Mode of delivery and fecal incontinence at midlife: a study of 2,640 women in the Gazel cohort

OBJECTIVE: To estimate obstetric risk factors of fecal incontinence among middle-aged women. METHODS: We conducted a mail survey of the Gazel cohort of volunteers for epidemiologic research. In 2000, a questionnaire on anal incontinence was mailed to 3,114 women who were then between the ages of 50 and 61 years; 2,640 (85%) women returned the completed questionnaire. Fecal incontinence was defined by involuntary loss of stool. Logistic regression was used to estimate the effect of obstetric and general risk factors. RESULTS: Prevalence of fecal incontinence in the past 12 months was 9.5% (250). Significant risk factors for fecal incontinence were completion of high school (adjusted odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1-2.0), self-reported depression (OR 2.1, 95% CI 1.6-2.7), overweight or obesity measured by body mass index (BMI) (OR 1.5 for BMI of 25-30, 95% CI 1.1-2.0; OR 1.6 for BMI more than 30, 95% CI 1.1-2.5), surgery for urinary incontinence (OR 3.5, 95% CI 2.0-6.1), and anal surgery (OR 1.7, 95% CI 1.1-2.9). No obstetric variable (parity, mode of delivery, birth weight, episiotomy, or third-degree perineal tear) was significant. Prevalence of fecal incontinence was similar for nulliparous, primiparous, secundiparous, and multiparous women (11.3%, 9.0%, 9.0%, and 10.4%, respectively), and among parous women, it was similar for women with spontaneous vaginal, instrumental (at least one), or only cesarean deliveries (9.3%, 10.0%, and 6.6%, respectively). CONCLUSION: In our population of women in their 50s, fecal incontinence was not associated with either parity or mode of delivery.     

Fecal incontinence after high-risk delivery

OBJECTIVE: To investigate the prevalence of and factors associated with fecal incontinence and its precursors among high-risk women at 12 months postpartum. METHODS: A survey of women in the immediate and later postpartum was conducted. Participants were 568 women at higher risk of anal sphincter damage, namely those who had an instrumental delivery and/or delivered a high birth weight infant (4000 g or more) at tertiary teaching hospitals in Australia. Women participated in a baseline hospital-based interview and a 12-month follow-up telephone interview. The main outcome measures were frank fecal incontinence (solid and/or liquid stool) and precursor symptoms (flatal incontinence, soiling, and/or fecal urgency) at 12 months postpartum. RESULTS: Prevalence rates were 2.6% for solid stool incontinence and 4.9% for liquid stool incontinence. Overall, 6.9% women had either one or both of these symptoms of frank fecal incontinence. Prevalence rates were 24.4% for flatal incontinence, 10.9% for soiling, and 14.8% for fecal urgency. Overall, 32.4% women had at least one of these precurser symptoms. Concurrent urinary incontinence and postpartum constipation were significantly associated with both frank fecal incontinence and precursor symptoms. In addition, joint hypermobility and older maternal age were associated with frank fecal incontinence, whereas inability to stop the urine flow and multiparity was associated with precursor symptoms. CONCLUSION: The present findings suggest that older and multiparous women, and women with joint hypermobility are at increased risk of postpartum anal incontinence symptoms after a high-risk delivery. Concurrent urinary incontinence, flow-stopping inability, and constipation are also associated with postpartum anal incontinence symptoms after high-risk deliveries.     

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.     

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 14–3.6) 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.     

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.     

Parity, mode of delivery, and pelvic floor disorders

OBJECTIVE: This study aimed to assess the associations between parity, mode of delivery, and pelvic floor disorders. METHODS: The prevalence of pelvic organ prolapse, stress urinary incontinence, overactive bladder, and anal incontinence was assessed in a random sample of women aged 25-84 years by using the validated Epidemiology of Prolapse and Incontinence Questionnaire. Women were categorized as nulliparous, vaginally parous, or only delivered by cesarean. Adjusted odds ratios and 95% confidence intervals (CIs) for each disorder were calculated with logistic regression, controlling for age, body mass index, and parity. RESULTS: In the 4,458 respondents the prevalence of each disorder was as follows: 7% prolapse, 15% stress urinary incontinence, 13% overactive bladder, 25% anal incontinence, and 37% for any one or more pelvic floor disorders. There were no significant differences in the prevalence of disorders between the cesarean delivery and nulliparous groups. The adjusted odds of each disorder increased with vaginal parity compared with cesarean delivery: prolapse = 1.82 (95% CI 1.04-3.19), stress urinary incontinence = 1.81 (95% CI 1.25-2.61), overactive bladder = 1.53 (95% CI 1.02-2.29), anal incontinence = 1.72 (95% CI 1.27-2.35), and any one or more pelvic floor disorders = 1.85 (95% CI 1.42-2.41). Number-needed-to-treat analysis revealed that 7 women would have to deliver only by cesarean delivery to prevent one woman from having a pelvic floor disorder. CONCLUSION: The risk of pelvic floor disorders is independently associated with vaginal delivery but not with parity alone. Cesarean delivery has a protective effect, similar to nulliparity, on the development of pelvic floor disorders when compared with vaginal delivery. LEVEL OF EVIDENCE: II-2.     

Risk factors for female anal incontinence: new insight through the Evanston-Northwestern twin sisters study

OBJECTIVE: To evaluate risk factors for anal incontinence using an identical twin sisters study design to provide control over genetic variance. METHODS: A total of 271 identical twin sister pairs (mean age 47 years) completed the validated Colorectal Anal Distress Inventory questionnaire detailing the presence and severity of anal incontinence. Data were analyzed using a stepwise logistic regression with repeated binary measures to account for correlated data within twin pairs. Three different statistical models were used to analyze nonobstetric as well as obstetric risk factors separately. RESULTS: Significant risk factors for anal incontinence and higher Colorectal Anal Distress Inventory anal incontinence subscale scores included age 40 years or older (fecal: odds ratio [OR] 2.82, 95% confidence interval [CI] 1.21-6.0; flatal: OR 1.90, 95% CI 1.11-3.24), menopause (fecal: OR 2.10, 95% CI 1.15-3.8; flatal: OR 2.11, 95% CI 1.43-3.13), increasing parity (parity > or = 2; fecal: OR 3.09, 95% CI 1.25-7.65; flatal: OR 2.72, 95% CI 1.65-4.51), and the presence of stress urinary incontinence (fecal: OR 2.11, 95% CI 1.12-3.98; flatal: OR 1.72, 95% CI 1.14-2.59). Obesity was associated with significantly higher Colorectal Anal Distress Inventory anal incontinence subscale scores (mean difference 5.18, P = .007). Cesarean delivery after initiation of labor was associated with a lower prevalence of anal incontinence than vaginal birth; however, this difference was not statistically significant (17% compared with 4%, P = .11). No anal incontinence was noted in women who had only elective cesarean deliveries. CONCLUSION: Age, menopause, obesity, parity, and stress urinary incontinence are the major risk factors for female anal incontinence.     

Risk of stress urinary incontinence twelve years after the first pregnancy and delivery

OBJECTIVE: To estimate the impact of onset of stress urinary incontinence in first pregnancy or postpartum period, for the risk of symptoms 12 years after the first delivery. METHODS: In a longitudinal cohort study, 241 women answered validated questions about stress urinary incontinence after first delivery and 12 years later. RESULTS: Twelve years after first delivery the prevalence of stress urinary incontinence was 42% (102 of 241). The 12-year incidence was 30% (44 of 146). The prevalence of stress urinary incontinence 12 years after first pregnancy and delivery was significantly higher (P<.01) in women with onset during first pregnancy (56%, 37 of 66) and in women with onset shortly after delivery (78%, 14 of 18) compared with those without initial symptoms (30%, 44 of 146). In 70 women who had onset of symptoms during first pregnancy or shortly after the delivery but remission 3 months postpartum, a total of 40 (57%) had stress urinary incontinence 12 years later. In 11 women with onset of symptoms during the first pregnancy or shortly after delivery but no remission 3 months postpartum, a total of 10 (91%) had stress urinary incontinence 12 years later. Cesarean during first delivery was significantly associated with a lower risk of incontinence. Other obstetric factors were not significantly associated with the risk of incontinence 12 years later. Patients who were overweight before their first pregnancy were at increased risk. CONCLUSION: Onset of stress urinary incontinence during first pregnancy or puerperal period carries an increased risk of long-lasting symptoms.     

Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study.

OBJECTIVE: To investigate the association between parity and urinary incontinence, including subtypes and severity of incontinence, in an unselected sample, with special emphasis on age as a confounder or effect modifier. METHODS: This was a cross-sectional study (response rate 80%) with 27,900 participating women. Data on parity and urinary leakage, type, frequency, amount, and impact of incontinence were recorded by means of a questionnaire. A validated severity index was used. Relative risks (RR) with nulliparous women as reference were used as an effect measure. RESULTS: Incontinence was reported by 25% of participants. Prevalences among nulliparous women ranged from 8% to 32%, increasing with age. Parity was associated with incontinence, and the first delivery was the most significant. The association was strongest in the age group 20-34 years with RR 2.2 (95% confidence interval [CI] 1.8, 2.6) for primiparous women and 3.3 (2.4, 4.4) for grand multiparous women. A weaker association was found in the age group 35-64 years (RRs between 1.4 and 2.0), whereas no association was found among women over 65 years. For stress incontinence in the age group 20-34 years, the RR was 2.7 (2.0, 3.5) for primiparous women and 4.0 (2.5, 6.4) for grand multiparous women. There was an association with parity also for mixed incontinence, but not for urge incontinence. Severity was not clinically significantly associated with parity. CONCLUSION: Parity is an important risk factor for female urinary incontinence in fertile and peri- and early postmenopausal ages. Only stress and mixed types of incontinence are associated with parity. All effects of parity seem to disappear in older age.     

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.     

Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery

ObjectiveTo determine the prevalence of and risk factors for urinary and fecal incontinence four months after vaginal delivery.MethodsAll patients who had vaginal deliveries at a tertiary care hospital over a three-month period were approached during their postpartum hospital stay regarding participation in the study. Participants underwent a telephone interview at four months after their delivery to determine the presence and type of any incontinence.ResultsOf 632 patients, 145 (23%) had stress incontinence, 77 (12%) had urge incontinence, 181 (29%) had any urinary incontinence and 23 (4%) had fecal incontinence. In univariate analysis, stress incontinence was found to be increased in patients ≥30 years of age (26.2%) compared with patients < 30 years of age (19.3%) (RR 1.4; 95% CI 1.0–1.8, P = 0.05). Urge incontinence was increased in patients who had a forceps delivery (21%) compared with no forceps delivery (9%) (RR 2.2; 95% CI 1.4–3.6, P = 0.005), an episiotomy (32.4%) compared with no episiotomy (18.7%) (RR 1.9; 95% CI 1.2–2.9, P < 0.01) and a longer second stage of labour (108 min vs. 77 min, P = 0.01). The prevalence of any urinary incontinence was increased with forceps delivery (15.5%) compared with no forceps delivery (8.7%) (RR 1.5; 95% CI 1.1–2.1, P = 0.01) and maternal age of ≥30 years (34.1%) compared to < 30 years (23.5%) (RR 1.5; 95% CI 1.1–1.9, P = 0.003). In multivariate analysis, the two variables that remained significant for any urinary incontinence were maternal age ≥30 years (P < 0.01) and forceps delivery (P < 0.01). There were no identified risk factors for fecal incontinence.ConclusionUrinary incontinence is common in women at four months post partum. Fecal incontinence is less common. Maternal age and forceps assisted delivery were risk factors for urinary incontinence.     

Low urinary tract symptoms after Thierry's spatula delivery at first pregnancy

OBJECTIVE: This study was undertaken to evaluate prevalence of low urinary tract symptoms (LUTS) after Thierry's spatula delivery at first pregnancy. PATIENTS AND METHODS: A retrospective study of 236 primiparous with instrumental delivery or spontaneous delivery who had delivered from January 2001 to December 2002. Low urinary tract symptoms (LUTS) were evaluated one year after delivery with a questionnaire. Incidence of LUTS was compared depending on mode of delivery. RESULTS: Of the 236 patients included, 88.1% replied to the questionnaire, 106 who delivered spontaneously and 102 who underwent Thierry's spatula delivery. The incidence of urinary incontinence was similar after instrumental deliveries and after spontaneous vaginal deliveries (34.9 versus 24.5%, p=0.10). In univariate analysis, symptoms of urinary urgency and urinary frequency were higher after instrumental delivery than after spontaneous delivery, respectively, 34.9 versus 22.5%, p=0.049 and 19.8 versus 8.8%, p=0.03. After controlling for confounding factors, no difference in LUTS was observed between the two groups; the respective adjusted odds-ratios (95% IC) were 1,5 (0.8-3) for urinary incontinence, 1.7 (0.9-3.5) for urgency and 2.5 (0.9-6.3) for urinary frequency. DISCUSSION AND CONCLUSION: One year after delivery, one third of patients will present urinary incontinence and more than 50% will complain of bladder instability symptoms. Compared to spontaneous vaginal delivery, the use of Thierry's spatulas at first pregnancy does not induce higher risk of LUTS.     

Frequency of de novo urgency in 463 women who had undergone the tension-free vaginal tape (TVT) procedure for genuine stress urinary incontinence--a long-term follow-up

BACKGROUND: To determine risk factors for the appearance of de novo urgency symptoms, and subsequent accompanying problems, after the tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence. METHOD: A structured preoperative analysis of the incontinence symptoms was made. A mailed questionnaire was distributed to 970 women that underwent the TVT procedure between 1995 and 2001. Average follow-up was 5.2 years (range 2-8 years). The questionnaire included specific questions on current urinary symptoms and incontinence. The disease-specific quality of life instruments IIQ-7 and UDI-6 were used to compare women with, and those without de novo urgency. RESULTS: Seven hundred and sixty women (78.3%) responded and 463 of those were identified as genuine stress incontinence preoperatively. De novo urgency occurred in 67 (14.5%) of the women. The frequency was similar irrespective of duration since the TVT procedure. The women that reported de novo urgency symptoms were compared with those without symptoms. Risk factors for occurrence of de novo urgency symptoms were older age (64.7 years versus 60.9 years; p=0.01), parity (2.6 versus 2.3; p=0.05), history of cesarean section (9.5% versus 2.5%; odds ratio 5.4), and history of recurrent urinary infections (29.7% versus 18.8%; odds ratio 1.6, but non-significant. De novo urgency had a severe impact on quality of life, as compared to the remaining study population. CONCLUSION: Old age, parity and history of cesarean section were risk factors for de novo urgency after TVT surgery. Postoperative de novo urgency symptoms are as bothersome for the patient as the preoperative stress urinary incontinence.     

Anal incontinence after two vaginal deliveries without obstetric anal sphincter rupture

Purpose

To evaluate prevalence and risk factors for long-term anal incontinence in women with two prior vaginal deliveries without obstetric anal sphincter injury (OASIS) and to assess the impact of anal incontinence-related symptoms on quality of life.

Methods

This is a nation-wide cross-sectional survey study. One thousand women who had a first vaginal delivery and a subsequent delivery, both without OASIS, between 1997 and 2008 in Denmark were identified in the Danish Medical Birth Registry. Women with more than two deliveries in total till 2012 were excluded at this stage. Of the 1000 women randomly identified, 763 were eligible and received a questionnaire. Maternal and obstetric data were retrieved from the national registry.

Results

The response rate was 58.3%. In total, 394 women were included for analysis after reviewing responses according to previously defined exclusion criteria. Median follow-up time was 9.8 years after the first delivery and 6.4 years after the second. The prevalence of flatal incontinence, fecal incontinence and fecal urgency were 11.7, 4.1, and 12.3%, respectively. Overall, 20.1% had any degree of anal incontinence and/or fecal urgency. In 6.3% these symptoms affected their quality of life. No maternal or obstetric factors including episiotomy and vacuum extraction were consistently associated with altered risk of anal incontinence in the multivariable analyses.

Conclusions

Anal incontinence and fecal urgency is reported by one fifth of women with two vaginal deliveries without OASIS at long-term follow-up. Episiotomy or vacuum extraction did not alter the risk of long-term anal incontinence.

     

New postnatal urinary incontinence: obstetric and other risk factors in primiparae

OBJECTIVE: To identify obstetric and other risk factors for urinary incontinence that occurs during pregnancy or after childbirth. DESIGN: Questionnaire survey of women. SETTING: Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). POPULATION: A total of 3405 primiparous women with singleton births delivered during 1 year. METHODS: Questionnaire responses and obstetric case note data were analysed using multivariate analysis to identify associations with urinary incontinence. MAIN OUTCOME MEASURES: Urinary incontinence at 3 months after delivery first starting in pregnancy or after birth. RESULTS: The prevalence of urinary incontinence was 29%. New incontinence first beginning after delivery was associated with older maternal age (oldest versus youngest group, OR 2.02, 95% CI 1.35-3.02) and method of delivery (caesarean section versus spontaneous vaginal delivery, OR 0.28, 95% CI 0.19-0.41). There were no significant associations with forceps delivery (OR 1.18, 95% CI 0.92-1.51) or vacuum delivery (OR 1.16, 95% CI 0.83-1.63). Incontinence first occurring during pregnancy and still present at 3 months was associated with higher maternal body mass index (BMI>25, OR 1.68, 95% CI 1.16-2.43) and heavier babies (birthweight in top quartile, OR 1.56, 95% CI 1.12-2.19). In these women, caesarean section was associated with less incontinence (OR 0.39, 95% CI 0.27-0.58) but incontinence was not associated with age. CONCLUSIONS: Women have less urinary incontinence after a first delivery by caesarean section whether or not that first starts during pregnancy. Older maternal age was associated with new postnatal incontinence, and higher BMI and heavier babies with incontinence first starting during pregnancy. The effect of further deliveries may modify these findings.     

Does a second delivery increase the risk of anal incontinence?

Objective To evaluate the prevalence of anal incontinence and anal sphincter defects after a first vaginal delivery and assess the effect of a second delivery.Design Prospective cohort study using postal questionnaires assessing incontinence to flatus and stools at three and thirty months postnatally and anal endosonography at three months following delivery.Setting Recruitment was from the antenatal clinic at the University Hospitals of Geneva, Switzerland.Population One hundred women with a vaginal delivery of their first child.Main outcome measures Prevalence of anal incontinence and anal sphincter defects.Results Anal incontinence was reported by 16/92 (17%) of women at three months after delivery and by 11/77 (14%) at 30 months. At that time, 5/54 (9%) with no further delivery reported incontinence, compared with 6/23 (26%) of those who had had another delivery (RR 2.8, 95% CI 1.0-8.3). Anal sphincter defects were diagnosed by endosonography in 46/87 (53%) women and were associated with reported incontinence at both three months (RR 1.9; 95% CI 1.4-2.6) and 30 months (RR 1.9; 95% CI 1.3-2.8) after delivery. The prevalence of anal incontinence at 30 months was highest (5/13, 39%) among those in whom a sphincter defect was diagnosed by endosonography after their first delivery and with a second delivery.Conclusion Anal incontinence after childbirth is associated with defects of the anal sphincter diagnosed by endosonography. Subsequent deliveries increase the risk of incontinence, particularly among women with a sphincter defect diagnosed after the first delivery.     

Effects of parity and mode of delivery on urinary incontinence among postmenopausal women in Taiwan

ObjectiveTo investigate the association between the prevalence of urinary incontinence and parity or mode of delivery among Taiwanese women aged 60 years or older.MethodsBetween July 1999 and December 2000, a nationwide epidemiologic study was conducted in Taiwan among 2410 women selected by a multistage random sampling method. Face-to-face interviews with 1517 women were conducted. The relationship between the prevalence of urinary incontinence and the number of vaginal deliveries or number of cesarean deliveries was assessed by frequency and Pearson χ² test using a significance level of less than 0.05. Logistic regression was used to investigate the significance of dichotomous dependent variables.ResultsDecades ago, most Taiwanese women (1435 of 1511 respondents, 94.97%,) gave birth via vaginal delivery and the rate of cesarean delivery was low (20 of 1513 respondents, 1.32%). Parity (odds ratio [OR], 2.42; 95% confidence interval [CI], 0.87–6.71; P = 0.091), vaginal delivery (OR, 0.76; 95% CI, 0.39–1.47; P = 0.408), and cesarean delivery (OR, 1.47; 95% CI, 0.59–3.70; P = 0.409) did not increase the risk of urinary incontinence.ConclusionThere was no association between urinary incontinence and parity or mode of delivery among Taiwanese postmenopausal women decades after their first delivery.     

Postpartum urinary symptoms: prevalence and risk factors

OBJECTIVES: To assess the prevalence of urinary symptoms, the relationship between urinary symptoms and vaginal descent, and the association between urinary symptoms and obstetric factors. STUDY DESIGN: Five hundred and thirty-seven women were interviewed and underwent a urogynaecological evaluation 3 months after vaginal delivery. Quantitative-type variables were subjected to Student's t test. Simple logistic regression analyses were carried out on the symptoms studied as a function of risk factors. RESULTS: 8.2% of primiparae showed stress urinary incontinence and multiparae in 20% (P=0.0001); urge incontinence was present in 5.5% of primiparae and in 13% of multiparae (P=0.004). Significant correlations were found among operative vaginal delivery, dysuria (P=0.048) and frequency (P=0.036). Urinary incontinence appeared associated with induced labour with prostaglandins (P=0.018) and with general maternal factors, such as parity (P=0.001) and elevated weight at the beginning of pregnancy (P=0.019). CONCLUSIONS: It is likely that the pathogenesis of postpartum urinary incontinence includes not only the effects of pelvic floor trauma on urethrovesical mobility under stress, but also a deficiency in urethral resistance caused by drugs, such as prostaglandins.     

Parturition and urinary incontinence in primiparas

OBJECTIVE: To estimate the incidence and relative risk of postpartum urinary incontinence in primiparas. METHODS: Over 3 years (1996-1998), healthy nulliparas with no significant history of urinary tract abnormalities were prospectively enrolled. Power analysis indicated that 452 women must complete the study. Participants completed a questionnaire about urinary, fecal, and flatal incontinence. At 6 weeks' and 6 months' postpartum, the same questionnaire was mailed to participants. Statistical analysis consisted of chi-square and Fisher exact tests for nominal variables and analysis of variance and Kruskal-Wallis tests for interval variables. Logistic regression tested independence of variables. RESULTS: A total of 690 primiparas were enrolled in the study and 595 delivered at our hospital: 147 (25%) cesareans, 333 (56%) spontaneous vaginal deliveries, and 115 (19%) instrumental vaginal deliveries. Median birth weight was 3489 g. Urinary incontinence rate at 6 months was 26%. Vaginal delivery was associated with a higher incidence of urinary incontinence (relative risk, 2.8) compared with cesarean. Forceps delivery increased the risk of urinary incontinence (relative risk, 1.5) compared with spontaneous vaginal delivery. There was no significant difference between cesareans done before and during labor. None of the obstetric risk factors were independently significant. CONCLUSION: Cesarean delivery at any stage of labor reduces postpartum urinary incontinence. With multivariable analysis, obstetric risk factors are not significant.     

Risk factors for lower urinary tract symptoms in women 40 to 60 years of age

OBJECTIVE: To determine the relationship between lower urinary tract symptoms and possible associated risk factors in women 40-60 years old. METHODS: In a normal population study, 502 women with lower urinary tract symptoms and 742 women with no symptoms (controls) were asked about possible associated factors. RESULTS: Four hundred eighty-seven women (97.0%) with symptoms and 564 controls (76.0%) completed the study. Stress incontinence was associated with parity (primipara odds ratio [OR] 2.2, 95% confidence interval [CI] 1.0, 4. 9; para 2 OR 3.9, 95% CI 1.9, 8.0; para 3 OR 4.5, 95% CI 2.1, 9.5), use of diuretics (OR 2.2, 95% CI 1.2, 3.9), hysterectomy (OR 2.4, 95% CI 1.6, 3.7), and increased body mass index (BMI). Urge incontinence was associated with use of diuretics (OR 4.0, 95% CI 2. 2, 7.1) and BMI. Urgency was associated with parity (primipara OR 1. 9, 95% CI 0.9, 4.2; para 2 OR 3.0, 95% CI 1.5, 5.9; para 3 OR 3.1, 95% CI 1.5, 6.5), use of diuretics (OR 2.7, 95% CI 1.5, 4.7) and BMI. Associations between non-incontinence symptoms (except urgency) and observed factors were weak and inconsistent. Straining at stool and constipation were inversely associated with lower urinary tract symptoms. Overall, lesion of sphincter ani, episiotomy, fetal weight, physical activity, and hormonal status had minor association with lower urinary tract symptoms. CONCLUSION: Lower urinary tract symptoms were associated positively with parity, BMI, prior hysterectomy, use of diuretics, straining at stool, and constipation.