Int Urogynecol J DOI 10.1007/s00192-012-1855-3
ORIGINAL ARTICLE
Clinical impact of and contributing factors to urinary incontinence in women 5 years after first delivery Ching-Chung Liang & Ming-Ping Wu & Shu-Jen Lin & Yu-Jr Lin & Shuenn-Dhy Chang & Hui-Hsuan Wang
Received: 20 March 2012 / Accepted: 3 June 2012 # The International Urogynecological Association 2012
Abstract Introduction and hypothesis This study was conducted to investigate the prevalence of and contributing factors to urinary incontinence (UI) in women 5 years after their first birth and to evaluate the associations of UI with delivery mode and quality of life. Methods Between 2005 July and 2006 March, primiparous women who delivered at term in a tertiary hospital were recruited into this cohort study. Immediately postpartum, the women completed a structured urogynecological questionnaire C.-C. Liang : S.-D. Chang Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan C.-C. Liang : S.-D. Chang Department of Obstetrics and Gynecology, College of Medicine, Chang Gung University, Taoyuan, Taiwan M.-P. Wu Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics and Gynecology, Chi Mei Foundation Hospital, Tainan, Taiwan M.-P. Wu Department of Obstetrics and Gynecology, College of Medicine, Taipei Medical University, Taipei, Taiwan S.-J. Lin : H.-H. Wang (*) Department of Health Care Management, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Taoyuan 333, Taiwan e-mail:
[email protected] Y.-J. Lin Resource Center of Clinical Research, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
regarding lower urinary tract symptoms. Then the same urogynecological questionnaire, the Incontinence Impact Questionnaire (IIQ-7), and the Urinary Distress Inventory (UDI-6) were mailed to them 5 years later to follow up on UI. Three hundred and twelve women responding to the mailed questionnaires were included in the analyses. Results The prevalence 5 years after first delivery of stress (SUI) and urge (UUI) UI were 43.6 % and 19.2 %, respectively. Women with UI during their first pregnancy were more likely to develop UI 5 years postpartum than those without it; women who delivered their first child vaginally had a greater incidence of UI than those having cesarean birth; UUI in women following cesarean delivery more negatively impacted emotional health than it did following vaginal birth, whereas the impact of SUI did not significantly differ between delivery groups. Conclusions UI during the first pregnancy and vaginal delivery in primiparous women may predict an increased risk of having UI 5 years after delivery. UUI adversely affected women’s emotional health, especially in those undergoing cesarean section. Keywords Lower urinary tract symptoms . Postpartum . Pregnancy . Urinary incontinence
Introduction Pregnancy and birth trauma are commonly considered to be associated with the development of urinary incontinence (UI) [1–3]. The prevalence of UI in women after delivery is high but varies depending on definitions applied and study population and design. Many risk factors for postpartum UI have been widely studied [1–6]; however, most studies conducted to investigate the relationship between pregnancy/delivery and UI had follow-up periods of ≤1 year [1–4, 6]. Without long-term results, researchers are unable to determine the pathophysiology of
Int Urogynecol J
childbirth-related injuries to the pelvic floor. The prevalence of UI and other types of lower urinary tract symptoms (LUTS) increase over the course of pregnancy [7]. Some authors point out that UI during pregnancy is predictive of UI after delivery [2, 6, 8], but parity and delivery mode are also commonly reported determinants of UI [2, 3, 5, 9]. After childbirth, the reported prevalence of LUTS declines rapidly within 6 months [9–11], but only few cohort studies followed postpartum UI over the course of 4 years [11–14]. We hypothesized that both vaginal and cesarean delivery modes and UI during pregnancy are predictive of UI 5 years postpartum. In recent years, we conducted a prospective study to evaluate the relationship between various obstetric parameters and UI before and during pregnancy [7]. In the study reported here, we used the same cohort of women, all of whom filled out a structured urogynecological questionnaire regarding LUTS, which was the same as the one used in our previous report for investigating the correlation between results of the Pelvic Organ Prolapse Quantification (POP-Q) system and LUTS in 125 primiparous women from the same cohort after vaginal delivery [15]. The purposes of this study were to investigate the prevalence and contributing factors of UI in women 5 years after their first delivery and evaluate its association with delivery mode and quality of life (QoL).
Materials and methods Between July 2005 and March 2006, 1,501 consecutive primiparous women with singleton births who delivered after 36 weeks of gestation in a tertiary hospital serving a population of >5 million people were invited to participate this prospective cohort study. Exclusion criteria were: (1) severe cardiopulmonary diseases or renal diseases, (2) pre-eclampsia, (3) insulindependent diabetes mellitus, (4) neurogenic diseases, and (5) previous surgeries for POP or UI. On the second or third postpartum day, all women were questioned by a single examiner in face-to-face interviews in the obstetric wards as to whether or not they had experienced UI or other types of LUTS before and duringpregnancy. A structured urogynecological questionnaire was used to asses LUTS [15], which were defined according to recommendations of the International Continence Society [16]. The questionnaire comprised eight questions that described symptoms of nocturia, diurnal micturation frequency, urgency, stress UI (SUI), urge UI (UUI), incomplete emptying, voiding difficulty, and straining. The focus stayed on SUI and UUI symptoms. SUI was considered present if participants lost urine on coughing, sneezing, or physical exertion. Participants who reported urine leakage accompanied by urgency were considered to have UUI. In June 2010, the same urogynecological questionnaire was mailed to the patient cohort, along with the short form of the Incontinence Impact Questionnaire (IIQ-7) and the
short form of the Urinary Distress Inventory (UDI-6), inviting them to take part in the study. The IIQ-7 and UDI-6 were used to assess life impacts associated with UI in all recruited women. Scoring comprised a 4-point Likert scale: 0 for “not at all,” 1 for “slightly,” 2 for “moderately,” and 3 for “greatly.” The higher the score, the worse the symptoms, and the worse the perceived QoL. The UDI-6 indicates overall bladder symptom distress, combining information on irritating, stress, and obstructive/discomfort symptoms [17]. The IIQ-7 is divided into four domains: physical activity (items 1 and 2), travel (items 3 and 4), social activity (item 5), and emotional health (items 6 and 7). Three hundred and twelve (20.8 %) responders completed all questionnaires; 1,047 were nonresponders, and 142 letters were returned for the wrong address. Written informed consent for participation was obtained through from each responder. All nonresponders were sent the questionnaires one more time and finally contacted once by telephone. For further analyses, responders were divided into two groups: vaginal delivery, which included women who had spontaneous and instrumental vaginal deliveries; and cesarean delivery. The incidence of UI 5 years after delivery and the relationships between obstetric risk factors and QoL were analyzed. Data are summarized as means± standard deviations (SD) or percentages, as appropriate. Student’s t test was applied for analysis of continuous variables and the χ2 test for categorical data. When data were not normally distributed and numbers were small, the Mann–Whitney test was performed. Risk factors for women with UI 5 years after delivery were investigated using multivariate logistic regression. Appropriate odds ratios (OR) with 95 % confidence intervals (CI) were calculated. Probability values 40
18
13.2
1.086 (0.374–3.287)
0.965
8.1 72.8
1.0 0.984 (0.572–1.695)
0.955
19.1
1.386 (0.674–2.851)
0.375
13.2 68.4
1.0 0.903 (0.443–1.838)
0.778
25
18.4
1.667 (0.668–4.160)
0.274
Primipara Multipara (≧2)
53 83
39.0 61.0
1.0 1.392 (0.860–2.254)
0.178
Mode of delivery Cesarean Vaginal
35 101
25.7 74.3
1.0 3.214 (2.231–4.631)
< 0.001
Labor duration >400 min No 64 Yes 37
63.4 36.6
1.0 1.10 (0.56–2.14)
0.792
Birth weight > 3,500 g No 85 Yes 51
62.5 37.5
1.0 1.36 (0.64–2.92)
0.436
SUI in first pregnancy No 81
59.6
1.0
40.4
2.328 (1.371–3.950)
0.002
75.0 25.0
1.0 1.147 (0.531–2.481)
0.727
Age (years)
BMI at delivery (kg/m2) < 25 11 25–30 99 > 30
26
BMI at 5 years (kg/m2) < 25 18 25–30 93 > 30 Parity
a
Yes 55 UUI in first pregnancy No 102 Yes 34 101 vaginal deliveries
Discussion
OR odds ratio, CI confidence interval, BMI body mass index, UUI urge urinary incontinence
Our results show that some women who gave birth continued to experience UI in their daily lives throughout the 5year postpartum period. The prevalence of SUI increased from 26.7 % during pregnancy to 43.6 % 5 years after delivery, and the prevalence of UUI increased from 4.7 % during pregnancy to 19.2 % 5 years postpartum [7]. Pregnancy itself can cause mechanical or hormonal changes or both that lead to UI [18], but delivery is the main contributing factor to postpartum UI, possibly because of damage to pelvic muscles or nerves [19]. UI during pregnancy is regarded as a predictor of UI after childbirth [2, 6, 8, 20, 21] and later in life [11–13]. Our data demonstrate that
women who experience UI during their first pregnancy have a significantly higher risk of SUI and UUI 5 years postpartum than those who do not. Dolan et al. [12] observed similar results; of the women who had SUI during their first pregnancy, two thirds had SUI 15 years later. Viktrup and Lose [22] reported that the prevalence of SUI or UUI 5 years after first delivery was significantly greater in women who experienced onset during their first pregnancy than in the women who did not. In addition to UI during first pregnancy, vaginal delivery is another predictor of UI after childbirth. Foldspang et al. [23] found that UI during pregnancy and vaginal delivery is
Int Urogynecol J Table 3 Risk factors associated with urge urinary incontinence (UUI) 5 years postpartum Risk factors
Total UUI (N = 60)
OR (95% CI)
P value
N
%
5
8.3
45
75.0
0.724 (0.222–1.951)
0.563
16.7
1.186 (0.334–4.287)
0.775
13.3 71.7
1.0 1.562 (0.447–2.802)
0.195
15.0
1.119 (0.796–3.006)
0.810
16.7 73.3
1.0 0.984 (0.345–2.995)
0.970
6
10.0
1.016 (0.418–2.314)
0.977
Primipara Multipara (≧2)
22 38
36.7 63.3
1.0 1.402 (0.777–2.532)
0.262
Mode of delivery Cesarean Vaginal
23 37
38.3 61.7
1.0 1.047 (0.58–1.888)
0.880
64.9 35.1
1.0 1.2 (0.8–1.8)
0.374
Birth weight >3,500 g No 36 Yes 24
60 40
1.0 1.1(0.9–1.5)
0.438
SUI in first pregnancy No 35
58.3
1.0
41.7
1.770 (0.973–0.220)
0.061
76.7 23.3
1.0 3.997 (1.803–8.860)
0.001
Age (years) 20–29 30–39
> 40 10 BMI at delivery (kg/m2) < 25 8 25–30 43 > 30
9
BMI at 5 years (kg/m2) < 25 10 25–30 44 > 30 Parity
Labor duration >400 min No 24 Yes 13
Yes 25 UUI in first pregnancy No 46 Yes 14
1.0
b
37 vaginal deliveries OR odds ratio, CI confidence interval, BMI body mass index, SUI stress urinary incontinence
predictive of UI later in life. A systematic review showed UI after cesarean delivery has half the prevalence of UI after vaginal delivery within the first year postpartum [24]. To date, few long-term follow-up studies have reported the association between delivery mode and UI. Altman et al. [14] reported that vaginal delivery is independently associated with a significant increase in SUI symptoms 10 years after the first delivery. Viktrup et al. [13] reported that cesarean delivery for the first delivery was significantly associated with a lower risk of SUI at 12 years postpartum. Similarly, Altman et al. [25] observed that SUI was more
common following spontaneous vaginal delivery when compared with cesarean delivery 10 years after the first delivery. Two large community-based cohort studies [5, 26] assessing the relationship between delivery mode and UI demonstrated that SUI is more prevalent after vaginal compared with cesarean delivery. However, no statistical differences in delivery mode were found for UUI. In our study, women who delivered vaginally for their first delivery had a greater prevalence of postpartum SUI than those whose first delivery was by cesarean; however, the prevalence of postpartum SUI is not related to subsequent deliveries following first deliveries. In fact, the correlation between parity and SUI is not conclusive. Herrmann and Scarpa [9] reported a significant correlation between parity and SUI, observing that SUI is significantly more common after the third delivery. In contrast, several long-term cohort studies show that the number of vaginal deliveries is of limited importance for the outcome but, rather, that the first vaginal birth per se was associated with UI [5, 12, 14, 22]. Previous reports suggest that the first vaginal delivery is associated with the highest risk of loss of urethral support and subsequent UI [27]. In clinical neurophysiological studies, vaginal delivery has been shown to cause injuries to pelvic floor muscles and their innervation, which eventually leads to UI [19]. In our study, most women delivered vaginally, and none had more than three childbirths at long-term follow-up. Our data show there is no significant difference in the prevalence of UI whether subsequent deliveries are vaginal or cesarean. Approximately one third women in this study delivered their first baby via cesarean section, which was associated with a lower risk of postpartum SUI than if vaginal [13, 25]. Nevertheless, cesarean section per se may not prevent the development of SUI [5]. Rortveit et al. [5] investigated the association between childbirth and UI and found women who delivered by cesarean section had an increased risk of UI compared with nulliparous women. They further speculated that pregnancy itself may predispose women to UI because of mechanical or hormonal changes. For cesarean section performed for obstructed labor in some of our cases, pelvic floor injury may already have been extensive beyond remedy by surgical intervention for delivery [28]. Groutz et al. [28] reported that the prevalence of postpartum SUI is similar following vaginal delivery and cesarean section performed for obstructed labor, but elective cesarean section, with no trial during labor, was associated with lower prevalence of postpartum SUI. By contrast, Rortveit et al. [5] observed no significant difference in the rate of UI between women who underwent elective cesarean sections and those who received nonelective cesarean sections. Few studies have been conducted to evaluate the impact of UI on the health-related QoL of women after childbirth [8, 10, 29, 30]. Dolan et al. [10] investigated the impact of
Int Urogynecol J Table 4 Effect on quality of life of urinary incontinence 5 years postpartum assessed with the IIQ-7 according to the delivery method
Vaginal delivery
P value
Mean
SD
Mean
SD
(Total N0101) 0.83 (N032)
1.13
(Total N035) 0.78 (N010)
1.16
0.183
Travel
0.85 (N034)
1.24
0.91 (N016)
1.32
0.475
Social activity Emotional health
0.62 (N032) 0.67 (N029)
1.34 1.08
0.65 (N011) 0.71 (N014)
1.21 1.26
0.263 0.312
0.74 (N06) 0.78 (N06)
1.29 1.35
0.346 0.212
SUI Physical activity
UUI
SUI stress urinary incontinence, UUI urge urinary incontinence, SD standard deviation
Cesarean delivery
(Total N037)
(Total N023)
Physical activity Travel
0.89 (N014) 0.96 (N015)
Social activity
0.59 (N011)
1.09
0.47 (N04)
1.08
0.456
Emotional health
0.27 (N04)
0.81
0.83 (N08)
1.19
0.035
UI on QoL during and 3 months after the first pregnancy using the King’s Health Questionnaire (KHQ) and found most women with UI experienced deterioration in general and personal health after delivery. Van Brummen et al. [8] used the UDI and IIQ questionnaires to assess the effect of LUTS on the QoL between nulliparous pregnant women who gave birth vaginally or by cesarean delivery. They reported that UUI affected emotional functioning more after cesarean delivery; no difference was found for the effect of SUI on QoL between groups. Urogenital symptoms were assessed using the UDI in a prospective study investigating the severity of both SUI and overactive bladder symptoms during and after the first pregnancy [30]. Van Brummen et al. [30] reported that cesarean delivery seemed to be protective for bothersome SUI 1 year after birth, but bothersome UUI was more prevalent after cesarean than vaginal deliveries. A population-based cohort study conducted by van der Vaart et al. [29] evaluated the effect of UI on QoL in women aged 20–45 years using the UDI and IIQ questionnaires. They found that UUI was especially associated with feelings of embarrassment, whereas SUI did not significantly affect QoL [29]. As already stated, this is the first reported study to evaluate the association of postpartum UI with QoL in women more than 4 years after their first birth, although a few studies investigating the association between delivery mode and UI have longer follow-up periods [11–14]. Our results show that UUI in women following cesarean delivery more negatively impacts women’s emotional health than those who deliver vaginally. However, this result derived from a change in IIQ-7 score in four vaginal and eight cesarean deliveries, so whether it is clinically significant requires larger case series. On the other hand, the impact of SUI did not differ significantly between women who gave birth by cesarean or vaginal delivery. There were several limitations to our study: A low response rate to the mailed questionnaires could have affected
1.22 1.67
prevalence calculations for UI 5 years after delivery. One reason the response was low could be that our hospital serves a large population (> 5 million people), and it is therefore difficult to contact all 5 years after their first delivery. Low response rate is likely to result in selection bias: it may be that women with UI had more interest in answering the questionnaires than did women without. However, from our data, between responders and nonresponders, no significant differences were found in patient characteristics, indicating that the lower response rate probably did not impact the study results to a significant extent. Second, UI symptoms were not confirmed by objective measures, such as urodynamic investigations or pad tests. Third, the first questionnaire was completed face to face, whereas the 5-year questionnaire was selfadministered; thus, validity between questionnaires might not be consistent. Despite these limitations, the two strengths were that we measured the prevalence of urogenital symptoms during pregnancy and used validated, structured questionnaires to evaluate the associations of UI with delivery mode and QoL 5 years after childbirth. In conclusion, UI during the first pregnancy and subsequent vaginal delivery in primiparous women may predict an increased risk of UI 5 years after delivery. UUI adversely affected women’s emotional health especially in women undergoing cesarean section. Acknowledgments This work was supported by the Medical Research Project, Chang Gung Memorial Hospital (grant numbers CMRPG391741 and CMRPG33048). Conflicts of interest None.
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