Antenatal prediction of postpartum urinary and fecal incontinence

doi:10.1016/S0029-7844(99)00364-6

Obstetrics & Gynecology

Volume 94, Issue 5, Part 1, November 1999, Pages 689-694

https://doi.org/10.1016/S0029-7844(99)00364-6 Get rights and content

Abstract

Objective: To investigate the effect of pregnancy and delivery on continence and to assess whether physical markers of collagen weakness can predict postpartum urinary and fecal incontinence (including incontinence of flatus).

Methods: In a prospective, longitudinal study in a London teaching hospital, 549 nulliparas were interviewed after 34 weeks’ gestation and again 3 months postpartum regarding urinary and fecal symptoms before and during pregnancy and after delivery. Family histories of incontinence, prolapse, and collagen abnormalities were recorded also. Physical examination was done to assess markers of collagen weakness such as striae, hernia, varicose veins, and joint mobility.

Results: The prevalence of urinary incontinence before, during, and after pregnancy was 3.6%, 43.7%, and 14.6%, and rates of fecal incontinence were 0.7%, 6.0%, and 5.5%, respectively. Fecal urgency was more common in women who had spontaneous and instrument-assisted vaginal deliveries (n = 413) compared with cesareans (n = 131) (7.3% versus 3.1%; P = .046). Postnatal urinary or fecal dysfunction was not related to antenatal body mass index, smoking, race, striae, varicose veins, hemorrhoids, or family history of incontinence. Higher joint-mobility scores were associated with incontinence of flatus (P = .021) but not with other urinary or fecal symptoms.

Conclusion: Although collagen weakness was previously implicated in the pathogenesis of incontinence, physical markers in this study could not predict postpartum urinary and fecal incontinence. Either those markers were not representative of collagen weakness, or a larger study with longer follow-up is necessary.

Section snippets

Methods

We interviewed consecutive women who were nulliparous, English-speaking, and had singleton pregnancies in the third trimester. A structured questionnaire was completed by each woman for this pilot study, and each signed an informed consent. Exclusion criteria included active urinary tract infection, history of urinary tract abnormality, recurrent urinary tract infection, history of anorectal surgery or trauma, and active anorectal infection. The women were interviewed during their routine

Results

Five hundred forty-nine women were interviewed antenatally and all completed postpartum follow-up. The ethnic distribution was 382 white (69.6%), 82 black (14.9%), 84 Asian (15.3%), and one Southeast Asian (0.2%), which was similar to that of the institution. The obstetric and neonatal data of the study population were compared with those of the overall nulliparous, registered population delivered over the same period, and there were no statistically significant differences (Table 1). The mean

Discussion

Our study confirmed previous reports of a high prevalence of urinary and fecal incontinence related to pregnancy and childbirth.12, 13 None of these women complained voluntarily or sought medical help, which is not surprising because these symptoms are embarrassing and known to be underreported.14 Although data regarding prepregnancy symptoms were retrospective, the low incidence of incontinence agrees with previous data linking parity to incontinence.12, 15, 16 We chose not to do objective

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Fecal urgency, which is defined by the sudden need to rush to the bathroom to empty one’s bowel, is one of the common and distressing symptoms experienced by patients with inflammatory bowel disease.
We performed a narrative review to investigate the definition, pathophysiology, and therapeutic management of fecal urgency.
Definitions of fecal urgency in inflammatory bowel disease, but also in irritable bowel syndrome, oncology, nononcologic surgery, obstetrics and gynecology, and in proctology, are empirical and heterogenous, lacking standardization. In the majority of these studies, nonvalidated questionnaires were used. When nonpharmacologic measures (dietary regimen, cognitive behavioral program) fail, medications such as loperamide, tricyclic antidepressants, or biofeedback therapy may become necessary. Medical management of fecal urgency may be challenging, in part because only limited data are available regarding the treatment of this symptom in randomized clinical trials of biologics in patients with inflammatory bowel disease.
There is an urgent need for a systematic approach to assessment of fecal urgency in inflammatory bowel disease. It is time to consider fecal urgency as an outcome in clinical trials to remedy this disabling symptom.
Changes of pelvic organ prolapse and pelvic floor dysfunction throughout pregnancy in singleton primigravidas: A prospective cohort study
2021, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Moderate correlations were observed between posterior vaginal descent and anorectal symptoms, and between the changes in genital hiatus and prolapse symptoms. In review of the literature regarding pelvic organ support changes evaluated by the POPQ examination, PFMS and PFDI and other validated questionnaires during the first pregnancy, the existing few studies have reported controversial results [8–13,17–25] (Table 4). Similar to our study, O’Boyle et al., reported significant descent of all the vaginal POPQ points except point D showing a cranial shift, and lengthening of the genital hiatus, perineal body and transvaginal length [10,11].
To document the deterioration in pelvic organ support occurring throughout all trimesters during the first pregnancy of women with no known risk factors. Secondarily to make a comprehensive review in order to verify the current findings and methodologies of similar studies in the literature.
In this prospective study, forty-one primigravid women with a singleton pregnancy were recruited during their first trimester. During follow-up pelvic organ support changes were documented by using Pelvic Organ Prolapse Quantification (POP-Q) system. Additionally, pelvic floor muscle strength examination, by modified Oxford scoring (MOS), and symptom assessment by Pelvic Floor Distress Inventory-Short Form (PFDI-20) were performed at three time points: first (T1), second (T2), and third trimester (T3) (n = 33). The Wilcoxon test was performed to test the significance of pairwise differences. Spearman correlation coefficient was estimated to determine the linear association of the findings.
Both distal and proximal anterior and posterior vaginal walls (Points Aa, Ba, Ap and Bp) with cervix (C) descended towards the hymen, throughout first pregnancy with a significant caudal shift on progressing from T2 to T3 (p ≤ 0.017). Posterior fornix (Point D) made a non-significant cranial shift (p = 0.527). The genital hiatus, perineal body and total vaginal length increased significantly (p ≤ 0.001). No significant difference in MOS was observed throughout pregnancy. The scores of PFDI-20 with all its domains worsened significantly during pregnancy, especially in T3 (p ≤ 0.011). Moderate correlations were observed between posterior vaginal descent and anorectal symptoms (rho 0.427, p < 0.05), and between the changes in genital hiatus and prolapse symptoms (rho 0.406, p < 0.05).
A significant descent both in all compartments of vaginal wall and perineum with an increase in total vaginal length, was observed together with an associated pelvic floor dysfunction throughout the first pregnancy of women.
Birthweight and urinary incontinence after childbirth: a systematic review and meta-analysis
2020, European Journal of Obstetrics and Gynecology and Reproductive Biology: X
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.
The effect of childbirth on urinary incontinence: a matched cohort study in women aged 40–64 years
2019, American Journal of Obstetrics and Gynecology
Citation Excerpt :
Earlier studies have shown that almost 100% of nulliparous women with UI continued to leak during and after pregnancy; among continent nulliparous women, the incidence during pregnancy was about 1 in 5, and in more than every second instance, the onset occurred during the third trimester.16,17 This indicates that gestational incontinence largely depends on distension exerted by intraabdominal pressure and is also supported by the observation that, after CS, postpartum UI and stress UI rapidly decreased towards prepregnancy rates.18–20 A few studies have followed UI in primiparous women during the first year after childbirth and have found that UI and stress UI were relatively stable but higher after VD compared with CS.21
The relative impact of age, pregnancy and vaginal delivery on urinary incontinence is still an unresolved issue that involves the controversial question about the protective effect of cesarean delivery.
The purpose of this study was to estimate and compare the effect size of 1 pregnancy, 1 vaginal delivery, and the derived protective effect of cesarean delivery for different aspects of urinary incontinence in women 40–64 years old, all 20 years after birth.
This Swedish nationwide matched cohort study involved 14,335 women. Data from 3 restricted, randomly selected, source cohorts of (1) nulliparous women who were unexposed to childbirth (n=9136), (2) primiparous women who had experienced cesarean delivery and who had been exposed to 1 pregnancy (n=1412), and (3) primiparous women who had been exposed to 1 pregnancy followed by vaginal delivery (n=3787) were retrieved from The Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014, respectively. Parous women were all assessed 20 years postnatally. One-to-one matching with an interval for pairing of 3 years and 3 body mass index units was used in women 40–64 years old with information about body mass index (kilograms/square meters) and urinary incontinence. The procedure succeeded in 2630 of 2635 women (99.8%) and resulted in an adequate distribution of age and body mass index between groups. The surveys used a postal- and an internet-based questionnaire with validated questions for various aspects of urinary incontinence. Fisher’s exact test and the Mann-Whitney U test were used for comparisons between matched groups; trend was analyzed with Mantel-Haenszel statistics. Predicted, age-related values of different aspects of urinary incontinence were obtained by logistic regression analysis.
Pregnancy increased the prevalence of urinary incontinence from 20.1–30.1% (odds ratio, 1.71; 95% confidence interval, 1.43–2.05; P<.0001]. Urinary incontinence increased further after vaginal delivery to 43.0% (odds ratio, 1.75; 95% confidence interval, 1.49–2.05; P<.0001); “moderate” and “severe” urinary incontinence increased from 12.7–19.5% (odds ratio, 1.67; 95% confidence interval, 1.35–2.07; P <.0001). There was a parallel increase in urinary incontinence from 40–65 years of age in nulliparous and vaginally and cesarean delivered women. Cesarean delivery, compared with vaginal delivery, was associated with a 30.0% reduction of urinary incontinence (P<.0001) and a 35–52% reduction of more severe grades of urinary incontinence (P<.0001) and was unaffected by age.
Both pregnancy and vaginal delivery incurred an increased risk of urinary incontinence in the long term. The age-related gap for urinary incontinence between nulliparous and primiparous women who were delivered by vaginal delivery or cesarean delivery was constant between parallel trajectories that spanned ages from 40–64 years. The calculated protective effect of cesarean delivery was unaltered and significant during the same age interval.
Internal anal sphincter: Clinical perspective
2017, Surgeon
To summarise current knowledge of Internal anal sphincter.
The internal anal sphincter (IAS) is the involuntary ring of smooth muscle in the anal canal and is the major contributor to the resting pressure in the anus. Structural injury or functional weakness of the muscle results in passive incontinence of faeces and flatus. With advent of new assessment and treatment modalities IAS has become an important topic for surgeons. This review was undertaken to summarise our current knowledge of internal anal sphincter and highlight the areas that need further research.
The PubMed database was used to identify relevant studies relating to internal anal sphincter.
The available evidence has been summarised and advantages and limitations highlighted for the different diagnostic and therapeutic techniques.
Our understanding of the physiology and pharmacology of IAS has increased greatly in the last three decades. Additionally, there has been a rise in diagnostic and therapeutic techniques specifically targeting the IAS. Although these are promising, future research is required before these can be incorporated into the management algorithm.
Postpartum Care and Long-Term Health Considerations
2016, Obstetrics: Normal and Problem Pregnancies

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^☆: Supported by the South Thames Project Grant Scheme.

¹: The authors thank Professor Martin Bland for advice regarding statistical analysis of the data.

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Original ArticlesAntenatal prediction of postpartum urinary and fecal incontinence1☆,

Abstract

Section snippets

Methods

Results

Discussion

J Invest Dermatol

J Neurol Sci

Lancet

Am J Obstet Gynecol

Int J Gynaecol Obstet

Int J Gynaecol Obstet

J Chronic Dis

Collagen synthesis in women with genital prolapse or stress urinary incontinence

Neurourol Urodyn

Different biochemical composition of connective tissue in continent and stress incontinent women

Acta Obstet Gynecol Scand

Pelvic floor disordersThe role of fascia and ligaments

Clin Obstet Gynecol

Decreased collagen synthesis in stress-incontinent women

Obstet Gynecol

Analysis of the pelvic floor electromyography and collagen status in premenopausal nulliparous females with genuine stress incontinence

Neurourol Urodyn

Sphincter denervation in anorectal incontinence and rectal prolapse

Gut

Original Articles
Antenatal prediction of postpartum urinary and fecal incontinence1☆,