Urinary incontinence in pregnancy and the puerperium

Association between striae gravidarum and pelvic floor dysfunction symptoms during pregnancy

INTRODUCTION AND HYPOTHESIS

Striae gravidarum are linear atrophic scars appearing on the abdomen of pregnant women reported to be related to pregnancy-induced changes in the connective tissue. Pelvic floor distress symptoms are also known to be linked to connective tissue weakness. Given that common pathophysiological pathways may play a role in both striae gravidarum and pelvic floor dysfunction symptoms, we sought to examine whether there is a correlation between them during pregnancy.

METHODS

A prospective observational study among third-trimester pregnant women who visited a tertiary medical center for routine pregnancy follow-up was conducted by using the Pelvic Floor Distress Inventory (PFDI-20) questionnaire to evaluate pelvic floor distress symptoms and the Davey method for evaluating striae gravidarum severity. Obstetrical characteristics as well as pelvic floor distress symptoms were compared between two groups according to the severity of striae gravidarum. Univariate analysis was carried out using appropriate tests; PFDI scores were compared between the groups using the Mann-Whitney test.

RESULTS

Women with striae gravidarum were significantly older (31.06 vs. 28.83 years, p < 0.01), had a lower body mass index (27.5 vs. 30.98, p < 0.01), and gave birth to smaller neonates (3155 vs. 3389 g, p < 0.01). In addition, the overall and median PFDI-20 scores differed between the groups (with severe SG having the highest median score of 20 and those with milder SG having a score of 16 compared to 14 in those without SG). A distinct association between the PFDI-20 score and SG severity was not demonstrated (p = 0.63).

CONCLUSIONS

In our population, an association was demonstrated between pelvic floor distress symptoms and the presence of striae gravidarum. However, following a linear regression model, no statistically significant association between SG severity and total PFD-20 score was seen. Our findings strengthen the hypothesis of common connective tissue involvement in the pathophysiology of both conditions.

Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to compare (1) the effects of the instrument-assisted perineal stretching technique with different application protocols in combination with perineal massage and (2) the effects of the isolated techniques on the extensibility and strength of the pelvic floor muscles (PFMs).

METHODS

A randomized controlled clinical trial with parallel randomization, assessor blinding, and concealed allocation was conducted in the Campus Physical Education at the Federal University of Uberlândia in Brazil. Ninety-six pregnant women (18-40 years of age) were allocated into 4 groups: perineal massage (PnM) group (PnM protocol for 10 minutes); instrument-assisted perineal stretching with a long static protocol for 15 minutes [IStrLS group]); PnM + IStrLS group (both techniques applied in the 2 previous groups); and PnM + IStrSR group (the same techniques as used in the PnM + IStrLS group but with a short repeated protocol; 4 sets lasting 30 seconds each). Eight interventions were performed in all 4 groups twice weekly (beginning at the 34th gestational week). The primary outcome was PFM extensibility, assessed using vaginal dilator circumference, and the secondary outcome was PFM strength, assessed using vaginal manometry.

RESULTS

For the PFM extensibility variable, a significant main effect of time (F2,88 = 87.951) and group (F3,88 = 7.193) was found. Tukey post hoc test results showed that the PnM + IStrSR group presented greater extensibility than the PnM and IStrLS groups. The PnM group showed increased PFM strength after 8 sessions compared with the other groups.

CONCLUSIONS

Women who were pregnant and received the combination of perineal massage and instrument-assisted perineal stretching with short repeated application had a greater increase in PFM extensibility than perineal massage and instrument-assisted perineal stretching alone.

IMPACT

The combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol led to better PFM extensibility results than the application of the techniques alone in women who were pregnant.

LAY SUMMARY

Pregnant women can benefit from intervention using the combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.

Prevalence, incidence and bothersomeness of urinary incontinence in pregnancy: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is a common and embarrassing complaint for pregnant women. Reported prevalence and incidence figures show a large range, due to varying case definitions, recruited population and study methodology. Precise prevalence and incidence figures on (bothersome) UI are of relevance for health care providers, policy makers and researchers. Therefore, we conducted a systematic review and meta-analysis to investigate the prevalence and incidence of UI in pregnancy in the general population for relevant subgroups and assessed experienced bother.

METHODS

All observational studies published between January 1998 and October 2018 reporting on prevalence and/or incidence of UI during pregnancy were included. All women, regardless of weeks of gestation and type of UI presented in all settings, were of interest. A random-effects model was used. Subgroup analyses were conducted by parity, trimester and subtype of UI.

RESULTS

The mean (weighted) prevalence based on 44 included studies, containing a total of 88.305 women, was 41.0% (range of 9-75%). Stress urinary incontinence (63%) is the most prevalent type of UI; 26% of the women reported daily loss, whereas 40% reported loss on a monthly basis. Bother was experienced as mild to moderate.

CONCLUSIONS

UI is very prevalent and rising with the weeks of gestation in pregnancy. SUI is the most common type and in most cases it was a small amount. Bother for UI is heterogeneously assessed and experienced as mild to moderate by pregnant women.

Is there a correlation between pelvic floor dysfunction symptoms during pregnancy and the duration of the second stage of labor?

BACKGROUND

Pelvic floor dysfunction (PFD) most commonly results from weakened or injured muscles and ligaments whose purpose is to support the pelvic floor. Many studies have placed vaginal delivery and prolonged second stage of labor (SSL) as major risk factors for PFD, supposedly through generating enhanced pressure in the pelvic area. Although many studies describe the effects of vaginal delivery and labor on structure and function of the pelvic floor, not much is known regarding PFD deriving from pregnancy and its prevalence and severity in the postpartum. We aimed to evaluate whether a correlation exists between PFD symptoms during pregnancy and the duration of the SSL.

METHODS

We conducted a cross sectional study of 200 women who gave birth at Soroka University Medical Center, Beer-Sheva, Israel. Those who had consented completed the Pelvic Floor Distress Inventory-20 (PFDI-20), a condition specific questionnaire developed to measure quality-of-life and the extent of injury to the pelvic floor in women with all forms of PFD. The duration of the SSL and clinical and obstetrical characteristics were retrieved from the participants' medical records. We assessed correlations using Spearman's correlation coefficient.

RESULTS

PFD during pregnancy was found to be correlated to the duration of the SSL (R = -0.183, p = .021). When evaluating each component of the PFDI-20 separately, CRAD was significantly correlated with the duration of the SSL (R = -0.195, p = .014).

CONCLUSIONS

There is a correlation between PFD symptoms during pregnancy, specifically symptoms of CRAD and the duration of the SSL.

The impact of breastfeeding on pelvic floor recovery from pregnancy and labor

OBJECTIVE

Pelvic floor dysfunction (PFD) symptoms are prevalent during pregnancy and are mostly reversible thereafter. The pelvic floor muscles and their surrounding connective tissue support are estrogen-responsive. Breastfeeding is a condition of estrogen deficiency. We hypothesized that in breastfeeding women there may be a slower spontaneous recovery of PFD symptoms following birth. We aimed to determine the impact of breastfeeding on recovery from gestational PFD symptoms.

METHODS

We conducted a prospective cohort study of women who gave birth at the Soroka University Medical Center, Beer-Sheva, Israel. Those who have consented completed the Pelvic Floor Distress Inventory-20 (PFDI-20), after delivery and three months postpartum. Breastfeeding status was evaluated three months after delivery. Clinical and obstetrical characteristics were retrieved from the participants' medical records.

RESULTS

A total of 119 women had completed the PFDI-20 after delivery and three months postpartum. We found a significant difference between PFD during pregnancy, and PFD three months postpartum (P < 0.001). The overall PFDI-20 score was significantly decreased from a scale score of 64 to 27 (delta 36, P < 0.001), and this decrease remained significant for all components of the PFDI-20: pelvic organ prolapse distress (delta 14, P < 0.001); colorectal and anal dysfunction (delta 3.9, P = 0.01); and urinary dysfunction (delta 18, P < 0.001). No significant differences were noted in the extent of recovery of PFD symptoms between women who did and did not breastfeed (P = 0.59).

CONCLUSIONS

There is a clinical and statistically significant spontaneous recovery from gestational PFD symptoms at three months postpartum. Women with PFD symptoms prior to or during pregnancy can be reassured that breastfeeding probably does not delay the pelvic floor recovery.

Consequences of maternal morbidity on health-related functioning: a systematic scoping review

OBJECTIVES

To assess the scope of the published literature on the consequences of maternal morbidity on health-related functioning at the global level and identify key substantive findings as well as research and methodological gaps.

METHODS

We searched for articles published between 2005 and 2014 using Medline, Embase, Popline, CINAHL Plus and three regional bibliographic databases in January 2015.

DESIGN

Systematic scoping review PRIMARY OUTCOME: Health-related functioning RESULTS: After screening 17 706 studies, 136 articles were identified for inclusion. While a substantial number of papers have documented mostly negative effects of morbidity on health-related functioning and well-being, the body of evidence is not spread evenly across conditions, domains or geographical regions. Over 60% of the studies focus on indirect conditions such as depression, diabetes and incontinence. Health-related functioning is often assessed by instruments designed for the general population including the 36-item Short Form or disease-specific tools. The functioning domains most frequently documented are physical and mental; studies that examined physical, mental, social, economic and specifically focused on marital, maternal and sexual functioning are rare. Only 16 studies were conducted in Africa.

CONCLUSIONS

Many assessments have not been comprehensive and have paid little attention to important functioning domains for pregnant and postpartum women. The development of a comprehensive instrument specific to maternal health would greatly advance our understanding of burden of ill health associated with maternal morbidity and help set priorities. The lack of attention to consequences on functioning associated with the main direct obstetric complications is of particular concern.

REVIEW REGISTRATION

CRD42015017774.

Prevalence and trends of pelvic floor disorders in late pregnancy and after delivery in a cohort of Israeli women using the PFDI-20

OBJECTIVE

To investigate the prevalence of pelvic floor disorders (PFD) in a cohort of Israeli women at late pregnancy and three months postpartum, to define changes in PFD rates and to evaluate various obstetrical factors that may correlate with these changes.

METHODS

A prospective longitudinal cohort study was conducted between March and July 2014. The PFDI-20 questionnaire (validated in the Hebrew language) was used to evaluate pelvic floor distress symptoms 24h and 3 months after delivery (representing the third trimester and post-partum period, respectively). Patients with a preterm delivery (<36 completed weeks of gestation), delivery of a stillbirth, non-fluency in Hebrew and patients with inability to complete the questionnaire due to a communication problem were excluded from the study. In addition to the PFDI results demographic and clinical data were collected from the patients' medical records. Routine statistical methods were used to interpret the results.

RESULTS

During the study period 117 women answered the first questionnaire and only 37 had filled the second questionnaire. The most prevalent item group reported in the third trimester was the urinary distress symptoms. Urinary frequency was the most common with 65% of patients reporting this symptom. At the post-partum period the most prevalent item group reported was the colorectal and anal distress with 31.5% of patients reporting increased straining efforts. There was a mixed trend in the changes noted between the two questionnaires. While some items improved in the puerperium as compared with late pregnancy others have worsened. In a multivariable analysis the only statistically significant finding was that at the post-partum follow-up, stress urinary incontinence was significantly associated with spontaneous perineal tears at delivery. Other obstetrical parameters including episiotomy and birth weight were not found to be significantly associated with any of the PFD items.

CONCLUSION

We have demonstrated that PFD is prevalent both in late pregnancy and in the puerperium. There are mixed trends of spontaneous recovery following childbirth. A significant association between perineal tears and SUI 3 months after delivery was noted.

Prevalence and predictors of urinary/anal incontinence after vaginal delivery: prospective study of Nigerian women

INTRODUCTION AND HYPOTHESIS

Urinary and anal incontinence are major public health problems impacting on the quality of life of affected women, with resultant loss of self-esteem. Despite the anticipated magnitude of this public health problem in sub-Saharan Africa, there is paucity of data on the prevalence of urinary and/or anal incontinence after childbirth in the region. This study determined the prevalence and predictors of urinary and anal incontinence after vaginal delivery among women in Enugu, southeastern Nigeria.

METHODS

This was a longitudinal study of 230 consecutive parturients at the University of Nigeria Teaching Hospital, Enugu, Nigeria. Eligible women were followed up immediately, 6 weeks, and 3 months postpartum to assess the development of urinary and/or anal incontinence using validated questionnaires.

RESULTS

Overall, 28 women had urinary incontinence, giving a cumulative prevalence rate of 12.2 %. The cumulative prevalence rate was 13.5 % for anal incontinence and 3 % for combined urinary and anal incontinence. Age, social class, parity, prolonged second stage of labor, and neonatal birth weight were significantly associated with postpartum urinary incontinence (P < 0.05). On the other hand, age, parity, prolonged second stage of labor, episiotomy, and instrumental vaginal delivery were significantly associated with postpartum anal incontinence (P < 0.05).

CONCLUSION

Urinary and anal incontinence are common after vaginal delivery in Enugu, Nigeria. Modification of obstetric care and discouraging preventable predisposing factors for incontinence, such as prolonged second stage of labor and vaginal delivery of macrosomic babies, are measures that may reduce the prevalence of postpartum incontinence in our population.

Prevalência de incontinência urinária autorreferida no pós-parto e fatores relacionados

OBJETIVOS: Verificar a prevalência de incontinência urinária (IU) autorreferida por mulheres no pós-parto e identificar os fatores relacionados. MÉTODOS: Estudo epidemiológico transversal, realizado no período de janeiro a agosto de 2009. Foram entrevistadas 288 mulheres com 30 dias a 6 meses de pós-parto. Os dados foram analisados estatisticamente. RESULTADOS: Observou-se prevalência de 24,6% de IU autorreferida no pós-parto. A idade média das mulheres foi de 26 anos, apenas a cor da pele apresentou diferença estatística significante, com maior representatividade em mulheres brancas. Dentre as 71 entrevistadas que referiram IU no pós-parto, a maioria era primípara e submeteu-se ao parto normal. CONCLUSÃO: A ocorrência de IU autorreferida no pós-parto associa-se à cor da pele com predominância em primíparas em comparação às não primíparas. Identificar os fatores relacionados à IU em mulheres no pós-parto e sua prevalência contribui no planejamento de atenção de enfermagem obstétrica à mulher que vivencia o período reprodutivo.

Incontinência urinária autorreferida no pós-parto

Trata-se de um estudo epidemiológico, transversal, que entrevistou 288 mulheres com até seis meses de pós-parto, frequentadoras de um serviço de saúde do município de São Paulo. Teve como objetivo caracterizar a ocorrência de incontinência urinária autorreferida pela mulher no período pós-parto. Os resultados mostraram que, dentre as 71 mulheres autorreferidas como incontinentes, 20 (28%) relataram que a perda involuntária de urina interferia na sua vida diária; 38 (53,5%) eram primíparas; 277 mulheres (96%) não foram orientadas sobre o preparo do períneo na gestação ou no pós-parto. Verificou-se que, no pós-parto, as mulheres não informam sobre a ocorrência de incontinência urinária ao profissional de saúde, e aquelas que o fazem, não recebem tratamento. A gestação e o pós-parto são momentos importantes para a prevenção desta morbidade.

Perinatal urinary and fecal incontinence: suffering in silence

This article focuses on the prevention, identification, and management of urinary and fecal incontinence in the perinatal period. Both urinary and fecal incontinence are common concerns affecting women throughout pregnancy, intrapartum, and postpartum. These are the problems that are not approached by healthcare providers during the initial antepartal assessment, nor are they fully investigated after delivery. Many women hesitate to disclose this information. Women tend to consider this to be a minor discomfort of pregnancy and a consequence resulting from childbirth in the postpartum period. Intervention strategies and nursing care components in the perinatal period will be presented.

Factors associated with postpartum urinary/anal incontinence in primiparous women in Quebec

OBJECTIVE

To identify the factors associated with urinary incontinence (UI), anal incontinence (AI), and combined UI and AI (UI/AI) in primiparous women in Quebec at six months postpartum.

METHODS

A questionnaire was mailed to 2492 primiparous women at six months postpartum to collect data on incontinence status, sociodemographic characteristics, elimination habits, lifestyle, and severity index scales. Obstetric characteristics were obtained via Quebec's Med-Echo databank. Pearson chi-square, t test, analysis of variance, univariate regression, and stepwise modelling techniques were used for data analysis.

RESULTS

The prevalence of UI in responders was 29.6%, of AI, 20.6%, and of combined UI/AI, 10.4%. Significant adjusted odds ratios were (1) for UI, English spoken (2.04 [95% confidence intervals 1.13-3.69]) and shoulder dystocia (2.90 [1.09-7.69]); (2) for AI, age > 35 years (2.13 [1.12-4.03]), duration of second stage of labour (1.67 [1.11-2.51]), and third or fourth degree tears (4.00 [2.32-6.89]); and (3) for UI and AI, age (2.00 [1.04-3.83]), English spoken (2.55 [1.25-5.19]), shoulder dystocia (4.91 [1.76-13.71]), instrumental delivery (2.28 [1.30-3.99]), third or fourth degree tears (3.58 [1.95-6.57]), and episiotomy (2.24 [1.162-4.33]). Caesarean section was associated with less UI (0.45 [0.28-0.72]), and smoking was associated with less AI (0.38 [0.19-0.76]).

CONCLUSION

Combined UI/AI is associated with several obstetrical factors. The association of UI and AI is observed more frequently after complicated delivery (requiring the application of forceps) or involving perineal damage and episiotomy. As most of the identified factors are modifiable, a preventive treatment policy is advisable.

Urinary incontinence in a group of primiparous women in the Czech Republic

BACKGROUND/AIM

Not only the process of childbirth itself, but also processes during pregnancy seem to be strongly associated with urinary incontinence (UI). According to some epidemiological studies, UI during pregnancy occurs in 23-70% of the pregnant women. These studies also documented some risk factors (e.g., race, age, or body mass index). The aim of our study was to explore the prevalence of UI during pregnancy in the Czech Republic.

METHODS

474 primiparas who gave birth at our maternity ward from June 14, 2004, through January 31, 2005, received a questionnaire. The questionnaire concentrated on the occurrence and presentation of UI before and during pregnancy.

RESULTS

339 women (72%) completed the questionnaire. UI and the length of pregnancy are significantly related. We found a baseline UI prevalence before pregnancy of 17%, but before delivery one of 64%. We did not find any statistically significant relation between the prevalence of UI during pregnancy and body mass index before pregnancy as well as before delivery, weight gain during pregnancy, age, and birth weight.

CONCLUSION

Our results show that pregnancy is a risk factor for the development of UI.

Symptoms of stress incontinence 1 year after childbirth: prevalence and predictors in a national Swedish sample

BACKGROUND

The aims of the present study were to describe the prevalence of stress incontinence, as described by women themselves, 1 year after childbirth in a national sample of Swedish-speaking women, and to identify possible predictors.

METHODS

A cohort study, including 2390 women recruited from 593 antenatal clinics in Sweden during three 1-week periods evenly spread over 1 year (1999-2000), representing 53% of women eligible for the study and 75% of those who consented to participate. Data were collected by means of questionnaires in early pregnancy, 2 months and 1 year after the birth, and from the Swedish Medical Birth Register.

RESULTS

One year after the birth, 22% of the women had symptoms of stress incontinence but only 2% said it caused them major problems. The strongest predictor was urinary incontinence (overall leakage) 4-8 weeks after a vaginal delivery (OR 5.5, CI 95% 4.1-7.4) as well as after a cesarean section (OR 11.9, CI 95% 2.9-48.1). Other predictors in women with a vaginal delivery were: multiparity (OR 1.4; CI 95% 1.1-1.8), obesity (OR 1.6; CI 95% 1.1-2.4) and constipation 4-8 weeks postpartum (OR 1.4; CI 95% 1.1-1.9).

CONCLUSION

Stress incontinence 1 year after childbirth is a common symptom, which could possibly be reduced by identifying women with urinary leakage at the postnatal check-up.