Stress urinary incontinence: pre-pregnancy history and effects of mode of delivery on its postpartum persistency

Development and external validation of clinical predictive model for stress urinary incontinence in Chinese women : a multicenter retrospective study

BACKGROUND

Stress urinary incontinence (SUI), the prevalent form of urinary incontinence, significantly impairs women's quality of life. This study aims to create a visual nomogram to estimate the risk of SUI within one year postpartum for early intervention in high-risk Chinese women.

METHODS

We recruited 1,531 postpartum women who gave birth at two hospitals in Kunshan City from 2021 to 2022. Delivery details were meticulously extracted from the hospitals' medical records system, while one-year postpartum follow-ups were conducted via phone surveys specifically designed to ascertain SUI status. Utilizing data from one hospital as the training set, logistic regression analysis was performed to pinpoint significant factors and subsequently construct the nomogram. To ensure robustness, an independent dataset sourced from the second hospital served as the external validation cohort. The model's performance was rigorously evaluated using calibration plots, ROC curves, AUC values, and DCA curves.

RESULTS

The study population was 1,125 women. The SUI incidence within one year postpartum was 26% (293/1125). According to the regression analysis, height, pre-pregnancy BMI, method of induction, mode of delivery, perineal condition, neonatal weight, SUI during pregnancy, and SUI during the first pregnancy were incorporated into the nomogram. The AUC of the nomogram was 0.829 (95% CI 0.790-0.867), and the external validation set was 0.746 (95% CI 0.689-0.804). Subgroup analysis based on parity showed good discrimination. The calibration curve indicated concordance. The DCA curve showed a significant net benefit.

CONCLUSION

Drawing from real-world data, we have successfully developed an SUI predictive model tailored for postpartum Chinese women. Upon successful external validation, this model holds immense potential as an effective screening tool for SUI, enabling timely interventions and ultimately may improve women's quality of life.

Psychosocial Factors Associated with Lower Urinary Tract Symptoms One Year Postpartum

Pregnancy carries substantial risk for developing lower urinary tract symptoms (LUTSs), with potential lifelong impacts on bladder health. Little is known about modifiable psychosocial factors that may influence the risk of postpartum LUTSs. We examined associations between depressive symptoms, perceived stress, and postpartum LUTSs, and the moderating effects of perceived social support, using data from a cohort study of Expect With Me group prenatal care (n = 462). One year postpartum, 40.3% participants reported one or more LUTS. The most frequent LUTS was daytime frequency (22.3%), followed by urinary incontinence (19.5%), urgency (18.0%), nocturia (15.6%), and bladder pain (6.9%). Higher odds of any LUTS were associated with greater depressive symptoms (adjusted odds ratio (AOR) 1.08, 95% confidence interval (CI) 1.04-1.11) and perceived stress (AOR 1.12, 95% CI 1.04-1.19). Higher perceived social support was associated with lower odds of any LUTS (AOR 0.94, 95% CI 0.88-0.99). Perceived social support mitigated the adverse effects of depressive symptoms (interaction AOR 0.99, 95% CI 0.98-0.99) and perceived stress (interaction AOR 0.97, 95% CI 0.95-0.99) on experiencing any LUTS. Greater depressive symptoms and perceived stress may increase the likelihood of experiencing LUTSs after childbirth. Efforts to promote bladder health among postpartum patients should consider psychological factors and social support.

Influence of prenatal urinary incontinence and mode of delivery in postnatal urinary incontinence: A systematic review and meta-analysis

BACKGROUND

It is likely that the pathophysiology of urinary incontinence (UI) differs between women who are incontinent before the first delivery and those whose incontinence occurs after. In this systematic review, we aimed to assess the association between the mode of delivery and the risk of postpartum UI in primiparous women with and without prenatal UI.

METHODS

We searched MEDLINE, Cochrane, Web of Science, Embase and CINHAL databases. Prospective studies including primiparous women during their pregnancy with a comparison of the rate of postpartum UI in women who underwent cesarean delivery or vaginal delivery according to continence status before delivery were included. The Risk Ratio (RR) was calculated with a 95% confidence interval (95% CI) using the total number of events and patients extracted from the individual studies. A subgroup comparison analysed the potential influence of women's prenatal continence status. Heterogeneity was estimated using I² statistics.

RESULTS

The risk of postpartum UI was significantly higher after vaginal delivery than after cesarean section (RR 1.80, 95% CI 1.48- 2.18). According to the subgroup test, the postpartum UI risk following a vaginal delivery, compared to cesarean section, was significantly higher in the subgroup of continent women during pregnancy (RR 2.57, 95% CI 2.17-3.04) than in the subgroup of incontinent pregnant women (1.56, 95% CI 1.27-1.92).

CONCLUSIONS

The effect of a cesarean section in preventing postpartum UI appears controversial, particularly in women with prenatal UI.

Performance of self-reported and unsupervised antenatal pelvic floor muscle training and its effects on postpartum stress urinary incontinence among Chinese women: a cohort study

OBJECTIVES

We investigated performance of antenatal pelvic floor muscle training (PFMT) among Chinese pregnant women, to explore its effects on postpartum stress urinary incontinence (SUI).

METHODS

We conducted a prospective cohort study in Shenzhen, China among 815 singleton pregnant women age ≥18 years, who were continent before pregnancy. Telephone follow-up was conducted at 6 weeks postpartum. Logistic univariable and multivariable regression analyses were used to estimate effects of antenatal PFMT (frequency and duration) on SUI postpartum among subgroups defined by SUI during pregnancy. The interactions of antenatal PFMT and PFMT duration on SUI postpartum were tested.

RESULTS

Among 798 women included in the analysis, 127 (15.91%) had SUI at 6 weeks postpartum. Only 157 (19.67%) women performed antenatal PFMT, none under supervision. After adjusting potential confounders, neither frequency (odds ratio (OR) = 1.08, 95% confidence interval (CI) 0.89-1.32) nor duration (OR = 1.03, 95% CI 0.87-1.23) of antenatal PFMT was a significant factor in postpartum SUI. No interactions of antenatal PFMT and PFMT duration on SUI postpartum were found in any participants or subgroups.

CONCLUSION

No effect of self-reported, unsupervised, self-initiated antenatal PFMT on SUI 6 weeks postpartum was found. Low doses and no supervision may have contributed to the negative results.

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.

Aftermath of a Midurethral Sling Placed in the First Trimester: A Case Report

There are limited data on the management of pregnancy and delivery after midurethral sling (MUS) surgery for stress urinary incontinence (SUI). We report a case of a 39-year-old woman who underwent an MUS in July 2017. She reported a 10-year history of frequency, urgency with rare urge incontinence, nocturia, and occasional SUI when coughing or sneezing. Preoperative assessment did not include a pregnancy test. Two days after MUS placement, she developed complete urinary retention, and it was determined that she was 6 weeks pregnant. She was referred to a tertiary urogynecology unit and was seen at 23 weeks' gestation with worsening symptoms of urinary frequency and nocturia. She also described difficulty voiding but no incontinence. She was managed with conservative measures initially, but by 35 weeks, she required intermittent self-catherization (ISC). She underwent an elective cesarean delivery at 39 weeks' gestation. She reported postvoid dribbling, urge incontinence, and recurrent SUI at 10 months postpartum. This case report adds to the body of knowledge around outcomes of MUS during and after pregnancy.

Prevalence, potential risk factors, and symptomatic bother of lower urinary tract symptoms during and after pregnancy

OBJECTIVES

Nationwide prospective studies of lower urinary tract symptoms (LUTS) during and after pregnancy have never been conducted in mainland China. A prospective longitudinal study was performed to evaluate the association of pregnancy and delivery on LUTS in a representative sample of primiparous Chinese women.

METHODS

A national survey on urinary incontinence (UI) was conducted in 10,098 pregnant females during late pregnancy (37 to 42 weeks of gestation) and at 6 weeks postpartum.in seven administrative regions of China from September 2007 to May 2009. No intervention was implemented. International Consultation on Incontinence Questionnaire Female Lower Urinary tract Symptoms Module (ICIQ-FLUTS) was administered. The participants were asked about the presence of individual LUTS and rated their symptom bother. Data were analyzed by descriptive statistics, Chi-square tests, and multivariate logistic regression.

RESULTS

Among all participants (mean ± SD maternal age 26.44 ± 3.97 years), the most commonly reported storage LUTS during pregnancy were nocturia (72.3%) and frequency (43.9%). LUTS were much less prevalent after childbirth than during pregnancy. Moderate to severe bother was more common during than after pregnancy. Compared with vaginal delivery (VD), cesarean section (CS) was a protective factor against voiding LUTS (AOR (adjusted odd ration), 0.66; 95% CI, 0.52-0.82) and storage LUTS (AOR, 0.74; 95% CI, 0.66-0.83).

CONCLUSIONS

LUTS were much more prevalent during than after pregnancy, with nocturia and frequency being the most prevalent. Moderate or severe bother was more common during pregnancy than after pregnancy. CS was associated with a decreased prevalence both of storage and voiding LUTS after delivery.

Lower urinary tract symptoms 7 years after the first delivery: Correlation to the mode of delivery

OBJECTIVE

To investigate the extent of lower urinary tract symptoms (LUTS) during pregnancy and 7 years after birth in primipara and their association with delivery mode history and other factors.

METHODS

A longitudinal cohort study was conducted in 12 hospitals representative of the diversity of the seven administrative regions of China. Of 10 098 women recruited at the third trimester, 3862 (38.25%) responded at 1 year, and 1115 (11.04%) responded at 7 years. A modified Chinese Bristol Female Lower Urinary Tract Symptoms questionnaire was administered. No intervention was implemented.

RESULTS

Among the participants, 75.4% reported nocturia during gestation, followed by frequency (58.4%), which gradually decreased after delivery. The prevalence of urge urinary incontinence (UUI) increased from 5.7% during pregnancy to 22.8% at 1 year after delivery and 10.2% at 7 years postpartum. The prevalence of stress urinary incontinence (SUI) increased from 29.9% during pregnancy to 46.4% at 1 year postpartum and 23.7% at 7 years after delivery. The odds of storage LUTS and voiding LUTS 7 years after delivery were lower for the cesarean section (CS) group than for the vaginal delivery (VD) group (OR = 0.49, 95%CI, 0.36-0.68; OR = 0.25, 95%CI, 0.09-0.70). The most frequent moderately to severely bothersome LUTS after VD was SUI (19.18%), while that for CS was UUI (19.18%).

CONCLUSION

The incidence of storage LUTS was higher than that of voiding LUTS both during pregnancy and postpartum. The most frequently reported LUTS during pregnancy were nocturia and frequency, while the most frequent LUTS after delivery were urgency and SUI. CS was associated with a decreased prevalence of both storage and voiding LUTS after delivery.

Evaluation of isolated urinary stress incontinence according to the type of levator ani muscle lesion using 3/4D transperineal ultrasound 36 months post-partum

INTRODUCTION

Vaginal delivery can lead to pelvic floor disorders. Many authors have described pelvic floor injuries that can predict future defects such as urinary incontinence and pelvic organ prolapse. We propose the assessment of urinary stress incontinence and its association with levator ani muscle (LAM) microtrauma (>20% in the levator hiatus area during Valsalva) and macrotraumas (avulsion) identified by 3/4D transperineal ultrasound (3D-TpUS) 36 months post-partum.

MATERIALS AND METHODS

This was a prospective observational study including 168 nulliparous women. All patients included were nulliparous with singleton gestation in cephalic presentation, at ≥37 weeks and were recruited on the first day after delivery. Thirty-six months after delivery, 3D-TpUS was carried out to identify LAM lesions (macro or micro). Clinical assessment of urinary stress incontinence (USI) was based on the ICIQ-UI-SF test; a simple stress test and urodynamic test were carried out in the same visit.

RESULTS

A total of 105 nulliparous women were studied (51 spontaneous deliveries [SpD] and 54 vacuum-assisted deliveries [VD]). Microtraumas were identified in 35.3% of SpD and 20.4% of VD. Macrotraumas (avulsion) were identified in 9.8% of SpD and 35.2% of VD (p = 0.006). No differences were found in USI between study groups or in relation to the identification of LAM defects (19.2% in the no lesion group, 25% in the macrotrauma and 13.8% in the microtrauma groups; p = not significant). Nor were significant differences found in the results from the different study groups in the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) test (12.7±2.2 in the no lesion group, 12.5±4.2 in the macrotrauma and 13.25±4.8 in the microtrauma groups; p = NS).

CONCLUSION

No difference was observed in USI between patients with and without LAM lesions (microtrauma or macrotrauma) 36 months post-delivery.

Effect of pregnancy and delivery on urinary incontinence after the midurethral sling procedure

INTRODUCTION AND HYPOTHESIS

To evaluate the continence status and to reveal the optimal delivery mode of women who had an infant after application of a midurethral sling to treat stress urinary incontinence.

METHODS

Between January 2007 and January 2013, 12 women who delivered an infant after application of a midurethral sling were detected and demographic data, type of MUS, interval between MUS and delivery, mode of delivery, birth weight of the newborn, complications during pregnancy, and continence status after delivery were collected. Between 2000 and 2014, in 14 articles listed in Pubmed, the data of 54 patients who had delivered after successful midurethral sling application were included. Postpartum recurrence of urinary incontinence was evaluated according to delivery type in 54 patients.

RESULTS

Mean age of 12 patients at the time of MUS was 33.1 ± 4.3 years old and the interval between MUS procedure and pregnancy was 30.2 ± 14.2 months. Four patients had a transvaginal tape (TVT; 33.3%) and 8 had transobturator tape (TOT) procedure (66.7%) and mean follow-up after MUS surgery was 52 ± 12.3 months. Seven women had cesarean section (CS; 58.3%) and 5 women delivered vaginally (41.7%). Nine women were continent during pregnancy (75%) and 10 were continent after delivery (83.3%). Among 54 women who were included in the review, 28 underwent CS (51.9%), 26 women delivered vaginally (48.1%), and 11 women had postpartum incontinence (20.3%). In the case of postpartum urinary incontinence, there was no statistically significant difference between the CS and vaginal delivery groups (14.3 vs 26.9% respectively, p = 0.32). In logistic regression, incontinence during pregnancy was a risk factor for postpartum incontinence (OR:5.5; 95% CI: 1.1-27.6, p = 0.036).

CONCLUSION

Risk of postpartum SUI recurrence in women who underwent application of midurethral slings seems to be similar independent of delivery mode and incontinence during pregnancy may be a risk factor for postpartum incontinence.

Urinary incontinence related to perineal muscle strength in the first trimester of pregnancy: cross-sectional study

Objective To analyze pelvic floor muscle strength (PFMS), urinary continence and quality of life related to urinary incontinence (UI) of women in the first trimester of pregnancy. Method Cross-sectional study with a sample of 500 women who started prenatal care in a complementary healthcare facility in Guarulhos, state of São Paulo, from 2012 and 2013. Pelvic floor muscle strength was evaluated through perineometry. The pregnant women who presented UI answered the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). Results It was found that maternal age (OR=1.06; CI95% 1.02-1.11) and prior UI (OR=15.12; 95%CI 8.19-27.92) are the variables that, in tandem, best explain the occurrence of UI at the beginning of pregnancy. The mean score on the ICIQ-SF was 8.2 (SD=3.9), considered a moderate impact on quality of life. Conclusion Older pregnant women with prior UI are more likely to have UI in the first trimester of pregnancy.


Pregnancy and delivery following midurethral sling surgery for stress urinary incontinence

OBJECTIVE

To analyze the available clinical evidence on the continued effectiveness of midurethral sling (MUS) surgery for stress urinary incontinence (SUI) in women who become pregnant and undergo delivery, and then to determine the optimal mode of delivery for such women.

METHODS

An online search was carried out to retrieve the available evidence regarding the risk of SUI recurrence during pregnancy and after delivery following a successful MUS treatment. Appropriate keywords were used to identify all relevant reports published from 1996 through 2011. Basic patient characteristics, mode of delivery, and presence of SUI during pregnancy and the postpartum were analyzed.

RESULTS

No more than 36 relevant cases were found. The overall urinary continence rates were 91.7% during pregnancy and 80.6% during the postpartum. Most (58.3%) of the women were delivered vaginally.

CONCLUSION

The evidence indicates that the risk of SUI recurrence is not significantly different after a vaginal or a cesarean delivery. In women successfully treated with a MUS, pregnancy care and delivery mode therefore need to be considered case by case, according to factors other than the risk of recurrence.

[Urinary incontinence 6 months after childbirth]

BACKGROUND AND OBJECTIVE

Urinary incontinence initiated before and right after delivery and persisting 3 months after delivery tends to become chronic. We intended to estimate the persistence of urinary incontinence 6 months postpartum and to analyse the different factors associated with it.

PATIENTS AND METHODS

Follow-up study 6 months after delivery of women presenting urinary incontinence symptoms in gestation or in the first 2 months of postpartum. The dependent variable was the persistence and the independent variables were grouped in obstetric and non-obstetric. Odds ratio (OR) were calculated with their confidence interval at 95% (IC 95%) in the bivariate analysis. The variables that showed an important risk of persistence of incontinence were used to perform a multivariate model of logistic regression.

RESULTS

The persistence of incontinence 6 months after delivery was 21.4% (CI 95% 16-26.7). The risk of persistence increased with the Kristeller maneuver (OR 7.89, CI 95% 3.04-20.49), not weight recovery (OR 3.64, CI 95% 1.10-12.02), not practising pelvic floor muscle exercises in postpartum (OR 9.36, CI 95% 2.71-32.33), appearance of incontinence after delivery (OR 6.66, CI 95% 2.37-18.68) and the weight of the newborn>3.5 kg (OR 6.76, CI 95% 2.54-18.03), all of them explaining 58% of the variability of persistence.

CONCLUSION

21.4% of women with urinary incontinence caused by pregnancy/delivery will continue to have it 6 months postpartum. An important part of this persistence is associated with some factors easy to modify.