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

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

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

Determination of a cutoff value for pelvic floor distensibility using the Epi-no balloon to predict perineal integrity in vaginal delivery: ROC curve analysis. Prospective observational single cohort study

CONTEXT AND OBJECTIVE

Several risk factors are involved in perineal lacerations during vaginal delivery. However, little is known about the influence of perineal distensibility as a protective factor. The aim here was to determine a cutoff value for pelvic floor distensibility measured using the Epi-no balloon, which could be used as a predictive factor for perineal integrity in vaginal delivery.

DESIGN AND SETTING

Prospective observational single cohort study conducted in a maternity hospital.

METHODS

A convenience sample of 227 consecutive at-term parturients was used. All women had a single fetus in the vertex presentation, with up to 9.0 cm of dilation. The maximum dilation of the Epi-no balloon was measured using a tape measure after it had been inflated inside the vagina up to the parturients' maximum tolerance. The receiver operating characteristic (ROC) curve was used to obtain the Epi-no circumference measurement with best sensitivity and specificity.

RESULTS

Among the 161 patients who were included in the study, 50.9% underwent episiotomy, 21.8% presented lacerations and 27.3% retained an intact perineum. Age > 25.9 years; number of pregnancies > 3.4; number of deliveries > 2.2 and circumference measured by Epi-no > 21.4 cm were all directly correlated with an intact perineum. Circumference measurements using the Epi-no balloon that were greater than 20.8 cm showed sensitivity and specificity of 70.5% and 66.7% (area under curve = 0.713), respectively, as a predictive factor for an intact perineum in vaginal delivery.

CONCLUSION

Circumferences greater than 20.8 cm achieved using the Epi-no balloon are a predictive factor for perineal integrity in parturients.

Long-term Impact of Mode of Delivery on Stress Urinary Incontinence and Urgency Urinary Incontinence: A Systematic Review and Meta-analysis

Context

Stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) are associated with physical and psychological morbidity, and large societal costs. The long-term effects of delivery modes on each kind of incontinence remain uncertain.

Objective

To investigate the long-term impact of delivery mode on SUI and UUI.

Evidence acquisition

We searched Medline, Scopus, CINAHL, and relevant major conference abstracts up to October 31, 2014, including any observational study with adjusted analyses or any randomized trial addressing the association between delivery mode and SUI or UUI ≥1 yr after delivery. Two reviewers extracted data, including incidence/prevalence of SUI and UUI by delivery modes, and assessed risk of bias.

Evidence synthesis

Pooled estimates from 15 eligible studies demonstrated an increased risk of SUI after vaginal delivery versus cesarean section (adjusted odds ratio [aOR]: 1.85; 95% confidence interval [CI], 1.56–2.19; I² = 57%; risk difference: 8.2%). Metaregression demonstrated a larger effect of vaginal delivery among younger women (p = 0.005). Four studies suggested no difference in the risk of SUI between spontaneous vaginal and instrumental delivery (aOR: 1.11; 95% CI, 0.84–1.45; I² = 50%). Eight studies suggested an elevated risk of UUI after vaginal delivery versus cesarean section (aOR: 1.30; 95% CI, 1.02–1.65; I² = 37%; risk difference: 2.6%).

Conclusions

Compared with cesarean section, vaginal delivery is associated with an almost twofold increase in the risk of long-term SUI, with an absolute increase of 8%, and an effect that is largest in younger women. There is also an increased risk of UUI, with an absolute increase of approximately 3%.

Patient summary

In this systematic review we looked for the long-term effects of childbirth on urinary leakage. We found that vaginal delivery is associated with an almost twofold increase in the risk of developing leakage with exertion, compared with cesarean section, with a smaller effect on leakage in association with urgency.

Effect of urinary incontinence on the quality of life of asthmatic women

OBJECTIVES

Urinary incontinence (UI) has been associated with chronic respiratory symptoms, and it affects quality of life. This study evaluated the quality of life of asthmatic patients from the Assistance Program for Asthmatic Patients (PAPA) with and without UI.

METHODS

This is an analytical descriptive cross-sectional study using a sample of 358 women with asthma. Data were collected via the International Consultation Incontinence Questionnaire-Simplified Form (ICIQ-SF), Quality of Life in Asthma Questionnaire (QLAQ-ASTHMA) and Short Form 36 Health Survey (SF-36).

RESULTS

We found a general prevalence of UI of 55.3%. Overall quality of life scores in the SF-36 and QLAQ-ASTHMA were not related to the presence of UI. However, the amount of urine lost was significantly correlated with the subdomains physical aspects, general health, social functioning and mental health of the SF-36 and with socioeconomic and psychosocial domains of the QLAQ-ASTHMA.

CONCLUSIONS

Urinary incontinence may affect a large proportion of older women with asthma. This study demonstrates the importance of routinely evaluating the occurrence of UI in order to improve the quality of life of asthmatic patients.

Assessing the impact of twin pregnancies on the pelvic floor using 3-dimensional sonography: a pilot study

OBJECTIVES

The purpose of this study was to compare the morphologic characteristics of the pelvic floor musculature between women with twin and singleton pregnancies.

METHODS

We conducted a cross-sectional case-control study of 40 nulliparous women aged 20 to 38 years to compare women with singleton pregnancies (n = 23) to women with twin pregnancies (n = 17). Biometric measurements of the levator hiatus and the sagittal and coronal diameters were made by transperineal 3-dimensional sonography between the 28th and 38th gestational weeks. Comparisons were statistically assessed by the unpaired Student t test and Mann-Whitney U test.

RESULTS

For the women with singleton pregnancies, the mean sagittal diameters at rest, during the Valsalva maneuver, and during pelvic floor contraction were 5.3, 5.7, and 4.5 cm, respectively, and the mean coronal diameters under these conditions were 3.8, 4.1, and 3.6 cm. For the women with twin pregnancies, the corresponding values were as follows: mean sagittal diameters, 5.3, 5.8, and 4.6 cm; and mean coronal diameters, 4.3, 4.3, and 3.8 cm. The differences in coronal diameters were statistically significant at rest (P < .01) and during contraction (P = .04). The mean levator hiatal areas for the women with singleton pregnancies were 14.6, 16.9, and 11.7 cm(2) at rest, during Valsalva, and during contraction, respectively; for the women with twin pregnancies, these values were 16.0, 18.6, and 12.6 cm(2).

CONCLUSIONS

Hiatal measurements were higher in twin than in singleton pregnancies, with coronal diameters reaching significance at rest and during contraction, suggesting that pelvic support undergoes greater changes during twin pregnancy.

Perineal Distensibility Using Epi-no in Twin Pregnancies: Comparative Study with Singleton Pregnancies

The aims of this study were to compare perineal distensibility between women with twin and singleton pregnancies and to correlate these women's perineal distensibility with anthropometric data. This prospective cross-sectional case-control study was conducted among nulliparous women, of whom 20 were pregnant with twins and 23 with a single fetus. Perineal distensibility was evaluated in the third trimester by means of Epi-no, which was introduced into the vagina and inflated up to the maximum tolerable limit. It was then withdrawn while inflated and its circumference was measured. The unpaired Student's t-test was used to compare perineal distensibility in the two groups and Pearson's correlation coefficient (r) was used to correlate the pregnant women's perineal distensibility with their anthropometric data. There was no difference in perineal distensibility between the twin group (16.51 ± 2.05 cm) and singleton group (16.13 ± 1.67 cm) (P = 0.50). There was a positive correlation between perineal distensibility and abdominal circumference (r = 0.36; P = 0.01). The greater the abdominal circumference was, the greater the perineal distensibility was, regardless of whether the pregnancy was twin or singleton.

Parity is not associated with urgency with or without urinary incontinence

INTRODUCTION AND HYPOTHESIS

Evidence varies on the relation between parity and urgency or urge incontinence (UUI). We used data from the General Longitudinal Overactive Bladder Evaluation to determine whether differences in case definitions could account for variation in findings.

METHODS

We simulated case criteria to correspond to studies of urgency, UUI, and parity using data from 1,880 patients. Logistic models were run for each case-control scenario corresponding to previously used case definitions.

RESULTS

Parity was significantly associated with urgency (odds ratios (OR) 1.70; CI: 1.30-2.22) and UUI (odds ratios (OR) 1.87; CI: 1.34-2.60) only when the case criteria included individuals with stress incontinence (SUI). Parity was not associated with UUI when individuals with SUI were excluded or with urgency when individuals with incontinence were excluded.

CONCLUSIONS

Neither urgency nor UUI symptoms appear to be associated with parity among women 40 years of age and older. Previous associations appear to be explained by inclusion of individuals with SUI.

[Impact of twin gestation on the risk of postpartum stress incontinence]

OBJECTIVE

To study twin pregnancy and delivery as a risk factor for developing postpartum stress urinary incontinence (SUI).

PATIENTS AND METHODS

Retrospective single centre study comparing 117 patients who have delivered twins to 117 patients who have given birth to singletons, between January 2003 and December 2005 in a tertiary maternal-foetal medicine unit. The risk factors associated with the onset of postpartum SUI, its severity, and its impact on the quality of life were studied.

RESULTS

Sixty patients in the twin pregnancy group and 59 in the singleton pregnancy group have answered an auto-questionnaire and were included in the study. The medium-term follow-up of the patient was 20.2 months+/-10.1. The prevalence of SUI in the total population was 30%. The rate was significantly higher in the "twin" group (40%) than in the "singleton" group (20%) (p=0.03). Twin gestation was significantly associated with postpartum SUI for more than 20 months after delivery (OR=2.6 [1.1-5.9]). The univariate analysis found six other risk factors: prenatal urinary incontinence (OR=4.2 [1.7-10.4]), BMI greater than 30 (OR=6.3 [1.2-34.1]), labour duration greater than 8h (OR=4.8 [1.6-14.5]), fundal uterine pressure (OR=4.5 [1.1-18.3]), total intrauterine foetal weight (p=0.003), and immediate postpartum urinary incontinence (OR=12.9 [5-33.5]).

DISCUSSION AND CONCLUSION

The vaginal delivery of two successive foetuses does not seem more purveyor of SUI than caesarean. In twin pregnancies, the high rate of postpartum SUI appears to be related to total intrauterine weight.

Case-controlled study of the relationship between delivery method and incidence of post-partum urinary incontinence

The protective role of caesarean section against urinary incontinence was investigated in this descriptive case-controlled study of 125 women with urinary incontinence who had been referred to obstetrics and gynaecology clinics in Tehran, Iran, compared with 125 control women without urinary incontinence. A gynaecologist visited all women to complete a questionnaire and episiotomy scar, stress incontinence, and severity of cystocele and rectocele were also determined. Data were analysed by Student's t-test for quantitative variables, the chi(2)-test for qualitative variables and logistic regression. Increased age and body mass index were found to be significant risk factors of urinary incontinence (bivariate and multivariate analyses). There were also significant relationships between urinary incontinence and gravidity, parity, delivery mode, episiotomy, type of caesarean section (elective or emergency), cystocele, rectocele and chronic constipation (bivariate analysis only). There was no relationship between urinary incontinence and fetal birth weight or maternal employment status. The results suggest that caesarean section can decrease the rate of urinary incontinence.

Symptoms of anal and urinary incontinence following cesarean section or spontaneous vaginal delivery

OBJECTIVE

The objective of the study was to compare the prevalence of incontinence disorders in relation with spontaneous vaginal delivery or cesarean section.

STUDY DESIGN

Two hundred women with spontaneous vaginal deliveries only were compared with 195 women with cesarean deliveries only 10 years after first delivery.

RESULTS

When compared with cesarean section, vaginal delivery was associated with an increased frequency of stress urinary incontinence (P = .006) and an increased use of protective pads (P = .008) as well as an increased frequency of fecal urgency (P = .048) and gas incontinence (P = .01). At multivariate regression analysis, mode of delivery showed no significant association with incontinence symptoms other than an increased risk for flatus incontinence in women with a history of obstetric anal sphincter injury (odds ratio 3.1; 95% confidence interval, 1.5 to 8.9).

CONCLUSION

Incontinence symptoms are more common following spontaneous vaginal delivery when compared with cesarean section 10 years after first delivery. However, cesarean section is not associated with a major reduction of anal and urinary incontinence.

The diagnostic strength of the 24-h pad test for self-reported symptoms of urinary incontinence in pregnancy and after childbirth

The clinical impact of incontinence in pregnancy and after childbirth is growing because some studies report the efficacy of physiotherapy in pregnancy and because obstetric choices are supposed to have significant impact on post-reproductive urinary function (Goldberg et al. in Am J Obstet Gynecol 188:1447–1450, 2003). Thus, the need for objective measurement of urinary incontinence in pregnancy is growing. Data on pad testing in pregnancy are lacking. We assessed the clinical relevance of the 24-h pad test during pregnancy and after childbirth, compared with data on self-reported symptoms of urinary incontinence and visual analogue score. According to the receiver operating characteristic curve, the diagnostic value of pad testing for measuring (severity of) self-reported incontinence during pregnancy is not of clinical relevance. However, for the purposes of research, pad tests, combined with subjective/qualitative considerations, play a critical role in allowing comparisons across studies, quantifying the amount of urine loss and establishing a measure of severity.

Risk factors for urinary incontinence in Taiwanese women aged 60 or over

To determine risk factors of urinary incontinence (UI) in Taiwanese women aged 60 or over, face-to-face interviews with 1,517 women, selected by a multistage random method, were completed. The prevalence of UI in this age group was 29.8%. Factors and their prevalence associated with UI were age [odds ratio (OR)=1.04 per year], diabetes mellitus (39.8%, p = 0.002), hypertension (39.5%, p = 0.001), abdominal gynecological surgery (41.4%, p = 0.001), hysterectomy (42.4%, p = 0.003), history of drug allergy (41.3%, p = 0.001), smoking (45.5%, p = 0.010), hormone replacement therapy (41.5%, p = 0.026), and high body mass index (OR = 1.05 per unit). Alcohol consumption and marriage did not increase the risk of UI. UI is a common and costly problem in elderly women. It diminishes the quality of life of the affected women. Of the associated factors that are preventable, modifiable, or controllable, smoking, prior hysterectomy, and obesity may have the greatest impact on the prevalence of UI.

The effect of mode of delivery, parity, and birth weight on risk of urinary incontinence

To examine the relationship between symptoms of urinary incontinence (UI) and mode of delivery, parity, and birth weight, data were obtained from a population-based random sample of 3,205 black, Hispanic, and white women age 30-79 in the Boston Area Community Health Survey. Measures include UI symptoms [>or=3 (moderate/severe) Sandvik's severity index]; reproductive history [live birth(s), no live births, never pregnant]; mode of delivery for live births (>or=1 vaginal birth, cesarean delivery only); parity (1, 2, >or=3); and maximum birth weight of live births (<4,000 g, >or=4,000 g). Using logistic regression, women having >or=1 vaginal delivery had twice the odds of UI compared to women with no pregnancies (P = 0.002) or only cesarean deliveries (P = 0.032). There was no difference in odds of UI between cesarean delivery only and never pregnant, by parity or birth weight. Vaginal delivery contributes to risk of UI for black, Hispanic, and white women.

A urogynecologist's view ofthe pelvic floor effects of vaginal delivery/cesarean section for the urologist

Pregnancy and parturition have been implicated in the development of pelvic floor dysfunction. These disorders include urinary incontinence, fecal incontinence, pelvic organ prolapse, and other pelvic and sexual dysfunctions. The urologist caring for women with urinary dysfunction needs to be familiar with the causes of pelvic floor dysfunction and their implications. Defects of the pelvic floor have clearly resulted from the traumatic effect of vaginal delivery. The likely mechanisms of injuries during vaginal delivery involve stretching and compression of the pudendal nerve and peripheral branches, as well as an additional tearing of muscles and connective tissue. Optimal management of labor and optimal techniques of repair of unavoidable sphincteric lacerations, ante- and postpartum pelvic floor muscle conditioning, and timely and proper indications for cesarean delivery will minimize the effect of incidental traumatic delivery.

Pelvic floor muscle training is not effective in women with UI in pregnancy: a randomised controlled trial

The objective of this study was to test the short- and long-term effects of pelvic floor muscle training (PFMT) during pregnancy in women at risk, i.e. women who were already affected by urinary incontinence (UI) during pregnancy. The intervention consisted of three sessions of PFMT between week 23 and 30 during pregnancy and one session 6 weeks after delivery, combined with written information. The research design was a randomised, controlled trial with four follow-ups up to 1 year after delivery. Participants in the study were 264 otherwise healthy women with UI during pregnancy, allocated at random to the intervention (112) or usual care (152) group. The main outcome measure was a UI severity scale and a 7-day bladder diary. No effect of pelvic floor muscle training was shown in this study at (half) a year after pregnancy. UI decreased strongly after pregnancy, irrespective of usual care or PMFT during pregnancy. For most women, usual care appears to be sufficient. The results support a 'wait and see' policy: wait for the urinary incontinence to take its natural course and see if, for women still incontinent half a year after pregnancy, pelvic floor muscle training is effective.

Persistent urinary incontinence and delivery mode history: a six-year longitudinal study

OBJECTIVE

To investigate the prevalence of persistent and long term postpartum urinary incontinence and associations with mode of first and subsequent delivery.

DESIGN

Longitudinal study.

SETTING

Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand).

POPULATION

Women (4214) who returned postal questionnaires three months and six years after the index birth.

METHODS

Symptom data were obtained from both questionnaires and obstetric data from case-notes for the index birth and the second questionnaire for subsequent births. Logistic regression investigated the independent effects of mode of first delivery and delivery mode history.

MAIN OUTCOME MEASURES

Urinary incontinence-persistent (at three months and six years after index birth) and long term (at six years after index birth).

RESULTS

The prevalence of persistent urinary incontinence was 24%. Delivering exclusively by caesarean section was associated with both less persistent (OR=0.46, 95% CI 0.32-0.68) and long term urinary incontinence (OR=0.50, 95% CI 0.40-0.63). Caesarean section birth in addition to vaginal delivery, however, was not associated with significantly less persistent incontinence (OR 0.93, 95% CI 0.67-1.29). There were no significant associations between persistent or long term urinary incontinence and forceps or vacuum extraction delivery. Other significantly associated factors were increasing number of births and older maternal age.

CONCLUSIONS

The risk of persistent and long term urinary incontinence is significantly lower following caesarean section deliveries but not if there is another vaginal birth. Even when delivering exclusively by caesarean section, the prevalence of persistent symptoms (14%) is still high.

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.

Histochemical and stereological analysis of the levator ani (pubocaudal) muscle in nulliparous and multiparous beagles

Fiber-type composition and several stereological parameters of the levator ani (pubocaudal) muscle were evaluated in five nulliparous and five multiparous beagles using myosin ATPase-histochemistry and systematically selected muscle cross-sections. With respect to the narrow canine pelvic cavity, this study was also undertaken to determine whether vaginal birth of at least seven litters causes similar neuromuscular changes in the canine levator ani (pubocaudal) muscle analoguous to those seen in the pelvic floor muscles of women after vaginal delivery. The canine pubocaudal muscle is comprised of approximately equal amounts of slow twitch type I and fast twitch type II (IIA, IIS) fibers. The muscles of both the nulliparous and multiparous beagles did not display any signs indicative of denervation or myopathology. The multiparous dogs exhibited significantly increased mean absolute muscle (1720 mm(3)) and total fiber-type I volumes (850 mm(3)) as well as relevantly increased mean diameter of type I fibers (72.0 microm) when compared with the nulliparous group. The canine levator ani (pubocaudal) muscle is not pathologically affected by vaginal deliveries and seems to adapt to numerous successive pregnancies and births through fiber-type I hypertrophy.

Obstetric antecedents for postpartum pelvic floor dysfunction

OBJECTIVE

The purpose of this study was to evaluate prospectively the association between selected obstetric antecedents and symptoms of pelvic floor dysfunction in primiparous women up to 7 months after childbirth.

STUDY DESIGN

All nulliparous women who were delivered between June 1, 2000, and August 31, 2002, were eligible for a postpartum interview regarding symptoms of persistent pelvic floor dysfunction. Responses from all women who completed a survey at or before their 6-month contraceptive follow-up visit were analyzed. Obstetric antecedents to stress, urge, and anal incontinence were identified, and attributable risks for each factor were calculated.

RESULTS

During the study period, 3887 of 10,643 primiparous women (37%) returned within 219 days of delivery. Symptoms of stress and urge urinary incontinence, were significantly reduced (P < .01) in women who underwent a cesarean delivery. Symptoms of urge urinary incontinence doubled in women who underwent a forceps delivery (P = .04). Symptoms of anal incontinence were increased in women who were delivered of an infant who weighed >4000 g (P = .006) and more than doubled in those women who received oxytocin and had an episiotomy performed (P = .01).

CONCLUSION

The likelihood of symptoms of pelvic floor dysfunction up to 7 months after delivery was greater in women who received oxytocin, who underwent a forceps delivery, who were delivered of an infant who weighed >4000 g, or who had an episiotomy performed. Women who underwent a cesarean delivery had fewer symptoms of urge and stress urinary incontinence.

Urinary incontinence after multiple gestation and delivery: impact on quality of life

An anonymous 77-item urogenital symptom questionnaire was administered to 769 women with a history of previous multifetal gestation and delivery, including long forms of the Incontinence Impact Questionnaire (IIQ) and Urogenital Distress Inventory (UDI). IIQ and UDI scores were analyzed using univariate and multivariate regression to determine the impact of incontinence on quality of life (QOL). Mean age was 37 years (22-75), and nearly half [49.8% (365)] reported at least one type of incontinence. Higher mean UDI scores were reported by women with stress incontinence (SI) (12.3 vs 4.7, p=0.0001), urge incontinence (UI) (14.9 vs 5.7, p=0.0001), and mixed incontinence (15.1 vs 6.2, p=0.0001) compared to continent women. Similarly, higher mean IIQ scores were associated with SI (6.9 vs 1.9, p=0.0001), UI (9.4 vs 2.2, p=0.0001), and mixed incontinence (9.3 vs 2.7, p=0.0001). In conclusion, among "mothers of multiples," stress and urge urinary incontinence were associated with strongly adverse effects on QOL at a young age.

Primary nonmedically indicated cesarean section ("section on request"): evidence based or modern vogue?

Cesarean section, initially described as an emergency operative procedure for delivering moribund parturients, is now advocated by many as a routine technique with major advantages over vagi-nal delivery. In fact, it has been suggested that labor and vaginal delivery are no longer the desired consequence of pregnancy, a conclusion that reflects perceived medical advantages and patient and physician convenience. This article systematically reviews the various medical implications to the mother and infant of this procedure in the hope of facilitating a more rational approach to this spreading and controversial phenomenon.

Parity and route of delivery: does cesarean delivery reduce bladder symptoms later in life?

OBJECTIVE

This study was undertaken to investigate the impact of reproductive factors on the prevalence of urinary symptoms.

STUDY DESIGN

Participants were women scheduled for hysterectomy (n=1299). Before surgery, urinary symptoms were assessed by questionnaire. Multiple logistic regression analysis was used to investigate the association between bladder symptoms and parity, route of delivery, and other characteristics.

RESULTS

Stress incontinence and urinary urgency were more prevalent among parous than nulliparous women (P <.01). Controlling for parity and other characteristics, women who had a history of cesarean delivery were significantly less likely to report stress incontinence than women with a history of vaginal delivery (odds ratio 0.60; 95% CI 0.39-0.93).

CONCLUSION

Women who have undergone vaginal delivery are more likely to report stress incontinence than women who have delivered by cesarean section. Although this suggests that cesarean delivery might reduce incontinence later in life, further research is needed to clarify the long-term risks, benefits, and costs of cesarean delivery.