Preventing urinary incontinence during pregnancy and postpartum: a review

Development and Validation of a Risk Prediction Model for Female Stress Urinary Incontinence in Rural Fujian, China

Purpose

With China's rapidly aging population and the rising proportion of obese people, an increase in the number of women suffering from urinary incontinence (UI) is to be expected. In order to identify high-risk groups before leakage occurs, we aimed to develop and validate a model to predict the risk of stress UI (SUI) in rural women.

Patients and methods

This study included women aged 20-70 years in rural Fujian who participated in an epidemiologic survey of female UI conducted between June and October 2022. Subsequently the data was randomly divided into training and validation sets in a ratio of 7:3. Univariate and multivariate logistic regression analyses were used to identify independent risk factors as well as to further construct a nomogram for risk prediction. Finally, concordance index (C-index), calibration curve and decision curve analysis were applied to evaluate the performance of the predictive models.

Results

A total of 5290 rural females were enrolled, of whom 771 (14.6%) had SUI. Age, body mass index (BMI), postmenopausal status, number of vaginal deliveries, vaginal delivery of large infant, constipation and family history of pelvic organ prolapse (POP) and SUI were included in the nomogram. C-index of this prediction model for the training and validation sets was 0.835 (95% confidence interval [CI] = 0.818-0.851) and 0.829 (95% CI = 0.796-0.858), respectively, and the calibration curves and decision analysis curves for both the training and validation sets showed that the model was well-calibrated and had a positive net benefit.

Conclusion

This model accurately estimated the SUI risk of rural women in Fujian, which may serve as an effective primary screening tool for the early identification of SUI risk and provide a basis for further implementation of individualized early intervention. Moreover, the model is concise and intuitive, which makes it more operational for rural women with scarce medical resources.

Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it?

Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.

Prevalence and course of pregnancy symptoms using self-reported pregnancy app symptom tracker data

During pregnancy, almost all women experience pregnancy-related symptoms. The relationship between symptoms and their association with pregnancy outcomes is not well understood. Many pregnancy apps allow pregnant women to track their symptoms. To date, the resulting data are primarily used from a commercial rather than a scientific perspective. In this work, we aim to examine symptom occurrence, course, and their correlation throughout pregnancy. Self-reported app data of a pregnancy symptom tracker is used. In this context, we present methods to handle noisy real-world app data from commercial applications to understand the trajectory of user and patient-reported data. We report real-world evidence from patient-reported outcomes that exceeds previous works: 1,549,186 tracked symptoms from 183,732 users of a smartphone pregnancy app symptom tracker are analyzed. The majority of users track symptoms on a single day. These data are generalizable to those users who use the tracker for at least 5 months. Week-by-week symptom report data are presented for each symptom. There are few or conflicting reports in the literature on the course of diarrhea, fatigue, headache, heartburn, and sleep problems. A peak in fatigue in the first trimester, a peak in headache reports around gestation week 15, and a steady increase in the reports of sleeping difficulty throughout pregnancy are found. Our work highlights the potential of secondary use of industry data. It reveals and clarifies several previously unknown or disputed symptom trajectories and relationships. Collaboration between academia and industry can help generate new scientific knowledge.

Effect of pilates performed during pregnancy on postpartum stress urinary incontinence in primipara women

INTRODUCTION

Stress urinary incontinence (SUI) constitutes the majority of urinary incontinence (UI) cases that occur due to anatomical and physiological changes during pregnancy and postpartum period. The objcetive of this study was to evaluate the effect of pilates in preventing the occurrence of SUI in the postpartum period.

METHODS

A retrospective case-control study was conducted in a private hospital. Participants consisted of patients who gave birth vaginally at the hospital and were admitted to the hospital for routine control at the postpartum 12th week. The women did pilates for two days a week from the 12th week of pregnancy until the birth were included in the case group. The women did not do pilates in the control group. Data was collected using the "Michigan Incontinence Symptom Index". To detect the presence of SUI, researchers asked women "Do you have urinary incontinence problems in your daily life?". STROBE research check-list was used for reporting the study.

RESULTS

The study was completed with a total of 142 women consisting of 71 women in each group. Of the women, postpartum SUI occurred in 39.4%. The severity score of women who did pilates were found to be statistically significantly lower than those who did not do pilates.

CONCLUSION

During pregnancy, women should be encouraged to do pilates about the prenatal period by health professionals.

Efficacy of supervised pelvic floor muscle training with a home-based biofeedback device for urinary incontinence in postpartum women: protocol for a multicentre randomised controlled trial

INTRODUCTION

Supervised pelvic floor muscle training (PFMT) of at least 3 months duration has been strongly recommended as a first-line treatment for women with stress urinary incontinence (SUI) or SUI-predominant mixed urinary incontinence (MUI), including elderly and postnatal women. However, for the treatment of SUI and MUI in postpartum women, it is currently uncertain whether supervised PFMT combined with a biofeedback device is superior to PFMT alone. Despite some supportive results, more reliable evidence is lacking.

METHODS AND ANALYSIS

The study is designed as a multicentre assessor-blinded parallel-group randomised controlled trial comparing the efficacy of PFMT with a home-based pressure-mediated biofeedback device (intervention group) and that of at-home PFMT alone (control group) for women with new-onset SUI or SUI-predominant MUI after delivery. Five hundred eligible women from the obstetric outpatient clinics of five tertiary hospitals will be randomly allocated (1:1) and evaluated with repeated questionnaires, physical examinations and pelvic floor assessments at baseline (pretest), 3 months, 6 months and 12 months (postintervention) during the study period. Both groups will be instructed to follow the same training protocol under 3-month supervision after randomisation. The use of a biofeedback device with a self-assessment function will be added to the PFMT regime for patients in the intervention group. The primary outcome is the self-reported severity of urinary incontinence assessed through the short form of the International Consultation on Incontinence Questionnaire-Urinary Incontinence. Secondary outcomes include pelvic muscle support and strength, symptoms of pelvic organ prolapse, quality of life, sexual function, self-efficacy and adherence.

ETHICS AND DISSEMINATION

Ethical approval has been received from the Peking Union Medical College Hospital ethics committee (JS-3192D). All results from the study will be submitted to international journals and international conferences.

TRIAL REGISTRATION NUMBER

NCT05115864.

Multifunctional Evaluation Technology for Diagnosing Malfunctions of Regional Pelvic Floor Muscles Based on Stretchable Electrode Array Probe

The pelvic floor dysfunction (PFD) has become a serious public health problem. Accurate diagnosis of regional pelvic floor muscle (PFM) malfunctions is vitally important for the prevention and treatment of PFD. However, there is a lack of reliable diagnostic devices to evaluate and diagnose regional PFM abnormality. In this work, we developed a multifunctional evaluation technology (MET) based on a novel airbag-type stretchable electrode array probe (ASEA) for the diagnosis of malfunctions of regional PFM. The inflatable ASEA has specifically distributed 32 electrodes along the muscles, and is able to adapt to different human bodies for tight contact with the muscles. These allow synchronous collection of high-quality multi-channel surface electromyography (MC-sEMG) signals, and then are used to diagnose regional PFM malfunctions and evaluate inter-regional correlation. Clinical trial was conducted on 15 postpartum stress urinary incontinence (PSUI) patients and 15 matched asymptomatic women. Results showed that SUI patients responded slowly to the command and have symptoms of muscle strength degeneration. The results were consistent with the relevant clinical manifestations, and proved the reliability of MET for multifunctional PFM evaluation. Furthermore, the MET can diagnose malfunctions of regional PFM, which is inaccessible with existing technology. The results also showed that the dysfunction of PSUI patients is mainly located in iliococcygeus, pubococcygeus, and urethral sphincter regions, and there is a weak correlation between these specific regions and nearby regions. In conclusion, MET provides a point-of-care diagnostic method for abnormal function of regional PFM, which has a potential for the targeted point-to-point electrical stimulation treatment and PFD pathology research.

An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders

AIMS

The terminology of obstetric pelvic floor disorders should be defined and reported as part of a wider clinically oriented consensus.

METHODS

This Report combines the input of members of two International Organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA). The process was supported by external referees. Appropriate clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 12 main rounds of internal and 2 rounds of external review was involved to exhaustively examine each definition, with decision-making by consensus.

RESULTS

A terminology report for obstetric pelvic floor disorders, encompassing 357 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it usable by different specialty groups and disciplines involved in the study and management of pregnancy, childbirth and female pelvic floor disorders. Clinical assessment, investigations, diagnosis, conservative and surgical treatments are major components. Illustrations have been included to supplement and clarify the text. Emerging concepts, in use in the literature and offering further research potential but requiring further validation, have been included as an Appendix. As with similar reports, interval (5-10 year) review is anticipated to maintain relevance of the document and ensure it remains as widely applicable as possible.

CONCLUSION

A consensus-based Terminology Report for obstetric pelvic floor disorders has been produced to support clinical practice and research.

Relationships between Women's and Men's Modifiable Preconception Risks and Health Behaviors and Maternal and Offspring Health Outcomes: An Umbrella Review

Parental health before conception effects maternal and offspring health outcomes. Preconception care provides healthcare to prospective parents addressing modifiable preconception risks and health behaviors. This umbrella review aimed to consolidate evidence on women's and men's modifiable preconception risks or health behaviors associated with maternal and offspring health outcomes. MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, and PsycINFO were searched from March 4, 2010, to March 4, 2020. Eligible studies were systematic reviews or meta-analyses of observational studies examining associations between modifiable preconception risks or health behaviors and maternal and offspring health outcomes. Screening, data extraction, and methodological quality assessment (AMSTAR 2) occurred independently by two reviewers. Degree of overlap was examined. Findings were summarized for evidence synthesis. Twenty-seven systematic reviews were included. Modifiable preconception risks and health behaviors were identified across categories: body composition (e.g., overweight, obesity), lifestyle behaviors (e.g., caffeine, smoking), nutrition (e.g., micronutrients), environmental exposures (e.g., radiation), and birth spacing (e.g., short interpregnancy intervals). Outcomes associated with exposures affected embryo (e.g., embryonic growth), maternal (e.g., gestational diabetes mellitus), fetal/neonate (e.g., preterm birth), and child (e.g., neurocognitive disorders) health. For real-world practice and policy relevance, evidence-based indicators for preconception care should include body composition, lifestyle, nutrition, environmental, and birth spacing.

Aspects of Pelvic Floor Protection in Spontaneous Delivery - a Review

The necessity of increasingly addressing aspects of pelvic floor protection, i.e., prevention of the most frequent female pelvic floor disorders, such as urinary incontinence, faecal incontinence and pelvic organ prolapse, is the result of the steadily improving understanding of the association of pregnancy and delivery with the prevalence of these disorders. About a quarter of all women experience one or more such symptoms during their life. Apart from age and weight, pregnancies and births play an important part. While initial discussion of pelvic floor protection often focused very rapidly on the mode of delivery and elective caesarean section as a possible protective intervention, it has become apparent in the last few decades how varied and wide-ranging the options are that can be used to protect against pelvic floor disorders. The mode of delivery as such is "only" one element among numerous other considerations and has diminished markedly in importance. Interprofessionality and interdisciplinarity undoubtedly represent an important development as resulting recommendations must always be incorporated in an overall context that considers mother and child at the same time. Considering the pelvic floor only certainly does not make sense. This review article will analyze in greater detail important pre-, intra- and postpartum aspects that in their entirety can provide insight into the various aspects of pelvic floor protection. The authors regard the following article as an additional basis for discussion on achieving a sustained reduction in the incidence and prevalence of female pelvic floor disorders.

Patient-Reported Outcome measures for pregnancy-related urinary and fecal incontinence: a prospective cohort study in a large Italian population

OBJECTIVE

To investigate prevalence and risk factors of pregnancy-related urinary/fecal incontinence (UI/FI) in a large Italian population.

METHODS

This is a prospective cohort study analyzing patient-reported outcome (PRO) measures obtained from the systematic longitudinal survey on the maternity pathway of Tuscany from March 2019 to April 2021. Four questionnaires were completed by 6,023 women from the beginning of pregnancy until six months postpartum, each including two PRO measures - Wexner scale for FI and ICIQ-SF for UI -, and questions investigating sociodemographic/clinical factors. After assessing UI/FI prevalence at each time-point, we run panel regressions to explore the related risk factors.

RESULTS

Women reporting UI and FI were, respectively, 24.3% and 6.2% in the third trimester, and 12.6% and 4.2% six months postpartum. UI occurrence and severity were higher in highly-educated, aged > 30, and overweight/obese women. Spontaneous tears or episiotomy were risk factors for postpartum UI, while receiving cesarean-section and performing pelvic-floor-muscle-training during pregnancy were protective, mainly in specific groups. Finally, higher FI prevalence and severity emerged in overweight, aged > 40, highly-educated, non-Italian women and in those undergoing tears.

CONCLUSION

We employed PRO measures to investigate the epidemiology of pregnancy-related UI/FI and detect the main risk groups. Pelvic-floor-muscle-training may be recommended in women with peculiar sociodemographic/clinical features.

Physical activity and urinary incontinence during pregnancy and postpartum: A systematic review and meta-analysis

To assess the association of physical activity and urinary incontinence, or its recovery, during pregnancy and postpartum. A search of publications indexed in five major electronic databases (CENTRAL, PubMed, EMBASE, CINAHL and PEDro) was performed from their respective inception dates to the 30 March 2020 with a combination of keywords to identify studies of interest. Google Scholar was used for non-indexed literature. All studies comparing physical activity with standard care in pregnant and postpartum women were selected. Two reviewers independently selected studies, assessed quality and extracted data. Odds ratios with 95% confidence intervals were calculated using fixed effects or random effects models, for low and moderate heterogeneity between studies, respectively. Seven studies (n = 12479) were included. Data of four studies could be pooled for meta-analyses; subgroup and sensitivity analyses were not possible. Physical activity, either during pregnancy or postpartum, is not associated with urinary incontinence, OR 0.90 (95% CI: 0.69-1.18) and OR 1.31 (95% CI: 0.74-2.34), respectively. Due to a lack of available data, urinary incontinence recovering could not be assessed. The available low evidence does not show that physical activity during pregnancy or postpartum is associated with urinary incontinence. Moderate physical activity should therefore be encouraged for the evidence-based benefits on other obstetrical outcomes.

Pelvic floor muscle training program for women in the puerperal period: clinical progress after intervention

OBJECTIVE

To evaluate the sexual function of women in the puerperal period after a postpartum pelvic floor musculature training program. We also sought to evaluate correlations between sexual dysfunction in the women and their delivery type and compare the frequency of sexual dysfunction and the quality of resumed sexual function following vaginal and cesarean deliveries.

METHODS

This clinical study included an intervention, carried out between July and December 2019, in which data were collected about 28 rooming-in women at a Maternity School. Data were divided into vaginal delivery and cesarean delivery. Sexual function was evaluated by the Female Sexual Function Index and the International Consultation on Incontinence Questionnaire-Short Form to assess the Incontinence Urinary and qualifies urinary loss. The intervention consisted of a muscle training exercise program. ANOVA tests were used to establish differences between groups.

RESULTS

There was an improvement in all outcomes, but there was no time versus group interaction. Improvement in sexual function was observed (p<0.001), the impact of urinary incontinence on quality of life (p<0.001), and pressure of the muscles of pelvic floor muscles (p<0.001) over time. There was no time versus group interaction for sexual function (p=0.87), the impact of urinary incontinence on quality of life (p=0.88), and pressure of the pelvic floor muscles (p=0.66).

CONCLUSIONS

Pelvic floor muscle exercise programs seem to be a very promising strategy concerning improving sexual activity among puerperal patients.

Prevalence and trends in urinary incontinence among women in the United States, 2005-2018

BACKGROUND

Women are disproportionately affected by urinary incontinence compared with men. Urinary incontinence results in physical and psychological adverse consequences and impaired quality of life and contributes to significant societal and economic burden. Previous studies reported high urinary incontinence burden in the United States. However, the current prevalence and recent trends in urinary incontinence and its subtypes among US women have not been described. In addition, correlates of urinary incontinence among US women have not been systematically evaluated in the contemporary population.

OBJECTIVE

The purpose of this study was to determine the prevalence and trends in urinary incontinence among adult women in the United States from 2005 to 2018. In addition, this study aimed to investigate the relationship of urinary incontinence subtypes with several sociodemographic, lifestyle, health-related, and gynecologic factors.

STUDY DESIGN

We used data from the National Health and Nutrition Examination Survey, a nationally representative series of surveys that was designed to evaluate the health status of the US population. Data on urinary incontinence from 7 consecutive 2-year cycles (2005-2006 to 2017-2018) were used for this study. A total of 19,791 participants aged ≥20 years were included. Weighted prevalence estimates and 95% confidence intervals were calculated in each study cycle for stress, urgency, and mixed urinary incontinence. Multivariate-adjusted weighted logistic regression was used to investigate the temporal trends in urinary incontinence, in addition to determining the association between urinary incontinence subtypes with several participants' factors.

RESULTS

In the 2017-2018 cycle, stress urinary incontinence was the most prevalent subtype (45.9%; 95% confidence interval, 42.1-49.7), followed by urgency urinary incontinence (31.1%; 95% confidence interval, 28.6-33.6) and mixed urinary incontinence (18.1%; 95% confidence interval, 15.7-20.5). The prevalence rates of urgency and mixed urinary incontinence were higher in women aged 60 years and older (urgency, 49.5% [95% confidence interval, 43.9-55.2]; mixed, 31.4% [95% confidence interval, 26.2-36.6]) than in those aged 40 to 59 years (urgency, 27.9% [95% confidence interval, 23.6-32.1]; mixed, 15.9% [95% confidence interval, 12.9-19.0]) and those aged 20 to 39 years (urgency, 17.6% [95% confidence interval, 13.8-21.5]; mixed, 8.3% [95% confidence interval, 5.4-11.3]). The overall prevalence of stress and mixed urinary incontinence was stable throughout 2005 to 2018 (both P_trend=.3), with increases in mixed urinary incontinence among women aged 60 years and older (P=.001). The prevalence of urgency urinary incontinence significantly increased, particularly among women aged 60 years and older (both P=.002). Age, obesity, smoking, comorbidities, and postmenopausal hormone therapy were associated with higher prevalence of all types of urinary incontinence. Black women were less likely to report stress urinary incontinence but more likely to report urgency urinary incontinence.

CONCLUSION

Although the estimated overall prevalence of stress and mixed urinary incontinence remained stable from 2005 to 2018, the prevalence of urgency and mixed urinary incontinence significantly increased among women aged 60 years and older. All subtypes of urinary incontinence were higher among women with obesity and comorbidities, those who used postmenopausal hormone therapy, and those who smoke.

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

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.

Regular antenatal exercise including pelvic floor muscle training reduces urinary incontinence 3 months postpartum-Follow up of a randomized controlled trial

INTRODUCTION

Urinary incontinence is a frequently reported condition among women with pregnancy and delivery as established risk factors. The aims of this study were to evaluate the effect of an antenatal exercise program including pelvic floor muscle training on postpartum urinary incontinence, and to explore factors associated with urinary incontinence three months postpartum.

MATERIAL AND METHODS

This is a short-term follow-up and secondary analysis of a randomized controlled trial conducted at two Norwegian University Hospitals including healthy, pregnant women aged >18 years with a singleton live fetus. Women in the exercise group received a 12-week standardized exercise program including pelvic floor muscle training, with once weekly group exercise classes led by a physiotherapist and twice weekly home exercise sessions. The controls received standard antenatal care. Data were obtained from questionnaires answered in pregnancy weeks 18-22, and three months postpartum. Urinary incontinence prevalence in the exercise and control groups was compared, and multivariable logistic regression analyses were applied. Urinary incontinence prevalence three months postpartum was assessed by the Sandvik severity index.

RESULTS

Among the 722 (84%) women who responded three months postpartum, significantly fewer women in the exercise group (29%) reported urinary incontinence compared with the standard antenatal care group (38%, P = .01). Among women who were incontinent at baseline, 44% and 59% (P = .014) were incontinent at three months postpartum in the exercise and control groups, respectively. Urinary incontinence three months postpartum was associated with age (OR 1.1, 95% CI 1.0-1.1), experiencing urinary incontinence in late pregnancy (OR 3.6, 95% CI 2.3-5.9), birthweight ≥4000 g (OR 1.8, 95% CI 1.2-2.8), and obstetric anal sphincter injuries (OR 2.6, 95% CI 1.1-6.1). Cesarean section significantly reduced the risk of urinary incontinence three months postpartum compared with spontaneous vaginal delivery (OR 0.2, 95% CI 0.1-0.5).

CONCLUSIONS

A moderate-intensity exercise program including pelvic floor muscle training reduced prevalence of urinary incontinence 3 months postpartum in women who were incontinent at baseline.

Birthweight and urinary incontinence after childbirth: a systematic review and meta-analysis

Birthweight and urinary incontinence after childbirth: a systematic review and meta-analysis Stian Langeland WESNES, Elin SEIM MD Urinary incontinence (UI) is common after childbirth. Many cohort and cross-sectional studies have reported data on birthweight, but results have not been pooled. It is unclear how birthweight affects UI after childbirth. The objective is to review the effect of birthweight on UI after childbirth through meta-analyses. Searches were performed in Medline, Embase, Svemed+, ClinicalTrials.gov, Cochrane, and Cinahl in August 2016. Additional reference checking was performed. Included articles evaluated birthweight as a possible risk factor for maternal UI. We included articles that were presented in Norwegian, Danish, Swedish, or English. Two independent reviewers extracted the data and analysed it using Review Manager 5.3 software. Available data from included studies on birthweight (≥4000 g and ≥3500 g, respectively) and UI were combined in meta-analyses. PRISMA and MOOSE guidelines were used. Eighteen studies (N = 30 070) reported data on birthweight >4000 g vs <4000 g. Birthweight>4000 g compared to weight <4000 g was associated with a significantly increased OR of any UI (OR 1.49, 95% CI 1.24 - 1.80). Five studies (N = 15 066) reported data on birthweight >3500 g vs <3500 g. Birthweight>3500 g was also associated with a significantly increased OR of UI (OR 1.26, 95% CI 1.15 - 1.37). High birthweight appears to increase OR of UI after childbirth. Preventative strategies should be targeted towards women at particular risk.

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.

A Mobile Application Penyikang Applied in Postpartum Pelvic Floor Dysfunction: A Cross-Sectional Study to Analyze the Factors Influencing Postpartum Pelvic Floor Muscle Strength and Women's Participation in Treatment

Objectives

Postpartum pelvic floor muscle (PFM) injuries are the result of pregnancy and delivery, which lead to a series of symptoms requiring long-term follow-up. Mobile health platforms are progressively used for monitoring clinical conditions in medical subjects. This survey was a cross-sectional design based on collecting data from an application (Penyikang). We retrospectively analyzed the risk factors for weak postpartum PFM and further analyzed the factors influencing women's participation in the treatment which may help to improve the app's application in the future.

Methods

We enrolled postpartum women who gave birth at the Women's Hospital, Zhejiang University School of Medicine from August to November 2017; trained them to use the app; and collected the demographic and clinical information. This app requires users to fill questionnaires to assess their knowledge of pelvic floor dysfunction (PFD) and pelvic floor muscle training (PFMT) and experience with PFMT, and each therapy evaluation was restored. The relationship between the knowledge of PFMT/PFD, UI symptoms, and PFM strength was analyzed. Cluster analysis was used to define the degree of participation and identify the factors influencing the patients' participation in intensive therapy and evaluation.

Results

1982 postpartum women who enrolled in the app program were defined as weak PFM. Younger maternal age, cesarean section, and without delivery injury were found as the prognostic factors to PFM strength (both type I and type II muscle fibers) (P < 0.05), and higher educational level was also in favor of type II muscle fibers (P < 0.05). Patient-reported UI symptoms were associated with weak PFM strength (P < 0.05); there were no significant differences between knowledge of PFMT or PDF and PFM strength. Finally, patients with a higher degree of participation were more likely to accept the treatment (P < 0.05).

Conclusions

The mobile app provides a new applicative way to investigate postpartum PFD. The factors influencing women's participation can help us focus on strategies to increase the patients' compliance, and then we will apply the app into more areas to improve the prevention and treatment of postpartum PFD.

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.

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.

Urinary incontinence among pregnant women in Southern Brazil: A population-based cross-sectional survey

Urinary incontinence (UI) is a common condition that causes significant harm to the well-being and quality of life of pregnant women. This cross-sectional population-based study aimed to estimate the prevalence and identify factors associated with the occurrence of UI during pregnancy in women living in the municipality of Rio Grande (RS), Southern Brazil, between January 1 and December 31 of 2016, and included all puerperae living in this municipality that had a child in one of the two local maternity hospitals. The previously trained interviewers used a single standardized questionnaire, within 48 hours after delivery to retrieve information on maternal demographic, behavioral and reproductive/obstetric history, as well as socioeconomic status of the household and care received during pregnancy and childbirth. The multivariate analysis followed a previously defined hierarchical model using Poisson regression with robust variance adjustment and prevalence ratio (PR) as a measure of effect. As a result, 2,716 puerperae were identified, of which 2,694 (99.2%) participated in this study. The prevalence of urinary incontinence in the gestational period was 14.7% (95%CI: 13.4%-16.1%). After adjusted analysis, the likelihood of UI occurring varied significantly as per women's characteristics. For example, the PR for the occurrence of UI among women over 30 years of age was 2.05 (95% CI: 1.39-3.01) compared to adolescents. In two other groups of women who had their first pregnancy before the age of 20 or after the age of 30, the PR for UI was 1.36 (95% CI: 1.04-1.76) and 1.59 (95% CI: 1.01-2.51), respectively, when compared to those who became pregnant for the first time between 20 and 29 years of age. Finally, in two other groups of women, namely, those who reached 90 kg and over at the end of pregnancy and those who performed regular physical exercise and reported frequent urinary urgency, the PR was 2.49 (95% CI: 1.74-3.57), and 2.90 (95% CI: 2.10-4.00) compared to those who did not exercise and did not report urinary urgency, respectively. The authors concluded that UI showed a high prevalence in the study population. The identified risk factors can be well administered at primary health care level. The recommendation of regular physical exercise in pregnancy must be reviewed and better investigated with more robust designs because of possible facilitators for the occurrence of UI in this period.

Prevalence of Lower Urinary Tract Symptoms in Pregnant Adolescents and the Influencing Factors

STUDY OBJECTIVE

To determine the prevalence of lower urinary tract symptoms (LUTS) and associated risk factors in pregnant adolescents.

DESIGN

Descriptive study.

SETTING

The obstetrics and gynecology outpatient departments of a training and research hospital in Turkey.

PARTICIPANTS

Two hundred six pregnant adolescents younger than the age of 19 years.

INTERVENTIONS

None. Questionnaire-based data and the Bristol Female Lower Urinary Tract Symptoms-Short Form (BFLUTS-SF) were collected from pregnant adolescents.

MAIN OUTCOME MEASURES

Comparisons were made with independent samples t test, one-way analysis of variance, Mann-Whitney U, and Kruskal-Wallis tests, and linear regression for the analysis of the potential risk factors.

RESULTS

The prevalence of at least 1 of the LUTS in pregnant adolescents was 78.6% (162/206). The prevalence of storage symptoms was more than those of urinary incontinence and voiding symptoms. Among LUTS, the prevalence of nocturia, urgency, frequency, bladder pain, and urinary incontinence was 59.3% (122/206), 54.4% (112/206), 39.3% (81/206), 37.4% (77/206), and 27.2% (56/206), respectively. Of pregnant adolescents with LUTS, 30.2% (49/162) of pregnant adolescents with LUTS reported seeking treatment for LUTS in this study. The total median scores from the BFLUTS-SF increased with gestational week, but no statistical significant difference was identified (P > .05). According to the results of the linear regression analysis, daily coffee consumption, smoking, chronic coughing, constipation, and urinary tract infection history were found to be associated with the total mean score on the BFLUTS-SF in pregnant adolescents.

CONCLUSION

LUTS were found to be common among pregnant adolescents, with storage symptoms being the most frequently reported. Prenatal education could increase the number of adolescents who seek treatment, thereby improving the clinical course of LUTS.

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.

Lower urinary tract symptoms and related factors in female university students

OBJECTIVES

Our study aims to determine the symptoms and frequency of lower urinary tract in female university students and its related factors.

METHODS

This cross-sectional study was conducted between January and June 2017. To determine their sociodemographic characteristics and toilet habits, the Bristol Female Lower Urinary Tract Symptoms questionnaire, a 21-item questionnaire, was applied to female university students accepting to participate in the study using the face-to-face interview method.

RESULTS

The study was completed with 1091 individuals. The mean age of the participants was 20.27±1.69 years. The question "Do you feel a sudden urination sensation and run to the toilet?" was answered by 1.1% (n: 12) of the participants with "Always," while 34.8% (n: 380) replied "Never." In terms of feeling a sudden urination sensation, 0.5% (n: 6) of the participants stated that they "always" experience micturition, while 15.0% (n: 164) answered with "Seldom." The complaint of being unable to empty their bladder completely while urinating was higher in students with constipation problems (P .04) and a body mass index (BMI) > 24.9 (P .02).

CONCLUSIONS

Lower urinary tract complaints are a common problem. We believe that routine medical screening should be performed for female university students whose living conditions change when they start university; besides, we suggest that well-attended and repeatable training programs for healthy living behaviors, urinary habits, and hygiene should be organized for university students.

Will future doctors know enough about stress urinary incontinence to provide proper preventive measures and treatment?

Background: Stress urinary incontinence (SUI) is an embarrassing condition, which is one of the last taboos in modern medicine. The study aim was an attempt to assess medical students' knowledge of female stress urinary incontinence.Methods: The study involved 432 students of the Medical Department at the Medical University of Silesia in Katowice. Participants answered open-ended questions about: risk factors, prevention, diagnostic tests, conservative and surgical treatment in stress urinary incontinence.Results: The obtained results indicated that female students know more about SUI than male students. Women - more often than men - could provide the definition of SUI (p < 0.01); additionally, they more frequently indicated prevention methods (p < 0.01), diagnostic testing (p < 0.001) and conservative methods of treatment (p < 0.001). Not all the respondents were able to properly define stress urinary incontinence. Risk factors were known to most of the respondents but only half of them were aware of surgical treatment and prevention methods. Even fewer answered questions about conservative treatment and diagnostic tests correctly.Conclusions: We conclude that the knowledge of medical undergraduates who took part in the survey was not satisfactory. Most of the students were able to define properly the disease and point out risk factors. However, several steps should be taken to make stress urinary incontinence a disease much more known to medical students.Abbreviations: SUI: Stress urinary incontinence; Group F: Females Group; Group M: Males Group; TVT: Tension Free Vaginal Tape; TOT: Transobturator Tape.

Review of the 6th International Consultation on Incontinence: Primary prevention of urinary incontinence

AIMS

To report the state of the science on primary prevention of urinary incontinence (UI) in adults from the 6th International Consultation on Incontinence with an update through January 2019.

METHODS

Online databases PubMed, CINAHL, PsycInfo, and Medline were searched in March 2016 and February 2019 with a focus on literature published after 2010. The International Consultation on Urological Diseases modified Oxford Centre for Evidence-Based Medicine Levels of Evidence and grades of recommendation were used to evaluate the literature.

RESULTS

Grade B recommendations to prevent UI in pregnant and postpartum women are available and promising evidence exists for educational interventions to prevent UI up to 2 years in older women. There is little evidence for adding preoperative pelvic floor muscle exercises to postprostatectomy pelvic floor muscle exercises for men to regain continence. Insufficient evidence exists for the effectiveness of screening for UI in women. The absence of information on primary prevention remains for adolescents, nulliparous and perimenopausal women, and middle-aged and aged men and women.

CONCLUSIONS

Few primary prevention interventions for UI exist for specific populations, especially pregnant and postpartum women. Research interest in developing foundational knowledge to design these interventions is growing.

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.

Non-pharmacological interventions for treating sexual dysfunction in postpartum women: a systematic review protocol

INTRODUCTION

Sexual dysfunction in the postpartum period is a very common and relevant clinical problem, which has a significant adverse impact on the health of women. We aim to analyse the efficacy and safety of non-pharmacological interventions for treating sexual dysfunction in postpartum women. Our review aims to provide accurate data for effective policy-making and improve our understanding of the treatment of postpartum sexual dysfunction with non-pharmacological therapies.

METHODS AND ANALYSIS

The Cochrane Central Register of Controlled Trials in The Cochrane Library, clinicaltrials.gov, Medline/PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Literatura Latino-americana e do Caribe em Ciências da Saúde) and Embase will be used to search for articles dated from database inception to July 2019. Randomised controlled clinical trials and large prospective cohorts with control groups using non-pharmacological treatments for sexual dysfunction in postpartum women will be included. Sexual problems are directly linked to sexual dysfunction; thus, the primary outcome will be the absolute number or percentage of sexual issues in each treatment group. The secondary outcomes will be assessed by decreased sexual problems, such as lack of lubrication, decreased libido and difficulty reaching orgasm. Three reviewers will independently select trials and extract data from the original publications. The citations will be screened independently by reviewers in duplicate. The risk of bias of the included studies will be assessed according to the Cochrane risk of bias tool. Data synthesis will be performed using Review Manager (RevMan) software V.5.2.3. In the event that a meta-analysis is possible, we will assess the heterogeneity across the studies by computing the I² statistic.

ETHICS AND DISSEMINATION

As the design of this study includes a review of published data, the need to obtain ethical approval was waived by our institutional review committee. We intend to publish the findings of this systematic review in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018103077.

Pelvic Floor Physical Therapy and Women's Health Promotion

Pelvic floor dysfunction is defined as abnormal function of the pelvic floor and includes conditions that can have significant adverse impacts on a woman's quality of life, including urinary incontinence (stress, urge, and mixed), fecal incontinence, pelvic organ prolapse, sexual dysfunction, diastasis recti abdominis, pelvic girdle pain, and chronic pain syndromes. Women's health care providers can screen for, identify, and treat pelvic floor dysfunction. This article examines the case of a woman with multiple pelvic-floor-related problems and presents the evidence for the use of pelvic floor physical therapy (PFPT) for pregnancy-related pelvic floor dysfunction. PFPT is an evidence-based, low-risk, and minimally invasive intervention, and women's health care providers can counsel women about the role that PFPT may play in the prevention, treatment, and/or management of pelvic floor dysfunction.

Prevalence and predictors of double incontinence 1 year after first delivery

INTRODUCTION AND HYPOTHESIS

Urinary (UI) and anal incontinence (AI) are common pelvic floor disorders (PFD), and postpartum women experiencing double incontinence (DI), the combination of UI and AI, tend to have more severe symptoms and a greater impact on quality of life. Our objective was to investigate the prevalence and predictors of postpartum DI and UI alone 1 year after first delivery.

METHODS

In this prospective cohort study, 976 women reported the prevalence of DI and UI alone 1 year after their first delivery in one of two hospitals in Norway using the St Marks score and the ICI-Q UI SF.

RESULTS

DI was significantly reduced from 13% in late pregnancy to 8% 1 year later, whereas 30% reported UI at both time points. Incontinence in late pregnancy predicted incontinence 1 year after delivery. Higher age was associated with UI alone. Compared with caesarean delivery, normal vaginal or instrumental delivery increased the risk of UI alone more than three and four times respectively. Obstetric anal sphincter injuries showed a four-fold increase in the risk of DI.

CONCLUSIONS

Nearly 50% reported incontinence symptoms 1 year after first delivery. Continence status during pregnancy was one of the main predictors of postpartum continence status. Mode of delivery increased the risk of postpartum UI, whereas obstetric anal sphincter injuries increased the risk of postpartum DI.

Differences in urinary incontinence symptoms and pelvic floor structure changes during pregnancy between nulliparous and multiparous women

Background

This study was performed to compare changes in urinary incontinence (UI) symptoms and pelvic floor structure during pregnancy between nulliparous and multiparous women.

Methods

A cross-sectional survey was performed among pregnant women from July 2016 to January 2017. In total, 358 pregnant women from two hospitals underwent an interview and pelvic floor transperineal ultrasound assessment. A questionnaire regarding sociodemographic, gynecological, obstetric features and the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) were used for the interview. Imaging data sets were analyzed offline to assess the bladder neck vertical position (BNVP), urethral angles (α, β, and γ angles), and hiatal area (HA) at rest and at maximal Valsalva maneuver (VM).

Results

After excluding 16 women with invalid data, 342 women were included. The prevalence (χ² = 9.15, P = 0.002), frequency (t = 2.52, P = 0.014), usual amount of UI (t = 2.23, P = 0.029) and scores of interference with daily life (t = 2.03, P = 0.045) during pregnancy were higher in multiparous than nulliparous women. A larger bladder neck descent (BND) (F = 4.398, P < 0.001), HA (F = 6.977, P < 0.001), α angle (F = 2.178, P = 0.030), β angle (F = 4.404, P < 0.001), and γ angle (F = 2.54, P = 0.011) at VM were discovered in pregnant women with UI than without UI. Multiparous women had a significantly higher BND (t = 2.269, P = 0.024) and a larger α angle (F = 2.894, P = 0.004), β angle (F = 2.473, P = 0.014), and γ angle (F = 3.255, P = 0.001) at VM than did nulliparous women.

Conclusion

Multiparous women experienced more obvious UI symptoms and pelvic floor structure changes during pregnancy than did nulliparous women.

Delivery parameters, neonatal parameters and incidence of urinary incontinence six months postpartum: a cohort study

INTRODUCTION

Contradictory results have been reported regarding most delivery parameters as risk factors for urinary incontinence. We investigated the association between the incidence of urinary incontinence six months postpartum and single obstetric risk factors as well as combinations of risk factors.

MATERIAL AND METHODS

This study was based on the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health during 1998-2008. This substudy was based on 7561 primiparous women who were continent before and during pregnancy. Data were obtained from questionnaires answered at weeks 15 and 30 of pregnancy and six months postpartum. Data were linked to the Medical Birth Registry of Norway. Single and combined delivery- and neonatal parameters were analyzed by logistic regression analyses.

RESULTS

Birthweight was associated with significantly higher risk of urinary incontinence six months postpartum [3541-4180 g: odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2-1.6; >4180 g: OR 1.6, 95% CI 1.2-2.0]. Fetal presentation, obstetric anal sphincter injuries, episiotomy and epidural analgesia were not significantly associated with increased risk of urinary incontinence. The following combinations of risk factors among women delivering by spontaneous vaginal delivery increased the risk of urinary incontinence six months postpartum; birthweight ≥3540 g and ≥36 cm head circumference; birthweight ≥3540 g and forceps, birthweight ≥3540 g and episiotomy; and ≥36 cm head circumference and episiotomy.

CONCLUSION

Some combinations of delivery parameters and neonatal parameters seem to act together and may increase the risk of incidence of urinary incontinence six months postpartum in a synergetic way.

Reduced Pelvic Floor Muscle Tone Predisposes to Persistence of Lower Urinary Tract Symptoms after Puerperium

Pregnant primiparous women at term were enrolled in the study. ICIQ-FLUTS questionnaire was used to find out prevalence of LUTS. MOS was used to assess pelvic floor muscle strength. Women were followed up after 8-10 weeks of delivery to find out remission or persistence of these symptoms. We found that increased frequency of micturition was the most common (82%) LUTS seen in primiparous women at term. More than half (51%) of these women who complained of LUTS had a poor pelvic floor muscle tone (MOS grade 3). Out of those who had symptoms during pregnancy 11% remained symptomatic even after puerperium. Interestingly 61% of those with persistence of symptoms demonstrated a very poor pelvic floor muscle tone at term (MOS grade 2), while the remaining 39% also had a tone of only MOS grade 3. Thus women with LUTS during pregnancy should be screened for their pelvic floor muscle tone with simple MOS system which will help to predict the persistence of these symptoms later on. Women with a low score (three or less) should be triaged for regular pelvic floor muscle exercises.

Primary Prevention of Urinary Incontinence: A Case Study of Prenatal and Intrapartum Interventions

A wealth of information is available regarding the diagnosis and treatment of urinary incontinence. However, there is a dearth of quality information and clinical practice guidelines regarding the primary prevention of urinary incontinence. Given the high prevalence of this concern and the often cited correlation between pregnancy, childbirth, and urinary incontinence, women's health care providers should be aware of risk factors and primary prevention strategies for stress urinary incontinence (SUI) in order to reduce associated physical and emotional suffering. This case report describes several common risk factors for SUI and missed opportunities for primary prevention of postpartum urinary incontinence. The most effective methods for preventing urinary incontinence include correct teaching of pelvic floor muscle training (PFMT; specifically Kegel exercises), moderate combined physical exercise regimens, counseling and support for weight loss, counseling against smoking, appropriate treatment for asthma and constipation, and appropriate labor management to prevent pelvic organ prolapse, urethral injury, and pelvic floor muscle damage.

Position in the second stage of labour and de novo onset of post-partum urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the role of the maternal position at the time of delivery on the onset of de novo symptoms of urinary incontinence (UI) in the post-partum period.

METHODS

This prospective study evaluated the data of consecutive women undergoing labour and delivery, between January 2014 and July 2014. We included only women with a singleton pregnancy undergoing vaginal delivery. During the study period, patients chose to deliver in the position that they considered the most comfortable. The onset of UI was evaluated according to the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-sf).

RESULTS

Overall, 716 primiparous women were included in the study. Sixty women refused the 12-week post-partum interview (8.4%). Women were divided in two groups: 296 women (45.1%) who chose an upright position during delivery (group 1) and 360 women (54.9%) who chose a supine position (group 2). Group 1 had a significantly lower episiotomy rate, but a higher rate of greater than second degree perineal tears. In group 1 we found a significantly lower rate of de novo UI (40.5% vs 48.9%, p = 0.03) and in particular of stress urinary incontinence. Via multivariate analysis, birth position was the only factor correlating with the occurrence of urinary incontinence in the post-partum period (OR: 1.52; 95%CI: 1.06, 2.18; p = 0.02).

CONCLUSIONS

Upright positions at delivery are related to a lower episiotomy rate and a higher rate of greater than second degree perineal tears. Supine positions are an independent risk factor for the onset of de novo UI.

Indications for and Risks of Elective Cesarean Section

BACKGROUND

Rates of cesarean section have risen around the world in recent years. Accordingly, much effort is being made worldwide to understand this trend and to counteract it effectively. A number of factors have been found to make it more likely that a cesarean section will be chosen, but the risks cannot yet be clearly defined.

METHODS

This review is based on pertinent publications that were retrieved by a selective search in the PubMed, Scopus, and DIMDI databases, as well as on media communications, analyses by the German Federal Statistical Office, and guidelines of the Association of Scientific Medical Societies in Germany (AWMF).

RESULTS

The increased rates of cesarean section are thought to be due mainly to changed risk profiles both for expectant mothers and for their yet unborn children, as well as an increase in cesarean section by maternal request. In 1991, 15.3% of all newborn babies in Germany were delivered by cesarean section; by 2012, the corresponding figure was 31.7%, despite the fact that a medical indication was present in less than 10% of all cases. This development may perhaps be explained by an increasing tendency toward risk avoidance, by risk-adapted obstetric practice, and increasing media attention. The intraoperative and postoperative risks of cesarean section must be considered, along with complications potentially affecting subsequent pregnancies.

CONCLUSION

Scientific advances, social and cultural changes, and medicolegal considerations seem to be the main reasons for the increased acceptibility of cesarean sections. Cesarean section is, however, associated with increased risks to both mother and child. It should only be performed when it is clearly advantageous.

Lower Urinary Tract Symptoms and Urinary Incontinence During Pregnancy

OBJECTIVE

Lower urinary tract symptoms (LUTS) can frequently be seen in pregnant women. Pregnancy and delivery have been considered as risk factors in the occurrence of pelvic floor dysfunction and determinants of LUTS. The main associated risk factor is parity. In the present study, we aim to determine the frequency of LUTS and urinary incontinence (UI) during pregnancy and the associated risk factors.

METHODS

This prospective study was carried out in a total of 250 women during their 28- and 40-gestational week checks. The Urinary Distress Inventory-6, the Incontinence Impact Questionnaire-7, and International Consultation on Incontinence Questionnaire-Short Form were used to determine LUTS and its effect on quality of life.

RESULTS

The mean age and gestational age of the participants were 29.41 ± 5.70 year (range 18-44) and 35.45 ± 2.98 weeks (range 28-40), respectively. The prevalence of LUTS was 81.6%. The prevalence of UI during pregnancy was 37.2%. Stress urinary incontinence, urge urinary incontinence and mixed urinary incontinence were diagnosed as 15.6, 4.8 and 16.8%, respectively. We found that advanced age, smoking and multiparity were risk factors associated with incontinence. Incontinence reduced pregnant women's quality of life.

CONCLUSIONS

Lower urinary tract symptoms are commonly seen among pregnant women and these symptoms negatively affect the quality of life of pregnant women. Advanced age, smoking and multiparity were risk factors associated with urinary incontinence and LUTS. Obstetricians should be on the lookout for individual urological problems in pregnancy. Resolving any urological issues and cessation of smoking for the affected individuals will help alleviate the problem.

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.


Preventing urinary incontinence in women

PURPOSE OF REVIEW

This review examines the evidence to date, analyzes specific risk factors and assesses the ability to prevent urinary incontinence in women, while providing clinical recommendations. More extraordinary risk factors such as ethnicity and race, mixed and fecal incontinence, iatrogenic and neurogenic factors should be discussed in a follow-up report.

RECENT FINDINGS

Studies have revealed that certain factors place women at risk for developing urinary incontinence, including age, obesity, diabetes, pregnancy and delivery, high-impact physical exercise factors and estrogen deficiency.

SUMMARY

Healthcare providers should screen women who are at risk for developing urinary incontinence and institute specific interventions, specifically behavioral and even rehabilitative techniques, to prevent this prevalent and distressing condition.