f6c.jpg"},{"id":90794157,"identity":"9321c7f2-b379-43a7-9cac-95b02424a539","added_by":"auto","created_at":"2025-09-08 08:41:37","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":223300,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between UI Incidence and bladder neck descent\u003c/p\u003e","description":"","filename":"Figure2RelationshipbetweenUIIncidenceandbladderneckdescent.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7356888/v1/5e722daf67353c5f03eaae3f.jpg"},{"id":90794997,"identity":"6688eab4-25e0-4956-8621-cb991defb81f","added_by":"auto","created_at":"2025-09-08 08:49:37","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":225602,"visible":true,"origin":"","legend":"\u003cp\u003eRelationship between UI Incidence and bladder neck position (at Valsalva)\u003c/p\u003e","description":"","filename":"Figure3RelationshipbetweenUIIncidenceandbladderneckpositionatValsalva.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7356888/v1/0e7b917d62bae71ef175e3ba.jpg"},{"id":90795986,"identity":"1a19d357-4639-47c8-8a8b-f0b342475c18","added_by":"auto","created_at":"2025-09-08 08:57:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1259768,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7356888/v1/19e1b694-5fd5-4186-ba64-7e29bb433a19.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The association between pelvic floor deficiency and urinary incontinence: a retrospective study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrinary incontinence (UI) is defined as the involuntary leakage of urine under any circumstances (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Its prevalence is approximately 10\u0026ndash;20%, with higher rates (21%-30%) among postpartum women (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Risk factors were reported including vaginal delivery, high BMI, smoking, chronic cough, diabetes, UI during pregnancy, and older age (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). UI often causes embarrassment, leading to reduced social engagement and strong associations with anxiety, depression, and lower quality of life (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Despite its impact, few women seek medical help, either due to embarrassment or lack of awareness (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). While the exact mechanisms remain unclear, pelvic floor structural defects are known to play a significant role in its development.\u003c/p\u003e\u003cp\u003eUltrasound has been increasingly used in recent years to assess pelvic floor structures, with studies confirming its reliability (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The Pelvic Organ Prolapse Quantification (POP-Q) system evaluates the pelvic compartments indirectly through vaginal wall measurements so that its accuracy can vary depending on the examiner\u0026rsquo;s judgment (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In contrast, 4D pelvic floor ultrasound provides more precise measurements of organ displacement across all three pelvic compartments. It also allows assessment of additional parameters, such as urethral funnel, levator avulsion and hiatal area, offering a more comprehensive evaluation of pelvic floor function (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). While studies have reported the relationship between pelvic organ prolapse (POP) and UI, it remains unclear whether defects in all three pelvic compartments contribute equally (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Large-scale studies on this question are still lacking. Since cesarean delivery rarely causes levator ani muscle injury, this study focused exclusively on vaginal delivery patients. The aim of this study was to investigate the relationship between pelvic floor structural defects and UI using 4D pelvic floor ultrasound.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study analyzed 2,745 women who received care at Fujian Maternity and Child Health Hospital between December 2019 and June 2022. Trained hospital staff collected comprehensive maternal and obstetric data, including height, weight, age, BMI, education level, neonatal birth weight, gestational weight gain, history of gestational diabetes mellitus, abortion, gravidity, parity, and delivery mode, with all information stored in the electronic medical record system. UI status was assessed using the Chinese version of the Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF)\u0026nbsp;(17). This validated self-report instrument, which has received Grade-A recommendation from the International Continence Society for evaluating UI-related quality of life, has demonstrated excellent reliability in previous Chinese validation studies (18, 19). Eligibility criteria included: vaginal delivery of a live birth, postpartum evaluation within 8 weeks of delivery. Exclusion criteria included: active vaginal bleeding, history of pelvic surgery, Inability to perform Valsalva maneuver.\u0026nbsp;This study was approved by the Ethics Committee of\u0026nbsp;Fujian Maternity and Child Health Hospital\u0026nbsp;(No. 2022KYLLR03045) and were in accordance with the Helsinki declaration. No informed consent was obtained from the patients because the retrospective nature of this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of Pelvic floor 4D ultrasound\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll ultrasound examinations were performed by the lead investigator (Y.W.), a specialist with over 15 years of clinical experience in ultrasonic imaging, using a Mindray Resona 8s 3D ultrasound system (Mindray, Shenzhen, China) with a D8-2U transducer placed on the perineum in the mid-sagittal plane at an 85-degree sweep angle. To ensure diagnostic accuracy, all scans were independently reviewed by a second author (Y.Z.). Participants underwent imaging during three functional states (resting phase, Valsalva maneuver, and pelvic floor muscle contraction), with up to three attempts allowed for both Valsalva maneuvers and pelvic floor muscle contraction, and the most effective effort selected for analysis. Tomographic ultrasound imaging was used to assessed the integrity of levator ani muscle . The volumes were obtained at maximal pelvic floor muscle contraction from 5mm below to 12.5mm above the plane of minimal hiatal dimensions with a 2.5 mm slice intervals. Levator avulsion was defined as the continuity of the levator echo is interrupted in three or more consecutive fault planes. Key measurements included urethral rotation angle (difference between urethral tilt angles at rest and during Valsalva) and bladder neck descent (vertical displacement of bladder neck from rest to Valsalva). Pelvic organ prolapse was assessed using established ultrasound criteria: cystocele (bladder neck descent\u0026nbsp;\u0026ge;0 mm below symphysis pubis), uterine prolapse (cervical descent\u0026nbsp;\u0026ge;0 mm), rectocele (rectal ampulla descent\u0026nbsp;\u0026ge;15 mm), and proctocele (posterior vaginal wall extrusion \u0026gt; 0 mm from the reference line parallel to the anal canal extending from the ventral internal anal sphincter), with negative values indicating organ position below the symphysis pubis inferior margin.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the guideline of events per variable, approximately 103 UI cases per independent variable was included in the final model, which meets accepted standards for logistic regression (20).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using SPSS software (Version 26.0) and R software (Version 4.4.3). Categorical data are shown as numbers and percentages [n (%)], and continuous data as means with standard deviations (SD). We used both univariate and multivariate logistic regression to examine the relationship between pelvic floor measurements and UI. Generalized additive models (GAMs) were further used analyse the non-linear relationship between bladder neck position (at rest and Valsalva) and bladder neck descent and UI, and inflection points were also calculated. The population-attributable fraction (PAF) for UI was calculated separately for each risk factor and for combinations of factors. All calculations for combined factors and PAF estimates were based on adjusted models. A p-value less than 0.05 (two-tailed test) was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBasic characteristics of the study population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter excluding 1,717 participants with incomplete data and 555 participants who had undergone cesarean delivery, our final analysis included 2,745 individuals. The key demographic characteristics of the study population are summarized in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation between pelvic floor parameters and UI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur results indicated that bladder neck position (at Valsalva), bladder neck descent, cystocele, and urethral funnel were risk factors of UI (OR 0.823, 95% CI: 0.753-.899; OR 1.175, 95% CI: 1.077-1.281; OR 1.388, 95% CI: 1.154-1.669; OR 1.985, 95% CI: 1.664-2.368). Moreover, the effects of bladder neck position (at rest), bladder neck position (at Valsalva), cystocele, and urethral funnel were statistically significant after adjusting for additional confounding factors (BMI, age, education, gestational diabetes mellitus, abortion, neonatal weight, delivery mode, gestational weight gain, delivery mode, gravidity, parity) (OR: 0.695, 95% CI: 0.533-0.905; OR: 0.883, 95% CI: 0.805-0.969; OR: 1.255, 95% CI: 1.037-1.518; OR: 1.862, 95% CI: 1.556-2.228) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe non-linear association between bladder neck position (at rest), bladder neck position (at Valsalva), bladder neck descent and UI, and the inflection point analysis of bladder neck position (at rest), bladder neck descent and UI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth bladder neck position (at rest) and bladder neck descent exhibited U-shaped associations with UI, with identified inflection points at 2.54 and 3.02, respectively (Table 3). Notably, when values exceeded these thresholds, higher bladder neck position (at rest) showed a protective effect against UI (OR: 0.544, 95% CI: 0.358-0.829), while greater bladder neck descent became a risk factor (OR: 1.265, 95% CI: 1.041-1.538) (Figure 1 and Figure 2). These findings strongly support the use of a two-piece-wise linear regression model for optimal data fitting. In contrast, bladder neck position (at Valsalva) showed a different pattern, despite having an inflection point at -0.83, its relationship with UI approximated a downward-sloping linear trend (Figure 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInteraction between cystocele,\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eu\u003c/strong\u003e\u003cstrong\u003erethral\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003efunnel\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;and UI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants who had cystocele, urethral funnel had the highest risk of UI (adjusted OR 2.078, 95 % CI 1.630-2.650, and the PAF for the two factors were 4.7% and 8.0% respectively and 12.7% in combination accounted for 22.63 % of UI. In addition, the PAF value of the combination declined to 9.6% in the sensitivity analyses (Table 4 and Table 5).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study found a significantly higher prevalence of UI (44.92%) in the early postpartum period compared to the 9.5% reported by Zhu et al (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), which is not surprising given the well-established impact of vaginal delivery on pelvic floor integrity (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). To reduce UI incidence, two key strategies were recommended: first, controlling gestational weight gain to minimize macrosomia risk and implementing proper perineal protection during the second stage of labor (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Second, performing regular Kegel exercises during pregnancy and postpartum as a simple yet effective preventive measure (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur findings demonstrate a particularly strong association between UI and anterior compartment defects, consistent with previous studies identifying cystocele, urethral hypermobility, and urethral funneling as key risk factors (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Urethral funnel are resulting from intrinsic sphincter deficiency impairs urethral closure mechanisms and leading to UI (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The exact mechanism by which cystocele contributes to UI remains unclear, but surgical evidence strongly implicates anterior compartment defects as the most critical factor (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Procedures correcting only middle/posterior compartment prolapse often result in de novo UI, while concurrent anterior repair prevents this complication (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Both bladder neck position (at rest) and bladder neck descent exhibited U-shaped associations with UI. Overall, higher bladder neck position (at rest) and smaller bladder neck descent appear protective against UI. The relationship between bladder neck position (V) and UI incidence showed a nearly linear pattern, supporting the use of the pubic symphysis inferior margin as the reference point for defining cystocele. When the bladder neck position (V) fell below \u0026minus;\u0026thinsp;0.83 cm, UI incidence essentially reached a plateau. Wu Manli et al. proposed defining cystocele as 1.00 cm for Chinese women (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), which closely matches our findings and suggests this threshold may be most effective for predicting UI. However, sensitivity analysis indicated that using the pubic symphysis inferior margin as the reference point provided better combined predictive value (12.7%).\u003c/p\u003e\u003cp\u003eInterestingly, our study failed to find any significant association between hiatal area, levator avulsion and UI. Theoretically, the levator ani muscle provides dynamic urethral support through its connection to the endopelvic fascia of the anterior vaginal wall (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This anatomical connection should theoretically elevate the bladder neck and prevent urine leakage. However, our findings, consistent with previous meta-analyses, could not demonstrate any relationship between levator avulsion and UI. Similarly, while hiatal ballooning may indicate reduced pelvic floor muscle contractility, our data showed no correlation between hiatal area and UI (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). These unexpected findings suggest that the levator ani muscle's role in UI may be less significant than traditionally assumed, warranting further investigation into alternative mechanisms of UI pathogenesis.\u003c/p\u003e\u003cp\u003eSeveral limitations should be acknowledged in our study. First, the exclusive inclusion of vaginally delivered postpartum women limits the generalizability of our findings to other female populations. Second, the lack of differentiation between various types of urinary incontinence might have introduced bias in assessing the levator avulsion-UI relationship. Finally, due to the retrospective nature of this study, potential confounding effects from unmeasured variables cannot be excluded.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDeficiency of anterior compartment including cystocele and urethral funnel, increases the risk of urinary incontinence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Fujian Maternity and Child Health Hospital (No. 2022KYLLR03045) and were in accordance with the Helsinki declaration. No informed consent was obtained from the patients because the retrospective nature of this study. The Ethics Committee of Fujian Maternity and Child Health Hospital has waived the informed consent procedure for the study. Administrative permissions for the data were acquired by the authors for research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest regarding the publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;study was funded by the fujian provincial natural science foundation of China (2024J011047) and the fujian provincial health technology project (2024TG013).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ.F. developed the project; Y.W. and Y.Z. collected the data; J.S. and Y.W. supervised the project; Y.W. and Y.Z. managed the data; J.F. and J.S. wrote the manuscript; J.F. and J.S. analysed the data; J.F. and J.S. edited the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eYu Wang, Department of ultrasound, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350000, People\u0026apos;s Republic of China. Fujian Key Laboratory of Women and Children\u0026rsquo;s Critical Diseases Research [Fujian Maternity and Child Health Hospital (Fujian Women and Children\u0026rsquo;s Hospital)], Fuzhou, Fujian 350000, People\u0026apos;s Republic of China. . Email: [email protected]\u003c/li\u003e\n \u003cli\u003eYan Zhuo, Department of ultrasound, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350000, People\u0026apos;s Republic of China. Email: [email protected]\u003c/li\u003e\n \u003cli\u003eJianqi Fang, Department of women\u0026rsquo;s health care, Fujian Maternity and Child Health Hospital, Fuzhou, Fujian 350000, People\u0026rsquo;s Republic of China. Email: [email protected]\u003c/li\u003e\n \u003cli\u003eJinming Shen. Department of Rehabilitation, Fujian University of Traditional Chinese Medicine, People\u0026apos;s Republic of China, Fuzhou, Fujian 350000, People\u0026apos;s Republic of China. Email: [email protected]\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBo K, Frawley HC, Haylen BT, Abramov Y, Almeida FG, Berghmans B, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Neurourol urodynam. 2017;36(2):221-44.\u003c/li\u003e\n\u003cli\u003eDai S, Chen H, Luo T. Prevalence and factors of urinary incontinence among postpartum: systematic review and meta-analysis. BMC Pregnancy Childbirth. 2023;23(1):761.\u003c/li\u003e\n\u003cli\u003eLukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. Urinary Incontinence in Women: A Review. Jama-j am med assoc. 2017;318(16):1592-604.\u003c/li\u003e\n\u003cli\u003eAlmutairi S, Alobaid O, Al-Zahrani MA, Alkhamees M, Aljuhayman A, Ghazwani Y. Urinary incontinence among Saudi women: prevalence, risk factors, and impact on quality of life. Eur rev med pharmaco. 2021;25(20):6311-8.\u003c/li\u003e\n\u003cli\u003eHage-Fransen MAH, Wiezer M, Otto A, Wieffer-Platvoet MS, Slotman MH, Nijhuis-van der Sanden MWG, et al. Pregnancy- and obstetric-related risk factors for urinary incontinence, fecal incontinence, or pelvic organ prolapse later in life: A systematic review and meta-analysis. Acta obstet gyn scan. 2021;100(3):373-82.\u003c/li\u003e\n\u003cli\u003ePang H, Lv J, Xu T, Li Z, Gong J, Liu Q, et al. Incidence and risk factors of female urinary incontinence: a 4-year longitudinal study among 24\u0026thinsp;985 adult women in China. Bjog-int j obstet gy. 2022;129(4):580-9.\u003c/li\u003e\n\u003cli\u003eCoyne KS, Kvasz M, Ireland AM, Milsom I, Kopp ZS, Chapple CR. Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom, and the United States. Eur urol. 2012;61(1):88-95.\u003c/li\u003e\n\u003cli\u003eBerger MB, Patel DA, Miller JM, Delancey JO, Fenner DE. Racial differences in self-reported healthcare seeking and treatment for urinary incontinence in community-dwelling women from the EPI Study. Neurourol Urodyn. 2011;30(8):1442-7.\u003c/li\u003e\n\u003cli\u003eHammad FT. Prevalence, social impact and help-seeking behaviour among women with urinary incontinence in the Gulf countries: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2021;266(null):150-6.\u003c/li\u003e\n\u003cli\u003eLasserre A, Pelat C, Gu\u0026eacute;roult V, Hanslik T, Chartier-Kastler E, Blanchon T, et al. Urinary incontinence in French women: prevalence, risk factors, and impact on quality of life. Eur urol. 2009;56(1):177-83.\u003c/li\u003e\n\u003cli\u003eNyhus M, Oversand SH, Salvesen \u0026Oslash;, Salvesen K, Mathew S, Voll\u0026oslash;yhaug I. Ultrasound assessment of pelvic floor muscle contraction: reliability and development of an ultrasound-based contraction scale. Ultrasound obst gyn. 2020;55(1):125-31.\u003c/li\u003e\n\u003cli\u003eSiafarikas F, Staer-Jensen J, Braekken IH, B\u0026oslash; K, Engh ME. Learning process for performing and analyzing 3D/4D transperineal ultrasound imaging and interobserver reliability study. Ultrasound obst gyn. 2013;41(3):312-7.\u003c/li\u003e\n\u003cli\u003eHarmanli O. POP-Q 2.0: its time has come! Int urogynecol j. 2014;25(4):447-9.\u003c/li\u003e\n\u003cli\u003eHaylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP). Neurourol urodynam. 2016;35(2):137-68.\u003c/li\u003e\n\u003cli\u003eFal\u0026ograve; E, Leombroni M, Buca D, Savone R, Gustapane S, Santarelli A, et al. EP31.01: Pelvic floor ultrasound in the evaluation of postpartum perineal diseases: pelvic organ prolapse. Ultrasound obst gyn. 2016;48(S1):390-.\u003c/li\u003e\n\u003cli\u003eTunn R, Baessler K, Kn\u0026uuml;pfer S, Hampel C. Urinary Incontinence and Pelvic Organ Prolapse in Women. Dtsch Arztebl Int. 2023;120(5):71-80.\u003c/li\u003e\n\u003cli\u003eYoshida M, Murayama R, Haruna M, Matsuzaki M, Yoshimura K, Murashima S, et al. Longitudinal comparison study of pelvic floor function between women with and without stress urinary incontinence after vaginal delivery. J med ultrason. 2013;40(2):125-31.\u003c/li\u003e\n\u003cli\u003eAvery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol urodynam. 2004;23(4):322-30.\u003c/li\u003e\n\u003cli\u003eHuang L, Zhang SW, Wu SL, Ma L, Deng XH. The Chinese version of ICIQ: a useful tool in clinical practice and research on urinary incontinence. Neurourol urodynam. 2008;27(6):522-4.\u003c/li\u003e\n\u003cli\u003ePeduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J clin epidemiol. 1996;49(12):1373-9.\u003c/li\u003e\n\u003cli\u003eZhu J, Pang H, Wang P, Chen Y, Li H, Liu Q, et al. Female urinary incontinence in China after 15 years\u0026apos; efforts: Results from large-scale nationwide surveys. Sci bull. 2024;69(20):3272-82.\u003c/li\u003e\n\u003cli\u003eBlomquist JL, Mu\u0026ntilde;oz A, Carroll M, Handa VL. Association of Delivery Mode With Pelvic Floor Disorders After Childbirth. Jama-j am med assoc. 2018;320(23):2438-47.\u003c/li\u003e\n\u003cli\u003eAshton-Miller JA, Delancey JO. On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng. 2009;11(null):163-76.\u003c/li\u003e\n\u003cli\u003eAbu Raddaha AH, Nasr EH. Kegel Exercise Training Program among Women with Urinary Incontinence. Healthcare (Basel). 2022;10(12):null.\u003c/li\u003e\n\u003cli\u003eArrue Gabilondo M, Belar MJ, Diez-Itza I. De novo urethral hypermobility at 6\u0026thinsp;months after first delivery as a risk factor for stress urinary incontinence 12\u0026thinsp;years postpartum. Int J Gynaecol Obstet. 2025;168(2):634-9.\u003c/li\u003e\n\u003cli\u003eLi M, Wang B, Liu X, Qiao P, Jiao W, Jiang T. MR defecography in the assessment of anatomic and functional abnormalities in stress urinary incontinence before and after pelvic reconstruction. Eur j radiol. 2020;126(null):108935.\u003c/li\u003e\n\u003cli\u003eYou C, Zhao Y, Zhang C, Chen M, Shen W. Pelvic floor parameters predict postpartum stress urinary incontinence: a prospective MRI study. Insights Imaging. 2023;14(1):160.\u003c/li\u003e\n\u003cli\u003eBergstr\u0026ouml;m BS. Reflections in light of the recently published urethral hanging theory of female stress urinary incontinence. Neurourol urodynam. 2017;36(3):829-30.\u003c/li\u003e\n\u003cli\u003eBaessler K, Christmann-Schmid C, Maher C, Haya N, Crawford TJ, Brown J. Surgery for women with pelvic organ prolapse with or without stress urinary incontinence. Cochrane Database Syst Rev. 2018;8(null):Cd013108.\u003c/li\u003e\n\u003cli\u003evan der Ploeg JM, van der Steen A, Oude Rengerink K, van der Vaart CH, Roovers JP. Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta-analysis of randomised trials. Bjog-int j obstet gy. 2014;121(5):537-47.\u003c/li\u003e\n\u003cli\u003eWu M, Wang X, Zheng Z, Cao J, Xu J, Wu S, et al. Ultrasound assessment of bladder descent and its correlation with prolapse severity in Chinese women: a prospective multicenter study. Int urogynecol j. 2022;33(10):2887-93.\u003c/li\u003e\n\u003cli\u003eSmeets CFA, Vergeldt TFM, Notten KJB, Martens FMJ, van Kuijk SMJ. Association between levator ani avulsion and urinary incontinence in women: A systematic review and meta-analysis. Int j gynecol obstet. 2021;153(1):25-32.\u003c/li\u003e\n\u003cli\u003eHoff Br\u0026aelig;kken I, Majida M, Engh ME, B\u0026oslash; K. Morphological changes after pelvic floor muscle training measured by 3-dimensional ultrasonography: a randomized controlled trial. Obstet gynecol. 2010;115(2 Pt 1):317-24.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ultrasound, urethral funnel, cystocele risk factors, urinary incontinence","lastPublishedDoi":"10.21203/rs.3.rs-7356888/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7356888/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eThis study aimed to examine the association between pelvic floor deficiency and urinary incontinence.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e We reviewed records from 2,745 women who visited our hospital between December 2019 and June 2022. Pelvic floor 4-dimension ultrasound was performed to screen the pelvic floor structural deficiency of postpartum women. Linear regression and generalized addictive model were used to analyse the relationship between urinary incontinence and pelvic floor parameters. In addition, population-attributable fraction value for UI were calculated for cystocele, urethral funnel separately and for the combinations of them.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe bladder neck position (at rest), bladder neck position (at Valsalva), cystocele, and urethral funnel were risk factors for urinary incontinence after adjusting for additional confounding factors (BMI, age, education, gestational diabetes mellitus, abortion, neonatal weight, delivery mode, gestational weight gain, delivery mode, gravidity, parity) (OR: 0.695, 95% CI: 0.533\u0026ndash;0.905; OR: 0.883, 95% CI: 0.805\u0026ndash;0.969; OR: 1.255, 95% CI: 1.037\u0026ndash;1.518; OR: 1.862, 95% CI: 1.556\u0026ndash;2.228). The population-attributable fraction value for cystocele and urethral funnel were 4.7% and 8.0%, and the combined value was 12.7%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eDeficiency of anterior compartment including cystocele and urethral funnel, increases the risk of urinary incontinence.\u003c/p\u003e","manuscriptTitle":"The association between pelvic floor deficiency and urinary incontinence: a retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 08:41:33","doi":"10.21203/rs.3.rs-7356888/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-08T07:24:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324091848473746309382210117861046667056","date":"2026-03-19T10:23:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"216971711183619648189392635783111554927","date":"2026-03-19T10:18:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T11:33:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125030908051941034577423861361820676680","date":"2025-08-30T06:52:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T02:57:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-18T15:30:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T23:37:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-14T23:37:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-08-12T14:30:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6325beeb-0d3f-4def-a0c7-cac633e280bd","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-08T07:24:43+00:00","index":100,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T08:41:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-08 08:41:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7356888","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7356888","identity":"rs-7356888","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}