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October 2018

Urinary Incontinence after Pregnancy -- Does it Get Better?

Prevalence

Many women experience involuntary leak of urine towards the second and last trimester of pregnancy. The leaks occur with sudden exertion during coughing, sneezing or running. At the outset, it can be scary to lose control of a private body function for no apparent cause. Soon they become daily annoyances. Up to 50% of adult pre-menopausal women may complain of stress urinary incontinence. Of these incontinent women, more than 60% attribute their condition to their pregnancy, childbirth or post-delivery care.

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.

Why?

Pregnancy and mode of delivery are indeed major determinants of urinary incontinence risk among younger adults. The passage of the baby through the pelvic floor during vaginal delivery and increasing parity are important events. Earlier ultrasound studies identified a shift in the position of the urethra (urine pipe) and bladder neck position after childbirth. This suggested that as the baby comes through the birth canal, it effectively dislodge the urethral complex from the originally well supported level.

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.

Natural history

About 50% of pregnant women developed transient urinary incontinence, and at three months after childbirth, the prevalence goes down to between 10% and 30%. Most of the women recover by one year. When assessed 5 years after delivery, 92% of those who were still leaking urine at the third month reported relapse of the condition.

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.

Treatment options

Pelvic floor muscle training, a.k.a Kegel exercise, has been the primary non-surgical conservative treatment for stress urinary incontinence over the past thirty years. Studies in the nineties endorsed the effectiveness of PFMT. Amongst women who suffered urinary incontinence after childbirth, those who received PFMT would be 40% less likely to have the problem at twelve months after delivery.

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.

Involuntary urine leakage, stress urinary incontinence, loss of bladder control and urge urinary incontinence affect many adult women in Singapore. It is well known that about 50% of elderly females above 60 years old suffer from a weak bladder. These women commonly complain of frequent urination, leaking urine whenever they cough or exercise, and overactive bladder or sensitive bladder symptoms which lead to urge urinary incontinence. In order to keep dry, the women often need to use incontinence pads, incontinence diapers or incontinence pants. Their bladder problem may become so severe that the elderly women avoid drinking fluids and keep away from social activities, until they submit themselves to definitive incontinence treatment.

What is urinary incontinence?

When you experience involuntary loss of urine, you suffer from urinary incontinence. It may occur rarely, occasionally, frequently or daily; and the volume of urine leakage may be minimal or substantial. If it is mild leakage, you may not be bothered. On the other hand, frequent severe urine leak may cause you unending distress. No matter how you are affected, urinary incontinence is an abnormal condition. You should not brush it aside, attributing it as a consequence of growing old. Although more elderly women suffer from it, women of all ages suffer from it.

Control of micturition

The human body needs to be adequately hydrated to have normal physiological processes. Excess body fluid is expel in different ways, one of which ends up as urine - filtered through the kidneys and stored in the bladder before being released as urine. The bladder acts as a reservoir for urine. A healthy woman maintains bladder continence throughout most of the day, and only void when it is socially appropriate at her convenience. During the storage phase, it is essential that the bladder remains relaxed and the urethra remains contracted, so as to allow its capacity to build up. This is possible only when there is normal neurological control involving the brain and spinal cord. When this normal balance exists, urine does not leak out. In situation when one or more of the control elements become disordered, the woman fails to maintain urinary continence, resulting in involuntary loss of urine.

What are the causes of urinary incontinence?

Women may suffer from urinary incontinence as a transient phenomenon or as a progressive pathological condition. Transient urinary incontinence is often seen when a women complains of urinary tract infection, vaginal inflammation or constipation. When a women becomes restricted in physical movements as in the acute phase of a stroke, severe arthritis or Parkinson’s disease, the impaired mobility prevent her normal toileting capacity. Certain medications can cause of worsen urinary incontinence as well. These situations are mostly temporary and continence is usually restored with the resolution of the initial impediments. When the urinary incontinence persists or progresses over time, it implies that the integrity of the continence mechanism has been bridged. It is likely that the bladder, urethra or nervous system has sustained pathological damage. The damage may be a result of:

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

Types of urinary incontinence

The leaking of urine occurs when the bladder control mechanism becomes defective. The position and the muscle tone of the water-pipe (urethra) usually keep the urine in the bladder effectively. When this continence device fails, urine flows out of the body at inappropriate times. Urinary incontinence is classified either as:

Genuine stress incontinenc

Loss of urine with coughing, sneezing, laughing or lifting a heavy weight.

Urge urinary incontinence

Loss of urine when the bladder fails to keep the urine in when a strong urge suddenly develops.

Mixed urinary incontinence

A combination of the above two types.

Overflow urinary incontinence

Intermittent loss of urine with the sensation of a full bladder and difficulty in completely emptying it.

Continuous urinary incontinence

Continuous loss of urine through a false passage that is formed between the bladder or the ureter and the vagina.

How does it impact?

The impact that urinary incontinence has on the suffering woman reflects on her anticipated quality of life desired. Urinary incontinence by and large is not a fatal illness; that is, no one dies directly from it. It does definitely has considerable bearing on how she lives her life – at home, at work, socially, financially and psychologically. The age and pre-morbid social and physical activity level affects how a woman copes with the inconvenience of urinary incontinence.

Treatment for Urinary Incontinence

Urine leakage may be mild and infrequent, or it may progress to become excessive and incapacitating. It tends to be severe when two or more types of urinary continence combine to complicate the condition in the same woman. Effective treatment may be prescribed once the cause of the urinary incontinence is determined. Life-style modification, pelvic floor exercises, bladder re-training and surgery have helped many women whose lives were scourged by the condition. The singular hurdle to management of urinary incontinence is the delay and reluctance of the woman to seek treatment. This is understandable because urine leakage is a highly embarrassing complaint that relates to a very private part of the body, and woman rather endures the inconvenience than talk about it. With proper evaluation and applying the apt treatment, success rate of 90% is expected. Women the world over is experiencing new freedom once their bladder function is restored.

What are the available treatments?

There are multiple strategies to manage urinary incontinence. Whether it is conservative measures, medication or surgical intervention, urinary incontinence can be treated according to the types and severity. Via life style changes, bladder retraining and pelvic floor exercises, may urinary symptoms may be obviated. Persistent and discipline suppression of urge restore significant central control on the continence mechanism, thereby improving overactive bladder. Effective contraction of the pelvic floor muscles in a timely fashion helps to reduce many stress leak accidents. Various groups of medications may be used to manage bladder infection, irritation and over-activity. Hormonal preparations are extremely useful in menopausal women with irritating symptoms of the lower uro-genital tract. New formulas have been introduced to treat mild to moderate stress urinary incontinence lately as well. When the condition becomes severe and does not response to conventional therapies, surgical procedures may be performed. It is recognized that surgery is the definitive treatment for severe stress urinary incontinence. Similarly surgery may have to be applied when the bladder has complete loss of control and is giving intolerable grief. It is usually the last form of treatment when all else failed. On the other hand, early access to surgical treatment alleviates tremendous suffering and restores a good quality of living for many years. It is extremely important to discuss this option with the expert before the appropriate decision is reached.

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