Changes in urinary and fecal incontinence symptoms with weight loss surgery in morbidly obese women

OBJECTIVE: To examine changes in the prevalence and severity of urinary incontinence (UI) and fecal incontinence in morbidly obese women undergoing laparoscopic weight loss surgery. METHODS: In a prospective cohort study, 101 women (aged 20-55 years) with body mass index (BMI) of 40 or more underwent laparoscopic Roux-en-Y gastric bypass and were followed to 6 and 12 months. Presence, severity, and effect of UI were assessed using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire. Fecal incontinence was assessed by self-report of anal leakage. RESULTS: Mean BMI decreased from 48.9+/-7.2 presurgery to 35.3+/-6.5 at 6 months and 30.2+/-5.7 at 12 months postsurgery. Prevalence of UI decreased from 66.7% presurgery to 41.0% at 6 months and 37.0% at 12 months (P<.001; 95% confidence interval [CI] for change 18.6-40.0%). Reduction in prevalence of UI was significantly associated with decreases in BMI (P=.01). Among incontinent women who lost 18 or more BMI points, 71% regained urinary continence at 12 months. Medical, Epidemiological, and Social Aspects of Aging Questionnaire urge and stress scores decreased (both P<.001; 95% CI 0.5-1.85 and 2.71-5.34, respectively), as did scores on the Urogenital Distress Inventory (P<.001; 95% CI 8.31-16.21) and Incontinence Impact Questionnaire (P<.001; 95% CI 4.71-14.60), indicating reduction in severity. Prevalence of fecal incontinence (solid or liquid stool) decreased from 19.4% to 9.1% at 6 months and 8.6% at 12 months (P=.018; 95% CI 2.1-19.4%). CONCLUSION: Prevalence of UI and fecal incontinence decreased after bariatric surgery. Magnitude of weight loss was associated with reduction in UI prevalence, strengthening the inference that improvements are attributable to weight loss. LEVEL OF EVIDENCE: II.     

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.     

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.     

Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse

OBJECTIVE: To investigate risk factors and prevalence of anal incontinence among women with pelvic floor dysfunctions. METHODS: We evaluated 881 women with symptoms of urinary incontinence and/or genital prolapse. Each completed a bowel questionnaire and underwent a detailed medical, surgical, obstetric, and gynecologic history, and a pelvic examination. Additional testing, when indicated, included office cystometry or multichannel urodynamic evaluation. Multivariable analysis using logistic regression was used to test the overall significance of all variables significantly associated with anal incontinence, using univariate analysis. RESULTS: A total of 178 women had anal incontinence (20%). These patients were on average older, had a greater body mass index, and had larger birth weight infants than their anal-continent counterparts; 511 were diagnosed with urinary incontinence, and 122 (24%) also had anal incontinence. Women with urinary incontinence were more likely to report anal incontinence events than women continent of urine (24% versus 15%, P =.002). The following associations were found with anal incontinence: infant with birth weight 3800 g or greater (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1, 2.2), rectocele greater than grade 2 (OR 1.9, 95% CI 1.1, 3.3), urinary incontinence (OR 1.9, 95% CI 1.3, 2.8), hemorrhoidectomy (OR 2.7, 95% CI 1.1, 7.0), irritable bowel syndrome (OR 6.3, 95% CI 3.5, 11.5). CONCLUSION: Among women with symptoms of urinary incontinence and pelvic organ prolapse, the prevalence of anal incontinence was 20%. Urinary incontinence and severe rectocele were found to be associated with anal incontinence.     

Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence

OBJECTIVE: To assess the role of anal sphincter damage following delivery in the development of anorectal complaints and urinary incontinence, and to identify obstetric factors associated with subsequent fecal incontinence. METHODS: The retrospective cohort study with matched controls used a postal questionnaire and analysis of delivery and operation records from all women who underwent primary repair of a third or fourth degree perineal rupture in our hospital between 1971 and 1991, and their controls, matched for date and parity. Frequencies of complaints were compared using the Mantel-Haenszel common odds ratio [OR] for matched-control studies. Obstetric risk factors for fecal incontinence were assessed with multivariate logistic regression analysis. RESULTS: In the period studied, 171 women underwent a primary repair. One hundred and forty-seven of which returned the questionnaire (86%), compared with 131 of the controls (73%). Analysis was performed on 125 matched pairs with a median follow-up of 14 years. Fecal incontinence was reported by 39 patients and 16 controls (OR: 3.09; 95% confidence interval: 1.57-6.10). Urinary incontinence was reported by 65 cases and 52 controls (OR:1.46; 95% CI: 0.91-2.37). Among women with anal sphincter damage, the extent of anal sphincter damage was an independent risk factor for fecal incontinence. (OR: 2.54; 95% CI: 1.45-4.45). Subsequent vaginal delivery was not associated with the development of fecal incontinence (OR: 2.32; 95% CI: 0.85-6.33). In primiparous women mediolateral episiotomy protected for fecal incontinence after anal sphincter damage (OR: 0.17; 95% CI: 0.05-0.60). CONCLUSIONS: Anal sphincter damage following delivery is significantly associated with subsequent anorectal complaints, but not with urinary incontinence. The extent of sphincter damage is an independent risk factor for the development of fecal incontinence. Mediolateral episiotomy protects for fecal incontinence in primiparous women.     

Anal incontinence after vaginal delivery: a five-year prospective cohort study

OBJECTIVE: The long-term prevalence of anal incontinence after vaginal delivery is unknown. The aim of the present study was to evaluate the prevalence of anal incontinence in primiparous women 5 years after their first delivery and to evaluate the influence of subsequent childbirth. METHODS: A total of 349 nulliparous women were prospectively followed up with questionnaires before pregnancy, at 5 and 9 months, and 5 years after delivery. A total of 242 women completed all questionnaires. Women with sphincter tear at their first delivery were compared with women without such injury. Risk factors for development of anal incontinence were also analyzed. RESULTS: Anal incontinence increased significantly during the study period. Among women with sphincter tears, 44% reported anal incontinence at 9 months and 53% at 5 years (P = .002). Twenty-five percent of women without a sphincter tear reported anal incontinence at 9 months and 32% had symptoms at 5 years (P < .001). Risk factors for anal incontinence at 5 years were age (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0-1.2), sphincter tear (OR 2.3; 95% CI 1.1-5.0), and subsequent childbirth (OR 2.4; 95% CI 1.1-5.6). As a predictor of anal incontinence at 5 years after the first delivery, anal incontinence at both 5 months (OR 3.8; 95% CI 2.0-7.3) and 9 months (OR 4.3; 95% CI 2.2-8.2) was identified. Among women with symptoms, the majority had infrequent incontinence to flatus, whereas fecal incontinence was rare. CONCLUSION: Anal incontinence among primiparous women increases over time and is affected by further childbirth. Anal incontinence at 9 months postpartum is an important predictor of persisting symptoms.     

Anal incontinence in women presenting for gynecologic care: prevalence, risk factors, and impact upon quality of life

OBJECTIVE: The purpose of this study was to estimate the prevalence and impact upon quality of life of anal incontinence (AI) in women aged 18 to 65. STUDY DESIGN: Consecutive women presenting for general gynecologic care were given a bowel function questionnaire. Women with AI were prompted to complete the Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL). RESULTS: The cohort was composed of 457 women with a mean age of 39.9 +/- 11 years. AI prevalence was 28.4% (95% CI 24.4-32.8). After logistic regression, IBS (OR 3.22, 1.75-5.93), constipation (OR 2.11, 1.22-3.63), age (OR 1.05, 1.03-1.07), and BMI (OR 1.04, 1.01-1.08) remained significant risk factors. The mean FISI score was 20.4 +/- 12.4. Women with only flatal incontinence scored higher, and women with liquid loss scored lower on all 4 scales of the FIQL. CONCLUSION: AI is prevalent in women seeking benign gynecologic care, and liquid stool incontinence has the greatest impact upon quality of life.     

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.     

Predictors of Success and Satisfaction of Nonsurgical Therapy for Stress Urinary Incontinence

OBJECTIVE:: To identify factors that may predict success and satisfaction in women undergoing nonsurgical therapy for stress urinary incontinence. METHODS:: Baseline demographic and clinical characteristics of women participating in a multicenter randomized trial of pessary, behavioral, or combined therapy for stress urinary incontinence were evaluated for potential predictors of success and satisfaction. Success and satisfaction outcomes were assessed at 3 months and included the Patient Global Impression of Improvement, stress incontinence subscale of the Pelvic Floor Distress Inventory, and Patient Satisfaction Questionnaire. Logistic regression was performed to identify predictors, adjusting for treatment and other important clinical covariates. Adjusted odds ratios (ORs), 95% confidence intervals (CIs), and associated P values are presented. RESULTS:: Four hundred forty-six women were randomized. College education or more and no previous urinary incontinence surgery predicted success based on the stress subscale of the Pelvic Floor Distress Inventory (adjusted OR 1.61, 95% CI 1.01-2.55, P=.04 and adjusted OR 3.15, 95% CI 1.04- 9.53, P=.04, respectively). Menopausal status predicted success using the Patient Global Impression of Improvement (adjusted OR 2.52 postmenopausal compared with premenopausal, 95% CI 1.29-4.95; adjusted OR 1.32 unsure menopausal status compared with premenopausal, 95% CI 0.65-2.66; P=.03 across all three groups). Fewer than 14 incontinence episodes per week predicted satisfaction with the Patient Satisfaction Questionnaire (adjusted OR 1.97, 95% CI 1.21-3.19; P=.01). These predictors did not differ across the three treatment groups. CONCLUSION:: Menopause, higher education, no previous urinary incontinence surgery, and lower incontinence frequency were found to be predictors of success and satisfaction with nonsurgical therapy for stress urinary incontinence. This information may help better-align provider and patient expectations with nonsurgical treatment outcomes. CLINICAL TRIAL REGISTRATION:: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00270998. LEVEL OF EVIDENCE:: II.     

Anal incontinence in women with and those without pelvic floor disorders

OBJECTIVE: To compare the prevalence of anal incontinence and anal sphincter injury in women with pelvic floor disorders (cases) with those in a group of normal control subjects and to evaluate the relationship between sphincter injury and anal incontinence in each group. METHODS: We previously reported the results of a cross-sectional study of 100 women with pelvic floor disorders (> or = stage II pelvic organ prolapse and/or urinary incontinence). In this study, we compared those cases with 90 controls (stage 0 or I pelvic organ prolapse and no urinary incontinence) who completed the Rockwood-Thompson fecal incontinence severity index, in which scoring (0-61) is based on the frequency and type of anal incontinence. All women underwent endoanal ultrasonography, and the internal and external anal sphincters were reported as intact versus disrupted. Chi-square test, Student t test, and logistic regression were used for statistical analysis. RESULTS: Women with pelvic floor disorders were significantly more likely to report anal incontinence (54% versus 17.8%, odds ratio [OR] 5.4, 95% confidence interval [CI] 2.8-10.6, P < .001) and had higher mean fecal incontinence severity index scores (22.3 +/- 13 versus 12.7 +/- 6.3, P = .006) than controls. Cases demonstrated higher rates of anal sphincter defects on ultrasound examination than did controls (52% versus 30%, P = .007). Anal incontinence was significantly associated with anal sphincter injury in women with pelvic floor disorders (OR 36.4, 95% CI 12-114, P < .001) and in controls (OR 5.9, 95% CI 3-11, P = .002). CONCLUSION: Anal incontinence was more common in women with pelvic floor disorders than normal controls and may be due to higher rates of anatomic anal sphincter disruption in this group.     

Urinary incontinence: its prevalence, risk factors and effects on the quality of life of women living in a region of Turkey

BACKGROUND: The aim of this population-based cross-sectional study was to determine the prevalence and risk factors of urinary incontinence (UI) in women aged 20 years or older and to assess its influence on the quality of life (QOL). MATERIALS AND METHODS: The study group was comprised of 625 women determined using the stratified sampling technique according to age and residence. The data were collected through a questionnaire and the Urinary Incontinence Quality of Life Instrument. RESULTS: The prevalence of UI was 25.8%. UI was significantly associated with body mass index (OR 12.75, 95% CI 6.68-24.6), diabetes mellitus (OR 3.55, 95% CI 1.44-8.73), neurological disorders (OR 3.80, 95% CI 1.69-8.58), recurrent urinary tract infections (OR 4.73, 95% CI 2.52-8.88). Impairment of QOL was related with the type of UI, frequency of UI episodes, amount of leakage and UI during sexual intercourse. CONCLUSION: Our study results determined that UI is common in women. The QOL of women was either mildly and moderately affected by UI.     

女性压力性尿失禁发生的危险因素分析

目的 调查城市社区女性压力性尿失禁发生的危险因素。方法 按照1：8随机抽样的方法,抽取福州市鼓楼区6066例妇女。调查项目包括：年龄、职业、文化程度、体重、血压、月经史、孕产史、分娩方式、新生儿体重、慢性疾病(高血压、糖尿病、慢性咳嗽、习惯性便秘)、腹腔或盆腔手术史、生活习惯(吸烟、酗酒、体育锻炼方式等)、尿失禁症状和发生频率、就医情况等。数据采用多因素回归分析。结果 问卷回收率为92．1％(5587／6066)。尿失禁发生率为18．1％,其中压力性尿失禁占8．8％。调查显示,诸因素中年龄[OR：1．010;95％可信限(CI)：1．001—1．025]、高体重指数(OR：1．092;95％CI：1．054—1．132)、高血压(OR：2．342;95％CI：1．026～5．349)、便秘(OR：1．448;95％CI：1．216—1．725)、多次流产(OR：1．306;95％,CI：1．113～1．533)、多次阴道分娩(OR：1．205;95％CI：1．009—1．440)、加腹压助产(OR．1．684;95％CI:1．140—2．489)、会阴直切(OR：2．244;95% CI：1．162～4．334)、会阴裂伤(OR：2．576;95％CI：1．724～3．851)、会阴切口感染(OR：5．988;95％CI：1．936—18．616)是尿失禁发生的危险因素。结论 压力性尿失禁的发生与多种因素有关,尤其与年龄和妊娠、分娩等产科因素关系密切。     

Factors associated with pelvic floor dysfunction with emphasis on urinary and fecal incontinence and genital prolapse: an epidemiological study

OBJECTIVE: To describe a general population of women with regard to factors associated with urinary and fecal incontinence and genital prolapse symptoms. METHODS: A questionnaire about medical background, urinary and fecal incontinence and genital prolapse symptoms was mailed to 100040-year-old and 100060-year-old Swedish women. Associations were described by odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Sixty-seven percent answered the questionnaire. Multivariate analysis showed urinary incontinence to be associated with anal sphincter rupture [OR 4.4 (95% CI 1.0-18.8)], pelvic heaviness [3.8 (2.1-7.0)], body mass index (BMI) >or=30 kg/m2[3.7 (2.0-6.7)], multiparity [1.8 (1.0-3.4)], varicose veins surgery [1.9 (1.2-3.2)] and age [1.9 (1.2-3.2)]. Univariate analyses revealed statistically significant associations between urinary incontinence and incontinence for flatus [4.8 (3.0-7.8)], for liquid stool [5.0 (2.9-8.6)] and for solid stool [5.9 (2.4-14.2)]. Chronic bronchitis [5.7 (1.7-18.9)] was strongly associated with urinary incontinence but was only reported by the older age group. Prolapse symptoms were strongly associated with both urinary and fecal incontinence. Prolapse symptoms as opposed to urinary and fecal incontinence seemed to be associated more with injuries at delivery than with chronic pelvic floor strain. CONCLUSIONS: Women with urinary incontinence are also likely to suffer from fecal incontinence and prolapse and vice versa. Other associated factors for pelvic floor dysfunction were overweight, and especially obesity, chronic bronchitis, vaginal delivery and multiparity, age, heredity and diseases suggestive of collagen disorders. A multidisciplinary management of women with pelvic floor symptoms is suggested and possible prevention is discussed.     

Incontinence severity and major depression in incontinent women

OBJECTIVE: Research has shown an association between urinary incontinence and depression. Studies that use community-based samples and major depressive disorder diagnostic criteria are needed. The objective of this study was to estimate the prevalence of and factors associated with major depression in women with urinary incontinence. METHODS: We conducted an age-stratified postal survey of 6,000 women aged 30-90 years. Subjects were randomly selected from enrollees in a large health maintenance organization in Washington state. Main outcome measures were prevalence of current major depression and adjusted odds ratios for factors associated with major depression in women with urinary incontinence. RESULTS: The response rate was 64% (n = 3,536) after applying exclusion criteria. The prevalence of urinary incontinence was 42% (n = 1,458). The prevalence of major depression was 3.7% (n = 129), with 2.2% in those without incontinence versus 6.1% in those with incontinence. Among women with incontinence, major depression prevalence rates differed by incontinence severity (2.1% in mild, 5.7% in moderate, and 8.3% in severe) and incontinence type (4.7% in stress, 6.6% in urge/mixed). Obesity (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3-4.0), current smoking (OR 2.7, 95% CI 1.5-4.9), lower educational attainment (OR 2.0, 95% CI 1.2-3.3), moderate incontinence (OR 2.7, 95% CI 1.1-6.6), and severe incontinence (OR 3.8, 95% CI 1.6-9.1) were each associated with increased odds of major depression in women with urinary incontinence, controlling for age and medical comorbidity. Compared with women with incontinence alone, women with comorbid incontinence and major depression had significantly greater decrements in quality of life and functional status and increased incontinence symptom burden. CONCLUSION: Women with moderate-to-severe urinary incontinence should be screened for comorbid major depression and offered treatment if depression is present. LEVEL OF EVIDENCE: II-2.     

北京市成年女性粪失禁患病率调查

目的 调查北京市成年女性粪失禁(FI)的患病率,分析FI患病的影响因素.方法 采用分层多阶段系统抽样的方法,应用自填式问卷,对北京市6个区(县)20岁及以上成年女性进行问卷调查.结果 本研究符合条件的调查对象共3058例,年龄在20～79岁之间,平均(48±16)岁.北京市成年女性FI患病率为1.28%(39/3058),FI患病率随年龄增加而升高(P＜0.01).多因素非条件logistic回归分析显示,5个因素进入回归方程,分别为:年龄≥40岁(OR值为3.3,95%CI:1.7～6.8)、患尿失禁(OR值为3.0,95%CI:1.5～6.1)、自然分娩(OR值为2.4,95%CI:1.2～4.9)、家庭人均月收入≤2000元(OR值为3.3,95%CI:1.6～6.5)、经常感到疲劳(OR值为3.0,95%CI:1.5～5.8).结论 北京市成年女性FI患病率不高,但影响因素复杂,应该进一步开展相关研究.     

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.     

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.     

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.     

Predictors of urinary incontinence in a prospective cohort of postmenopausal women

OBJECTIVE: To prospectively assess risk factors associated with occurrence of urinary incontinence among postmenopausal women. METHODS: We followed up 1,017 postmenopausal health maintenance organization enrollees, aged 55 to 75 years, for 2 years. The primary outcome measures were any urinary incontinence and severe incontinence reported at 12- or 24-month follow-up visits. RESULTS: Baseline prevalence of any amount or frequency of urinary incontinence in the past year was 66%. Among the 345 women without incontinence at baseline, 65 (19%) at 1 year and 66 (19%) at 2 years reported any incontinence. Ninety-two of 672 (14%) and 96 of 672 (14%) women with incontinence at baseline reported no incontinence at years 1 and 2. In an adjusted multiple logistic regression model, independent predictors of any incontinence included white race (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.6), vaginal estrogen cream (OR 2.0, CI 1.1-3.7), vaginal dryness (OR 1.6, CI 1.2-2.2), vaginal discharge (OR 1.5, CI 1.0-2.2), 6 or more lifetime urinary tract infections (OR 1.8, CI 1.2-2.6), and diabetic peripheral neuropathy (OR 1.7, CI 1.0-3.1). In adjusted models, predictors of severe incontinence were history of hysterectomy (OR 1.8, CI 1.1-2.7) and any vaginal symptom (OR 1.7, CI 1.0-2.8). CONCLUSION: A substantial proportion of incontinence-free postmenopausal women developed urinary incontinence during 2 years of follow-up. Because vaginal symptoms are associated with urinary incontinence, their relationship with other risk factors, including vaginal Escherichia coli colonization and vaginal estrogen cream use, warrant additional study. Similarly, diabetic peripheral neuropathy and hysterectomy associations suggest areas for future investigation. LEVEL OF EVIDENCE: II-2.     

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.