Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. Int Urogynecol J. 2013;24:901-912. [PMID: 23436035 PMCID: PMC3671107 DOI: 10.1007/s00192-013-2061-7]

Therapeutic massage in women with stress urinary incontinence: a pilot study

Background: Stress incontinence affects 25–60% of women of all ages and causes constant discomfort, significantly lowering quality of life. The most common causes of urinary incontinence are weakened sphincter muscles or bladder failure. Aim of the study: The aim of this study was to assess the effectiveness of therapeutic massage therapy for stress urinary incontinence and to determine whether therapeutic massage can restore the normal function of the bladder sphincters. Material and methods: The study involved eleven women with a diagnosis of primary stress urinary incontinence, aged 50–79 years. The women attended therapeutic massage sessions twice a week for four weeks. A sanitary pad test was performed before starting and immediately after ending the therapy to verify its effectiveness. Results: In eight women, the amount of urine that leaked decreased after therapy. This result was statistically significant (p = 0.02). In three cases, urine leakage was reduced to zero. Conclusions: Therapeutic massage, acting locally, improves the function of the bladder sphincters, their flexibility and the ability to contract and relax. Massage eliminates or significantly reduces the symptoms of stress urinary incontinence.

Urinary incontinence and associated factors among pregnant women attending antenatal care in public health facilities of Mekelle city, Tigray, Ethiopia

Background:

Urinary incontinence is any involuntary leakage of urine. It has serious negative health impacts on quality of life in pregnant women. According to the scientific committee of the International Continence Society report, worldwide prevalence of urinary incontinence estimated ranges between 32% and 64% among pregnant women. However, there is scarcity of evidence on prevalence and associated factors of urinary incontinence in Ethiopia.

Objective:

The aims of this study were to assess prevalence and associated factors of urinary incontinence among pregnant women attending antenatal care in public health facilities of Mekelle city, Tigray, Ethiopia.

Methodology:

Institution-based cross-sectional study design was conducted. Data were collected using an interviewer-administered structured questionnaire. Physical examination was done to assess the strength of pelvic floor muscles. The data were entered to EPI Info version 7 and analyzed using SPSS version 23. Bivariate and multivariate logistic regression analyses were done to investigate the factors associated with urinary incontinence.

Results:

Among 317 respondents, the prevalence of urinary incontinence was 23%. The contributing factors that had statistically significant association with urinary incontinence were gestational age (adjusted odds ratio: 9.6 (1.87–49.39, 95%), parity (adjusted odds ratio: 6.32 (1.48–27.05), 95% confidence interval), prior miscarriage (adjusted odds ratio: 6.28 (2.15–18.28), 95% confidence interval), constipation (adjusted odds ratio: 8.25 (3.12–21.84), 95% confidence interval), respiratory problem (adjusted odds ratio: 6.31 (2.05–19.43), 95% confidence interval), and weak pelvic floor muscle (adjusted odds ratio: 7.55 (2.51–22.67), 95% confidence interval).

Conclusion:

The prevalence of urinary incontinence is moderate compared to other studies. Gestational age, parity, prior miscarriage, having constipation, having respiratory problem, and weak pelvic floor muscle had significant association with urinary incontinence. This finding will help to increase the awareness of health care professionals involved in the care of pregnant women about urinary incontinence.

Epidemiological investigation of urinary incontinence in peri- and postpartum women from Nanjing, China

OBJECTIVES

We aimed to determine the prevalence of urinary incontinence (UI) during the peri- and postpartum period in women from Nanjing, China, and estimate its risk factors.

METHODS

From January to December 2018, a total of 6500 postpartum women were enrolled and asked to complete the questionnaires. Of these, 6370 (98%) women returned the questionnaires with valid responses. Additional data were collected, including age, height, weight, gestation time and parity, and neonatal weight. The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form was used. Surface electromyography (sEMG) and a biofeedback training system were used as a testing platform, and PESEMG values were obtained.

RESULTS

The prevalence of UI during pregnancy and at 6 weeks postpartum in women was 29.76% and 12.50%, respectively. The prevalence of stress UI (SUI), urge UI (UUI), mixed UI (MUI), and other types of UI that developed during pregnancy was 25.48%, 1.66%, 1.65%, and 0.97%, respectively. The prevalence of SUI, UUI, MUI, and other types of UI at 6 weeks postpartum was 8.49%, 2.07%, 1.16%, and 0.77%, respectively. Multivariate analysis showed that advanced age, greater postpartum body mass index (BMI), macrosomia, multiparity, and vaginal delivery were risk factors of postpartum UI. Women with mild degree of UI in pregnancy, those who had undergone cesarean section, and those without UI before pregnancy were relieved from UI at 6 weeks postpartum.

CONCLUSIONS

The rate of UI in peri- and postpartum women from Nanjing is consistent across China. The most common type of UI was SUI, with many risk factors affecting its occurrence. Advanced age, greater postpartum BMI, multiparity, macrosomia, and vaginal delivery might be the main risk factors of UI in postpartum women.

Risk factors for accidental falls during pregnancy - a systematic literature review

INTRODUCTION

Falls during pregnancy occur in 25-27% of women and can cause serious harm to both the mother and the fetus. The objective of this systematic review was to identify intrinsic and extrinsic risk factors for falls during pregnancy by reviewing original studies and addressing possible forms of prevention.

METHODS

We searched PubMed, Cochrane library, and Web of Science databases for studies assessing risk factors for falling after a fall has occurred or by using posturographic assessment.

RESULTS

Fourteen studies were included in the review. The identified extrinsic risk factors include slippery floors, cluttered areas, uneven ground, inappropriate shoes, hurrying, walking on stairs, carrying additional loads, poor lighting or obstructed view, sedentary lifestyle and working in physically demanding jobs. The identified intrinsic factors include age less than 30, height more than 160 cm, advanced pregnancy, unintended pregnancy, multiparity, hyperemesis gravidarum, low back pain, gestational diabetes, increase in abdominal circumference, lower ankle stiffness and joint laxity. Physical activity, maternity support belts, and education are possible strategies for fall prevention.

CONCLUSION

Our systematic review identified 13 intrinsic and 11 extrinsic risk factors for falling during pregnancy. With the knowledge of risk factors and the optimal prevention strategy, healthcare providers could incorporate this information in the treatment of pregnant women and reduce the risk of falling.

Scale of pregnant women's assessment of knowledge, attitude and practice related to urinary incontinence

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is prevalent during pregnancy and negatively affects quality of life. Despite this, few women seek professional assistance during prenatal care. Assessing the knowledge, attitude and practice (KAP) of pregnant women related to UI can contribute to the development and improvement of the quality of interventions performed during this period. For this, it is essential to apply targeted and valid instruments for this population. Thus, the present study aimed to construct and validate the content of a scale to evaluate the KAP of pregnant women related to UI.

METHODS

Extensive literature review guided the operationalization of the instrument's initial items. Ten experts were selected for the theoretical analysis of the items, which was carried out using the Delphi technique, and the analysis of semantic adequacy proceeded from the application of the scale to 30 pregnant women. The data were analyzed using the content validity coefficient and kappa coefficient.

RESULTS

The proposed Scale of Pregnant Women's Assessment of Knowledge, Attitude and Practice related to UI was approved by consensus by the experts, with a mean Cohen's kappa of 0.84 (p < 0.01), comprising 23 items.

CONCLUSIONS

The results of the study confirm that the presented scale can be used as a valid tool to assess the KAP of pregnant women related to UI.

Antenatal and postnatal assessment of pelvic floor muscles in continent and incontinent primigravida women

INTRODUCTION AND HYPOTHESIS

Reduced pelvic floor muscle (PFM) strength and thickness are considered critical factors in pregnancy-related stress urinary incontinence. Various methods have been evaluated for the measurement of these two factors, but validity needs to be well established. The objective was to assess the strength and thickness of pelvic floor muscles of continent and incontinent primigravida women using the digital method and transperineal ultrasound, and to study the correlation between the two methods.

METHODS

Assessment of pelvic floor muscle strength and thickness using digital assessment and transperineal ultrasound antepartum and postpartum in 100 primigravida women.

RESULTS

A total of 100 primigravida women with 46 in the study group (incontinent) and 54 in the control group (continent) were assessed. PFM strength was lower in incontinent women, with a score of 3 or less in 82.61% (38 out of 46) compared with a score of 4 or more in 98.15% of continent women (53 out of 54; p < 0.0001) antenatally, as well as postnatally, with 81.25% of the incontinent women (26 out of 32), with a score of 3 or less compared with 100% of continent women (24 out of 24), with a score of 4 or more (p < 0.0001). The PFM thickness in the incontinent group compared with the continent group at relaxation was 5.94 ± 0.51 mm and 6.64 ± 0.26 mm (p < 0.0001) antenatally and 5.98 ± 0.55 mm and 6.69 ± 0.23 mm (p < 0.0001) postnatally; at contraction it was 7.29 ± 0.56 mm and 8.70 ± 0.24 mm (p < 0.0001) antenatally and 7.39 ± 0.56 mm and 8.77 ± 0.20 mm (p < 0.0001) postnatally. The Pearson correlation coefficient for the two methods during the antenatal and postpartum periods was 0.864 and 0.743 respectively, suggestive of a positive correlation between the two methods.

CONCLUSIONS

Pelvic floor muscle strength, as well as thickness, is significantly lower among the incontinent group than among the continent group, both during antenatal and during the postnatal period.

Frequency and Factors Associated with Urinary Incontinence in Pregnant Adolescents: A Cross-Sectional Study

STUDY OBJECTIVE

To determine the overall frequency of urinary incontinence in pregnant adolescents, focusing particularly on the presence of symptoms of stress urinary incontinence (SUI) and coital incontinence (CI), and to describe the biological, sociodemographic, clinical, urinary, reproductive, sexual, and lifestyle factors associated with incontinence.

DESIGN

A cross-sectional, descriptive study.

SETTING

The outpatient clinic for high-risk pregnancies at the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) in Recife, Pernambuco, in the Northeast of Brazil.

PARTICIPANTS

A convenience sample of 103 pregnant adolescents who attended for prenatal consultations during the study period.

INTERVENTIONS

Data were collected on the participants' characteristics and information based on the Incontinence Severity Index (ISI) questionnaire.

MAIN OUTCOME MEASURES

Frequency of urinary incontinence and possible correlations between the women's characteristics and SUI and CI symptoms.

RESULTS

Mean age (±standard deviation) was 16.76 ± 1.8 years. Urinary incontinence was present in 60.1% of the patients. Of these, 37.8% had SUI and 33.9% CI. In addition, 30.8% of the patients with CI also had SUI. There were statistically significant associations between CI and the occurrence of SUI prior to pregnancy (100%; PR: 1.77; 95% CI: 1.48-2.13; P = .011), between SUI and chronic coughing (60%; PR = 1.95; 95% CI: 1.23-3.09; P = .009), and between CI and height (41.9%; PR = 1.00; 95% CI: 0.27-1.00; P = .036).

CONCLUSION

Urinary incontinence is a dysfunction that may affect pregnant adolescents, with symptoms possibly beginning as early as the first trimester of pregnancy.

Urinary Incontinence in Physically Active Older Women of Northeast Brazil

Low- and moderate-impact physical activity (PA) is associated with the prevention of urinary incontinence (UI). The objective of the cross-sectional study presented herein is to analyze the factors associated with UI in physically older active women who participate in senior community groups. The variable UI was measured by the International Consultation Incontinence Questionnaire Short Form (ICIQ-SF). Socioeconomic variables were also collected, along with data on life habits and clinical history. The multivariate analysis employed Poisson's Regression with robust variance for factors associated with UI. Of the 106 participants evaluated, 54.7% presented UI, of which stress incontinence was more frequent, with 40.6%. UI presented a statistically significant association with dizziness/loss of balance during Activities of Daily Living (ADL) (prevalence ratio-PR 1.48; 95% CI 1.06-2.07) and nocturia (PR 1.63; 95% CI 1.05-2.55). Despite PA being a protection factor, UI presented an elevated prevalence in the older population, and therefore, other biological, social, and cultural aspects could also contribute to the occurrence of UI in this age group. Moreover, physically active older women with UI presented nocturia and dizziness/loss of balance during ADL, regardless of education levels and the number of births. These findings can help improve multi-professional programs aimed at promoting, preventing, and managing UI in the public.

Differences in Pelvic Floor Symptoms During Pregnancy Between Hispanic and Non-Hispanic White Women

OBJECTIVES

This study aimed to describe and compare pelvic floor symptoms and symptom burden between nulliparous Hispanic and non-Hispanic white women in the third trimester of pregnancy and to determine, in women with stress urinary incontinence (SUI), whether bother differs between groups, adjusted for UI severity.

METHODS

In this cross-sectional analysis, participants completed the Epidemiology of Prolapse and Incontinence and Incontinence Severity Index questionnaires. We compared differences in symptom domains between groups using logistic regression and tested the effect of ethnicity on bother in women with SUI using linear regression.

RESULTS

The sample comprised 418 non-Hispanic white and 154 Hispanic women. Prevalence rates of symptom domains ranged from 5.0% and 7.1% for pelvic organ prolapse to 95.2% and 94.2% for overactive bladder in non-Hispanic white and Hispanic women, respectively. After adjusting age, height, weight, education, physical activity, and gestational age, non-Hispanic whites had 2.37-fold increased odds (95% confidence interval, 1.44-3.92) for defecatory dysfunction and had nonsignificant increases in other symptom domains. Non-Hispanic whites were more likely to endorse symptoms in 3 or more domains than Hispanic women (58.9% vs 40.3%, respectively; P = 0.0001). Given the same UI severity (Incontinence Severity Index), Hispanic women with SUI reported 7.5 points greater bother (Epidemiology of Prolapse and Incontinence) than non-Hispanic white women (P = 0.07).

CONCLUSIONS

After adjustment, we found few differences in the prevalence of pelvic floor symptom domains between Hispanic and non-Hispanic white women, apart from defecatory dysfunction. If differences by ethnicity in other pelvic floor symptoms exist, they do not seem to originate during the first pregnancy.

Effects of Oxytocin for Induction and Augmentation of Labor on Pelvic Floor Symptoms and Support in the Postpartum Period

OBJECTIVE

The aim of the study was to determine whether oxytocin for induction or augmentation of labor impacts the incidence or persistence of pelvic floor symptoms and support 5 to 10 weeks after first vaginal delivery.

METHODS

Participants in this prospective cohort study were nulliparous women 18 years or older that delivered vaginally at 37 weeks gestation or more and completed the Epidemiology of Prolapse and Incontinence Questionnaire (EPIQ) and the Pelvic Organ Prolapse Quantification examination in third trimester and 5 to 10 weeks postpartum. We compared the incidence and persistence of symptomatic EPIQ domains and worse vaginal support (maximal vaginal descent ≥0 cm) between women who received oxytocin with those that did not (with or without prostaglandin or mechanical methods in both groups). We performed modified binomial regression to calculate adjusted relative risks of each outcome with 95% confidence intervals.

RESULTS

The mean (SD) age of the 722 participants was 28.3 (5.2) years; 20% were Hispanic. There were no significant differences according to oxytocin exposure in either incidence or persistence of symptomatic EPIQ domains or worse vaginal support. We found similar results in sensitivity analyses comparing women who received oxytocin as the sole pharmacologic agent to women who received no pharmacologic agent. After adjusting for demographic and obstetric factors associated with incidence and persistence of symptoms and support, oxytocin exposure continued to have no effect.

CONCLUSIONS

Oxytocin during labor does not significantly increase the risks for the incidence or persistence of pelvic floor symptoms or worse vaginal support in the early postpartum period, although power for less frequent outcomes was limited.

Quality of life among pregnant women with urinary incontinence: A cross-sectional study in a Malaysian primary care clinic

BACKGROUND

Pregnant women have an increased risk of urinary incontinence (UI), affecting their quality of life (QoL). This study aims to determine UI and its relationship with QoL among incontinent pregnant women.

METHODS

This was a cross-sectional study in a semi-urban primary care clinic in Selangor, Malaysia, among pregnant women aged 18 years old and above. The validated study instruments consisted of questions on socio-demography, the International Consultation on Incontinence Questionnaire-UI Short Form (ICIQ-UI SF) to determine UI and the International Consultation on Incontinence Questionnaire Lower Urinary Tract Symptoms Quality of Life Module (ICIQ-LUTSQoL) to assess their QoL. A generalised linear model was used to determine the association between the continent and incontinent pregnant women with QoL.

RESULTS

Of the approached 610 respondents, 440 consented to participate in the study, resulting in a response rate of 72.1%. The mean age was 29.8 years old (SD 4.69) with 82.2% (n = 148) having stress UI. Significant independent factors related to the decreased QoL were mid to late trimester (OR 3.06, 95% CI 1.48-6.32), stress UI, (OR 6.94, 95%CI 4.00-12.04) and urge UI (OR3.87, 95%CI 0.48-31.28). Non-Malay improved QoL (OR 0.29, 95% CI 0.16-0.52).

CONCLUSIONS

All types of UI significantly affecting pregnant women's QoL. This information is useful in enhancing antenatal management at the primary care level, whereby they should be screened for UI and provided with effective early intervention to improve their QoL.

3D high frequency endovaginal ultrasound evaluation of urethral and pelvic morphology in stress urinary incontinence in first pregnancy

OBJECTIVE

We aimed to compare the morphological characteristics of pelvis and urethra in nulliparous pregnant women with and without stress urinary incontinence (SUI) by 3D high-frequency endovaginal ultrasound (3D-EVUS).

STUDY DESIGN

At 36-38 weeks of gestation, 40 nulliparous pregnant women with and without SUI underwent 3D-EVUS assessment. The anteroposterior and transverse diameters of levator hiatus (LH), pubovisceral muscle thicknesses at 3,9 and 12 o'clock, right and left paravaginal areas, symphysis angle, bladder-symphysis distance (BSD), uretral complex thickness (Ut), urethral complex width (Uw), urethral complex volume (UV), urethral length (UL), intramural urethra, rhabdosphincter thickness (Rt), rhabdosphincter width (Rw), rhabdosphincter length (RL), and rhabdosphincter volume (RV) were measured by 3D-EVUS.

RESULTS

Longer LH transverse diameter (34.8 ± 3.8 mm vs 31.1 ± 2.1 mm), shorter LH anteroposterior diameter (47.8 ± 6.2 mm vs 52.4 ± 2.6 mm), and wider symphysis angle (116.3 ± 5.6 vs 111.5 ± 5.3 degrees) were detected in nulliparous pregnant women with SUI compared those without SUI (p = 0.001, p = 0.001 and p = 0.013; respectively). RV of less than 1.26 cm³ was found to have a sensitivity of 100 % and a specificity of 100 % for the presence of SUI in nulliparous pregnant women.

CONCLUSIONS

Constitutionally different pelvic shape and decreased urethral rhabdosphincter measurements can be used to predict SUI in nulliparous pregnant women.

Investigating Pelvic Floor Muscle Strength in Women of Reproductive Age and Factors Affecting It

This descriptive study was designed to investigate the pelvic floor muscle strength (PFMS) of women aged 18 to 49 years and to examine the factors that may have an effect on PFMS. The study was conducted on 258 women who visited a gynecology outpatient clinic between January 2019 and January 2020, who met the research criteria, and who agreed to participate in the study. The data were collected using the Sociodemographic Characteristics Information Form. The Modified Oxford Scale (MOS) and a perineometer were used to evaluate the PFMS of the women. The mean PFMS value measured using the perineometer was 31.56 ± 12.17 cmH₂O (moderate pressure). The PFMS values were 20.00 to 29.9 cmH₂O (weak pressure) and 30.00 to 39.9 cmH₂O (moderate pressure) in 23.6% of the women, respectively. The PFMS values measured with MOS were of grade 3 strength (moderate pressure) in 23.6% of the women and grade 2 strength (weak pressure) in 23.3%. A statistically significant strong correlation was found between the perineometer measurement and the women's MOS values. Moreover, a statistically significant difference was found between the PFMS values measured with the perineometer, MOS scores, and women's age groups, educational status, marital status, employment status, income status, persistent cough, use of nicotine, alcohol and coffee consumptions, chronic constipation, history of frequent urinary tract infections, regular exercise, body mass index, history of pregnancy, mode of delivery, use of episiotomy at birth, perineal rupture at birth, use of forceps vacuum at birth, multiple pregnancies, delivery of a baby weighing ≥4,000 g, treatment during pregnancy, hysterectomy, menopause, frequency of sexual intercourse, and pain during sexual intercourse (p < .05). We conclude that most of the women in the study had weak to moderate PFMS, that the evaluation of PFMS with the MOS positively overlapped with the perineometric measurements, and that a number of sociodemographic and obstetric variables act as risk factors that affect PFMS. The PFMS of all women should be assessed as part of their routine gynecological examinations.

Mobile App-Based Intervention for Pregnant Women With Stress Urinary Incontinence: Protocol for a Hybrid Effectiveness-Implementation Trial

Background

Stress urinary incontinence (SUI) is a common source of distress among women during and after pregnancy. It has a negative effect on quality of life but with poor care-seeking. Mobile health (mHealth) may be a promising solution with potential advantages. However, there is uncertainty whether a mobile app is effective for SUI symptom improvement during and after pregnancy. The implementation is also unclear. We developed an app named UIW (Urinary Incontinence for Women) aimed at improving perinatal incontinence.

Objective

The objective of this study is to evaluate the effectiveness of the UIW app-based intervention in improving SUI symptoms among pregnant women and explore the facilitators and barriers to using the UIW app to help refine and optimize the intervention.

Methods

This study is a hybrid effectiveness-implementation trial with a randomized controlled trial alongside a mixed-methods process evaluation according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Pregnant women with SUI (n=336) will be recruited from a university-affiliated hospital in China. They will be randomly allocated (1:1) to either the intervention group that receive usual care plus UIW app or control group that receive usual care alone. The intervention period will last 2 months. The 5 dimensions of the RE-AIM framework will be evaluated at recruitment (-T1), baseline (T0), immediately after intervention (T1), 42 days after delivery (T2), 3 months after delivery (T3), and 6 months after delivery (T4) through project documents, online questionnaires and a pelvic floor muscle training diary, surface electromyography, log data in the background management system, and qualitative interviews. Data analysis will follow the intention-to-treat principle. Descriptive statistics, t tests, chi-square tests, and a linear mixed model will be used to analyze the quantitative data. Deductive and inductive content analysis will be used to analyze the qualitative data.

Results

The effectiveness-implementation trial started in June 2020, trial recruitment was completed in October 2020, and the intervention will last for a 2-month period. Completion of the 6-month follow-up will be in July 2021, and we anticipate that the results of this study will be published in December 2021.

Conclusions

This study will evaluate both effectiveness and implementation of the UIW app-based intervention among pregnant women. The hybrid effectiveness-implementation trial design according to the RE-AIM framework with a mixed-methods approach will give valuable insights into the effects as well as facilitators and barriers to the implementation that will influence the effects of the UIW app-based intervention.

Trial Registration

Chinese Clinical Trial Registry ChiCTR1800016171; http://www.chictr.org.cn/showproj.aspx?proj=27455

International Registered Report Identifier (IRRID)

PRR1-10.2196/22771

Changes in Morphology of the Urethral Rhabdosphincter Postpartum

OBJECTIVE

The aim of the study was to determine the effect of pregnancy on urethral rhabdosphincter cross-sectional area (CSA) and any association of CSA to urinary symptoms.

METHODS

Nulliparous women planning pregnancy (N = 135) underwent standardized evaluations (symptom and quality of life [QOL] questionnaires, magnetic resonance imaging, ultrasonography, and neurophysiologic testing) between January 2008 and December 2013 (V1). The participants who became pregnant and gave birth underwent the same evaluations at 6 weeks (V2) and 6 months postpartum (V3). Participants who had magnetic resonance imaging data from both V1 and V3 were selected. We measured urethral rhabdosphincter CSA from high-resolution axial MRIs in a masked fashion. The mean CSA for each participant was calculated. The change from V1 to V3 was assessed.

RESULTS

Sixty-eight women were evaluated. There was a significant decrease of 0.05 cm2 (interquartile range, -0.03 to 0.16 cm2; P = 0.002) in the median sphincter CSA between V1 and V3. There was a significant increase in the median Urinary Distress Inventory (UDI) subscore of the Pelvic Floor Distress Inventory (PFDI) from V1 to V3 (median increase of 0 [IQR, 0 to 8.3]; P = 0.033), but this was not significantly correlated with the change in the urethral CSA (Spearman correlation, 0.199; P = 0.107). Increasing fetal weight was correlated with a decrease in CSA postpartum after vaginal birth (Spearman correlation, -0.340; P = 0.017).

CONCLUSIONS

There is a decrease in urethral rhabdosphincter CSA with worsening Urinary Distress Inventory scores from prepregnancy to postpartum, but these two do not correlate in this cohort with low symptom levels. Among women who give birth vaginally, decrease in rhabdosphincter CSA is correlated with increasing fetal weight, perhaps with ramifications to be seen later in life.

Musculoskeletal and anthropometric factors associated with urinary incontinence in pregnancy

INTRODUCTION

Urinary incontinence (UI) is a common pelvic floor dysfunction in pregnancy. The relationship between biomechanical changes and pregnancy-related UI has not been fully elucidated.

OBJECTIVE

To investigate the association of various musculoskeletal and anthropometric changes in pregnancy that affect gestational UI.

METHODS

The study was conducted with 275 pregnant women. Ninety-three, 110 and 72 women were in first, second and third trimesters, respectively. Incontinence Impact Questionnaire for UI, Urogenital Distress Inventory-Short Form and Incontinence Severity Index were applied. Lumbar lordosis measurement was performed by Baseline Bubble Inclinometer while diastasis recti abdominis (DRA) measurement was carried out by finger-width method. Manual muscle test for rectus abdominis and right and left external oblique abdominal muscles, and Benign joint hypermobility test with Beighton scoring method were also applied as musculoskeletal measurements. Tape measurement at the waist, umbilical and hip levels, caliper with bi-iliac and bi-trochanteric diameters were also recorded as anthropometric measurements.

RESULTS

Significant associated factors for UI were: umbilical DRA (OR = 1.57; p = .012); rectus abdominis muscle strength (values of 3 and below, OR = 1.2; p = .014); umbilical environment (OR = 1.1; p = .029); bi-iliac diameter (OR = 1.1; p = .05;) and bi-trochanteric diameter (OR = 1.3; p = .05), respectively.

CONCLUSION

Changing musculoskeletal and anthropometric characteristics of pregnant women should be taken into consideration in UI follow-up during pregnancy.

KEPT-app trial: a pragmatic, single-blind, parallel, cluster-randomised effectiveness study of pelvic floor muscle training among incontinent pregnant women: study protocol

INTRODUCTION

Pelvic floor muscle training (PFMT) strongly recommended to incontinent pregnant women. The Kegel Exercise Pregnancy Training-app trial is a multicentre cluster-randomised study aims to assess the effectiveness and its cost-effectiveness of the mobile app guidance in PFMT among incontinent pregnant women.

METHODS AND ANALYSIS

370 pregnant women (aged 18 years old and above) will be recruited with International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form. Ten clusters (primary care clinics) will be randomly assigned to either PFMT or usual care in a 1:1 ratio by an independent researcher (sealed envelope). The primary outcome will be urinary incontinence, and the secondary outcomes (quality of life; PFMT adherence, psychological status and mobile apps' usability) will be assessed at four measurement time points (t0: baseline) and postintervention (t1: 4 weeks, t2: 8 weeks and t3: 8 weeks postnatal). T-test analysis will determine any significant differences at the baseline between the control and intervention groups. The mixed-model analysis will determine the effectiveness of the intervention at the population-average level for both the primary and secondary outcomes. For the cost-effectiveness analysis, expenditures during the study and 6 months after the intervention will be compared between the groups using the multiway sensitivity analysis. The recruitment planned will be in December 2020, and the planned end of the study will be in August 2021.

ETHICS AND DISSEMINATION

This study protocol was approved by the Ethics Committee for Research Involving Human Subjects, Universiti Putra Malaysia (JKEUPM-2019-368) and Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia, NMRR-19-412-47116 (IIR) with the ANZCTR registration. This study will obtain informed written consent from all the study participants. The results which conform with the Consolidated Standards of Reporting Trials and the Recommendations for Interventional Trials will be published for dissemination in peer-reviewed journals and conference proceedings.

TRIAL REGISTRATION NUMBER

ACTRN12619000379112.

Does Urinary Incontinence and Mode of Delivery Affect Postpartum Depression? A Nationwide Population-Based Cohort Study in Korea

We investigated the association between urinary incontinence and postpartum depression. Data were extracted from the Korean National Health Insurance Service-National Sample Cohort and included women who delivered between 2004 and 2013. Postpartum depression was determined using diagnostic codes during the six-month postpartum period. Urinary incontinence was identified as having a prescription of incontinence drugs or a diagnosis. Cox proportional hazard models were used to calculate adjusted hazard ratios. Of the 83,066 women, 5393 (6.49%) had urinary incontinence and 691 (0.83%) had postpartum depression. Postpartum depression was higher among women with urinary incontinence, aged 15–19 years, ≥40 years old, the lowest income level, and who underwent cesarean section delivery. In the combined analysis, women with urinary incontinence and cesarean section had an approximately three times higher risk of postpartum depression compared with those without urinary incontinence and with spontaneous delivery. Women without urinary incontinence and cesarean section, and those with urinary incontinence and spontaneous delivery were at higher risk of postpartum depression compared with the reference group. Urinary incontinence and cesarean section delivery were significantly associated with postpartum depression during the first six months after childbirth. Therefore, further research should be conducted to evaluate whether urinary incontinence contributes to postpartum depression.

Comparing Differences and Similarities Between Chinese and American Women's Experiences of Stress Urinary Incontinence and Health-Seeking Behaviors During Pregnancy

BACKGROUND

Stress urinary incontinence (SUI) is a globally pervasive health condition that is often first experienced during pregnancy and may well continue beyond pregnancy. Yet, definitive numbers of prevalence are uncertain due to multiple factors including embarrassment. This study compares differences and similarities between Chinese and American women's experiences of SUI and health-seeking behaviors during pregnancy.

METHODOLOGY

This study used a cross-sectional design to explore health-seeking behaviors of primigravida women within the first 5 days following birth in China (n = 178) and the United States of America (n = 178) who experienced SUI using the Impact of Incontinence Questionnaire short form (IIQ-SF).

RESULTS

While more Chinese women experienced SUI (p =.049), American women who experienced SUI experienced it earlier in their pregnancy (p = .003) and more frequently (p < .0001) than the Chinese women. Therefore, it can be assumed that although less American women experienced SUI, the impact was greater on their daily living activities. Irrespective of ethnicity, only 14% (n = 18) of women who described having SUI sought medical aid.

CONCLUSION

The disconnect between high incidence and low rates of seeking treatment needs future exploration to develop interventions tailored to educate women about SUI and its role during pregnancy.

Risk Factors for Urinary Incontinence in Pregnancy: A Case Control Study

OBJECTIVE

 Urinay incontinence (UI) is a major public health problem that can harm women in any period of life, including during the gestational period. Urinary incontinence during pregnancy has been studied because this condition can reduce the quality of life and interfere in several aspects of the maternal-fetal binomial. The aim of this study was to determine the prevalence of UI in nullipara pregnant women and to identify risk factors associated with UI in this population.

METHODS

 This is a case-control study in which we invited nullipara women between 12 and 20 weeks of pregnancy to participate in the research. They were asked to answer a specific questionnaire, write a 3-day bladder diary, and undergo a urogynecological evaluation including pelvic organ prolapse quantification (POP-Q), empty stress supine test (ESST), and pelvic floor muscle assessment.

RESULTS

 A total of 70 out of 73 patients accepted to participate in the study, and the prevalence of UI in this population was 18.3%. Tobacco use was identified as an independent risk factor for UI in pregnant women (odds ratio 8.0). All other factors analyzed were not significantly associated to UI in pregnancy.

CONCLUSION

 Urinary incontinence can be a major problem in pregnancy. We identified the use of tobacco as a risk factor for developing UI in pregnancy, which provides an extra reason to encourage patients to quit smoking.

Urinary incontinence experiences of pregnant women: A qualitative study

OBJECTIVE

The research was carried out to determine the life experiences of pregnant women who have urinary incontinence problems.

METHODS

The type of the research is of qualitative type. Views of pregnant women were coded according to repeating frequencies; then thematic grouping was done. Both common views and individual repetitions of the pregnant women were coded. During the study, 52 pregnant women stated that they had urinary incontinence problems. However, five pregnant women did not want to participate in the study and six pregnant women wanted to leave during the interview. Interviews ended with 41 pregnant women.

RESULTS

In the study, the mean age of the pregnant women was determined as 29.75 ± 4.83, and the mean gestational week was 27.85 ± 5.60. The views of pregnant women are divided into five main themes and 16 sub-themes. The main themes for the urinary incontinence life experiences of pregnant women were determined as "strategies to take precautions, psychological effects, pregnancy and baby-specific effects, physical effects and changes in their relationship with the spouse."

CONCLUSION

As a result, it was determined that urinary incontinence problem negatively affected the life experience of pregnant women.

Cardiopulmonary exercise testing during pregnancy

The goal of this review is to examine practical considerations when conducting cardiopulmonary exercise testing during pregnancy. In a clinical and research setting, cardiopulmonary exercise testing during pregnancy is valuable in identifying underlying cardiopulmonary conditions, stratifying the risk of adverse pregnancy outcomes, as well as establishing exercise tolerance/limitations. This review encompasses information regarding the unique physiological adaptations that occur throughout gestation (e.g., changes in resting heart rate, blood pressure, glucose, etc.) and how these adaptations impact the interpretation of physiological measurements. There are also key concerns that are unique to pregnant populations that should be considered when participating in exercise (i.e., fetus, ventilation, thermoregulation, urinary incontinence, low back pain, and pelvic girdle pain). This step-by-step review of cardiopulmonary exercise testing outlines pregnancy related adjustments to standardized methods (i.e., screening/documentation, pre- and post-test measurements, protocol specifics, modality selection, and fetal monitoring) which should be considered for the safety of both the participant and fetus. Currently, pregnancy specific exercise testing guidelines are lacking. Therefore, we will be discussing the limitations of current recommendations such as a safe cut off for resting heart rate and pregnancy specific test termination criteria.

Pelvic floor muscle training for women with lumbopelvic pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

It has been suggested that pelvic floor dysfunction may contribute to the development of lumbopelvic pain as a result of changes in trunk muscle control. However, there is limited evidence that pelvic floor muscle training (PFMT) can improve clinical outcomes in women with lumbopelvic pain.

DATABASES AND DATA TREATMENT

Six databases were searched for randomized controlled trials (RCTs) comparing the effectiveness of PFMT to other conservative interventions (usual physiotherapy care or minimal intervention), no treatment or placebo interventions on pain and disability in women with lumbopelvic pain.

RESULTS

We included eight RCTs totalling 469 participants. PFMT was more effective than minimal intervention for lumbopelvic pain [mean difference (MD) 15.9/100 (95% confidential interval (CI), 8.2 to 23.6; p = 0.00; I²  = 3.92%)] and disability [standardized mean difference (SMD) 0.5 (95% CI 0.1-0.9; p = 0.00; I²  = 0%)] during pregnancy. PFMT was more effective than usual physiotherapy care for pain (MD 11.7/100 [95% CI 7.5-15.9; p = 0.00; I²  = 94.14%]) and disability (SMD 0.3 (95% CI 0.0-0.6; p = 0.01; I²  = 82.54%]) in non-pregnant women. Effect sizes were in general of arguable clinical relevance.

CONCLUSIONS

Overall, the certainty of the evidence was very low to low. There is no conclusive evidence that the addition of PFMT to usual physiotherapy care or minimal intervention is superior to minimal intervention and usual care alone given the small number of studies and high levels of heterogeneity of included studies. Further well-designed trials are needed to establish the effectiveness of PFMT for lumbopelvic pain in women.

Effects of pelvic floor muscle training in pregnant women

Objective:

The aim is to verify the effectiveness of the pelvic floor muscle training (PFMT) program in pregnant women, by analyzing the amount of urine leakage.

Design:

Experimental study.

Location:

Care units in the Vila Real district, Portugal.

Participants:

Forty-three pregnant women divided into an experimental group (EG) (n = 22) and a control group (CG) (n = 21).

Interventions:

Both groups were evaluated in a predelivery stage (initial) and 6 months after delivery (final). The EG was given a PFMT exercise protocol with a duration of 6 weeks, applicable in classes and at home, another PFMT protocol for 9 weeks.

Main measurements:

The strength of the pelvic floor muscle was measured by the Oxford Grading Scale and the amount of urine was assessed with a Pad test. Quality of life was measured by the King's Health Questionnaire and self-efficacy by the Broome Pelvic Muscle Self-Efficacy Scale.

Results:

The loss of urine, significantly reduced from 0.86 ± 0.83 to 0.50 ± 0.67 in the EG (P = .021), whereas in the CG no significant change was observed. The degree of muscle contraction increased by 4.82 ± 0.39 in EG and 3.95 ± 0.67 in CG. The quality of life observed significant improvements in both groups (P < .05). As for self-efficacy, for the EG it improved significantly – initial (P = .001), final (P = .031), and for the CG the values remained the same.

Conclusions:

This PFMT protocol reduced urinary incontinence in pregnant women. The program allowed significant improvement in the quantity of urinary leakage and an increase in the strength of the pelvic floor muscle.

Prevention of Urinary Incontinence in Women

PURPOSE OF REVIEW

Despite available treatments for urinary incontinence, the data regarding prevention is less established. This review sought to identify prevention measures and discuss their underlying evidence base with an attempt to include the most recent updates in the field.

RECENT FINDINGS

Urinary incontinence is a prevalent issue among women, particularly surrounding pregnancy and menopause. Interventions regarding pregnancy include not only general health promotion but also potentially interventions such as pelvic floor muscle training and decisions regarding method of delivery. With regard to menopause, the literature suggests avoiding treatments that have adverse effects on continence. Lastly, promoting healthy life style and reducing effects of co-morbid conditions can impact a woman's continence. The literature indicates that preventative strategies exist for urinary incontinence, though the data is limited in this area. Further work is needed to determine the impact of prevention measures and how best to implement them.

Hemorrhoids Are Associated with Urinary Incontinence

Background: Hemorrhoids are a common anal disorder and are more frequent in women than in men. Urinary incontinence (UI) also occurs more frequently in women than in men. Although both diseases share similar risk factors, research on the association between the two diseases is lacking. This study aimed to investigate the relationship between hemorrhoids and UI in adult Korean women. Methods: This study was based on the data of the 2008-2009 Korean National Health and Nutrition Examination Survey. Logistic regression test was performed to determine the relationship between hemorrhoids and UI after adjusting for age, body mass index (BMI), smoking, heavy drinking, physical activity, education level, income, diabetes mellitus, and hypertension. Results: Analysis of the data of 8,139 adult women revealed that the prevalence of hemorrhoids, which were self-reported and diagnosed by a physician, was 17.5% and 7.9%, respectively. Both types of hemorrhoids were more prevalent in older women with spouses, those with a large waist circumference, and those with a high BMI. The prevalence of UI was significantly high in the hemorrhoid group, regardless of whether it was self-reported or diagnosed by a physician. Multiple logistic regression analyses revealed a significant association between the prevalence of UI and hemorrhoids, both of which were found to peak at 19-39 years of age. Conclusions: Our findings demonstrate that hemorrhoids are significantly correlated with UI in adult Korean women. When treating adult women with hemorrhoids, it is, therefore, necessary to consider other pelvic floor diseases such as UI.

Deleterious effects of gestational diabetes mellitus on the characteristics of the rectus abdominis muscle associated with pregnancy-specific urinary incontinence

AIMS

To evaluate the effects of gestational diabetes mellitus (GDM) on the structural characteristics of the rectus abdominis muscle (RAM) and its indirect effects on pregnancy-specific urinary incontinence (PSUI).

METHODS

A total of 92 pregnant women were divided into four groups, according to their clinical conditions: non-GDM continent, non-GDM associated PSUI, GDM continent and GDM associated PSUI. The muscle morphometry (histochemistry and immunohistochemistry) for the fiber types and collagen fiber distribution, the ultrastructural analysis (transmission electron microscopy), the protein expression of fiber types and calcium signaling (Western blotting), and the content of types I and III collagen fiber (ELISA) in RAM collected at delivery were assessed.

RESULTS

The GDM groups presented a significantly increased number of slow fibers and slow-twitch oxidative fiber expression; decreased fiber area, number of fast fibers, and area of collagen; an increase in central nuclei; ultrastructural alterations with focal lesion areas such as myeloid structures, sarcomere disorganization, and mitochondrial alteration. The PSUI groups presented a considerable decrease in types I and III collagen contents and the localization of collagen fiber.

CONCLUSIONS

Our data reveal that GDM causes morphological, biochemical and physiological changes in the RAM, and this might predispose women to PSUI.

Urinary incontinence and its association with pelvic floor muscle exercise among pregnant women attending a primary care clinic in Selangor, Malaysia

Background

Urinary Incontinence (UI) is when a person is unable to hold his/her urine effectively. This is a common problem which can develop and worsen during pregnancy. An effective way to manage UI is to educate patients on the Pelvic Floor Muscle Exercise (PFME) regularly. The present study aimed to ascertain the pregnant women’s knowledge, attitudes, and practices (KAP) related to PFME.

Methods

This was a cross-sectional study done in a one primary care clinic located in a semi-urban area in Selangor, Malaysia. Simple random sampling was conducted among pregnant women aged 18 years old and above at any gestation. The validated study instruments used consisted of questions on socio-demography, KAP on UI, and also the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form to determine UI among the respondents.

Results

The response rate for this study was 72.1%, where 440 pregnant women consented to take part in the study. The median age of study respondents was 30 years old and majority of the study respondents was from the Malay ethnicity (80.9%). The prevalence of UI was 40.9%. The proportion of pregnant women with good knowledge, attitude and practice scores were 58.0%, 46.6% and 45.2% respectively. There was a significant association between UI and age (p = .03), body mass index (p = .03), ethnicity (p = .04), gravida. (p = .001), knowledge on PFME (p = .007) and attitude towards PFME (p = .006).

Conclusions

Findings from this study fill a gap in the prevalence and KAP concerning PFME at the primary care level. The foundation areas for future education and health promotion on UI should address the importance of correct PFME. This education can be delivered through a pragmatic way to ensure its effectiveness and sustainability of the health promotion program.

Risk Factors for Postpartum Stress Urinary Incontinence: a Systematic Review and Meta-analysis

Stress urinary incontinence (SUI) is a distressing symptom affecting females globally and is one of the most common complications of delivery. The etiology of female SUI is multifactorial, and the trauma caused by delivery is one of the most important risk factors for SUI. We performed a meta-analysis to determine the relationship between these various factors and postpartum SUI. We searched PubMed, Embase, Web of Science, and the Cochrane Library until January 2019 using appropriate keywords and extracted 46 eligible studies that included 73,010 participants. The study protocol was registered with PROSPERO (No. CRD42020150094). The pooled results indicated that 12 risk factors, including vaginal delivery (OR 2.08, 95% CI 1.72-2.52), advanced age at gestation (OR 1.06, 95% CI 1.04-1.08), advanced maternal BMI (OR 1.04, 95% CI 1.03-1.06), excess weight gain during pregnancy (OR 1.13, 95% CI 1.00-1.26), advanced current BMI (OR 1.32, 95% CI 1.02-1.70), diabetes (OR 1.91, 95% CI 1.53-2.38), episiotomy (OR 1.76, 95% CI 1.06-2.94), forceps delivery (OR 2.69, 95% CI 1.25-5.76), gestational UI (OR 5.04, 95% CI 2.07-12.28), gestational SUI (OR 4.28, 95% CI 2.61-7.01), prenatal UI (OR 8.54, 95% CI 3.52-20.70), and early postpartum UI (OR 3.52, 95% CI 1.61-7.69), were associated with postpartum SUI. The findings of this analysis could serve to generate risk prediction models and provide a basis for developing treatment strategies for patients with postpartum SUI.

Pregnancy-specific urinary incontinence in women with gestational hyperglycaemia worsens the occurrence and severity of urinary incontinence and quality of life over the first year post partum

OBJECTIVE

To determine the occurrence and severity of pregnancy-specific urinary incontinence (PSUI) in women with gestational hyperglycaemia, and its impact on quality of life (QoL) over the first year post partum.

STUDY DESIGN

Three hundred and eighty-eight pregnant women with PSUI were distributed into two groups (normoglycaemic and hyperglycaemic) and analysed at five timepoints during pregnancy and the first year post partum. Gestational hyperglycaemia was defined according to the criteria of the American Diabetes Association and the glucose profile test. Relationships with outcome were analysed using Chi-squared test for categorical variables and Student's t-test for quantitative variables.

RESULTS

The overall prevalence rate of PSUI was 54.1 %, with prevalence rates of 43.3 % and 56.7 % in normoglycaemic and hyperglycaemic Brazilian pregnant women, respectively. Women with gestational hyperglycaemia had a higher amount of urine loss (p < 0.0027), frequency of UI (p < 0.0014), impact of UI on QoL (p < 0.0001), severity of UI (p = 0.0003) and total scores on the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-SF) and Incontinence Severity Index (ISI) (p<0.0001) at the two timepoints during pregnancy; and a higher amount of urine loss (p = 0.0079), frequency of UI (p = 0.0382), impact of UI on QoL (p < 0.0001), severity of UI (p = 0.0053) and questionnaire scores (p < 0.0001 for ICIQ-SF and p = 0.003 for ISI) over the first year post partum.

CONCLUSIONS

PSUI in women with gestational hyperglycaemia worsens the occurrence and severity of UI, and the impact of UI on QoL over the first year post partum. These results emphasize the interaction between PSUI, gestational hyperglycaemia and long-term maternal outcome.

Pelvic floor dysfunction symptoms and risk factors at the first year of postpartum women: a cross-sectional study

Objective: The aim of this study was to determine the frequency of pelvic floor dysfunction (PFD) symptoms experienced the first year of postpartum and obstetric risk factors. Methods: This research was a cross-sectional descriptive study. The study was conducted with 408 women between 3 and 12 months postpartum, in İzmir. Results: It was found that urinary incontinence had been experienced by 33.3% of the women during pregnancy and 25.2% postpartum and 2.9% had experienced fecal incontinence. Other frequently experienced symptoms of PFD were in the order of frequency, perineal pain (53.4%), constipation (40.7%), flatulence (34.1%), dyspareunia (27.7%) and fecal incontinence (2.9%). Conclusion: PFD symptoms are common in postpartum women. Early diagnosis, treatment and preventive approaches should be made by healthcare professionals for perinatal pelvic floor health. Impact statement: Healthcare professionals should acknowledge the importance of PFD after birth and identify the problems early period. Our study emphasizes the size of the problem and improvement for PFD.

Prenatal high-low impact exercise program supported by pelvic floor muscle education and training decreases the life impact of postnatal urinary incontinence: A quasiexperimental trial

BACKGROUND

Pregnancy and high impact exercise may cause postnatal urinary incontinence. We aimed to evaluate the life impact of postnatal urinary incontinence in women attending prenatal, high-low impact exercise program, supported by pelvic floor muscle education and training, in comparison to controls.

METHODS

It was a quasiexperimental trial among 260 postpartum Caucasian women (age 29 ± 4 years; mean ± standard deviation). The training group (n = 133) attended a high-low impact exercise and educational program from the 2nd trimester of pregnancy until birth, 3 times a week. We educated this group to contract and relax pelvic floor muscles with surface electromyography biofeedback and instructed how to exercise postpartum. Control women (n = 127) did not get any intervention. All women reported on the life impact of urinary incontinence 2 months and 1 year postpartum using the Incontinence Impact Questionnaire (IIQ).

RESULTS

Training group started regular pelvic floor muscle exercises substantially earlier postpartum than controls (P < .001). Significantly less training women reported the life impact of urinary incontinence both 2 months (P = .03) and 1 year postpartum (P = .005). Two months after birth, for the symptomatic women the IIQ scores were significantly lower in the training than in the control women (median [Me] = 9.4 vs Me = 18.9; P = .002). Between the 1st and 2nd assessments the number of women affected by incontinence symptoms decreased by 38% in the training group and by 20% in the controls.

CONCLUSION

High-low impact activities supported by pelvic floor muscle exercises and education should be promoted among pregnant, physically active women. Such activities may help women to continue high-intensity exercise with the simultaneous prevention of postnatal urinary incontinence.Thy study was registered at ISRCTN under the title "Pelvic floor muscle training with surface electromyography" (DOI 10.1186/ISRCTN92265528).

Prevalence and associated risk factors of urinary incontinence and dyspareunia during pregnancy and after delivery

OBJECTIVE

The objective of this study is to estimate the prevalence of dyspareunia and stress urinary incontinence (SUI) during pregnancy and after delivery, in addition to evaluating possible associated risk factors.

STUDY DESIGN

A cross-sectional study was conducted in 2016 with the target population being women who had given birth within the previous 12 months (n = 6436) in Galicia (Spain). Information was collected regarding the mother's status 6 months before pregnancy, during pregnancy, at the time of delivery, and at the time of the survey. The prevalence of SUI and dyspareunia were estimated and regression models were performed to identify variables associated with both pathologies.

RESULTS

The prevalence of SUI and dyspareunia after delivery were 20.4 % (CI95 %: 19.2-22.0) and 23.4 % (22.3-24.8), respectively. The presence of dyspareunia during pregnancy (adjusted prevalence ratio PR 2.1), breastfeeding (PR 1.2), and having a history of episiotomy (PR 1.3) were all variables associated with the presence of dyspareunia after delivery. SUI after delivery was related to the mother's history of SUI before pregnancy (PR 2.4) and during pregnancy (PR 2.0), as well as having undergone vaginal delivery (PR 2.0).

CONCLUSION

Knowing which factors are associated with the manifestation of SUI and dyspareunia in women after delivery is useful for identifying susceptible or "at risk" patients. These variables should be included in the clinical history of every pregnant woman.

Association between sexual intercourse frequency and pelvic floor muscle morphology in pregnant women

INTRODUCTION AND HYPOTHESIS

No studies have been performed to examine the association of sexual activity and pelvic floor muscle (PFM) morphology or function during pregnancy. The aim of this study was to survey the frequency of sexual intercourse and examine the associations between the frequency of sexual intercourse and the PFM morphology in pregnant women of mainland China. The relationship between sexual intercourse frequency and stress urinary incontinence (SUI)-related symptoms was also evaluated.

METHODS

Pregnant women in their first or second trimester were enrolled from January 2017 and November 2017. The morphology of the PFM was examined by transperineal ultrasound, and SUI-related symptoms were assessed by the International Consultation of Incontinence Questionnaire-Short Form (ICIQ-SF). Multivariable regression analyses were used to estimate coefficients [95% confidence intervals (CI)] with adjustment for the possible effects of cofounders.

RESULTS

In total, 323 pregnant women (mean age, 29.66 ± 4.32 years) were included in the analysis. Almost 49% of the women had no sexual intercourse during pregnancy. Compared with pregnant women who had no sexual intercourse, those who had sexual intercourse more than once a month had stronger LA th at rest (β = 0.59, P = 0.004 for two or three times per month; β = 0.59, P = 0.044 for weekly or more). No significant relationship was found between the frequency of sexual intercourse and any ICIQ-SF-related items.

CONCLUSIONS

Chinese women had inactive sexual intercourse during pregnancy. There is a slight association between increased sexual intercourse frequency and a thicker levator ani muscle in pregnant women. Future work may be directed at determining the causality of this association.

Prevalence and factors associated with the occurrence of urinary incontinence during pregnancy

Abstract Objectives: to determine the prevalence of urinary incontinence (UI) during pregnancy, to identify and quantify the factors associated with gestational UI. Methods: a cross-sectional study carried out with women admitted for deliveries in all maternity wards in the city of Botucatu (São Paulo). Data were collected through a structured questionnaire, based on the literature, containing questions about the occurrence of UI, its types, risk factors and moments when urinary losses occurred. Associations between UI and the predictive variables were analyzed with logistic regression models. Results: 950 women were interviewed, out of which 472 complained of urinary losses during pregnancy, resulting in a prevalence of 49.68% (CI95%= 46.51 - 52.86). The majority (61.8%) were classified as mixed UI. Among the covariates investigated, smoking (OR= 4.56), illicit drugs use (OR= 25.14), stimulant foods (OR= 1.84), constipation (OR=1.99), hypertensive disorders during gestation (OR= 3.23), gestational diabetes mellitus (OR= 2.89), parity (OR= 1.52) and previous caesarean sections (OR= 2.56) increased the chance of urinary losses during pregnancy. Conclusions: there was a high prevalence of UI during pregnancy. This condition was strongly associated with lifestyle habits and gestational morbidities. Finally, it is worth high-lighting the fact that delivery via caesarean section increased the chance of UI in subsequent pregnancies.

Pelvic floor muscles after birth: Do unstable shoes have an effect on pelvic floor activity and can this be measured reliably? – A feasibility study / Der Beckenboden nach der Geburt: Verändern instabile Schuhe die Aktivität und kann diese reliabel gemessen werden? – Eine Machbarkeitsstudie

Background

Women often suffer from urinary incontinence after childbirth. Pelvic floor muscle training is an evidenced-based intervention to prevent urinary incontinence and improve its symptoms

Aim

The primary purpose of this study was to determine if there is a change in the activation of the pelvic floor muscles with different extrinsic parameters (barefoot versus unstable shoe). Second, we wanted to define variables that can be measured reliably and correlated with pelvic floor activity.

Methods

Data of 15 women who were 8 weeks to 6 months postpartum were analyzed. Two conditions (“barefoot” and “kyBoot”) were tested, with each participant performing three different tasks: walking, standing with an active pelvic floor, and standing with a passive pelvic floor. Three-dimensional kinematics of the body were recorded. Activity of the abdominal, back, and gluteal muscles was measured using surface electromyography (EMG). The activity of the pelvic floor was recorded using a vaginal electrode. Maximum pelvic floor activity was compared for each condition, and correlations among pelvic floor activity, kinematic variables, and skeletal muscle activity were determined.

Results

The maximum activity of the pelvic floor while walking was significantly higher when participants were barefoot than when they were wearing kyBoot shoes. For the standing trials, no significant differences between the conditions were detected. No surrogate marker was found to measure the pelvic floor activity.

Conclusion

With regard to the pelvic floor musculature, no recommendation is possible in favor of or against wearing unstable shoes. Technical developments are necessary to provide solutions to reliably measure the pelvic floor activity.

Gene expression in stress urinary incontinence: a systematic review

INTRODUCTION

A contribution of genetic factors to the development of stress urinary incontinence (SUI) is broadly acknowledged. This study aimed to: (1) provide insight into the genetic pathogenesis of SUI by gathering and synthesizing the available data from studies evaluating differential gene expression in SUI patients and (2) identify possible novel therapeutic targets and leads.

METHODS

A systematic literature search was conducted through September 2017 for the concepts of genetics and SUI. Gene networking connections and gene-set functional analyses of the identified genes as differentially expressed in SUI were performed using GeneMANIA software.

RESULTS

Of 3019 studies, 4 were included in the final analysis. A total of 13 genes were identified as being differentially expressed in SUI patients. Eleven genes were overexpressed: skin-derived antileukoproteinase (SKALP/elafin), collagen type XVII alpha 1 chain (COL17A1), plakophilin 1 (PKP1), keratin 16 (KRT16), decorin (DCN), biglycan (BGN), protein bicaudal D homolog 2 (BICD2), growth factor receptor-bound protein 2 (GRB2), signal transducer and activator of transcription 3 (STAT3), apolipoprotein E (APOE), and Golgi SNAP receptor complex member 1 (GOSR1), while two genes were underexpressed: fibromodulin (FMOD) and glucocerebrosidase (GBA). GeneMANIA revealed that these genes are involved in intermediate filament cytoskeleton and extracellular matrix organization.

CONCLUSION

Many genes are involved in the pathogenesis of SUI. Furthermore, whole-genome studies are warranted to identify these genetic connections. This study lays the groundwork for future research and the development of novel therapies and SUI biomarkers in clinical practice.

Urinary incontinence after uncomplicated spontaneous vaginal birth in primiparous women during the first year after birth

Introduction and hypothesis

Urinary incontinence (UI) is associated with pregnancy and parity and can cause health problems for women. Our objective was to explore risk factors for UI and its effect on women’s daily activities, psychological health and wellbeing 9–12 months postpartum in a low-risk primiparous population.

Methods

In this prospective cohort study, first-time mothers in a low-risk population with a spontaneous vaginal birth reported the occurrence of UI and its effect on daily activities and on their psychological health and wellbeing in a questionnaire completed 1 year after birth. Descriptive and comparative statistics were employed for the analysis.

Results

A total of 410 women (75.7%) completed the questionnaire. The self-reported rates of stress urinary incontinence, urge urinary incontinence and mixed urinary incontinence were 45.4%, 38.0% and 27.0% respectively. Neither the duration of the second stage of labour, the baby’s head circumference or its birth weight were associated with the incidence of UI. There was an association between reported negative impact on daily activities and more negative psychological wellbeing (p < 0.001).

Conclusions

Urinary incontinence was common among primiparous women at 9–12 months postpartum. Women whose symptoms had a negative impact on their daily activities reported more psychological suffering.

Effectiveness of electrical stimulation combined with pelvic floor muscle training on postpartum urinary incontinence

BACKGROUND

Previous clinical trials have reported that electrical stimulation (ES) combined with pelvic floor muscle training (PFMT) can be used to treat postpartum urinary incontinence (PPUI) effectively. However, no systematic review has investigated the effectiveness and safety of ES plus PFMT for the treatment of patients with PPUI. In this systematic review, we will firstly assess the effectiveness and safety of ES and PFMT for treating PPUI.

METHODS

In this study, we will search the following electronic databases: Cochrane Library, Web of Science, Springer, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure from inceptions to the present without language restrictions. All eligible randomized controlled trials (RCTs) on the effectiveness of ES plus PFMT for PPUI will be included. We will also search grey literature to avoid missing any other potential qualified studies. Two authors will independently conduct the study selection, data extraction, and risk of bias assessment. A third author will be consulted to solve any disagreements between 2 authors. RevMan 5.3 Software will be used to pool the data and to carry out the meta-analysis.

RESULTS

This study will provide high quality evidence of ES and PFMT for PPUI. The primary outcome includes symptoms improvement. The secondary outcomes consist of incontinence-specific quality of life, clinician's observations, and adverse effects.

CONCLUSION

The findings of this study will summary up-to-dated evidence for judging whether ES combined PFMT is an effective intervention for PPUI or not.

ETHICS AND DISSEMINATION

This study does not needs ethical approval, because it will not involve individual patient data. Its findings will be disseminated through peer-reviewed journals.

SYSTEMATIC REVIEW REGISTRATION

CRD42019122540.

High-Low Impact Exercise Program Including Pelvic Floor Muscle Exercises Improves Pelvic Floor Muscle Function in Healthy Pregnant Women - A Randomized Control Trial

Background: Pregnancy and high-impact activity are considered as risk factors for pelvic floor dysfunctions, including urinary incontinence.

Aim: To investigate whether a structured exercise program, including high- and low-impact aerobics and supported by pelvic floor muscle exercises, improves the neuromuscular activity of the pelvic floor and does not reduce the quality of life in terms of urinary incontinence in healthy pregnant women.

Methods: This was a randomized control trial among 97 Caucasian healthy nulliparas in uncomplicated pregnancies (age 30 ± 4 years, 21 ± 5 weeks of gestation; mean ± SD). Women were assessed for pelvic floor muscle functions with surface electromyography (EMG) using vaginal probes and using the Incontinence Impact Questionnaire (IIQ). Only women able to contract pelvic floor muscles and with good quality of life based on IIQ were included for the study. Seventy women in the experimental group took part in a supervised exercise program including high-low impact aerobics and pelvic floor muscle exercises three times a week. Twenty-seven controls did not receive any exercise intervention. After 6 weeks both groups were re-tested with EMG and IIQ. Post- and pre-exercise program changes in each group were analyzed using a repeated-measures ANOVA.

Results: Women in the experimental group improved the neuromuscular activity of the pelvic floor in some motor tasks without any adverse outcomes of the intervention. After the exercise program we observed in the experimental group significantly higher EMG amplitude in the pelvic floor muscles during 3-s contractions (p = 0.014). We also noticed a beneficial trend in the increase of neuromuscular activity during 10- and 60-s contractions, but the changes were not statistically significant. The exercising women substantially improved their abilities for relaxation following 3- and 10-s contractions (p = 0.013 and p < 0.001). In controls, we reported no statistically significant improvement in either of the motor tasks. All study participants maintained good quality of life related to urinary incontinence.

Conclusion: Prenatal exercise programs that include high- and low-impact aerobics and are supported by pelvic floor muscle exercises should be recommended for pregnant women, especially those who are accustomed to higher exercise intensity before pregnancy. Nevertheless, these recommendations can be directed to continent women who can properly contract pelvic floor muscles.

ISRCTN. DOI: 10.1186/ISRCTN92265528: “Pelvic floor muscle training with surface electromyography”, retrospectively registered on the 25th of July, 2016.

The anatomy of urination: What every physician should know

Normal voiding needs a coordinated, sustained bladder contraction of adequate size and duration. It requires a decrease in resistance of the bladder neck and urethra and no obstruction. Voiding problems can arise from abnormal storage of urine or problems with urinary control. The aim of this article was to review the functional anatomy and physiology of urinary control and micturition and the pathophysiology of urinary control problems. The Medline (PubMed) database, Cochrane Library, and Science Citation Index were searched electronically to identify original published studies on bladder anatomy, function and urinary control. References were searched from relevant chapters in specialized texts and all were included. Voiding problems are the most common presenting urological symptoms in general medical practice. Urinary incontinence occurs when the normal process of storing and passing urine is disrupted. A history of coexisting fecal incontinence suggests a neuropathic etiology. A better understanding of the physiology of urinary control could lead to preventive measures for postoperative urinary retention and incontinence such as fluid restriction and to appropriate anesthesia/analgesia, autonomic nerve preservation, total mesorectal excision (TME) for rectal cancer, and biofeedback exercises. It could also suggest appropriate therapeutic measures for established urinary incontinence. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.

Prenatal exercise (including but not limited to pelvic floor muscle training) and urinary incontinence during and following pregnancy: a systematic review and meta-analysis

OBJECTIVE

To examine the relationships between prenatal physical activity and prenatal and postnatal urinary incontinence (UI).

DESIGN

Systematic review with random effects meta-analysis and meta-regression.

DATA SOURCES

Online databases were searched up to 6 January 2017.

STUDY ELIGIBILITY CRITERIA

Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcome (prenatal or postnatal UI).

RESULTS

24 studies (n=15 982 women) were included. 'Low' to 'moderate' quality evidence revealed prenatal pelvic floor muscle training (PFMT) with or without aerobic exercise decreased the odds of UI in pregnancy (15 randomised controlled trials (RCTs), n=2764 women; OR 0.50, 95% CI 0.37 to 0.68, I²=60%) and in the postpartum period (10 RCTs, n=1682 women; OR 0.63, 95% CI 0.51, 0.79, I²=0%). When we analysed the data by whether women were continent or incontinent prior to the intervention, exercise was beneficial at preventing the development of UI in women with continence, but not effective in treating UI in women with incontinence. There was 'low' quality evidence that prenatal exercise had a moderate effect in the reduction of UI symptom severity during (five RCTs, standard mean difference (SMD) -0.54, 95% CI -0.88 to -0.20, I²=64%) and following pregnancy (three RCTs, 'moderate' quality evidence; SMD -0.54, 95% CI -0.87 to -0.22, I²=24%).

CONCLUSION

Prenatal exercise including PFMT reduced the odds and symptom severity of prenatal and postnatal UI. This was the case for women who were continent before the intervention. Among women who were incontinent during pregnancy, exercise training was not therapeutic.

The frequency of maternal morbidity: A systematic review of systematic reviews

Background

Estimates of the burden of maternal morbidity are patchy.

Objective

To conduct a systematic review of systematic reviews of maternal conditions to: (1) make available the most up‐to‐date frequency estimates; (2) identify which conditions do not have reliable estimates; and (3) scrutinize the quality of the available reviews.

Search strategy

We searched Embase, MEDLINE, and CINAHL, combining terms for pregnancy, frequency (e.g. prevalence, incidence), publication type, and specific terms for each of 121 conditions.

Selection criteria

We included peer‐reviewed systematic reviews aiming to estimate the frequency of at least one of the conditions in WHO's list of maternal morbidities, with estimates from at least two countries.

Data collection and analysis

We present the frequency estimates with their uncertainty bounds by condition, region, and pregnancy/postpartum period. We also assess and present information on the quality of the systematic reviews.

Main results

Out of 11 930 found, 48 reviews were selected and one more was added. From 49 reviews we extracted 34 direct and 60 indirect frequency estimates covering 35 conditions. No review was available for 71% of the conditions on the WHO list. The extracted estimates show substantial maternal morbidity, spanning the time before and beyond childbirth. There were several gaps in the quality of the reviews. Notably, one‐third of the estimates were based only on facility‐based studies.

Conclusions

Good‐quality systematic reviews are needed for several conditions, as a research priority.

This study highlights that substantial maternal morbidity occurs along the pregnancy–postpartum continuum, and that conducting quality systematic reviews is a priority research gap.

Six-Week Pelvic Floor Muscle Activity (sEMG) Training in Pregnant Women as Prevention of Stress Urinary Incontinence

BACKGROUND Pelvic floor muscle exercises are a widely used and well-established form of stress incontinence treatment, with success rates varying from 21% to 84%, although with a better subjective than objective outcome. MATERIAL AND METHODS "Incontinence Impact Questionnaire" (IIQ), PFM EMG assessment was done at the beginning and after the 6-week training program. RESULTS Statistically significant differences appeared in the BASE and R values. In the symptomatic group (with SUI symptoms), the value of BASE was 3.26 µV, and after training it was 3.95 µV. The R values before and after training were 4.55 µV and 4.25 µV. In the symptomatic group (without SUI symptoms), the value of BASE was 2.88 µV and 3.52 µV and R values were 7.16 µV and 3.92 µV. In the control group, BASE was 3.05 µV and 4.11 µV and R was 7.82 µV and 4.39 µV. CONCLUSIONS The results indicate that a 6-week training process influences PFM EMG activity in pregnant women. During Q, the value of PFM activity after a training session tended to increase in the symptomatic and control groups, but in the symptomatic group it remains practically unchanged. Our results show the probable process of decreasing control of PFM activity during long-lasting contractions in symptomatic and control women. The comparison of BASE before and after training averaged the values of R after five 10-s contractions and showed an increase in the Base and decrease in the R.

Predicting stress urinary incontinence during pregnancy: combination of pelvic floor ultrasound parameters and clinical factors

INTRODUCTION

The aim of this study was to develop and validate a predictive tool that combines pelvic floor ultrasound parameters and clinical factors for stress urinary incontinence during pregnancy.

MATERIAL AND METHODS

A total of 535 women in the first or second trimester of pregnancy were included for an interview and transperineal ultrasound assessment from two hospitals. Imaging data sets were analyzed offline to assess for bladder neck vertical position, urethra angles (α, β and γ angles), hiatal area and bladder neck funneling. All significant continuous variables at univariable analysis were analyzed by receiver operating characteristics. Three multivariable logistic models were built on clinical factors, and combined with ultrasound parameters. The final predictive model with best performance and fewest variables was selected to establish a nomogram. Internal and external validation of the nomogram was performed by both discrimination represented by C-index and calibration measured by Hosmer-Lemeshow test. A decision curve analysis was conducted to determine the clinical utility of the nomogram.

RESULTS

After excluding 14 women with invalid data, 521 women were analyzed. β angle, γ angle and hiatal area had limited predictive value for stress urinary incontinence during pregnancy, with area under curves of 0.558-0.648. The final predictive model included body mass index gain since pregnancy, constipation, previous delivery mode, β angle at rest, and bladder neck funneling. The nomogram based on the final model showed good discrimination with a C-index of 0.789 and satisfactory calibration (p = 0.828), both of which were supported by external validation. Decision curve analysis showed that the nomogram was clinically useful.

CONCLUSIONS

The nomogram incorporating both the pelvic floor ultrasound parameters and clinical factors has been validated to show good discrimination and calibration, and could be an important tool for stress urinary incontinence risk prediction at an early stage of pregnancy.