Sexual Aspects of the Female Pelvic Floor

Abstract

This chapter is devoted to the pelvic floor (PF). Maternity care has always considered the PF muscles an essential part of the birth and its disturbances. Gradually, the pelvic floor became a vital element for both sexual pleasure and sexual problems. This chapter will start by explaining its role in posture and movement, and sexuality and delineate the differences between the normotonic, the hypotonic, and the hypertonic pelvic floor and their influences on sexuality. The chapter also gives some elementary education on assessing pelvic floor function. After explaining the PF concerning pregnancy and birth, the chapter will address aspects of prevention and prehabilitation. In other words, this chapter will also deal with how to optimally prepare the pregnant woman for a relaxed birth with as low as possible negative consequences regarding vaginal laxity or pelvic floor prolapse. For the severe pelvic floor disturbances and their implications on sexuality and quality of life, the reader is recommended to look at Chap. 16 .
This chapter is part of ‘Midwifery and Sexuality’, a Springer Nature open-access textbook for midwives and related healthcare professionals.

Full text

113
10
Sexual Aspects oftheFemale Pelvic
Floor
LiesbethWesterik-Verschuuren ,
MarjolijnLutke Holzik- Mensink,
MarleenWieffer-Platvoet, andMinkevan der Velde
10.1 Introduction
Because of its essential functions in the choreography of sexuality and childbirth,
two chapters of this book deal with the pelvic oor (PF). This chapter will start with
addressing the PF and its role in sexuality. Next, we will address the PF during
pregnancy, childbirth, and post-partum. Childbirth and the post-partum period are
crucial moments with potential PF damage. So, this chapter will also look at aspects
of preventing PF disturbances with extra attention to ‘prehabilitation’ (preparing the
PF for optimal functioning during childbirth and post-partum). Since most people
are not very aware of the functioning of their PF, they can easily and unnoticed get
outside the optimal muscle tone (between too high and too low). There is a gradual
transition from optimal to signicant PF disturbances.
In some countries, PF physiotherapy developed into a highly specialized profession
geared to treating PF disturbances. Some of those disturbances existed before getting
pregnant, whereas others originated during pregnancy or childbirth. Chapter 16 will deal
with the severe PF disturbances and their implications on sexuality and quality of life.
L. Westerik-Verschuuren (*)
Bekkenfysiotherapie Twente, Center of Expertise for Pelvic Floor Physiotherapy,
Enschede, The Netherlands
SOMT University of Physiotherapy, Master Pelvic Physiotherapy,
Amersfoort, The Netherlands
e-mail: l.westerik-verschuuren@somt.nl
M. Lutke Holzik-Mensink · M. Wieffer-Platvoet
Bekkenfysiotherapie Twente, Center of Expertise for Pelvic Floor Physiotherapy,
Enschede, The Netherlands
M. van der Velde
Seksuologiepraktijk Twente, Center for Sexology, Enschede, The Netherlands
© The Author(s) 2023
S. Geuens et al. (eds.), Midwifery and Sexuality,
https://doi.org/10.1007/978-3-031-18432-1_10

114
Men can have as well PF disturbances. This chapter will only address the PF
disturbances that can impair conception.
10.2 What Is thePelvic Floor?
The pelvic oor, literally the oor of the pelvis, is a layer of muscles and connective
tissue that spans the bottom of the pelvis (see Fig.10.1). They are striated, voluntary
muscles that, although hidden from view, can be consciously contracted (squeezed)
and relaxed. The PF consists of multiple muscles which stretch from the os coccygis
(tailbone) to the pubic bone and from one tuber ischiadicum (sitting bone) to the
other. In women, the PF muscles surround the hiatus genitalis, the space for the pas-
sage of the urethra, vagina, and anus. Together, these muscles support the pelvic
organs (bowel, uterus, and bladder) and give conscious control of the bladder and
bowel. They also contribute to core stability and motor control. Together with the
musculus multidus, the abdominal muscles, and the thoracic diaphragm, the PF
muscles keep the structure of the spine and pelvis stable and maintain the posture of
the trunk. In addition, the pelvic oor muscles have a role in sexual function.
The PF looks like a hammock or trampoline and can move up (contraction) and
down (relaxation). They can also move ventrally (from the back to the front) and
inward. So during contraction, the PF muscles make a lifting, closing, and ventral
movement. Therefore, contraction of the pelvic oor muscles makes the pelvic
organs lift, closes the urethra, vagina, and bowel, and pulls the urethra, vagina, and
bowel forward (ventral ward). That is how one can support the pelvic organs and
control or delay micturition and defecation until convenient.
LIGAMENTUM SUSPENSORIUM
CLITORIDIS
URETHRA
M. ISCHIOCAVERNOSUS
BULBUS VESTIBULI
FASCIA DIAPHRAGMATIS
UROGENITALIS INFERIOR
GLANDULA VESTIBULARIS
MAJOR (GL. BARTHOLINI)
M. TRANSVERSUS
PERINEI SUPERFICIALIS
CENTRUM
TENDINEUS
PERINEI
ARCUS TENDINEUS
(M. LEVATOR ANI)
FASCIA OBTURATO RIA
FASCIA DIAPHRAGMATIS
PELVIS INFERIOR
M. LEVATOR ANI
OS COCCYGIS
LIGAMENTUM ANOCOCCYGEUM
M. GLUTEUS
MAXIMUS
M. SPHINCTER
ANI EXTERNUS
FOSSA
ISCHIORECTALIS
LIGAMENTUM
SA
CROTUBEROSUM
TUBER
ISCHIADICUM
FASCIA
DIAPHRAGMATIS
UROGENITALIS
INFERIOR
SPATIUM PERINEI
SUPERFICIALE
FASCIA PERINEI
SUPERFICIALE
M. BULBOCAVERNOSUS
Fig. 10.1 The female pelvic oor
L. Westerik-Verschuuren et al.

115
The PF muscles play a role in the sexuality of men and women. In men, they are
important in getting and maintaining an erection and ejaculation. In women, volun-
tary contractions (squeezing) of the PF contribute to sexual sensation and arousal.
The pelvic oor has a different role in each sexual response phase. In everyday life,
the PF muscles are relaxed. When the woman becomes sexually aroused, the blood
circulation increases and the erectile bodies of the clitoris get engorged, causing
thickening of the vaginal wall and creating a cushion around the vaginal entrance to
allow smooth penetration. At the same time, lubrication appears. When sexual stim-
ulation continues, the muscle tension of the PF increases. In particular, the m. bul-
bospongiosus and m. ischiocavernosus contract and prevent the veins from
emptying. In this plateau phase, alternating contracting and relaxing the pelvic oor
leads to a more intense sensation, more friction between the vaginal wall and penis,
and increased sexual arousal. During orgasm, the PF muscles involuntary and rhyth-
mically contract, and, as a result, the hypercongestion of the veins will empty. The
orgasm experience depends on the strength of the muscle contractions, so a well-
trained pelvic oor contributes to a more intense sexual experience. In addition to
the contraction of the pelvic oor muscles, the smooth muscles of the uterus might
also contract rhythmically, thus intensifying the orgasm experience. In the resolu-
tion phase, the muscles relax, and all tissues recover to normal. About half of the
women can have several orgasms in a row.
If the PF muscles are too tensed (hypertonicity) or too relaxed (hypotonicity),
women’s sexuality usually is disturbed.
A hypertonic pelvic oor can lead to painful intercourse. The sexual response
cannot properly start up. The hypertonic muscles inhibit the extra blood circulation
needed for the vaginal wall and the erectile tissues of the clitoris. The vaginal sur-
face stays thin, and lubrication is insufcient, causing dyspareunia. The hypertonic
PF muscles close and nod the vagina causing the feeling of a narrow and short
vagina, an extra reason for pain at penetration. See Fig.10.2.
Painful intercourse can have an overwhelming impact on women, affecting self-
esteem and self-condence. This condition can need counselling and maybe
Fig. 10.2 The difference between relaxed and contracted levator ani muscle. On the left, the PF is
relaxed, with the vagina straight and accessible. On the right, the PF muscles are squeezed. The
vagina is curved and less accessible
10 Sexual Aspects oftheFemale Pelvic Floor

116
coaching. If a woman does not understand why she feels pain during intercourse,
she probably increasingly tenses her pelvic oor, reacting to the pain, and can
develop a vicious cycle of ‘(expected) pain → muscle tension → pain’. Education
is vital, as is re-education and relaxation of the pelvic oor. HCPs specialized in
women’s health like pelvic oor physiotherapists, nurses, or midwives can give
such education.
A hypotonic pelvic oor causes other sexual problems or inconvenience. During
the excitement phase, blood circulation can increase, and the erectile bodies can ll,
but the veins will deate, and the vaginal wall might stay unlubricated because the
bulbospongiosus and ischiocavernosus muscles do not contract sufciently. Besides,
the weak levator ani muscle contractions do not close the genital hiatus well, and
there will be not enough friction between the vagina and the penis. Both partners
will feel less, which can decrease excitement.
Furthermore, a weak pelvic oor can cause vaginal noise or vaginal atus.
Because the vagina cannot be closed sufciently, air will be sucked in or blown out,
causing noises. Most women feel ashamed and embarrassed by this phenomenon.
Squeezing the PF muscles can increase the friction and thus improve the sensa-
tion and reduce the vaginal noise. Though this condition, also called ‘vaginal lax-
ity’, does not hurt physically, it can need counselling. With an underactive pelvic
oor, women will not experience pain, but they do not have a satisfying sexual life.
Proper training will strengthen the PF muscles, increasing her ability to close the
hiatus, increasing the friction during intercourse, and decreasing the risk of vagi-
nal noise.
Unfortunately, there is still a taboo on talking about the pelvic oor or pelvic
oor function, particularly sexual dysfunctions. Furthermore, the pelvic oor mus-
cles have few sensors and have just a tiny area on the motor and sensory cortex. All
this leads to a low level of awareness of the pelvic oor.
Being aware of the function and properly controlling the pelvic oor muscles
will lead to good bladder and bowel control and to satisfying sex. Some authors call
it the ‘love muscle’. PF re-education is an essential part of the job of women’s health
caregivers, such as PF physiotherapists and midwives.
10.3 Prevention ofPelvic Floor Disorders
The risk factors have to be known to understand the prevention of pelvic oor dis-
orders (PFDs). Many studies looked at the various risks. Overall risk factors after
childbirth are delivery itself, instrumental delivery (forceps, vacuum), pelvic oor
disorders before pregnancy, higher maternal age (>36 years), higher maternal BMI
(>30), higher child weight (>4000 g), larger foetal head circumference (>35.5 cm),
longer duration of the second stage of labour (>1 h), (median) episiotomy, lacera-
tions, occiput posterior or forehead position, and shoulder dystocia. Some of these
risks can be inuenced, such as using forceps or vacuum or the duration of the
second stage, others not.
Several authors developed owcharts to prevent primary and secondary PFD or
prediction models focusing on potential, expectable PFD.
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For primiparous women, Jelovsek developed PFD-prediction models to discuss
before birth the probability of developing those disorders and thus make an indi-
vidual birth plan for every woman, facilitating decision-making in the prevention of
incontinence [1].
‘UR-CHOICE’ is another prediction model for PFD.They ne-tuned the model
with extensive long-term results [2]. See http://riskcalc.org/UR_CHOICE/.
To prevent primary disorders, one should carefully observe the function of the
pelvic oor, avoid the use of forceps and routine episiotomy, and limit the duration
of the second stage. Under these conditions, one can indicate vaginal birth.
However, with factors such as a foetal head circumference >35.5 cm, a maternal
age >35, a maternal BMI >30/35, and a family history of pelvic oor disorders, one
should consider Caesarean section.
All authors report the importance of good awareness and control of the PF mus-
cles. During expulsion, the muscles have to be relaxed and optimally stretchable.
With good (realistic) and honest education, pelvic oor muscle training (including
relaxation exercises) and perineal massage, one can reach this. In some centres, the
Epi-No® is used (see below). Women will benet from being coached on adequately
using their PF muscles.
10.4 How toAssess thePF Muscles
A woman with a well-functioning pelvic oor can consciously squeeze and relax her
PF muscles. Unfortunately, correctly contracting the PF muscles is not easy. In Belgian
research, 53% of post-partum women could not perform a correct PF muscle contrac-
tion [3]. So pelvic oor muscle assessment and training seem recommended. Below,
we address how this can be integrated into women’s health by instructors like health-
care professionals, pelvic oor physiotherapists, midwives, or nurses.
An assessment of the PF muscle function starts with an inspection followed by
palpation. Specialized pelvic physiotherapists often have other diagnostic tools like
biofeedback and ultrasound. These tools provide more specic, detailed informa-
tion, but inspection and palpation are usually sufcient to determine the function of
the PF muscles.
10.4.1 Inspection
During contraction, the vagina closes, and the vagina and perineum move inward.
During relaxation, the vagina and perineum move back to their original position. At
the Valsalva manoeuvre, the PF muscles have to relax unconsciously, and the
perineum should descend a bit. Unfortunately, many women are not able to perform
a Valsalva manoeuvre correctly. Instead of relaxing their PF muscles, they squeeze
them and push simultaneously (‘paradoxically pushing’). Proper pushing makes
stool or child pass outside. So, paradoxical pushing is a serious disadvantage. The
woman must be able to squeeze, relax, and push properly. If she cannot do so, she
should learn those skills.
10 Sexual Aspects oftheFemale Pelvic Floor

118
10.4.2 Palpation
One must prepare carefully for palpation, including consent and a good lubricant.
Gently introduce one nger (in the primipara) or two ngers (in the multipara) into the
vagina. This manoeuvre should never be painful in a healthy vulva with a well-
lubricated nger!
Start with determining the resting tone. With a good resting tone, the nger can
be introduced easily and without any resistance, and the PF muscles softly enclose
the examining nger. Ask her to contract: the nger will be rmly enclosed, pulled
inward, and ventralward.
Ask her to relax: the muscles and the nger will move back to the original posi-
tion. Ask her to perform the Valsalva manoeuvre: the muscles relax unconsciously
and move downward, by which the enclosing of the nger decreases, and the nger
partly is pushed out of the vagina.
The next part of the examination deals with coordination: the woman should be
able to squeeze and relax the PF muscles with proper strength, timing, and duration.
A woman should be able to make 10–15 fast contractions in a row without losing
strength and relax completely after each contraction. Furthermore, she should be
able to squeeze the PF muscles for 30 s continuously at 50–70% of her maximal
strength. After this endurance contraction, she should be able to relax immediately
and completely. We test this in several series with different ways of squeezing and
relaxing. One should always be aware that both contraction and relaxation are
important. The emphasis in pelvic oor muscle training should therefore be on both
actions. Only a completely relaxed pelvic oor can be stretched as much as neces-
sary (200–300%) during vaginal birth.
An underactive pelvic oor has a low resting tone, weak contractions, and little
endurance. The examining nger is just slightly enclosed. There is little strength and
little or no endurance. The woman can not rmly close the genital hiatus. The eleva-
tion of the bladder neck is absent or weak. Here, pelvic oor muscle training should
focus on gaining strength and endurance without forgetting coordination.
An overactive pelvic oor has a high resting tone, and the relaxation is delayed
and incomplete. It rmly encloses the examining nger. Whereas contraction can
vary from weak to strong, relaxation can be absent, delayed, or incomplete. Be
aware that overactive is not synonymous with strong. There is often a combination
of overactive PF with paradoxical pushing. Here, the training should focus on relax-
ation and coordination.
10.4.3 The PF Muscles During Pregnancy
Due to the release of the hormone relaxin, the connective tissue all over the body
softens during pregnancy. Because the PF muscles contain connective tissue, the
pelvic oor weakens. Furthermore, due to the growing size of the uterus, the intra-
abdominal pressure increases.
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119
Pregnancy itself can lead to disturbances in micturition and defecation, varying
from just a bit of inconvenience to real disorders. Due to the imbalance between the
increased intra-abdominal pressure and the decreased urethral closing pressure
(decreased PF muscle function), stress urinary incontinence (SUI) may occur.
Depending on the degree of imbalance, SUI may vary from just a few drops while
coughing to severe loss during all activities that increase the intra-abdominal
pressure.
Due to the growing uterus, there will be less and less space for the bladder, and
the bladder capacity will decrease, which can cause frequency.
The stool can change during pregnancy as well. The imbalance between the
intra-abdominal pressure and the anal closing pressure can cause atal inconti-
nence. Fortunately, there is rarely faecal loss during pregnancy. As written above,
incontinence will depend on the degree of imbalance. Constipation is another incon-
venience caused by the softening of the connective tissue of the smooth muscles of
the colon and rectum.
Besides the weakening of the PF muscles, pelvic oor dysfunctions can occur as
a compensation strategy for these complaints. These compensation strategies often
may exacerbate the original complaints. Appropriate, tailored coaching is important
to cope with these inconveniences or complaints.
10.4.4 The Pelvic Floor Muscles During Birth
During childbirth, the PF muscles are stretched by 200–300%. No other muscle in
the human body can stretch that much. Other tissues are also stretched, including
the connective tissue that supports the pelvic organs and the nerves. The more
relaxed a muscle is, the more stretchable it is. So the woman must be able to relax
her pelvic oor muscles and push properly. Pushing on a non-relaxed PF or pushing
paradoxically might lead to more PF and perineal damage.
Several authors have described the changes in PF anatomy and function during
the women’s lifetime. According to DeLancey [4], physiological lifespan of the
pelvic oor differs, with PF function being optimal between age 15–25, depending
on the age of the rst pregnancy and birth [5]. After 20–25, the pelvic oor function
decreases slowly. Women (and men) need a minimal function to maintain conti-
nence and other pelvic oor functions. That is why the elderly have many pelvic
oor dysfunctions like incontinence (Fig.10.3).
Vaginal birth affects PF anatomy and function but not to the same extent in every
woman. Many variables inuence changes in anatomy and function. Furthermore,
recovering from pelvic oor injuries varies in women. But not just the extent of
damage or dysfunction makes women feel impaired. Circumstances, culture, and
expectations inuence the woman to experience her pelvic oor disorders just as a
(temporal) inconvenience or as a real impairment.
10 Sexual Aspects oftheFemale Pelvic Floor

120
Despite repeated damage to the
continence mechanism, the
woman can compensate for the
damage and remains continent
Perucchini and DeLancey clarified the consequences of pregnancy and delivery and aging on the female
continence mechanism. This is an adapted version of their illustration in Chapter 1.1 in 'Pelvic Floor Re-
education: Principles and practice' (Springer 2008). [5]
The woman has less reserve and
becomes incontinent during her life,
though the number and magnitude
of the insults are no greater than in
women who remain continent.
Devastating obstetric damage can
cause loss of continence early in
life. Even if the woman was born
with good continence factors.
Continence threshold Continence threshold
first
pregnancy
& delivery
second
pregnancy
& delivery
first
pregnancy
& delivery
second
pregnancy
& delivery
first
pregnancy
& delivery
second
pregnancy
& delivery
Increasing age Increasing ag ncreasing age
Sum of continence factors
Sum of continence factors
eI
Fig. 10.3 How the female pelvic oor function can change over the lifetime
10.4.5 The Pelvic Floor inthePost-partum Period
After childbirth, all tissues of the PF have to recover. The muscles, the connective
tissue, and the nerves have been overstretched and possibly injured. Full recovery
usually takes 9 months in physiological conditions, with the most signicant recov-
ery occurring in the rst three months. For perivaginal tissue recovery, oestrogen is
important. So, breastfeeding can delay recovery.
The complaints of decreased PF function and other damage can vary from minor
discomfort to serious complaints. Chapter 16 will address the severe problems.
10.5 Prevention andPrehabilitation
Women benet from being well informed about their pelvic oor and its changes
during pregnancy and after childbirth. Unfortunately, most nulliparous women are
neither sufciently informed nor aware of how to squeeze, relax, or push properly
(even not during labour and post-partum). As long as pelvic oor awareness is not
taught in schools or by mothers, the midwife could take this role and teach how to
use the PF muscles to enjoy sex and optimize their function in preparation for child-
birth. It seems wise to start that process early in pregnancy because already through-
out pregnancy, the PF is changing.
Next to explaining anatomy with images or models, for increased awareness, it
is also relevant to touch and maybe massage the PF muscles, which will optimize
bladder and bowel control and improve sex life as well. Learning how and when to
squeeze or relax or push will, on the one hand, benet sexuality (‘love muscles’)
and will, on the other hand, prepare for a better functioning PF during the birth. An
easy way to increase awareness and learn relaxation might be to apply a warm com-
press to the perineum. The warmth will make the woman more aware of the PF
muscles’ localization and help her relax.
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Here, we will address two prehabilitation measures: perineal massage and PF
muscle training.
10.5.1 Perineal Massage
We recommend perineal massage during pregnancy [6]. Correctly performed mas-
sage will make the woman aware of her pelvic oor tone, teach her how to relax it,
and allow passage through her vagina (penis, baby, or dildo). It can be pleasant and
rewarding for both partners as a joint action. In primiparous women, it diminishes
perineal trauma and episiotomy [6]. It is generally well accepted by women.
Although pregnancy softens the connective tissues and weakens the PF muscles,
this does not automatically mean that they are relaxed. First, one must relax the
muscles since stretching is not possible when tensed. Warmth or a gentle massage
can help to achieve relaxation.
We recommended such a massage at least 1–2× per week from week 34 (see
Fig.10.4 for explanation).
Make sure that hands are clean and nails short
Choose a quiet place and posture in which legs can be bend and opened in a
relaxed way
1
2
If nesseccary lubricate thumbs and / or perineal tissues (for instance KY jelly)3
Insert both thumbs about 3–4 cm into the vagina, press down in the direction of the
anus and to both sides until a stretching sensation is felt, hold this 1–2 minutes
4
Massage the lower half of the vagina by making a U-shaped movement, stretching
the vagina wall dorsally and laterally during 2–3 minutes
5
Fig. 10.4 Steps in perineal massage
10 Sexual Aspects oftheFemale Pelvic Floor

122
One can also relax and stretch the pelvic oor with the Epi-No®. That is an inat-
able balloon coupled to a pressure display hand pump for gradual stretching of the
vagina and perineum in late pregnancy [7]. Applied correctly, it might teach women
to relax the PF.The Epi-No® does not prevent intrapartum levator ani damage or
anal sphincter and perineal trauma. The literature shows conicting evidence about
the effectiveness in preventing PF disorders. In our view, its use has to be coached
by trained midwives/HCPs.
10.5.2 PF Muscle Training (PFMT)
PFMT can prevent the detrimental negative effect of a poorly functioning pelvic
oor on women’s participation in sports and physical activity. In systematic reviews,
PFMT during pregnancy and after childbirth improved urinary continence because
of better PF function [8, 9].
A systematic review of prenatal and postnatal PFMT showed positive effects on
sexual function and female sexuality with post-partum improvements in desire,
arousal, orgasm, and satisfaction [10].
An Example of a PFMT Schedule
Start with making an assessment, which guides the training schedule. When the
woman can contract for instance for 4 s, that four-second period is the basis of the
schedule (as in Table10.1).
To improve muscle function, the woman should do this daily. After a while, she
should increase the contraction and rest time gradually to 6–8 s. Once the woman
can perform three series of ten contractions of 6–8 s, she can downgrade to 2–3×/
week. One can do this training lying down, sitting, or standing. It is best to do it in
the position in which the woman is most aware of her PF.
Table 10.1 PFMT schedule (based on an assessment of 4 s)
4s contraction and 4s rest: to be done 10×
Then 6 fast contractions
Then 1½–2min pause
This series to be repeated twice
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References
1. Jelovsek JE, Piccorelli A, Barber MD, etal. Prediction models for post-partum urinary and
fecal incontinence in primiparous women. Female Pelvic Med Reconstr Surg. 2013;19:110–8.
2. Jelovsek JE, Chagin K, Gyhagen M, etal. Predicting risk of pelvic oor disorders 12 and 20
years after delivery. Am J Obstet Gynecol. 2018;218:222.
3. Neels H, De Wachter S, Wyndaele JJ, et al. Common errors made in attempt to contract the
pelvic oor muscles in women early after delivery: a prospective observational study. Eur J
Obstet Gynecol Reprod Biol. 2018;220:113–7.
4. Delancey JO, Kane Low L, Miller JM, etal. Graphic integration of causal factors of pelvic
oor disorders: an integrated life span model. Am J Obstet Gynecol. 2008;199:610.
5. Perucchini D, DeLancey JOL.Functional anatomy of the pelvic oor and lower urinary tract.
In: Baessler K, Burgio KL, Norton PA, etal., editors. Pelvic oor re-education; principles and
practice. NewYork: Springer; 2008. p.3–21.
6. Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma.
Cochrane Database Syst Rev. 2013;4:CD005123Br.
7. Kamisan Atan I, Shek KL, Langer S, etal. Does the Epi-No® birth trainer prevent vaginal
birth-related pelvic oor trauma? A multicentre prospective randomised controlled trial.
BJOG. 2016;123(6):995–1003.
8. Woodley SJ, Lawrenson P, Boyle R, etal. Pelvic oor muscle training for preventing and treat-
ing urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst
Rev. 2020;5(5):CD007471.
9. Mørkved S, Bø K.Effect of pelvic oor muscle training during pregnancy and after child-
birth on prevention and treatment of urinary incontinence: a systematic review. J Sports Med.
2014;48:299–310.
10. Sobhgol SS, Priddis H, Smith CA, Dahlen HG.The effect of pelvic oor muscle exercise on
female sexual function during pregnancy and postpartum: a systematic review. Sex Med Rev.
2019;7:13–28.
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10 Sexual Aspects oftheFemale Pelvic Floor