During pregnancy, the prevalence rate of urinary incontinence rise up to 55%, whereas the incidence rate is between 20% and 40%. Dr PK Sands ran an adult identical twin studies more than ten years ago, which effectively control the differences due to genetic factors. He reported the rate of stress urinary incontinence of 67.1% in the twins who had vaginal deliveries, against 47.7% who had Caesarean sections, and 24% who had never been pregnant. This was consistent with other observational studies. The consensus is there are higher rates of incontinence after vaginal birth, and lower but not absent, risk after Caesarean section.
A 2018 report highlighted that pregnant women who were carrying the second or more child, who are older than 35 years old, and who are over-weight, have higher chance of developing urinary incontinence during the pregnancy. Repeated pregnancies and deliveries injure the nerves, connective tissue and pelvic floor muscle cumulatively, thereby reducing the urethral closure pressure and making it easier for women to leak. Likewise, older women may have weaker urethral sphincter due to increasing laxity of the ligaments and poorer muscle tone. With excessive body weight, the abdominal pressure in the pregnant woman is higher, that translate to higher bladder pressure and easier urine leak.
In Aug 2018, the latest Chinese survey that involved seven provinces went into print. It found prevalence of urinary incontinence at 26.7% in late pregnancy, 9.5% at 6 weeks, and 6.8% at 6 months after delivery. 3.7% of women who did not have urine leak in late pregnancy developed urinary incontinence at 6 weeks and a further 3.0% at 6 months. This later onset of urine leak that occur after childbirth is certainly attributed to the pelvic floor stretch and pudendal nerve injury during labour and the subsequent change in the pelvic organ position. Most cases recover after six months to a year. The Chinese survey highlighted that continuing urinary leak was linked to rural residence (probably due to early resumption of physical work in the rural setting), frequent exercises and birth related injuries. Other studies have correlated non-recovery from urinary incontinence to greater body built, larger babies delivered, pre-natal constipation, sphincter tear and having urinary incontinence during the incident pregnancy.
It came as a surprise when a 2013 research paper described the failure of postpartum PFMT to reduce the urinary incontinence prevalence six months after delivery. This was a European randomised controlled trial conducted by reputable physiotherapists, who were leaders in the field. Nevertheless, women with mild stress incontinence are still encouraged to undergo a well-designed pelvic floor rehabilitation protocol as a first line. , to optimise muscle tone recovery.
Vaginal laser treatment has emerged as a non-drug and non-surgery option to manage urinary incontinence. In the last two years, the Mona Lisa Touch CO2 laser therapy has surfaced against the multitudes of critical denouncement. Doctors in Europe and Central America have gathered evidence to show that laser treatment is efficacious. In directing the fractional laser pulses into the dermal layer of the vaginal skin, a thermal effect at 60-70 degC is established. The heating of the fibroblasts (cells) and the interstitium stimulate new collagen formation by the cells, and remodelling of the existing collagen fibrils in the ground substance. The resultant firm tissue integrity around the urethra and bladder improves the closure mechanism of the urethra, thereby reducing urinary leak.
Surgery remains the definitive treatment for moderate to severe stress urinary incontinence. This is far and few among those who had recently delivered. The recent furore against the mid-urethral slings is a kneejerk reaction to the lack of patient understanding. The attending gynaecologist has to manage patient’s expectation adequately before selecting the appropriate surgery.
|1||Disruption of the ligament support of the urethra and bladder, usually from multiple child-bearing & labor, assisted or traumatic vaginal delivery.|
|2||Connective tissue atrophy that accompanies the menopause|
|3||Further damage to pelvic floor musculature from increasing body weight (obesity), regular and severe abdominal straining from physical weight, constipation and chronic cough.|
|4||Neurological diseases (stroke and dementia) affecting the central nervous system|
|5||Chronic lifestyle disease that impact on the normal functioning of the nervous system|
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