In this large prospective cohort study of primiparous women, we evaluated bothersome PFD and its impact on HRQoL during pregnancy and up to 1 year postpartum. We found that the prevalence of bothersome UI increased significantly during pregnancy and up to 1 year postpartum, and this increase was seen in the groups reporting bothersome SUI and MUI. Very few women reported bothersome UUI and FI at any time point. Risk factors for bothersome UI 1 year postpartum were UI before pregnancy and bothersome UI in late pregnancy and at 8 weeks postpartum. Almost every fourth woman reported pelvic floor symptoms with an impact on HRQoL 1 year postpartum, but the median scores in IIQ-7 were low and most women did not report any effect on HRQoL at all.

To the best of our knowledge, only one previous study has examined bothersome urinary symptoms during pregnancy and up to 1 year postpartum [8]. In contrast to our finding that bothersome UI increased during pregnancy and up to 1 year after childbirth, Van Brummen et al. found that the prevalence of bothersome LUTS was highest at week 36 of gestation and declined 1 year after pregnancy, suggesting that it might be part of normal pregnancy [8]. Palmieri et al. also found that bothersome PFD was more prevalent in pregnancy than postpartum, but they only followed their cohort up to 6 weeks postpartum [16]. Van Brummen et al. found that bothersome SUI in early pregnancy and greater maternal age were predictive of bothersome SUI 1 year after childbirth [8]. In the present study, the small number of women reporting bothersome UI in early pregnancy also reported UI before pregnancy, so we used that as a predictor of bothersome UI 1 year postpartum. The finding that bothersome UI in late pregnancy and 8 weeks postpartum were predictive of bothersome UI 1 year postpartum is similar to the results of previous studies [17, 18]. However, both these previous studies focused on UI in general and not specifically on bothersome UI. Foldspang et al. reported that the highest risk of postpartum UI was found among women complaining of UI during pregnancy, which manifested as a crucial, independent precursor [18].

In the present study, few women reported bothersome FI at all time points. When comparing our lower FI prevalence figures with those reported in previous studies of FI not applying cut-offs based on bother [19, 20], it is clear that only a fraction of women with FI are bothered by it.

Few studies have evaluated the impact of PFD on HRQoL after pregnancy and childbirth [5, 7,8,9]. A minority of women with UI reported an impact on HRQoL in our study. Previous studies have reported various results. Dolan et al. reported that, during pregnancy, most women with UI experience minimal impact on HRQoL [9]. In contrast, in other studies UI had a significant impact on HRQoL during pregnancy [21, 22]. In a general population, Coyne et al. reported that women with UUI and MUI had significantly worse HRQoL than did women with SUI [23]. This is similar to our finding that women with MUI and UUI had the highest median IIQ-7 score 1 year postpartum; however, because the groups were small, it was not possible to conduct proper statistical evaluations. Even though the impairment in HRQoL in our total sample is low, it should be noted that some outliers have very high scores. These few women have more extensive limitations in their daily activities. When looking at the detailed IIQ-7 answers 1 year postpartum (Appendix 3), it seems as though physical activity is the domain with the highest score. That is probably because SUI, the most common symptom, is closely associated with physical activity.

The association between delivery mode and bothersome UI 1 year postpartum did not reach statistical significance. However, this was not the main objective of the study. A larger study sample and a longer follow-up time would be required to establish the effect of delivery mode on bothersome UI symptoms, as well as other bothersome PFD. Van Brummen et al. reported that women had more bothersome UUI after a cesarean delivery and more bothersome SUI after a vaginal delivery, but neither effect was statistically significant [8]. As other previous studies of postpartum UI have not focused on bothersome UI, we cannot entirely compare our results with theirs [5, 7, 17, 18]. It would have been interesting to include UI subgroups as well as bothersome FI in the association analysis, but the groups were too small.

A strength of this study is the prospective data collection from early pregnancy to 1 year postpartum. As the study sample comprised only primiparous women, the results were not influenced by previous pregnancy or childbirth. In general, the likelihood of recall bias is low in studies of prospective design. We consider it a strength to focus on bothersome PFD and impairment in HRQoL, because these, rather than symptom severity, are the forces that drive women to seek treatment [6]. Our questionnaire was a compilation of questions derived from various validated questionnaires. Compiling questions from several questionnaires may influence the validated characteristics of the questions [24]. Unfortunately, the questionnaire did not include any questions about bothersome vaginal bulging, limiting our understanding of how this symptom may bother women. The IIQ-7 is a standardized validated questionnaire for UI. In this study, we used a modified Swedish version asking about several pelvic floor symptoms, but the answer categories were not divided into different symptoms as in the PFIQ-7. Therefore, we cannot tell what PFD symptoms may have affected the HRQoL. Another limitation of IIQ-7 is that the questionnaire is constructed for condition-specific HRQoL among women with UI in clinical practice and is not validated for young women who have recently given birth. This has probably introduced floor effects, i.e., that most respondents score 0 points on the IIQ-7, making it difficult to manage and analyze the data. Finally, our definitions of bothersome PFD are not standardized or based on any core outcome set, as no core outcome set is available in this field [25]. There is an urgent need to define a core outcome set for PFD to make the results of different studies comparable.

Our findings indicate a low overall prevalence of bothersome UI during pregnancy and up to 1 year after first childbirth and that most women did not report PFD with impairment in HRQoL. This is a reassuring message for pregnant women. However, the minority of women actually suffering from bothersome UI and other PFD must be identified and adequately counseled in postnatal care. Studies have shown that women with SUI during first pregnancy or 3 months after first delivery are at a particularly high risk of long-lasting symptoms 5–15 years after childbirth [26, 27]. Altogether, this further supports the introduction of preventive measures, such as pelvic floor muscle training during pregnancy [28].