A prospective study of pelvic floor dysfunctions related to delivery

Objective

To estimate the prevalence and impact on quality of life of urinary incontinence (UI) and anal incontinence (AI) three months after first delivery; to identify risk factors involved in UI or AI; to evaluate possible changes in sexual behaviour and anatomical modifications of pelvic floor after childbirth.

Study design

A multicenter prospective study, in six Italian Ob/Gyn departments, of nulliparous women who delivered at term (37-42 weeks of gestation) between April and September 2005. A structured questionnaire investigated several maternal and obstetric variables. UI and AI were assessed by administration of the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and according to Wexner's Continence Grading Scale, at 2-3 days post-partum and at 3 months after delivery. Changes in sexual behaviour, and pelvic floor condition after delivery, were also recorded. Statistical analysis included comparison of means (Mann-Whitney or Student's t-test) and proportions (Chi-square test). Multiple logistic regression analysis was performed including variables that were significant in univariate comparisons.

Results

Of 960 enrolled women, 744 were evaluated 3 months after delivery and included in final analysis. The prevalences of UI and AI at that time were 21.6% and 16.3%, respectively. Onset of incontinence during pregnancy was an independent predictor for persistent UI (Odds Ratio (OR) 4.6, Confidence Interval (CI) 3.1-6.8, p < 0.001) and AI (OR 3.6, CI 2.2-6.1, p < 0.001). Family history of urinary or anal incontinence were respectively associated with UI (OR 2.6, CI 1.6-4.0, p < 0.001) and AI (OR 2.4, CI 1.4-4.0, p < 0.001) 3 months after delivery. Among obstetric factors, vaginal delivery was a strong risk factor for UI (OR 3.3, CI 2.0-5.3, p < 0.001). The sexual score improved 3 months after delivery in 72.4% of women. Urogynaecological evaluation showed a significant association between grade 1-2 anterior prolapse, urethral hypermobility and UI.

Conclusion

New onset of UI or AI during pregnancy, positive family history and vaginal delivery are independent risk factors for the persistence of symptoms of UI and AI in the early postpartum period. Adequate counselling and the implementation of targeted strategies to prevent or early identify these conditions are therefore mandatory to improve the patient's quality of life.     

Prevalence and impact of urinary incontinence among female athletes

Objective

To assess the prevalence of urinary incontinence (UI) in a group of female athletes and to explore its impact on their lives.

Methods

In total, 106 female athletics, basketball, and indoor football athletes were recruited. Data were collected through a questionnaire and a focus group and analyzed via Pearson's χ² test, 2-way analysis of variance, and thematic analysis.

Results

Urinary incontinence was experienced by 41.5% of the athletes. Its prevalence across the 3 types of sport was similar and was not affected by age. However, athletes who experienced UI had a lower body weight (P = 0.011) and a lower body mass index (P = 0.035). Most (95.5%) athletes had never discussed their condition with a health professional. In the focus group, all athletes described preventive urination to avoid urine leakage. It was mentioned that UI affected their performance and made them feel uncomfortable and frustrated.

Conclusion

Urinary incontinence is a prevalent condition among athletes that is not openly discussed. However, it causes regular changes in their physical performance and daily life. More research is needed to increase awareness of UI and to design interventions.     

Fecal incontinence in pregnancy and post partum

Objective

To assess the prevalence of fecal incontinence (FI) during pregnancy and post partum, and to determine any associations with demographic and birth variables.

Methods

Secondary analysis of 240 primiparous women conducted during pregnancy and post partum. Women were asked at various time points if they had lost control over their stool or bowel movements, and if they were practicing Kegel exercises. Associations of bowel symptoms with demographic and birth data were evaluated.

Results

Most participants were white (87%), with a median age of 30 years (range, 18-42 years). Women who reported fecal incontinence at 1 year were more educated than those who did not report it. No other demographic or birth data were associated with fecal incontinence at 1 year.

Conclusions

Prevalence of FI during pregnancy and post partum is low and not linked to low-risk birth. Furthermore, when FI occurs it is often sporadic. This should be reassuring to patients and providers alike.     

Urinary incontinence in hospital-based nurses working in Turkey

Objective

To determine the changes in quality of life due to urinary incontinence in female hospital-based nurses working in Turkey and whether professional help was sought by the nurses. Another aim was to determine the prevalence of urinary incontinence and its risk factors in working nurses.

Methods

Data were collected through administration of a questionnaire and the Incontinence Quality-of-Life Instrument. The data were analyzed via χ² test, t test, one-way analysis of variance, and binary logistic regression analysis.

Results

The prevalence of urinary incontinence was 21.5%. Explanatory variables for developing urinary incontinence were age, parity, and recurrent urinary tract infections. Nurses with stress incontinence or urge incontinence had better quality of life than did those with mixed incontinence.

Conclusion

In the present study, urinary incontinence was common in working nurses, and had a negative impact on their general quality of life.     

The prevalence of fecal incontinence and urinary incontinence in primiparous postpartum Chinese women

Objective

This study investigated the prevalence of fecal incontinence (FI) and urinary incontinence (UI) in primiparous postpartum Chinese women.

Study design

Questionnaires about FI and UI symptoms were completed via telephone interviews conducted within 6 months postpartum.

Results

A total of 1889 primiparous postpartum women were asked to participate in this investigation. Only 13 (0.69%) of them had FI within 6 months after parturition, including loss of flatus in six women (0.32%), loss of solid stool in one (0.05%), loss of liquid stool in two (0.11%) and fecal urgency in four (0.21%). Bivariate logistic regression analysis showed that FI was significantly associated with forceps delivery OR = 37.91 (95% CI 4.20-342.18, P = 0.001) and medio-lateral episiotomy OR = 11.79 (95% CI 1.47-94.46, P = 0.02). The prevalence of UI, stress urinary incontinence (SUI), urge urinary incontinence (UUI) and mixed urinary incontinence (MUI) was 9.9% (186), 8.0% (151), 1.0% (18) and 0.9% (17), respectively. Multinomial logistic regression analysis found that SUI prevalence was related to age OR = 1.08 (95% CI 1.04-1.12, P = 0.000), maternal weight OR = 1.04 (95% CI 1.02-1.06, P = 0.001), neonate head circumference OR = 1.17 (95% CI 1.01-1.36, P = 0.043), spontaneous labor OR = 5.42 (95% CI 2.60-11.32, P = 0.000), forceps delivery OR = 7.0 (95% CI 2.40-20.41, P = 0.000), and medio-lateral episiotomy OR = 5.24 (95% CI 3.15-8.72, P = 0.000).

Conclusions

1. FI and UI prevalence was lower in our department than reported in previous studies in other areas. 2. Vaginal delivery has a risk impact on women's FI and UI, especially forceps delivery and medio-lateral episiotomy. 3. Maternal age, weight, newborn head circumference, spontaneous vaginal delivery, forceps delivery, and medio-lateral episiotomy increase the risk of UI.     

Behavioral therapy for urinary incontinence in India

Objective

To ascertain the prevalence of urinary incontinence in a sample of women from northern India, and the impact of behavioral therapy to treat its occurrence and severity.

Methods

A randomized controlled trial conducted from 2005-2006 to test the null hypothesis that behavioral therapy would not have an effect on urinary incontinence. Following a prevalence study, a total of 198 women with urinary incontinence were randomized into 2 groups: an intervention group (behavioral therapy) and a control group (no therapy).

Results

The prevalence of urinary incontinence was 11.6%. After an 8-month follow-up period, 41 women (52.5%) in the intervention group had become continent, and severity had shifted from severe to mild in 19 women (24.4%). In contrast, 11 women (12.8%) in the control group had become continent. In the intervention group, mean daytime voiding frequency decreased from 9.56 to 7.64, mean nighttime voiding frequency decreased from 1.45 to 0.69, and mean episodes of urine leakage decreased from 1.97 to 0.23.

Conclusion

Behavioral therapy was effective in treating urinary incontinence, particularly in women with mild and moderate incontinence.     

Overactive bladder symptoms and uterine adenomyosis--is there any connection?

Objective

The aim of this study was to investigate a possible connection between uterine adenomyosis and the prevalence of symptoms of overactive bladder (OAB), and to study the impact of OAB symptoms on the quality of life (QoL) of women with uterine adenomyosis.

Study design

In this prospective pilot study, we included 98 women, 54 of them with an ultrasound (US) diagnosis of uterine adenomyosis and 44 with normal-appearing uterine myometrium during transvaginal US examination. After interview all women completed two questionnaires, the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire. Data were analyzed with SPSS statistical software by means of non-parametric statistics and logistic regression.

Results

The average age of all the women was 44 years. Women from the adenomyosis and control groups did not differ in any of the observed clinical variables. Analysis of the UDI questionnaire showed that irritative symptoms were most prevalent in the adenomyosis group as compared to the control group, 22.3% and 7.8%, respectively. Urge urinary incontinence was found in 25.9% of women in the adenomyosis group (3.7% in the control group). Results of logistic regression confirmed the greatest negative impact of irritative symptoms on QoL in women with uterine adenomyosis (p < 0.000).

Conclusion

As compared with healthy controls, women with adenomyosis more often experience OAB symptoms which significantly decrease their QoL. The connection between adenomyosis and OAB remains uncertain.     

Postpartum evaluation of stress urinary incontinence among primiparas

Objective

To assess the prevalence of postpartum stress urinary incontinence (SUI); the relationship between postpartum SUI and mode of delivery; and the association between SUI and other obstetric factors.

Method

In this prospective study, 1000 primiparas with no history of UI were recruited and followed up for 4 months after delivery. The χ² and Fisher's Exact tests were used to calculate the effects of the nominal variables.

Result

The prevalence of postpartum SUI was 14.1%, and the mode of delivery was significantly associated with SUI. The prevalence rates were 15.9% after vaginal delivery, 10.7% after elective cesarean section (CS), and 25% after CS performed for obstructed labor. The prevalence of postpartum SUI was similar following spontaneous vaginal delivery and CS performed for obstructed labor (P = .21). Meanwhile, elective CS with no trial of labor was found to be associated with a significantly lower prevalence of postpartum SUI (P = .01; χ² = 12.42). A maternal body mass index greater than 30 before pregnancy and fetal weight higher than 3000 g appeared to be associated with an increased rate of SUI (P = .001; χ² = 17.6 and P = .000; χ² = 22.5, respectively).

Conclusion

Elective CS significantly reduced the rate of postpartum SUI.     

Concomitant surgical correction of occult stress urinary incontinence by TOT in patients with pelvic organ prolapse

Objectives

To assess the post-operative urinary incontinence states of pelvic organ prolapse cases operated on with concomitant trans-obturator tape (TOT) procedure.

Study design

Urodynamic evaluation of 79 patients with pelvic organ prolapse, before and after operation, while reducing the prolapsed organs by ring forceps placed bilaterally on the anterolateral sulcuses avoiding urethral compression. According to urodynamic tests, 25 patients were diagnosed as having occult stress urinary incontinence.

Results

Post-operative overactive bladder, stress urinary incontinence and mixed incontinence were found in three (12%), two (8%) and one (4%) patients of the occult stress urinary incontinence group, respectively. The corresponding numbers were six (11%), five (9%) and three (6%) in the continent group. No significant difference was found between the groups in terms of post-operative overactive bladder symptoms, stress urinary incontinence and mixed incontinence (Kruskal-Wallis test, X² = 0.52, p = 0.820).

Conclusions

This retrospective study suggests that a complete pre-operative urodynamic evaluation, including urodynamic tests at the time of POP reduction by placing ring forceps on the anterolateral sulcuses, is an efficient method for the diagnosis of occult symptomatic stress urinary incontinence (SUI). Prospective randomized studies are needed to establish the benefits and the risks of concomitant prophylactic surgery in patients with pelvic organ prolapse.     

Short vs long second stage of labour: is there a difference in terms of postpartum anal incontinence?

Objective

Our purpose was to determine if prolonged second-stage labour independently increases postpartum anal incontinence.

Study design

360 primiparous women were studied retrospectively after vaginal delivery of term cephalic singletons, including a group with short second-stage labour (<30 min, n = 163) and a group with a prolonged second stage (>90 min, n = 197). A quality of life questionnaire on anal incontinence (FIQOL) was sent out at 15 months after delivery.

Results

184 women (96 with short second-stage labour and 88 with a prolonged second stage) answered the questionnaire (response rate 51%). Flatus incontinence was reported after prolonged second-stage labour in 9.1% of women vs 15.6% after short second stage (p = 0.18). Fecal incontinence was reported after prolonged second-stage labour in 2.3% vs 5.2% after a short second stage (p = 0.45).

Conclusion

We suggest that prolonged second stage of labour should not be associated with an increased risk of postpartum incontinence.     

Does urinary incontinence subtype affect sexual function?

Objective

Urinary incontinence (UI) may affect a woman's physical and psychological well-being in different aspects. The aim of this study was to compare the effects of urinary stress incontinence (USI), detrusor overactivity (DO) and mixed urinary incontinence (MUI) on sexual function.

Study design

One-hundred and seventy urinary incontinent, sexually active women were included in this cross-sectional study. After urodynamic evaluation, participants were divided into three subgroups as USI (n = 61), DO (n = 55) and MUI (n = 54). Patients were matched according to age, parity and body mass index (BMI), rendering the sample size to 41 patients in each group. Turkish version short form of the Pelvic Organ Prolapse/Incontinence Sexual Function Questionnaire (PISQ-12) was filled out by each of the participants. Totally, 52 patients were excluded from the study (47 could not be matched and 5 incomplete questionnaire). Demographic characteristics of the participants, total and three domain scores of PISQ-12 were compared among three UI subgroups.

Results

The study group was consisted of 38 (32.2%) DO, 41 (34.7%) USI and 39 (33.1%) MUI patients. Demographic characteristics of the patients were similar in three subgroups. Patients with a diagnosis of MUI had significantly lower mean PISQ-12 scores than the ones with USI and DO whereas patients with USI had lower mean PISQ-12 scores than patients with DO.

Conclusion

Although urinary stress incontinence effects sexual function more than detrusor overactivity in terms of PISQ-12 scores, mixed urinary incontinence has the greatest impact on sexual function when compared with urinary stress incontinence and detrusor overactivity.     

Epidemiology of mixed urinary incontinence in China

Objectives

To determine the prevalence and risk factors for mixed urinary incontinence (MUI) among Chinese women.

Method

In this cross-sectional survey study we analyzed the answers to a modified Bristol Female Lower Urinary Tract Symptoms questionnaire provided by 19 024 women older than 20 years and from 6 regions in China.

Results

The overall prevalence of MUI was 9.4%. The prevalence of MUI increased with age and reached 24.1% among women older than 70 years. Multivariable logistic regression analysis revealed that age, vaginal delivery, chronic constipation, pelvic organ prolapse, chronic pelvic pain, respiratory system disease, menstrual disorder, urinary system disease, alcohol consumption, pelvic surgery, obesity, and a low educational level were independent risk factors for MUI.

Conclusion

We found age, vaginal delivery, and chronic constipation to be the main risk factors for MUI among adult women in China.     

Comparison of Burch colposuspension and transobturator tape when combined with abdominal sacrocolpopexy

Objective

To compare the treatment outcomes of Burch colposuspension and transobturator tape (TOT) when each is combined with abdominal sacrocolpopexy (ASC) to treat stress urinary incontinence (SUI) with pelvic organ prolapse (POP).

Methods

Consecutive cases of Burch colposuspension and TOT combined with ASC were retrospectively reviewed. Patients with SUI and POP beyond stage III—according to the POP-quantification system—were included.

Results

Mean hospital stay was longer in the Burch group (n = 49) than in the TOT group (n = 60) (11.3 vs 7.8 days; P < 0.001), as was operation time (202.7 vs 170.1 minutes; P < 0.001); furthermore, there were higher rates of urinary retention (53.1% vs 11.7%; P < 0.001), de novo urgency (18.4% vs 3.3%; P = 0.01), and recurrent SUI (18.4% vs 1.7%; P = 0.003) in the Burch group. The cure rate was significantly higher in the TOT group than in the Burch group (98.3% vs 69.7%; P < 0.001).

Conclusion

The use of TOT with ASC resulted in higher cure rates and better functional outcomes than did Burch colposuspension with ASC.     

Factors predicting the response to biofeedback-assisted pelvic floor muscle training for urinary incontinence

Objective

To evaluate the efficacy of biofeedback-assisted pelvic floor muscle training (PFMT) for urinary incontinence and to determine the patient characteristics predictive of success.

Methods

Clinical and physiologic data of 86 patients with urinary incontinence who had received biofeedback-assisted PFMT were analyzed retrospectively. The clinical response was determined to be a success (requiring no more therapy) or a failure (requiring surgery or other medical therapy) at 3 months after completion of treatment.

Results

The success group included 57% of the enrolled patients. In the univariate analysis, the following factors had P values of less than 0.20: alcohol consumption, detrusor overactivity, type of urinary incontinence, and the change in the average amplitude of tonic contraction before treatment and after the 8th session of biofeedback-assisted PFMT. In the multiple logistic regression analysis, the only independent predictive factor of a successful response was a significant change in the average tonic contraction before treatment and after the 8th session (odds ratio, 1.661; 95% confidence interval, 1.015- 2.721).

Conclusion

After biofeedback-assisted PFMT, 57% of patients with urinary incontinence required no further therapy. Increased pelvic floor muscle activity after the 8th session of PFMT predicted a successful response to treatment.     

Comparison of retropubic and transobturator tension-free vaginal implants for the treatment of stress urinary incontinence

Objective

To compare the perioperative complications, failure rate, operating time, and length of hospital stay associated with 2 minimally invasive suburethral slings in the management of stress urinary incontinence in women.

Methods

Women diagnosed with stress urinary incontinence were treated with tension-free vaginal tape (TVT) or transobturator tape (TOT). The participants were followed for the next 2 years, with scheduled evaluations 6 weeks, then 3, 6, 12, and 24 months after surgery.

Results

Of the 104 participants, 55 were treated with TVT and 49 were treated with TOT. The condition was classified as “cured” in 81.8% of cases in the TVT group and 83.7% in the TOT group, and improvement occurred in 10.9% and 10.2% of cases, respectively. The mean operating time was shorter for patients treated with TOT than for those treated with TVT. There were no significant differences between the groups in terms of perioperative complications (abnormal voiding dysfunction, urinary infections, and de novo overactive bladder). The temporary and permanent urinary obstruction rates in the TVT group were approximately twice those in the TOT group.

Conclusion

Comparable complications and outcomes were observed with TVT and TOT. Tension-free vaginal implants are effective for the treatment of female stress urinary incontinence.     

Serum estradiol does not differentiate stress, mixed and urge incontinent women around menopause. A report from the Women's Health in the Lund Area (WHILA) study

Objective

To outline serum estradiol levels in perimenopausal women with stress, mixed or urge incontinence. We believe the majority of urgency symptoms in perimenopausal women to be caused by a pelvic floor dysfunction and a hypermobility of the bladder neck. If this is the case, there would be no difference in estradiol levels between the groups.

Study design

Setting: University hospital. In the observational Women's Health in the Lund Area study, a subset of 400/2221 women reporting urinary incontinence completed a detailed questionnaire regarding lower urinary tract symptoms and had their serum steroid hormone levels measured. Statistical analyses were made by Chi-square test, nonparametrical tests, ANOVA, multi- and univariate logistic regression analysis.

Results

Stress incontinence was reported by 196, mixed incontinence by 153 and urge incontinence by 43 women; in 369, serumestradiol values were available. Serum estradiol did not differ significantly between stress incontinent (median 49.5 pmo/l, range 2.63-875.4), urge incontinent (median 31.6 pmol/l, range 2.63-460.7) or mixed incontinent women (median 35.5 pmol/l, range 2.63-787.9, p = 0.62). Logistic regression analysis correcting for age, parity, hormonal status, smoking, hysterectomy and BMI also failed to show any difference in estradiol levels between the groups (p = 0.41-0.58).

Conclusion

No significant differences in serum estradiol levels between stress, mixed or urge incontinent perimenopausal women could be demonstrated.     

Collagen type 3 alpha 1 polymorphism and risk of pelvic organ prolapse

Objective

To investigate whether pelvic organ prolapse (POP) is associated with collagen 3 alpha 1 (COL3A1) polymorphisms and other factors.

Methods

A case-control association study was conducted with 84 women affected with POP and 147 controls. The genotypes of nucleotides COL3A1 rs1800255 and COL3A1 rs1801184 polymorphisms were ascertained by polymerase chain reaction and restriction fragment length polymorphism analysis.

Results

The distribution of the COL3A1 rs1800255 genotypes was significantly different among affected women and controls. Older age and incidence of COL3A1 rs1800255 genotype AA were significantly associated with risk of POP.

Conclusion

There may be an association between COL3A1 genotype and risk of POP.     

The use of the pessary test in preoperative assessment of women with severe genital prolapse

Objective

To investigate whether a preoperative pessary test could be used to identify patients with occult stress incontinence and if simultaneous anti-incontinence surgery with a midurethral sling could prevent postoperative incontinence.

Study design

Eighty-two patients with a positive pessary test and severe genital prolapse participated in the study: 43 patients underwent prolapse surgery and transobturator tension-free vaginal tape (TVT-O) insertion and 39 patients underwent prolapse surgery only.

Results

The objective cure rate for TVT-O and prolapse surgery was 90.7% at three months follow up and 88.4% at two years follow up. The objective cure rate for prolapse surgery only was 74.4% at three months and 58.9% at two years follow up.

Conclusion

The pessary test can be used preoperatively in patients with significant genitourinary prolapse to identify those with occult stress urinary incontinence. The TVT-O procedure in this context could be a useful optional procedure as it appears to be very effective and safe in patients with occult stress incontinence.     

Preoperative determinants for failure of transobturator tapes in the management of female urodynamic stress incontinence

Objectives

To determine significant preoperative risk factors for failure of transobturator tapes.

Methods

Secondary analysis of data from the E-TOT (Evaluation of Transobturator Tapes) study. Patient-reported outcomes (n = 310) and objective outcomes (n = 297) were analyzed using univariate and multivariate analyses.

Results

On univariate analysis, body mass index (BMI) ≥  35, maximum urethral closure pressure (MUCP) ≤ 30 cm H₂O, preoperative mixed incontinence on urodynamics, history of at least one previous incontinence procedure, and preoperative symptoms of urgency, nocturia, or urgency incontinence were associated with failure. On multivariate regression, BMI ≥ 35 (OR 6.37; 95% CI, 1.73-23.44; P = 0.005), nocturia (OR 2.18; 95% CI, 1.04-4.58; P = 0.039), urgency incontinence (OR 3.35; 95% CI, 1.07-10.51; P = 0.039), and previous incontinence surgery (OR 2.33; 95%CI, 1.1-5.48; P = 0.048) were independently associated with patient-reported failure. MUCP ≤ 30 cm H₂O (OR 7.06; 95% CI, 2.85-17.48; P < 0.001) and previous incontinence procedure (OR 6.22; 95%CI, 2.34-16.52; P < 0.001) were independently associated with objective failure.

Conclusion

History of previous incontinence surgery was the only independent risk factor for failure of transobturator tapes based on both the patient-reported and objective outcome.     

Impact of the tension-free vaginal tape obturator procedure on sexual function in women with stress urinary incontinence

Objective

To evaluate prospectively the impact of the tension-free vaginal tape obturator (TVT-O) procedure on sexual function in women with stress urinary incontinence (SUI).

Methods

The present prospective study included women with SUI and no concomitant prolapse who underwent a TVT-O procedure at Fuzhou General Hospital in Fuzhou, Fujian, China. Before and 6 months after surgery, the patients had their sexual function evaluated using the Female Sexual Function Index (FSFI) questionnaire. Only sexually active women were included in the final analysis.

Results

Among the 55 sexually active patients, 21.8% had coital incontinence, which was cured in 11 of 12 patients (91.7%). More than half (54.5%) the women reported an improvement in sexual function after surgery and 45.5% reported no change. No statistically significant difference was found between preoperative and postoperative total or domain (desire, arousal, lubrication, orgasm, satisfaction, and pain) scores on the FSFI.

Conclusion

The TVT-O procedure in women with SUI did not significantly affect sexual function. Further studies are needed to verify the findings and compare the impact of TVT-O on sexual function with that of other anti-incontinence procedures.