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

Prevalence and risk factors for urinary incontinence up to 2 years postpartum: a cross-sectional population-based study

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is common in the postpartum period; however, most studies focus on the early postpartum period and assess prevalence at only one or two time points. We hypothesized that UI would be prevalent across the first 2 years postpartum. Our secondary objective was to evaluate risk factors for postpartum UI among a nationally representative, contemporary sample.

METHODS

This cross-sectional, population-based study used National Health and Nutrition Examination Survey (2011-2018) data for parous women within 24 months following delivery. Prevalence of UI, UI subtypes, and severity were estimated. Multivariate logistic regression was used to estimate adjusted odds (aOR) of UI for exposures of interest.

RESULTS

Among 560 postpartum women, prevalence of any UI was 43.5%. Stress UI was most common (28.7%), and most women (82.8%) experienced mild symptoms. There was no significant change in prevalence of UI across the 24 months following delivery (R2 = 0.004). Individuals with postpartum UI tended to be older (30.3 ± 0.5 versus 28.8 ± 0.5 years) and had higher BMI (31.1 ± 0.6 versus 28.9 ± 0.6). In multivariate analysis, odds of postpartum UI were higher for women who had had a prior vaginal delivery (aOR 2.0, 95% CI: 1.3-3.3), prior delivery of a baby weighing 9 lb (4 kg) or more (aOR 2.5, 95% CI: 1.3-4.8), or who reported current smoking (aOR 1.5, 95% CI: 1.0-2.3).

CONCLUSIONS

During the first 2 years postpartum 43.5% of women report UI, with relatively stable prevalence over this period. This high prevalence supports screening for UI after delivery regardless of risk factors.

The effect of epidural analgesia on postpartum urinary incontinence: a systematic review

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is common during pregnancy and in the postpartum period. Some women appear to recover their usual urinary function but in others UI persists, playing an important role in women's quality of life. Even though postpartum UI seems to have a multifactorial etiology, pregnancy, vaginal delivery, birth weight and parity are recognized as risk factors. This systematic review aims to evaluate the effect of one particular potential risk factor, epidural analgesia, on the development of postpartum UI in women with vaginal delivery.

METHODS

PubMed, Cochrane and Scopus were searched for "epidural analgesia," "epidural anesthesia" or "epidural" and "urinary incontinence." All studies published until 31 July 2020 were considered. A total of 393 studies were identified, and 23 studies were included in the systematic review.

RESULTS

From the total 23 articles included in this review, 21 showed a non-significant association between epidural analgesia and postpartum UI. One study found that the risk of postpartum SUI and any type of UI was significantly, but only slightly, increased in women with epidural analgesia. Another study showed a protective effect but was lacking control for important confounders.

CONCLUSION

There appears to be no association between epidural analgesia and postpartum UI. Therefore, pregnant women should not fear epidural analgesia because of a possible increased risk of UI.

Japanese Practice Guidelines for Fecal Incontinence Part 1-Definition, Epidemiology, Etiology, Pathophysiology and Causes, Risk Factors, Clinical Evaluations, and Symptomatic Scores and QoL Questionnaire for Clinical Evaluations-English Version

Fecal incontinence (FI) is defined as involuntary or uncontrollable loss of feces. Gas incontinence is defined as involuntary or uncontrollable loss of flatus, while anal incontinence is defined as the involuntary loss of feces or flatus. The prevalence of FI in people over 65 in Japan is 8.7% in the male population and 6.6% among females. The etiology of FI is usually not limited to one specific cause, with risk factors for FI including physiological factors, such as age and gender; comorbidities, such as diabetes and irritable bowel syndrome; and obstetric factors, such as multiple deliveries, home delivery, first vaginal delivery, and forceps delivery. In the initial clinical evaluation of FI, the factors responsible for individual symptoms are gathered from the history and examination of the anorectal region. The evaluation is the basis of all medical treatments for FI, including initial treatment, and also serves as a baseline for deciding the need for a specialized defecation function test and selecting treatment in stages. Following the general physical examination, together with history taking, inspection (including anoscope), and palpation (including digital anorectal and vaginal examination) of the anorectal area, clinicians can focus on the causes of FI. For the clinical evaluation of FI, it is useful to use Patient-Reported Outcome Measures (PROMs), such as scores and questionnaires, to evaluate the symptomatic severity of FI and its influence over quality of life (QoL).

Birthweight and urinary incontinence after childbirth: a systematic review and meta-analysis

Birthweight and urinary incontinence after childbirth: a systematic review and meta-analysis Stian Langeland WESNES, Elin SEIM MD Urinary incontinence (UI) is common after childbirth. Many cohort and cross-sectional studies have reported data on birthweight, but results have not been pooled. It is unclear how birthweight affects UI after childbirth. The objective is to review the effect of birthweight on UI after childbirth through meta-analyses. Searches were performed in Medline, Embase, Svemed+, ClinicalTrials.gov, Cochrane, and Cinahl in August 2016. Additional reference checking was performed. Included articles evaluated birthweight as a possible risk factor for maternal UI. We included articles that were presented in Norwegian, Danish, Swedish, or English. Two independent reviewers extracted the data and analysed it using Review Manager 5.3 software. Available data from included studies on birthweight (≥4000 g and ≥3500 g, respectively) and UI were combined in meta-analyses. PRISMA and MOOSE guidelines were used. Eighteen studies (N = 30 070) reported data on birthweight >4000 g vs <4000 g. Birthweight>4000 g compared to weight <4000 g was associated with a significantly increased OR of any UI (OR 1.49, 95% CI 1.24 - 1.80). Five studies (N = 15 066) reported data on birthweight >3500 g vs <3500 g. Birthweight>3500 g was also associated with a significantly increased OR of UI (OR 1.26, 95% CI 1.15 - 1.37). High birthweight appears to increase OR of UI after childbirth. Preventative strategies should be targeted towards women at particular risk.

Maternal, obstetrical and neonatal risk factors' impact on female urinary incontinence: a systematic review

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is one of the most serious problems during pregnancy and after delivery. It can influence the quality of life and cause psychological problems that lead to depression and decreased self-esteem. We aimed to investigate the maternal, obstetrical and neonatal risk factors of urinary incontinence 3 to 12 months after childbirth.

METHODS

The Cochrane Library, Medline, Science Direct and Web of Science were searched for studies published from the inception of the databases up to December 2019, including any observational full-text papers. All data were analyzed using Review Manager 5.3. Of 338 articles reviewed, 20 studies were considered for meta-analysis.

RESULTS

The results of our study showed that vaginal delivery in contrast to cesarean section (OR = 3.74, 95% CI: [2.71, 5.15], P < 0.00001), UI in pregnancy (OR = 5.27, 95% CI: [3.40, 8.17], P < 0.00001), episiotomy (OR = 1.23, 95% CI: [1.05, 1.45], P < 0.01), perineal tear > grade 2, instrumental delivery in contrast to cesarean section, epidural or spinal anesthesia, maternal age, pre-pregnancy BMI and neonatal birthweight have a direct relationship with UI.

CONCLUSIONS

This study confirmed that urinary incontinence during pregnancy and vaginal births had the strongest relationship with postpartum urinary incontinence. Also, the maternal upright positions during labor did not reduce the likelihood of urinary incontinence. The awareness of this issue helps find effective strategies to reduce the likelihood of female urinary incontinence.

Prevalence and predictors of double incontinence 1 year after first delivery

INTRODUCTION AND HYPOTHESIS

Urinary (UI) and anal incontinence (AI) are common pelvic floor disorders (PFD), and postpartum women experiencing double incontinence (DI), the combination of UI and AI, tend to have more severe symptoms and a greater impact on quality of life. Our objective was to investigate the prevalence and predictors of postpartum DI and UI alone 1 year after first delivery.

METHODS

In this prospective cohort study, 976 women reported the prevalence of DI and UI alone 1 year after their first delivery in one of two hospitals in Norway using the St Marks score and the ICI-Q UI SF.

RESULTS

DI was significantly reduced from 13% in late pregnancy to 8% 1 year later, whereas 30% reported UI at both time points. Incontinence in late pregnancy predicted incontinence 1 year after delivery. Higher age was associated with UI alone. Compared with caesarean delivery, normal vaginal or instrumental delivery increased the risk of UI alone more than three and four times respectively. Obstetric anal sphincter injuries showed a four-fold increase in the risk of DI.

CONCLUSIONS

Nearly 50% reported incontinence symptoms 1 year after first delivery. Continence status during pregnancy was one of the main predictors of postpartum continence status. Mode of delivery increased the risk of postpartum UI, whereas obstetric anal sphincter injuries increased the risk of postpartum DI.

Pelvic floor morphometry and function in women with and without puborectalis avulsion in the early postpartum period

BACKGROUND

Pelvic floor muscles are subject to considerable stretching during vaginal birth. In 13-36% of women, stretching results in avulsion injury whereby the puborectalis muscle disconnects from its insertion points on the pubis bone. Until now, few studies have investigated the effect of this lesion on pelvic floor muscles in the early postpartum period.

OBJECTIVE

The primary aim of this study was to compare pelvic floor muscle morphometry and function in primiparous women with and without puborectalis avulsion in the early postpartum period. Our secondary objective was to compare the 2 groups for pelvic floor disorders and impact on quality of life.

STUDY DESIGN

In all, 52 primiparous women diagnosed with (n = 22) or without (n = 30) puborectalis avulsion injury were assessed at 3 months postpartum. Pelvic floor muscle morphometry was evaluated with 3-/4-dimensional transperineal ultrasound at rest, maximal contraction, and Valsalva maneuver. Different parameters were measured in the midsagittal and axial planes: bladder neck position, levator plate angle, anorectal angle, and levator hiatus dimensions. The dynamometric speculum was used to assess pelvic floor muscle function including: passive properties (passive forces and stiffness) during dynamic stretches, maximal strength, speed of contraction, and endurance. Pelvic floor disorder-related symptoms (eg, urinary incontinence, vaginal and bowel symptoms) and impact on quality of life were evaluated with the International Consultation on Incontinence Questionnaire and the Pelvic Floor Impact Questionnaire-Short Form. Pelvic Organ Prolapse Quantification was also assessed.

RESULTS

In comparison to women without avulsion, women with avulsion presented an enlarged hiatus area at rest, maximal contraction, and Valsalva maneuver (P ≤ .013) and all other ultrasound parameters were found to be significantly altered during maximal contraction (P ≤ .014). They showed lower passive forces at maximal and 20-mm vaginal apertures as well as lower stiffness at 20-mm aperture (P ≤ .048). Significantly lower strength, speed of contraction, and endurance were also found in women with avulsion (P ≤ .005). They also presented more urinary incontinence symptoms (P = .040) whereas vaginal and bowel symptoms were found to be similar in the 2 groups. Pelvic Organ Prolapse Quantification revealed greater anterior compartment descent in women with avulsion (P ≤ .010). The impact of pelvic floor disorders on quality of life was found to be significantly higher in women with avulsion (P = .038).

CONCLUSION

This study confirms that pelvic floor muscle morphometry and function are impaired in primiparous women with puborectalis avulsion in the early postpartum period. Moreover, it highlights specific muscle parameters that are altered such as passive properties, strength, speed of contraction, and endurance.

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

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Specific obstetrical risk factors for urinary versus anal incontinence 4 years after first delivery

AIM

Delivery can be complicated by urinary or anal incontinence (UI or AI). We hypothesized that the mechanisms of injury may differ for UI and AI. Hence, obstetrical risk factors may be specific for different types of incontinence.

DESIGN

Data on maternal characteristics were collected at first delivery. Data on incontinence were obtained by a questionnaire completed by 627 women 4 years after first delivery. UI was defined by "Do you have involuntary loss of urine" and AI by "Do you have involuntary loss of flatus or stool". A multinomial logistic regression analysis was conducted to assess risk factors for UI only, AI only, and UI+AI.

RESULTS

Twenty-two percent of women reported UI only, 6.5% AI only, and 6.5% both. Risk factors associated with UI only were age (at first delivery)≥ 30 (OR 2.27 [95% CI 1.47-3.49]), pre-existing UI (6.44 [2.19-19.0]) and pregnancy UI (3.64 [2.25-5.91]). Risk factors associated with AI only were length of the second active stage> 20minutes (2.86 [1.15-7.13]) and third degree perineal tear (20.9 [1.73-252]). Significant predictors of UI+AI were age ≥ 30 (2.65 [1.29-5.46]), no epidural (4.29 [1.65-11.1]), third degree perineal tear (20.0 [1.28-314]), and UI before pregnancy (32.9 [9.00-120]). Cesarean delivery was not significantly associated with UI, AI, or UI+AI, although for all three outcomes, the adjusted odds ratios were substantially less than one.

CONCLUSION

We found specific associations between obstetrical risk factors and urinary versus anal incontinence 4 years after first delivery. Our results are consistent with the hypothesis that the underlying mechanisms of injury differ for UI and AI.

Prevalence and risk factors for anal incontinence after obstetric anal sphincter rupture

OBJECTIVE

To study prevalence and risk factors for anal incontinence (AI) after obstetric anal sphincter rupture.

MATERIAL AND METHODS

This was a retrospective clinical observational study. Among 14 959 vaginal deliveries, 591 women were diagnosed with obstetric anal sphincter ruptures (3.9%) at one Norwegian University Hospital in 2003-2005. Patients were examined and interviewed approximately 10 months after delivery. Anal continence was classified with St. Mark's incontinence score (0, complete anal continence; ≥3, anal incontinence), and defects in anal sphincter muscles were diagnosed by endoanal ultrasound. Prevalence of anal incontinence was assessed in relation to obstetrical and maternal characteristics as well as the correlation between anal incontinence and ultrasound-detectable defects of sphincter muscle.

RESULTS

Anal incontinence with a St. Mark's score of ≥3 was reported by 21% of women with obstetric anal sphincter rupture, with inability to control gas as the most prevalent symptom. Women with AI were more likely to report urinary incontinence compared with women having no AI. In a multiple regression analysis of maternal and obstetrical risk factors, fourth degree sphincter tear was the only significant risk factor for AI. Anal incontinence was more frequent in patients diagnosed with than without ultrasound-identified anal sphincter muscle defects at 10 months postpartum follow-up.

CONCLUSION

Anal as well as urinary incontinence after delivery with obstetric anal sphincter rupture is common, and prenatal obstetric and maternal variables could not predict anal incontinence. Fourth degree perineal tear and a persistent ultrasound-detected defect in the anal sphincter muscles are associated with AI.

Impaired rectal sensation at anal manometry is associated with anal incontinence one year after primary sphincter repair in primiparous women

PURPOSE

This study investigates the association between endoanal ultrasonography and anorectal manometry in relation to anal incontinence after primary repair of obstetric sphincter injury in primiparous, premenopausal women.

METHODS

The study population of this nested case-control study comprised 108 women who had previously been part of a randomized controlled trial comparing immediate with delayed primary repair of obstetric sphincter injuries, and who had been evaluated by anorectal manometry and endoanal ultrasound 1 year after their repair. Twenty cases and 88 controls were defined. Cases were defined as having a score greater than 2 on the Pescatori incontinence scale. Controls had a score of 2 or less. Ten obstetric, 9 ultrasonographic, and 7 manometric variables were studied.

RESULTS

Of the manometric variables, volume of first sensation and volume of first urge proved to be associated with anal incontinence at univariate statistical analysis. Volume of first sensation remained independently associated with anal incontinence after multivariate analysis. In addition, age, degree of tear, duration of second stage of labor, and a distal scar at ultrasound proved to be independently associated with anal incontinence.

CONCLUSIONS

Impaired rectal sensation at anorectal manometry and a distal scar at endoanal ultrasonography are associated with anal incontinence 1 year after primary sphincter repair in primiparous women. Additional studies need to evaluate whether these findings are associated with increased risk of anal incontinence in women that are continent 1 year after primary repair.

Faecal incontinence after first instrumental vaginal delivery using Thierry's spatulas

OBJECTIVE

The purpose of this study is to estimate the prevalence of faecal incontinence after first vaginal delivery and to assess the impact of Thierry's spatulas-assisted delivery.

METHODS

A prospective observational study of primiparas who underwent a vaginal delivery at term was conducted. Faecal incontinence was assessed at 2 and 6 months postpartum by a questionnaire (Wexner score >or=5 was considered significant). Univariate and multivariate analyses were performed.

RESULTS

Five hundred thirty-eight women were recruited with undergoing 176 spatulas-assisted deliveries and 362 spontaneous vaginal deliveries. The response rate was 85.9% (2 months) and 80.5% (6 months). The prevalence of faecal incontinence was similar between the two groups at 2 months (14.3% and 9.7%). Episiotomy (odds ratio [OR] = 5.0) and maternal age over 35 years (OR = 4.1) were independently associated with faecal incontinence after adjustment.

CONCLUSIONS

Anal symptoms are common after the first vaginal delivery. Thierry's spatulas do not increase the prevalence of faecal incontinence after delivery given that an episiotomy is performed.

Cesarean delivery for the prevention of anal incontinence

BACKGROUND

Caesarean delivery (CD) is a common form of delivery of a baby, rising in frequency. One reason for its performance is to preserve maternal pelvic floor function, part of which is anal continence.

OBJECTIVES

To assess the ability of CD in comparison to vaginal delivery (VD) to preserve anal continence in a systematic review

SEARCH STRATEGY

Search terms include: "Caesarean section, Cesarean delivery, vaginal delivery, incontinence and randomised". PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (Central) were searched from their inception through July, 2009.

SELECTION CRITERIA

Both randomised and non-randomised studies that allowed comparisons of post partum anal continence (both fecal and flatus) in women who had had babies delivered by either CD or VD were included.

DATA COLLECTION AND ANALYSIS

Mode of delivery, and when possible mode of all previous deliveries prior to the index pregnancy were extracted, as well as assessment of continence post partum of both faeces and flatus. In Non-RCTs, available adjusted odds ratios were the primary end point sought. Incontinence of flatus is reported as a separate outcome. Summary odds ratios are not presented as no study was analysed as a randomised controlled trial. Numbers needed to treat (NNT) are presented, that is, the number of CDs needed to be performed to prevent a single case of fecal or flatus incontinence, for each individual study. Quality criteria were developed, selecting studies that allowed maternal age adjustment, studies that allowed a sufficient time after the birth of the baby for continence assessment and studies in which mode of delivery of prior pregnancies was known. Subgroup analyses were done selecting studies meeting all quality criteria and in comparisons of elective versus emergency CD, elective CD versus VD and nulliparous women versus those delivered by VD or CD, in each case again, not calculating a summary risk statistic.

MAIN RESULTS

Twentyone reports have been found eligible for inclusion in the review, encompassing 31,698 women having had 6,028 CDs and 25,170 VDs as the index event prior to anal continence assessment . Only one report randomised women (with breech presentation) to CD or VD, but because of extensive crossing over, 52.1%, after randomisation, it was analysed along with the other 20 studies as treated, i.e. as a non-randomised trial. Only one of these reports demonstrated a significant benefit of CD in the preservation of anal continence, a report in which incontinence incidence was extremely high, 39% in CD and 48% in VD, questioning, relative to other reports, the timing and nature of continence assessment. The greater the quality of the report, the closer its Odds ratio approached 1.0. There was no difference in continence preservation in women have emergency versus elective CD.

AUTHORS' CONCLUSIONS

Without demonstrable benefit, preservation of anal continence should not be used as a criterion for choosing elective primary CD. The strength of this conclusion would be greatly strengthened if there were studies that randomised women with average risk pregnancies to CD versus VD.

Epidemiologia das incontinências urinária e anal combinadas

A baixa investigação pelos profissionais de saúde quanto às perdas urinárias e anais, combinadas ou não, dificultam as ações voltadas para sua prevenção e originam problemas com repercussões física, psicológica e econômica. A escassez de publicações nacionais e a reduzida literatura internacional sobre a epidemiologia dessas incontinências combinadas, motivou a realização deste artigo de atualização.

Prevalence and risk factors for urinary and fecal incontinence four months after vaginal delivery

OBJECTIVE

To determine the prevalence of and risk factors for urinary and fecal incontinence four months after vaginal delivery.

METHODS

All 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.

RESULTS

Of 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>or=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 >or=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>or=30 years (P<0.01) and forceps delivery (P<0.01). There were no identified risk factors for fecal incontinence.

CONCLUSION

Urinary 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.