Fecal and urinary incontinence in primiparous women

OBJECTIVE: To prospectively investigate the relationship between anal sphincter tears and postpartum fecal and urinary incontinence. METHODS: The Childbirth and Pelvic Symptoms study was a prospective cohort study performed by the Pelvic Floor Disorders Network to estimate the prevalence of postpartum fecal and urinary incontinence in primiparous women: 407 with clinically recognized anal sphincter tears during vaginal delivery, 390 without recognized sphincter tears (vaginal controls), and 124 delivered by cesarean before labor. Women were recruited postpartum while hospitalized and interviewed by telephone 6 weeks and 6 months postpartum. We assessed fecal and urinary incontinence symptoms using the Fecal Incontinence Severity Index and the Medical, Epidemiological, and Social Aspects of Aging Questionnaire, respectively. Odds ratios were adjusted for age, race, and clinical site. RESULTS: Compared with the vaginal control group, women in the sphincter tear cohort reported more fecal incontinence (6 weeks, 26.6% versus 11.2%; adjusted odds ratio [AOR] 2.8, 95% confidence interval [CI] 1.8-4.3; 6 months, 17.0% versus 8.2%; AOR 1.9, 95% CI 1.2-3.2), more fecal urgency and flatal incontinence, and greater fecal incontinence severity at both times. Urinary incontinence prevalence did not differ between the sphincter tear and vaginal control groups. Six months postpartum, 22.9% of women delivered by cesarean reported urinary incontinence, whereas 7.6% reported fecal incontinence. CONCLUSION: Women with clinically recognized anal sphincter tears are more than twice as likely to report postpartum fecal incontinence than women without sphincter tears. Cesarean delivery before labor is not entirely protective against pelvic floor disorders. LEVEL OF EVIDENCE: II-3.     

Anal incontinence after vaginal delivery: a prospective study in primiparous women

Objective To investigate the incidence and degree of anal incontinence after vaginal delivery among primiparous women and to define associated risk factors.
Design Prospective observational study.
Setting Karolinska Institutet, Danderyd Hospital, Sweden, a university hospital.
Participants Three hundred and forty-nine primiparous women.
Methods Questionnaires distributed within the first days after delivery and re-distributed five and nine months postpartum. Analysis of delivery records.
Results Eighty percent of the women answered all questionnaires. At five months postpartum, 2% of the women had symptoms of faecal incontinence and 25% had symptoms of involuntary flatus. At nine months postpartum, 1 % of the women had symptoms of faecal incontinence and 26% had symptoms of involuntary flatus. The majority of the women had infrequent symptoms and a decrease in severity was noted at nine months. Symptoms of incontinence were more common in women who sustained a sphincter tear at delivery. Risk factors for incontinence at five months included maternal age, duration of the second stage of labour, instrumental vaginal delivery, and clinically diagnosed sphincter tear at delivery. Development of incontinence at nine months was associated with maternal age and clinically diagnosed sphincter tear at delivery.
Conclusions The present study demonstrates that infrequent involuntary flatus is a common symptom after vaginal delivery in primiparous women. These symptoms of involuntary flatus frequently improved and only a few women suffered from frank faecal incontinence. Factors associated with an increased risk of anal incontinence and sphincter tears should be considered during delivery.     

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.     

Anal incontinence after vaginal delivery: a prospective study in primiparous women.

OBJECTIVE: To investigate the incidence and degree of anal incontinence after vaginal delivery among primiparous women and to define associated risk factors. DESIGN: Prospective observational study. SETTING: Karolinska Institutet, Danderyd Hospital, Sweden, a university hospital. PARTICIPANTS: Three hundred and forty-nine primiparous women. METHODS: Questionnaires distributed within the first days after delivery and re-distributed five and nine months postpartum. Analysis of delivery records. RESULTS: Eighty percent of the women answered all questionnaires. At five months postpartum, 2% of the women had symptoms of faecal incontinence and 25% had symptoms of involuntary flatus. At nine months postpartum, 1% of the women had symptoms of faecal incontinence and 26% had symptoms of involuntary flatus. The majority of the women had infrequent symptoms and a decrease in severity was noted at nine months. Symptoms of incontinence were more common in women who sustained a sphincter tear at delivery. Risk factors for incontinence at five months included maternal age, duration of the second stage of labour, instrumental vaginal delivery, and clinically diagnosed sphincter tear at delivery. Development of incontinence at nine months was associated with maternal age and clinically diagnosed sphincter tear at delivery. CONCLUSIONS: The present study demonstrates that infrequent involuntary flatus is a common symptom after vaginal delivery in primiparous women. These symptoms of involuntary flatus frequently improved and only a few women suffered from frank faecal incontinence. Factors associated with an increased risk of anal incontinence and sphincter tears should be considered during delivery.     

Urinary and anal incontinence after vacuum delivery

OBJECTIVES: To evaluate urinary and fecal incontinence symptoms, and occult anal sphincter defects in women after vacuum and spontaneous vaginal delivery. STUDY DESIGN: In a case-control study, 50 primiparous women delivered by vacuum extraction were compared to 50 women delivered spontaneously. Urinary and anal incontinence symptoms, pelvic floor muscle strength and sphincter defects on endoanal ultrasound were evaluated 6-24 weeks postpartum. RESULTS: New anal incontinence symptoms after childbirth were found in 30% of the vacuum group compared to 34% of the controls, new urinary incontinence symptoms in 28 and 42%, respectively (not significant). After excluding Grade III perineal tear, sonographic sphincter defects were found in 11 (27.5%) after vacuum delivery compared to 4 (10%) after spontaneous delivery (P<0.05, chi(2)-test). CONCLUSION: Anal and urinary incontinence symptoms are frequent after vaginal delivery. Vacuum delivery causes more sonographic sphincter defects but appears to cause no more harm to pelvic floor function than spontaneous vaginal delivery.     

Adaptation and use of health services by primiparous women with urinary incontinence

OBJECTIVES: To describe the use of health services by primiparous women with urinary incontinence by (a) examining the quality of life of these women and (b) describing the different predictors associated with their use of health services. DESIGN AND SETTING: This correlative study is a secondary analysis of a broader epidemiologic study. PARTICIPANTS: The 382 women identified as having urinary incontinence in the main epidemiologic study in Quebec, Canada. MAIN OUTCOME MEASURES: Consultation rate; quality of life, predictors of quality of life, and use of health services; treatments received; and reasons for not seeking help. RESULTS: Consultation rate was 11.1%. Many sociodemographic, clinical, and urinary incontinence factors were significantly associated with a decreased quality of life. Only frequency of nocturia, severe urinary incontinence, use of sanitary protection, and lower scores on the quality-of-life scale were significantly associated with differences in consultation rates. Physiotherapy was the most popular treatment received (71.4%). Most women with urinary incontinence did not consult because they considered urinary incontinence to be normal (47.3%). CONCLUSIONS: Few women with urinary incontinence used health services for their urinary incontinence problem despite a decreased quality of life. Health professionals need to intervene early and promptly to help women with urinary incontinence deal more adequately with urinary incontinence and to inform women on how and where to seek help.     

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery

Objective

To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously.

Methods

Primiparous women who delivered by forceps were recruited retrospectively into 2 groups: forceps for fetal distress with short second stage (25 ± 11 minutes; n = 19); and forceps delivery for second stage arrest (137 ± 26 minutes; n = 19). MR images of the levator ani muscles were compared with a historical control group of women from a previous study who had delivered spontaneously (n = 129).

Results

Major defect rates were: 42% for forceps and short second stage; 63% for forceps and second stage arrest; and 6% for spontaneous delivery. The odds ratios for major injury were: 11.0 for forceps and short second stage compared with spontaneous delivery; 25.9 for forceps and second stage arrest compared with spontaneous delivery; and 2.3 for forceps and second stage arrest compared with short second stage (P = 0.07).

Conclusion

Women delivered by forceps have a higher rate of levator ani injury compared with spontaneous delivery controls; the difference between the forceps groups did not reach significance.     

Risk factors for urinary incontinence in women

Urinary incontinence is a common and distressing condition which, whilst not life threatening, is known to cause considerable morbidity. Causation is multifactorial, although many risk factors have been identified. The purpose of this review is to provide a critical overview of the epidemiological evidence when considering risk factors for urinary incontinence in women.     

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.     

分娩方式对产后妇女粪失禁及尿失禁的影响

目的 调查女性产后粪失禁和尿失禁的发生率及其相关因素.方法 电话随访2006年10月1日至2007年9月30日在北京大学第一医院妇产科分娩的产妇,共纳入2012例妇女,收集其产后6个月内粪失禁和尿失禁的症状.采用Logistic回归法分析分娩方式与尿失禁和粪失禁的关系.结果 (1)参与调查的2012例产后妇女,14例(0.70％)有粪失禁症状.Logistic回归分析显示,粪失禁与阴道产钳助产(OR=20.09,95％ CI:3.64～110.90,P=0.000)和会阴侧切术分娩相关(OR=6.11,95％ CI:1.29～28.80,P=0.024).(2)2012例妇女中产后尿失禁、压力性尿失禁(stress urinary incontinence,SUI)、急迫性尿失禁(urge urinary incontinence,UUI)、混合性尿失禁(mixed urinary incontinence,MUI)的发病率分别为10.04％(202例)、8.15％ (164例)、0.94％(19例)和0.94％(19例).Logistic回归分析显示,与SUI相关的因素有:母亲年龄(OR=1.07,95％ CI:1.04～1.11,P=0.000)、母亲分娩前体重(OR=1.04,95％CI:1.02～1.06,P=0.001)、新生儿头围(OR=1.20,95％ CI:1.05～1.39,P=0.010)、会阴侧切术分娩(OR=4.96,95％ CI:3.05～8.07,P=0.0005)、阴道自然分娩(OR=5.22,95％ CI:2.53～10.76,P=0.000)和阴道产钳助产(OR=9.20,95％ CI:4.07～20.79,P=0.000).与UUI相关的因素有:产妇分娩前体重(OR=1.51,95％CI:1.12～2.05,P=0.008).与MUI相关的因素有:产妇分娩前体重(OR=1.06,95％ CI:1.00～1.11,P=0.049)、第二产程时限(OR=1.01,95％ CI:1.00～1.03,P=0.010)、会阴侧切术分娩(OR=7.76,95％ CI:1.42～42.52,P=0.017)和阴道产钳助产(OR=15.21,95％ CI:1.61～143.44,P=0.018).(3)产后4d和产后42 d SUI的发病率较高分别为7.95％和9.10％.结论 (1)本院产后妇女粪失禁和尿失禁的发病率较先前报道的其他地区的发病率低.(2)阴道分娩是妇女产后粪失禁和尿失禁发生的高危因素,特别是阴道产钳助产和会阴侧切术分娩.(3)母亲的年龄、分娩前体重、新生儿出生时头围、阴道自然分娩、产钳助产、会阴侧切术是发生尿失禁的高危因素.     

Stress urinary incontinence six months after first vaginal delivery

Objective

To determine the prevalence, severity and impact on quality of life of stress urinary incontinence (SUI) six months after the first vaginal delivery, as well as to investigate the risk factors associated with it.

Study design

We designed a prospective study that included 396 women who had their first vaginal delivery in the Hospital Donostia. Diagnosis and identification of the type of urinary incontinence were carried out considering the 2002 ICS definitions. Women were interviewed and examined twice, at term and six months after delivery. The severity of the symptoms was evaluated with the Incontinence Severity Index (ISI) and the impact on quality of life was evaluated with the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form. The statistical analysis included comparison of means (Student's t-test or analysis of variance) and proportions (Chi square and Fisher's exact tests). Multiple logistic regression analysis was performed using variables that were close to statistical significance.

Results

15.1% of the women reported SUI six months after their first vaginal delivery. The ISI was slight or moderate in the majority of the cases and the impact on quality of life was low. The presence of SUI in pregnant women at term was the only independent risk factor associated with SUI after delivery (OR: 3.71; 95% IC: 1.95–7.06). The type of vaginal delivery did not influence in SUI six months after the birth, not even in women who were continent during pregnancy.

Conclusions

Slight or moderate SUI was common after the first vaginal delivery and the impact on quality of life was low. Urinary incontinence during pregnancy was the only risk factor independently associated with the presence of SUI six months after the first vaginal delivery.     

Risk of postpartum urinary incontinence associated with pregnancy and mode of delivery

AIM: The aim was to estimate the postpartum urinary incontinence (PP UI) impact of precursory UI during pregnancy (PR UI) and delivery performed by cesarean section (CS) vs. vaginal childbirth (VC). METHODS: Among the members of two population samples, in total 8610 women aged 20-59 years, 1232 had their first childbirth and 642 their second childbirth within 13-120 months prior to responding to a questionnaire that included information on PR UI occurrence, mode of delivery and PP UI occurrence. RESULTS: CS was applied in 12.2% of first childbirths, and 87.8% thus delivered vaginally; PR UI during the pregnancy leading to the first childbirth was reported by 15.6%, and a total of 26.3% reported PP UI. An increased PP UI occurrence was reported following VC (28.3% vs. 12.0% in women undergoing CS, p < 0.001) and after PR UI (first childbirth, 66.7% vs. 18.8% in women not reporting PR UI, p < 0.0001). Among cases of PP UI following the first childbirth, 56.1% and 69.5% of cases could be attributed to PR UI and VC, respectively. CONCLUSIONS: The highest PP UI risks were found among women complaining of PR UI, which manifested itself as a crucial, independent precursor of PP UI. Because of the high frequency of VC, more than seven out of 10 cases of UI following the first childbirth, however, seemed to be attributable to VC. The present data did not lend significant support to the assumption that the PP UI risk is also lowered after a subsequent delivery by CS.     

Obesity and urinary incontinence in women

Summary. In a series of 368 incontinent women who presented to our urodynamic clinic for assessment, 232 (63%) were diagnosed as having genuine stress incontinence, and 136 (27%) as having detrusor instability. Obesity (>20% more than average weight for height and age) was significantly more common in women with genuine stress incontinence and detrusor instability than in the normal population. In those with detrusor instability the body mass index was found to increase with age and parity. In women with genuine stress incontinence the body mass index increased with age and the number of previous incontinence operations; it was higher in nulliparous than in parous women. There was no significant difference between obese and nonobese women in any of the urodynamic variables measured in the two incontinence groups.     

Exercise and urinary incontinence in women

Urinary incontinence is a common problem in women and may significantly impair their quality of life. Although women often report stress urinary incontinence during exercise, current data indicates that most types of exercise are not a risk factor for the development of urinary incontinence. However, certain extreme high-impact sports such as parachute jumping may cause pelvic organ support defects that result in stress urinary incontinence. Eating disorders also increase the risk of urinary incontinence in athletes. Overall, women should be encouraged to pursue physical activity that will benefit their general health without the risk of development of urinary incontinence later in life. Women athletes should be counseled about the increased risk of urinary incontinence with ultra high-impact sports and eating disorders.     

Obesity and urinary incontinence in women

In a series of 368 incontinent women who presented to our urodynamic clinic for assessment, 232 (63%) were diagnosed as having genuine stress incontinence, and 136 (27%) as having detrusor instability. Obesity (greater than 20% more than average weight for height and age) was significantly more common in women with genuine stress incontinence and detrusor instability than in the normal population. In those with detrusor instability the body mass index was found to increase with age and parity. In women with genuine stress incontinence the body mass index increased with age and the number of previous incontinence operations; it was higher in nulliparous than in parous women. There was no significant difference between obese and nonobese women in any of the urodynamic variables measured in the two incontinence groups.     

Portsmouth operative delivery trial: a comparison vacuum extraction and forceps delivery

Summary. A total of 304 women, for whom operative delivery was considered necessary in the second stage of labour, were randomly assigned to delivery by vacuum extraction or forceps. Of those allocated to forceps a higher proportion of babies were actually delivered with the allocated instrument; however, the caesarean section rate was also higher in this group. Maternal trauma, use of analgesia and blood loss at delivery were significantly less in the group allocated to vacuum extraction. Vacuum extraction did, however, appear to predispose to an increase in mild neonatal jaundice. More serious neonatal morbidity was rare in both groups and the trial was of insufficient size to rule out a clinically important differential effect of the two instruments on these measures of outcome. Another trial is now needed to address this still open question more rigorously.     

Portsmouth operative delivery trial: a comparison vacuum extraction and forceps delivery

A total of 304 women, for whom operative delivery was considered necessary in the second stage of labour, were randomly assigned to delivery by vacuum extraction or forceps. Of those allocated to forceps a higher proportion of babies were actually delivered with the allocated instrument; however, the caesarean section rate was also higher in this group. Maternal trauma, use of analgesia and blood loss at delivery were significantly less in the group allocated to vacuum extraction. Vacuum extraction did, however, appear to predispose to an increase in mild neonatal jaundice. More serious neonatal morbidity was rare in both groups and the trial was of insufficient size to rule out a clinically important differential effect of the two instruments on these measures of outcome. Another trial is now needed to address this still open question more rigorously.