Healthcare overall was a casualty of the Covid-19 pandemic, as was Postnatal care (1). Women’s activities day-to-day changed with increased childcare, home-schooling, and working from home, while weight-gain and altered recreational exercise levels were also reported. As these factors impact pelvic floor health, we aimed to examine how women with pelvic dysfunction were affected by the pandemic.

A Survey Monkey™ online questionnaire examined the impact of the pandemic and Covid-19 infection on women’s pelvic problems, exercise, and weight. Also, history of Covid-19 infection, and its effect on continence and sexual function was sought using a previously developed tool (2). A free text box captured their comments, which were analysed using qualitative methods.

Results:
 647 women took part, 540 (84%) replying through a website for support garments (EVBTM).
Bladder control 265 (41%), prolapse 240 (37%), pelvic pain 40 (6%), sexual dysfunction 27 (4%), faecal incontinence 19 (3%) and other symptoms 56 (9%) were women’s main pelvic problems. Symptoms were unchanged for 331 (51%), worse for 243 (38%), and improved for 60 (10%). Weight was gained by 290 (45%), unchanged by 243 (38%), and lost by 114 (17%). Exercise levels were unchanged, worse, or better in 33% each. 
Access to medical appointments and date for surgery were difficult for 235 (36.5%) and 38 (6%) women respectively.
Sixty-six (10.3%) women reported covid-19 infection: distribution of pelvic problems, changes through the pandemic, weight and exercise patterns, and difficulty accessing a date for surgery or healthcare were similar to those not contracting infection. Sexual dysfunction was the main new/worsening problem, featuring 13 women (18%).

Seventy women commented- 16 postnatal, 54 with pre-existing pelvic symptoms. Five core themes were identified: mental health impact and physiotherapy services especially affected delivered women, while lifestyle alterations and conservative treatment tools were prominent in women with a pre-existing problem.

Our study found little difference between women who contracted Covid-19, and those who did not, apart from prominent sexual dysfunction in women recovered from Covid infection: this may be secondary to inflammatory change in pelvic organs and merits further study. 
Our respondents tended towards weight-gain: national lockdowns curtailed movement, contributing to increased BMI: this has been linked to adverse changes in mental health. Psychological distress is a feature of the pandemic worldwide through the strong association of Covid-19 with uncertainty and isolation. ‘Juggling’ was a phrase used by our respondents in relation to their responsibilities during the pandemic. The UK Household Longitudinal Study found that women who spent long hours on housework and childcare reported increased levels of distress. Our respondents had a more mixed experience of being at home: several used the time gained through not commuting as an opportunity for exercise, and the enhanced sense of control translated into better wellbeing. Presumably those with small children who could not attend school or creche were impacted more negatively, and several mothers viewed exercise as a critical outlet. 
Loss of face-to-face contact and personal avoidance by healthcare staff with our respondents were experienced as a lack of compassion, and telephone contact was found to be an inadequate substitute for in-person care. Access to Physiotherapy services was poor, especially postnatally, resulting in some attending privately. Several commented on the paucity of specialist physiotherapy services given the frequency of such issues. Those with pre-existing pelvic problems were familiar with a range of conservative measures, including online classes: these- support shorts in particular- were the subject of positive commentary. Many women commented on the beneficial influence of exercise on pelvic floor function. This adds to the mounting evidence suggesting that exercise and physical activity interventions affect physical and mental-health outcomes positively.
The qualitative data captured through the free text box is the main strength of this study. ‘Telling your story’ gives subjects the freedom to report in their own words what is important to them. The part played by women’s voices in delivery of obstetric and gynaecological care has been recognised (3).. Qualitative methods help us to “enter the world of its participants”. and are a rich source of data suitable for analysis13.
Because this research was conducted via the internet, there is a bias towards younger, more computer-literate respondents, and the EVBTM website attracts women who exercise and enjoy sport.

Our survey captures the suffering of women with pelvic dysfunction resulting from reduced access to healthcare in the pandemic. It underlines the importance women ascribe to exercise for pelvic floor health, its role in stress relief, and how pelvic floor dysfunction through limiting exercise can adversely affect mental health. 
Our study adds to previous calls for enhanced care and support for women postnatally and underlines pelvic health as an integral component. The finding of sexual dysfunction as part of recovery from Covid-19 infection merits further exploration.
Finally, the pandemic exposed the fact that female pelvic health services are not readily available to women in need.

Continence 2S2 (2022) 100469
DOI: 10.1016/j.cont.2022.100469