Incontinence Notes: Literature review
Definition
“Urinary incontinence is defined as leakage of urine which is socially or hygienically
unacceptable. In women it is widespread and often debilitating condition, which
generally remains well concealed in society. It may have far reaching consequences
for women’s social, psychological and medical well being. Women with incontinence
may become isolated from friends and family and even partners due to fear of
embarrassment. Midwives have a key role to play in the prevention and identification
of this condition.
Smalldridge J [2000] Incontinence after childbirth. MIDIRS Midwifery Digest.
10[1] Pp79-81
Urinary incontinence is common during pregnancy and is often transient, it is
attributed to the enlarged uterus, fluctuating hormone levels, increased glomerular
filtration rates and tempory changes in the urethrovesical angle. Unlike antenatal
incontinence postpartum incontinence is typically attributed to pathophysiological
changes as a consequence of delivery.
Burgio K, Zyczynski H, Locher J et al [2003] Urinary Incontinence in the 12
month postpartum period. Obstetrics and Gynaecology. 102[6] Pp 1291-1298
Prevalence.
In 2003 a telephone survey conducted in Australia, Canada, France, Germany, Italy,
Mexico, Spain, Sweden and UK. The rates of reported stress urinary incontinence was
second highest in the UK, only Canada was higher. Women with stress incontinence
reported having to change their lifestyles in many ways. In the UK 64 % of women
had not received any treatment, only 38% of women with incontinence symptoms had
consulted a doctor. More than 60% of the women did not feel it was an important
enough to bother a doctor.
Haslam J [2004] The prevalence of stress incontinence in women. Nursing Times.
100[20] Pp 71-73
One in every three women will have incontinence during her lifetime and up to 65%
of those women will recall that it began either during pregnancy or after childbirth.
The first vaginal delivery was the risk factor, subsequent deliveries were not found to
further increase the risk.
Goldberg R, Kwon C, Gandhi S et al [2003] Urinary incontinence among
mothers of multiples. American Journal of Obstetrics and Gynaecology. 188[6]
Pp 1447-1453
¼ of primiparous women and 1/3 of multiparous women with a history of vaginal
delivery have an anal sphincter defect. Hence the incidence of anal sphincter damage
is much higher than commonly estimated. At least 2/3 of these defects are
asymptomatic.
Oberwalder M, Conner J and Wexner S [2003] Meta-analysis to determine the
incidence of obstetric anal sphincter damage. British Journal Of Surgery 90[11]
Pp 13333-1337
When stress incontinence occurs during the first pregnancy the risk of stress
incontinence 15 years later is doubled. Even when symptoms resolve postnataly re-
occurance is likely. Subsequent pregnancy did not increase this risk. Postnatal
exercises were not seen to reduce the incidence of symptoms at 7 and 15 years. This
could be due to the motivation and supervision of exercise in the long term.
Dolan L, Hosker G, Mallett V et al [2003] Stress incontinence and pelvic floor
Neurphysiology 15 years after the first delivery. BJOG: An International
Journal of Obstetrics and Gyaenecology. 110[12] Pp 1107- 1114
Risk Factors
Vaginal births increased the risk of stress and mixed incontinence, but not urge
incontinence or over active bladder. The risk of all types of incontinence was
increased in women with high BMI, history of hysterectomy, urinary infection and
perineal trauma.
Heavy smokers have been shown to have a higher incidence of incontinence though
the reasons for this seem unclear.
Parazzini F, Chiaffarino F, Lavezzari M et al [2003] Risk factors for stress, urge
or mixed urinary incontinence in Italy. BJOG: An International Journal of
Obstetrics and Gynaecology. 110[10] Pp 927-933
Perineal trauma during childbirth is a causative factor of urinary incontinence;
contributing factors include forceps, episiotomy, large baby or long second stage.
Maintaining an intact perineum is not necessarily protective because there can still be
hidden nerve damage.
Layton S [2004] The Effect of perineal Trauma on Women’s Health. British
Journal Of Midwifery 12[4] Pp 231-236
Other factors significant in urinary incontinence include smoking which is thought to
be linked to increased pressure from coughing, Obesity and when antenatal
incontinence occurs there is greater risk of it continueing into the postpartum period.
Burgio K, Zyczynski H, Locher J et al [2003] Urinary Incontinence in the 12
month postpartum period. Obstetrics and Gynaecology. 102[6] Pp 1291-1298
Forceps delivery has been shown to increase the risks of urinary incontinence
compared to vaginal delivery or CS.
Arya L, Jackson N, Myers D [2001] Risk of new onset urinary incontinence after
forceps. American Journal of Obstetrics and Gynaecology. 185[6] Pp 1318-1324
Treatments
Pelvic floor exercises are more commonly associated with improvement of symptoms
than a total cure. It takes several months of pelvic floor muscle training to effect the
physiological muscle change to reduce or stop urinary leakage on exertion. They can
also help to avoid or delay the need for surgery and can increase sexual satisfaction.
The ability ti identify and contract the correct muscle is essential for pelvic floor
exercise success. Breif verbal or written instruction is unlikely to be effective in
assisting women in this.
Haslam J [2000] Pelvic Floor muscle exercises. Nursing Times plus. 96[42] Pp 24.
Non compliance of pelvic floor exercises are due to inconvienience, lack of time,
motivation problems and travel time to clinics. Pelvic floor exercises may not be
appropriate if significant prolapse and or denervation, or if intrinsic sphincter damage.
Wilson P and Herbison G. [1998] A randomised controlled trial of pelvic floor
exercises to treat postnatal urinary incontinence. International Urogynecology
Journal. 9 Pp 257- 264.
Non-surgical treatments for incontinence include: Pelvic floor exercises, electrical
stimulation, and vaginal cones. Surgical treatments include: laproscopic, open retro
pubic and needle colposuspension. Suburethral slings and anterior vaginal repair.
Postnatal pelvic floor exercises appear to be effective in decreasing postnatal urinary
incontinence, insufficient evidence exists to support there effectiveness in reducing
anal incontinence and prolapse.
Harvey MA [2003] Pelvic Floor exercises during and after pregnancy: a
systematic review of their role in preventing pelvic floor dysfunction. Journal of
Obstetric and Gynaecology Canada 25[6] Pp 487-498
Intensive pelvic floor muscle training during and after pregnancy prevents urinary
incontinence and significantly improved pelvic floor strength. Significantly fewer
women who practiced antenatal pelvic floor exercises reported symptoms of urinary
incontinence. No negative side effects were noted with the exercise regime.
Morkved S, Bo K, Schei B et al [2003] Pelvic floor muscle training during
pregnancy to prevent urinary incontinence: a single blind randomised controlled
trial. Obstetrics and Gynaecology 101[2] Pp 313-319
Supervised antenatal pelvic floor exercises are effective in reducing the risk of
postpartum stress incontinence in primigravidae. Clients who performed pelvic floor
exercises for 28 days or more were found to suffer less symptoms of stress
incontinence. Supervised pelvic floor exercises were more effective than verbal
instruction. It is noted that it is antenatal rather than postnatal exercises that were
found to be most effective.
Reilly E, Freeman R, Waterfield M [2002] Prevention of postpartum stress
incontinence in primigravidae with increased bladder neck mobility: a
randomised controlled trial of pelvic floor exercises. BJOG: An international
Journal of Obstetrics and Gynaecology. 109[1] Pp 68-76
Pelvic floor education begun 2 months postpartum, significantly reduced the
incidence of stress incontinence but not anal incontinence.
Meyer S, Hohfeild P, Achtari C et al [2001] Pelvic Floor education after vaginal
delivery. Obstetrics and Gynaecology. 97[5] Pp 637-677
Women who attended an antenatal programme of pelvic floor exercises and who
practised them daily had less risk of urinary stress incontinence.
Jones M [2000] Pelvic Floor exercises: a comparative study. British Journal Of
Midwifery. 8[8] Pp 492-498
Bladder training enables women to accommodate increasingly greater volumes of
urine in the bladder and gradually to extend the interval between voiding. Pelvic floor
muscle training increases awareness of function and strengthens these voluntary
muscles, promoting continence.
Sampselle C [2000] Behavioral intervention for urinary incontinence in women:
evidence for practice. Journal of Midwifery and women’s Health. 45[2] Pp 94103
RCT’s have found that Electrical stimulation reduces symptoms of stress incontinence
compared to no treatment at all. However no significant differences were noted
between the effect of electrical stimulation and the effect of pelvic floor exercises or
vaginal cones. Pelvic floor electrical stimulation has been associated with a small
number of cases of vaginal irritation.
Pelvic floor exercises were more beneficial in rates of cure or improvements
compared to no treatment but were not any more or less effective than other forms of
treatment.
While no difference in effects were seen between vaginal cones and pelvic floor
exercises at twelve months vaginal cones were less effective at reducing leakage at six
months compared to pelvic floor exercises. Vaginal cones were also associated with
difficulty maintaining motivation for use and a small number reported vaginitis and
abdominal pain. Vaginal cones were also more difficult to use and some women
reported an unpleasant feeling, discomfort, and bleeding and vaginal prolapse..
There is little available evidence comparing surgical treatments to no treatment or non
surgical treatment, however one review found that laproscopic colposuspension was
less effective than open retro-pubic colposuspension in improving objective cure rates
at 1 year.
Open retro pubic colposuspension increased cure rates at 1-5 years compared with
non surgical treatment, anterior vaginal repair or needle colposuspension. But it was
also associated with more adverse effects. No significant difference was found in
objective cure rates at five years.
Suburethral slings were associated with increased perioperative complications
including an increased risk of bladder perforation.
Bazian Ltd [2004] Stress Incontinence. Clinical Evidence. 11 Pp 2543-2557.
Pelvic floor exercises are shown to be effective in maintaining continence, however
they need to be explained carefully and practiced daily to be effective. Midwives have
an important role in informing women of the importance of practicing PFE.
Layton S [2004] The Effect of perineal Trauma on Women’s Health. British
Journal Of Midwifery 12[4] Pp 231-236
Managing the problem of urinary incontinence is extremely expensive conservative
estimates are in excess of £424 million annually in the UK.
Continence Foundation [2000] Incontinence cost NHS £424 million a year.
Continence Newsletter 6. Pp 1-2.
Conservative therepy including pelvic floor exercises combined with bladder training
and biofeedback has been demonstrated to be effective. Surgery is indicated in very
few selected patients
Lacima G and Pera M [2003] Combined fecal and urinary incontinence: an
update. Current opinion in Obstetrics and Gynaecology 15[5] Pp 405-410
Information/ midwives role
Many women suffering from stress incontinence do not seek medical advice for
various reasons including acceptance that incontinence is just a part of life and the
feeling that nothing can be done anyway.
The midwife has a unique position that allows her to act as detective, in identifying
women with genuine stress incontinence. It may be beneficial to adopt a a score
system focused on the risk factors. As midwives are not specifically trained in this
area the sytem would need to be easy and standardized. Pelvic floor exercises are a
cheap and simple initial treatment Midwives need to initiate this with verbal advice
followed by follow up in the clinical setting as verbal instructions alone are
insufficient. It is important that the pelvic floor instructor possesses the appropriate
skill.
Peeker I and Peeker R [2003] Early diagnosis and treatment of genuine stress
incontinence. Journal of Midwifery and Womens health.48[1] Pp 60-66
The majority of women asked were not given information about incontinence but said
that they wanted professional to warn them that the condition may appear, They also
wanted professional to actively ask for information regarding symptoms and not wait
for the woman to broach the subject. As the main form of treatment is pelvic floor
exercises midwives should actively seek out those experiencing problems and
recommend early commencement of a exercise programme. Health professionals need
to raise awareness of the condition, the treatment available and be pro active in
seeking out hose experiencing incontinence rather than wiat for women to come
forward.
Reluctance to seek advice also comes from ebarrassment and a feeling that they
should not bother health professionals. 69% of women studied had not received any
advice or information on Stress incontinence. Women requested information on this
condition during pregnancy as they said that it was quite a shock when it occurred.
Knowledge of the condition could lesson the taboo and the embaressment enabling
women to more readily seek help. Incontinecne is often viewed as a social problem
rather than a medical one. The lack of control over a bodily function taught as a child
is socially unacceptable.
Another reason for not seeking help was that women didn’t feel they new which
Health professional to approach and felt that they had lost touch with the midwives
too early. For many women ten days is too early to identify persistent problem such as
incontinence.
Mason L, Glenn S, Walton I et al [2001] Women’s reluctance to seek help for
stress incontinence during pregnancy and following childbirth. Midwifery. 17[3]
Pp 212-221
Childbirth is a major influence on stress incontinence. Pelvic floor exercises have
been shown to be effective in preventing or reducing symptoms of stress
incontinence. Midwives need to be taking opportunity to promote the correct practice
of pelvic floor exercises to women at antenatal classes and in the wider community.
Parker C [2001] Do midwives really promote pelvic floor exercises? Professional
care of mother and child. 11[3] Pp 73-75 Pp 73-75
In order to reduce the risk of incontinence after childbirth improvements in several
areas of care are needed. Improved information giving, improved professional
communication and improved recognition and management of third degree tears.
Clarkson J, Newton C, Bick D et al [2001] Achieving sustainable quality in
maternity services – using audit of incontinence and dyspareunia to identify
shortfalls in meeting standards. BMC Pregnancy and Childbirth. 1[4] Pp 5-10
Mediolateral episiotomy does not protect against urinary and anal incontinence and is
associated with lower pelvic floor strength compared to spontaneous perineal
lacerations and with more dyspareunia and perineal pain.
Sartore A, De Seta F, Maso G,et al [2004] The effects of Mediolateral Episiotomy
on Pelvic Floor Function After Vaginal Delivery. Obstetrics and Gynaecology.
103[4] Pp 669-673
The midwives decision regarding whether to suture 1st and 2nd degree tears was not
found to affect the incidence of urinary incontinence. As perineal damage is
significant when looking at anal incontinence this decision should only be reached
after careful assessment of damage.
Layton S [2004] The Effect of perineal Trauma on Women’s Health. British
Journal Of Midwifery 12[4] Pp 231-236
Health care professionals who come into regular contact with women during and after
pregnancy do not appear well-informed about the subject. Women are not receiving
the information they deserve to allow them to take control of the problem. Many
women are dissatisfied with the information on incontinence. Women believe the
problem to be part of being female and that nothing can be done.
Midwives suggest barriers to the introduction of the topic of PFE’s including lack of
knowledge, insufficient time, early discharge of mothers, poor quality information
leaflets, and women not attending parentcraft.
There is no agreed national standard to which instructors of PFE’s should work.
Logan K [2001] Audit of advice provided on pelvic floor exercises. Professional
Nurse. 16[9] Pp 1369-1372
Cure or improvement rates were usually higher in women who had more frequent
contact with Health professionals this was thought to be due to an increased
compliance rate with pelvic floor exercises.
BO K [1999] Single blind randomised controlled trial of pelvic floor exercises,
electrical stimulation, vaginal cones and no treatment in management of genuine
stress incontinence in women. British Medical Journal. 318 Pp487- 493
Motivation is critical prerequisite for influencing the ultimate success of pelvic floor
exercises. Health professional must develop an understanding of factors that influence
motivation if they are to optimise clients chances of successfully incorporating pelvic
floor exercises into their lives.
Gallo L and Saskin D [1996] Cues to action: pelvic floor muscle exercise
complience in women with stress urinary incontinence. Neurology and
Urodynamics 16 Pp167-177.
Nurses can play a crucial role in influencing compliance and are ideally placed to
work in partnership with women to explore imaginative approaches that will
assist women in maximising and maintaining compliance with pelvic floor
exercises.
Paddison K [2002] Complying with the pelvic floor exercises: a literature review.
Nursing Standard. 16[39] Pp 33-38
While it is recognised that pelvic floor exercises are beneficial in eliviating symptoms
they are usually not taught in a manner intensive enough to achieve significant results.
Health professionals need to be more robust in detecting at risk groups and
implementing an intensive programme of pelvic floor exercises.
Burgio K, Zyczynski H, Locher J et al [2003] Urinary Incontinence in the 12
month postpartum period. Obstetrics and Gynaecology. 102[6] Pp 1291-1298
There should be a muti-disciplinary approach which is of interest to at least three
professional disciplines. Cases who had received supervised pelvic floor exercise
programmes showed fewer symptoms of stress incontinence. No single profession
appeared to take responsibility for this and as a result the information in some cases
was replicated and in other completely absent.
Mason L [2001] Guidelines on the teaching of pelvic floor exercises. British
Journal of Midwifery 9[10] Pp 608-611
Anal Incontinence
Flatus and fecal incontinence is increased with age, birth weight greater than 4kg and
history of anal sphincter tears. Age was more of a risk factor then type of delivery
alone.
Hojberg K, Salvig J, Winslow N Et al [2000] Flatus and Faecal incontinence:
prevalence and risk factors at 16 weeks of gestation. BJOG: An International
Journal of Obstetrics and Gynaecology. 107[9] Pp 1097-1103
Mothers of multiples reported substantial rates of fecal and flatus incontinence. Rates
were further increased with age. CS alone was not significantly protective alone.
Though the study did not look at separating elective Cs with Cs following labour.
Goldberg R, Kwon C, Gandhi S [2003] Prevalence of anal incontinence among
mothers of multiples. American Journal of Obstetrics and Gynaecology. 189[6]
Pp 1627-1631
Caesarean section
No difference in stress incontinence between women who had vaginal delivery versus
CS following labour and CS with no labour therefore CS was not found to be
protective.
Reilly E, Freeman R, Waterfield M [2002] Prevention of postpartum stress
incontinence in primigravidae with increased bladder neck mobility: a
randomised controlled trial of pelvic floor exercises. BJOG: An international
Journal of Obstetrics and Gynaecology. 109[1] Pp 68-76
Vaginal delivery may cause maternal bowel and urinary symptoms which may perist
5 years after delivery.
Carter J, Johanson R, Heycock E et al [2001] Long-term health after childbirth.
British Journal of Midwifery. 9[12] Pp 748-753
Caesarean section was associated with a decreased risk of urinary incontinence; there
was no association with reduced risk of fecal incontinence.
Chaliha c, Digesa A, Hutchings A et al [2004] Caesarean section is protective
against stress incontinence: analysis of women with multiple deliveries. BJOG:
An international journal of obstetrics and Gynaecology. 111[7] Pp 754-755
Severe incontinence can occur even after elective caesarean section and current
evidence does not support the use of elective CS for prevention of urinary
incontinence. Mode of delivery should be depicted by obstetrics consideration.
Lal, M [2003] Prevention of urinary and anal incontinence: role of elective
caesarean delivery. Current Opinion in Obstetrics and Gynaecology. 15[5] Pp
439-448.
Women who have experience previous anal sphincter rupture are at increases risk of
anal incontinence. CS is protective and women should be seriously counselled on this
when making a choice for type of delivery.
McKenna D, Ester J, Fischer J [2003] Elective caesarean delivery for women
with a previous anal sphincter rupture. American Journal of Obstetric and
Gynaecology. 189[5] Pp 1251-1256
Planned Cs for breech presentation at term can be protective against incontinence with
no other problems found at three months postpartum. Though longer-term effects
were not analysed.
Hannah M, Hannah W, Hodnett E et al [2002] Outcomes at three months after
planned Caesarean vs. planned vaginal delivery for breech presentation at term:
the international randomised term breech trial. Journal of the American
Medical Association. 287[14] Pp 1822- 1831
Only stress incontinence was associated with the mode of delivery. The risk was
higher in women who had CS compared to women who had not had a baby but was
even higher in women who had a vaginal delivery.
8.4% higher prevalence of incontinence among women who had had vaginal
deliveries than among those who had had cs deliveries.
Though as incontinence still occurs in the CS group it is suggested that part of the risk
factors for incontinence may be pregnancy itself and the effects of hormones.
Recommending Cs as protective may be unrealistic as it only reduces the risks for
women who deliver all their babies by CS and the reduced risk only occurs at a
younger age, no difference is found in the over 50 age group.
Rortveit G, Daltveit A, Hannestad Y et al [2003] Urinary incontinence after
vaginal delivery or caesarean section. New England Journal of Medicine. 348[10]
Pp 900- 907
Multiple pregnancy puts greater strain on the pelvic floor and CS can offer a
significant reduction in the risk of stress incontinence. This protective effect is less
profound in women with singleton pregnancy so the findings should not be
generlisable.
Goldberg R, Kwon C, Gandhi S et al [2003] Urinary incontinence among
mothers of multiples. American Journal of Obstetrics and Gynaecology. 188[6]
Pp 1447-1453
Incontinence symptoms are also seen in women who have had a Cs therefore CS is
not wholly protective against urinary stress incontinence.
Chaliha C, Khullar V, Stanton S et al [2002] Urinary symptoms in pregnancy:
are they useful for diagnosis? British Journal of Obstetrics and Gynaecology.
109[10] Pp 1181-1183
Episiotomy/ Perineal trauma
Mediolateral episiotomy is associated with weaker pelvic floor strength and increased
dyspareunia and perineal pain. It was not found to be protective against either urinary
or fecal incontinence.
Sartore A, De Seta F Maso G Et al [2004] The effects of Mediolateral episiotomy
on pelvic floor function after vaginal delivery. Obstetrics and Gynaecology.
103[4]
Pp 669- 673
Anal Sphincter damage at delivery has been linked with an increased risk of anal
incontinence.
Zetterstrom J, Lopez A, Holmstrom B et al [2003] Obstetric sphincter tears and
anal incontinence: an observational follow-up study. Acta Obstetricia et
Gynecologica Scandinavica. 82[10] Pp 921-928
Training in perineal anatomy and repair is poorly taught and there is wide variation in
classification of perineal trauma, consequently many anal sphincter tears are missed
or inappropriately managed. Anal sphincter damage is significantly linked to anal
incontinence and this risk is further increased when trauma is unrecognised or miss
managed.
Sultan A, Thaker R [2002] Lower genital tract and anal sphincter trauma. Best
practice and research clinical obstetrics and gynaecology. 16[1] Pp 99-115
Risk factors
When compared to women who had not had a vaginal delivery, CS increased the risk
of incontinence, as did instrumental and vaginal delivery. Offer risk factors also
include History of urine infections, Hysterectomy, High BMI and history of perineal
trauma.
Parazzini F, Chiaffarino F, Lavezzari M, Et al [2003] Risk factors for stress,
urge or mixed incontinence in Italy. BJOG: An International Journal of
Obstetrics and Gynaecology. 110[10] Pp 927-933
Mothers with multiple pregnancy were found to be at increased risk of fecal
incontinence, this increased risk was also associated with maternal age, CS was not
found to be significantly protective.
Goldberg R, Kwon C, Gandhi S et al [2003] Prevalence of anal incontinence
among mothers of multiples and analysis of risk factors. American Journal of
Obstetrics and Gynaecology. 189[6] Pp 1627-1631
The causes of postpartum urinary incontinence may not only be associated with pelvic
floor trauma but also a deficiency in urethral resistance caused by drugs, such as
prostaglandins.
Pregazzi R, Sartore A, Troiano L et al [2002] Postpartum urinary symptoms:
prevalence and risk factors. European Journal of Obstetrics and Gynaecology
and Reproductive Biology. 103[2] Pp 179-182
In first time mothers incontinence persisted longer following a forceps delivery than a
normal or ventous extraction.
Arya L, Jackson N, Myers D Et al [2001] Risk of new-onset urinary incontinence
after forceps and vacuum delivery in primiparous women. American Journal of
Obstetrics and Gynecology. 185[6] Pp 1318-1324