Prevalence of stress incontinence among women delivered by elective cesarian section

Delivery mode is a major environmental determinant of stress urinary incontinence: results of the Evanston-Northwestern Twin Sisters Study

OBJECTIVE

We studied a large cohort of identical twin sisters, utilizing the unique properties of a twin research design to explore the relationship between obstetrical delivery mode and stress urinary incontinence.

STUDY DESIGN

An anonymous 67-item survey was completed by 271 identical twin pairs (n = 542) at the world's largest annual gathering of twins. Logistic regression for repeated binary measures was used to evaluate risk factors and accounting for shared genetics within pairs.

RESULTS

The twins had a mean age of 47.1 years (range 15 to 85 years), and stress urinary incontinence was reported by 51.8%. Stress urinary incontinence was associated with age (P = .001), parity (P = .001), obesity (P = .002), and birth mode, with vaginal delivery conferring a considerable increase in stress urinary incontinence risk relative to cesarean section (odds ratio 2.28, 95% confidence interval 1.14 to 4.55, P = .019).

CONCLUSION

Vaginal delivery mode represents a potent determinant of stress urinary incontinence, carrying more than twice the risk of cesarean section. This study of identical twins provides new insight into the epidemiology of female incontinence.

Physiotherapy for female stress urinary incontinence: individual therapy at the outpatient clinic versus home-based pelvic floor training: a 5-year follow-up study

AIMS

To compare the long-term effects of individual physiotherapy at an outpatient clinic, including electrical stimulation (ES), active pelvic floor muscle exercises (PFMEs), and training with a vaginal ball (VB), with home-based active PFMEs and training with a VB, in cases of female stress urinary incontinence (SUI).

MATERIALS AND METHOD

Thirty-three women with SUI (outpatient clinic group [Group I, n = 16] and home group [Group II, n = 17]) participated in the 5-year follow-up study. Both groups had an active PFME program and they used a VB during daily activities for intensive pelvic floor muscle (PFM) training. Group I was also treated at the outpatient clinic with maximal interferential ES, using frequencies varying from 10 to 50 Hz, and individually instructed exercises with biofeedback were carried out at the same time, once a week, an average of nine times in the first year. After baseline examinations, both groups visited the outpatient clinic at 4 months, 12 months, and at 5 years.

RESULTS

At 12 months, there were no statistically significant differences between the study groups in any of the outcome variables, but within the groups both the subjective and objective results were significantly better in comparison with the initial values. After 12 months, two (3%) patients in Group I continued physiotherapy and seven (41%) patients in Group II needed physiotherapy because of an unsatisfactory outcome. At 5 years, according to the urinary incontinence severity score (UISS) questionnaire, subjective discomfort had decreased in both groups (P < 0.01) and 21 of the 33 women (64%) perceived a subjective cure or improvement in their condition. The mean objective urine leakage verified by the pad test decreased from 23.0 to 1.0 g in Group I and from 13.0 to 1.0 g in Group II (P < 0.001 for both groups). The strength of PFMs tested in a standing position increased by 26% in Group I and by 19% in Group II (P values 0.001 and 0.084, respectively), and in a lying position by 28% in Group I and by 32% in Group II (P values 0.001 and 0.008, respectively).

CONCLUSIONS

Home-based PFMEs and training with a VB proved to be equally effective as once-a-week supervised therapy, and the 5-year follow-up results demonstrated a successful response in the treatment of female SUI.

Prevention of urinary and anal incontinence: role of elective cesarean delivery

PURPOSE OF REVIEW

Currently, prophylactic elective cesarean to prevent incontinence is being promoted without robust evidence supporting it, this has created confusion among health personnel [corrected]. Past research centered on defining the damaging effect of vaginal birth on continence whilst the limited research on elective cesarean considered it protective. Cesarean delivery has economic, obstetric, gynecological and psychosocial consequences, but incontinence is not uncommon with a persistent morbidity. There is confusion among health personnel about advocating elective cesarean delivery to prevent incontinence. Reviewing current research would facilitate obstetric thinking.

RECENT FINDINGS

Multiplanar endosonography and three-dimensional magnetic resonance imaging scanning are reportedly better in delineating structural alterations in the continence mechanism following vaginal birth and could be applied to postcesarean incontinence. Incontinence can follow vaginal or elective cesarean delivery and the severity following either mode is comparable. Urinary incontinence can resolve, persist or start de novo and the primiparous prevalence is similar following cesarean or vaginal birth. Transient anal incontinence can manifest during pregnancy. Paradoxically, pelvic floor strengthening exercises are beneficial for pregnancy-related incontinence, yet urinary incontinence occurs in nulliparas notwithstanding a strong pelvic floor.

SUMMARY

Improved imaging techniques should promote a better understanding of postcesarean incontinence. Since severe incontinence can occur after elective cesarean, its reportedly preventative role deserves more scrutiny. When incontinence occurs without labor, it is transient or shows exercise-related improvement; the role of elective cesarean delivery seems tenuous and needs careful evaluation. Current evidence does not support the routine use of elective cesarean to prevent incontinence so the delivery mode should continue to be dictated by obstetric considerations.

Urinary incontinence among mothers of multiples: the protective effect of cesarean delivery

OBJECTIVE

The purpose of this study was to assess the impact of delivery mode on the risk of urinary incontinence among women with previous multiple childbirth.

STUDY DESIGN

A 77-item questionnaire was administered to 733 mothers of multiples. Multivariate regression was used to control for potentially confounding variables.

RESULTS

The mean rate of stress urinary incontinence among women who were delivered by cesarean-only delivery was 39.6%, which was significantly lower than the 60.4% among women who reported previous vaginal births (P =.005). Cesarean-only delivery was associated with a markedly reduced risk (odds ratio, 0.52; P =.002) after controlling for age, parity, and body mass index by multivariate regression. Weaker associations were found for age (odds ratio, 1.08), body mass index (odds ratio, 1.06), and parity (odds ratio, 1.46). Urge incontinence was associated with parity, body mass index, and age, but not delivery mode (P =.76).

CONCLUSION

Vaginal delivery represents a major risk factor for stress incontinence among mothers of multiples. Delivery by cesarean delivery only confers an independent protective effect.

Urinary incontinence after vaginal delivery or cesarean section

BACKGROUND

It is uncertain whether women who deliver by cesarean section have an increased risk of urinary incontinence as compared with nulliparous women and whether women who deliver vaginally have an even higher risk.

METHODS

We studied 15,307 women enrolled in the Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) study, which involved a community-based cohort. The data base for this study was linked to data from the Medical Birth Registry of Norway. We included women who answered questions related to urinary incontinence, were younger than 65 years of age, and had had no deliveries, cesarean sections only, or vaginal deliveries only.

RESULTS

The prevalence of any incontinence was 10.1 percent in the nulliparous group; age-standardized prevalences were 15.9 percent in the cesarean-section group and 21.0 percent in the vaginal-delivery group. Corresponding figures for moderate or severe incontinence were 3.7 percent, 6.2 percent, and 8.7 percent, respectively; figures for stress incontinence were 4.7 percent, 6.9 percent, and 12.2 percent, respectively; figures for urge incontinence were 1.6 percent, 2.2 percent, and 1.8 percent, respectively; and figures for mixed-type incontinence were 3.1 percent, 5.3 percent, and 6.1 percent, respectively. As compared with nulliparous women, women who had cesarean sections had an adjusted odds ratio for any incontinence of 1.5 (95 percent confidence interval, 1.2 to 1.9) and an adjusted odds ratio for moderate or severe incontinence of 1.4 (95 percent confidence interval, 1.0 to 2.1). Only stress and mixed-type incontinence were significantly associated with cesarean sections. The adjusted odds ratio for any incontinence associated with vaginal deliveries as compared with cesarean sections was 1.7 (95 percent confidence interval, 1.3 to 2.1), and the adjusted odds ratio for moderate or severe incontinence was 2.2 (95 percent confidence interval, 1.5 to 3.1). Only stress incontinence (adjusted odds ratio, 2.4; 95 percent confidence interval, 1.7 to 3.2) was associated with the mode of delivery.

CONCLUSIONS

The risk of urinary incontinence is higher among women who have had cesarean sections than among nulliparous women and is even higher among women who have had vaginal deliveries. However, these findings should not be used to justify an increase in the use of cesarean sections.

Urinary symptoms in pregnancy: are they useful for diagnosis?

This is the second part of a study assessing 161 women 12 weeks after their first delivery. The urodynamic data have previously been published [Br J Obstet Gynaecol 2000;107:1354]. The symptoms have been assessed using a (non-validated) urinary symptom questionnaire. There was no correlation between symptoms and urodynamic findings and most importantly between the symptom of stress incontinence, a diagnosis of urodynamic stress incontinence (USI) and vaginal delivery. Symptoms of incontinence and abnormal urodynamic findings were also found in women who underwent caesarean section. These data explain why caesarean section does not appear to be wholly protective in preventing postpartum incontinence. This suggests that the aetiology of postpartum incontinence is multifactorial and urinary symptoms are misleading in determining the underlying causes.

The risk of lower urinary tract symptoms five years after the first delivery

AIM OF THE STUDY

To estimate the prevalence and 5-year incidence of lower urinary tract symptoms (LUTS) after the first delivery and to evaluate the impact of pregnancy per se and delivery per se on long-lasting symptoms.

MATERIALS AND METHODS

A longitudinal cohort study of 305 primiparae questioned a few days, 3 months, and 5 years after their delivery. The questionnaire used was tested and validated, and the questions were formulated according to the definitions of the International Continence Society (ICS). Maternal, obstetric, and neonatal data concerning every delivery and objective data concerning surgeries during the observation period were obtained from the records. From the sample of 278 women (91%) who responded 5 years after their first delivery, three subpopulations were defined: 1) women without initial LUTS before or during the first pregnancy or during the puerperal period, 2) women with onset of LUTS during the first pregnancy, and 3) women with onset of LUTS during the first puerperium. The risk of LUTS 5 years after the first delivery was examined using bivariate analyses. The obstetric variables in the bivariate tests with a significant association with long-lasting urinary incontinence were entered into a multivariate logistic regression.

RESULTS

The prevalence of stress and urge incontinence 5 years after first delivery was 30% and 15%, respectively, whereas the 5-year incidence was 19% and 11%, respectively. The prevalence of urgency, diurnal frequency, and nocturia 5 years after the first delivery was 18%, 24%, and 2%, respectively, whereas the 5-year incidence was 15%, 20%, and 0.5%, respectively. The prevalence of all LUTS except nocturia increased significantly during the 5 years of observation. The risk of long-lasting stress and urge incontinence was related to the onset and duration of the symptom after the first pregnancy and delivery in a dose-response-like manner. Vacuum extraction at the first delivery was used significantly more often in the group of women with onset of stress incontinence during the first puerperium, whereas an episiotomy at the first delivery was performed significantly more often in the group of women with onset of stress incontinence in the 5 years of observation. The prevalence of urgency and diurnal frequency 5 years after the first delivery was not increased in women with symptom onset during the first pregnancy or puerperium compared with those without such symptoms. The frequency of nocturia 5 years after the first delivery was too low for statistical analysis.

CONCLUSION

The first pregnancy and delivery may result in stress and urge incontinence 5 years later. Women with stress and urge incontinence 3 months after the first delivery have a very high risk of long-lasting symptoms. An episiotomy or a vacuum extraction at the first delivery seems to increase the risk. Subsequent childbearing or surgery seems without significant contribution. Long-lasting urgency, diurnal frequency, or nocturia cannot be predicted from onset during the first pregnancy or puerperium.

Urological problems in pregnancy

During pregnancy the urinary tract undergoes extensive anatomical and physiological changes. These changes can result in many symptoms and pathological conditions that may affect the mother and fetus. It is well documented that childbirth may result in urinary tract damage which may predispose to postpartum symptoms. This review describes the physiological and pathological consequences of pregnancy and delivery on the urinary tract, and how these may be minimized.

The risk of urinary incontinence of parous women who delivered only by cesarean section

OBJECTIVES

To evaluate the association of route of delivery with prevalence of urinary incontinence.

METHODS

Women with menopause who consulted at the Department of Gynecology and Obstetrics, Universidade Estadual de Campinas, were interviewed and examined to detect urinary incontinence. Obstetrics history and other possible factors that could influence incontinence were also recorded.

RESULTS

Urinary incontinence was diagnosed in 98 women (cases) while 91 were free of this problem. The risk of urinary incontinence was approximately five times higher among women with one or more pregnancies than among nulligravida, and 3.5 times higher among women who had had only cesarean sections than among nullipara.

CONCLUSIONS

Women cannot prevent urinary incontinence by delivering exclusively by cesarean section.

Urinary incontinence: prevalence and risk factors at 16 weeks of gestation

OBJECTIVE

To evaluate the prevalence of urinary incontinence at 16 weeks of gestation and to identify possible maternal and obstetric risk factors.

DESIGN

Cross-sectional study and cohort study.

SETTING

Department of Obstetrics and Gynaecology, Aarhus University Hospital, Denmark.

POPULATION

Cross-sectional study: 7795 women attending antenatal care. Cohort study: a sub-group of 1781 pregnant women with one previous delivery at our department.

RESULTS

Prevalence and maternal risk factors: the prevalence of urinary incontinence within the preceding year was 8.9% among women at 16 weeks of gestation (nulliparae, 3.9%, para 1, 13.8%, para 2+, 16.2%). Stress or mixed incontinence occurred at least weekly in 3% of all the women. After adjusting for age, parity, body mass index, smoking, previous abortions, and previous lower abdominal or urological surgery in a logistic regression model, primiparous women who had delivered vaginally had higher risk of stress or mixed urinary incontinence than nulliparous women (OR 5.7; 95% CI 3.9-8.3). Subsequent vaginal deliveries did not increase the risk significantly. Young age, body mass index > 30, and smoking were possible risk factors for developing urinary incontinence. Obstetric factors: weight of the newborn > 4000 g (OR 1.9; 95% CI 1.0-3.6) increased the risk of urinary incontinence; mediolateral episiotomy in combination with birthweight > 4000 g also increased the risk (OR 3.5; 95% CI 1.2-10.2); a number of other intrapartum factors did not increase the risk of urinary incontinence.

CONCLUSIONS

The first vaginal delivery was a major risk factor for developing urinary incontinence; subsequent vaginal deliveries did not increase the risk significantly. Birthweight > 4000 g increased the risk; episiotomy in combination with birthweight > 4000 g also increased the risk.

Is antenatal bladder neck mobility a risk factor for postpartum stress incontinence?

OBJECTIVE

To assess the contribution of constitutional factors, as demonstrated by antenatal bladder neck mobility, in the development of postpartum urinary stress incontinence.

DESIGN

A prospective investigational study.

SETTING

General district hospital.

POPULATION

One hundred and three primigravid women with no pre-existing urinary incontinence or neurological disorder.

METHODS

Antenatal and postnatal measurement of bladder neck mobility using perineal ultrasound.

MAIN OUTCOME MEASURE

Urinary stress incontinence at 10-14 weeks postpartum.

RESULTS

Women with postpartum urinary stress incontinence have significantly greater antenatal bladder neck mobility than those women continent postpartum. There were no significant differences in any labour or delivery variables, including mode of delivery, between the postpartum continent and incontinent women.

CONCLUSIONS

There is evidence for a constitutional risk factor (eg, defective pelvic floor connective tissue in the development of postpartum stress incontinence).

The influence of age, parity, oral contraception, hysterectomy and menopause on the prevalence of urinary incontinence in women

The influence of age, parity, duration of previous oral contraceptive use, hysterectomy and menopause on the prevalence of urinary incontinence was evaluated by means of a postal questionnaire in women 46 to 86 years old who resided in the city of Göteborg, Sweden. A sample of 10,000 women from the 7 birth cohorts of 1900 to 1940 was obtained at random from the population register. The overall response rate was 74.6%. The prevalence of urinary incontinence increased (p < 0.001) in a linear fashion from 12.1% in the 1940 birth cohort to 24.6% in the 1900 birth cohort. The prevalence of urinary incontinence in nulliparous women was 7.7% in the 1930 birth cohort and 5.5% in the 1940 birth cohort. The corresponding figures for women who had experienced 1 delivery were 11.1% and 10.6%, compared to 14.0% and 16.4% among women who had had 3 or more deliveries. Urinary incontinence was more prevalent in women who had undergone hysterectomy (p < 0.05). The prevalence of urinary incontinence was unaffected by the duration of previous oral contraceptive use and there was no evidence to suggest that the prevalence of urinary incontinence increased at the time of the last menstrual period.