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 2-4.
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 94-103
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