Urinary incontinence is common in pregnancy and is reported by about 60 percent of women. For these women, the severity of their condition can increase during the course of their pregnancy, especially peaking in the second and third trimesters. Of these women who experience incontinence in pregnancy, 70 percent go on to resolve the condition postpartum – and within the first year, the prevalence of incontinence drops down to 11 to 23 percent. Dr Bongi Makhubo, obstetrician gynaecologist from Life Anncron in Klerksdorp sheds more light on the topic.
Early incontinence is normal
Pregnancy can affect the normal way your urethra relaxes and contracts and many women, particularly those who had a vaginal birth, can experience incontinence after childbirth. “The pubic and pelvic muscles and the anal sphincter can be injured in up to 40-80% of births and so, leaking a little bit after birthing your baby vaginally is quite within the normal range, but it is not normal if it lasts for months afterwards,” says Dr Makhubo. “Directly after birth, using a thick maternity pad helps to absorb the leaks, but once you have stopped bleeding and incontinence persists, you might need a specialist appointment to discuss the problem further.”
Stress incontinence is also quite common in new mothers and affects roughly a third of women in the first year after birth. Stress incontinence leaks happen when the mother laughs, coughs, sneezes or goes for a run. Lifting heavy things can also cause these leaks, which are due to increased intra-abdominal pressure and a defective urethral support or closure.
<FACT BOX>What causes incontinence after birth? Dr Makhubo shares the facts:
- Weakening of the pelvic floor muscles or injury to the nerves supplying the structures of the pelvic floor, due to a prolonged or difficult labour.
- Carrying a bigger than normal baby in utero, leading to difficulty in delivering or stretching and compression of the pelvic floor.
- High levels of elastin, a hormone which allows for more stretching of the skin and connective tissue, can cause prolapse and in turn, incontinence (as opposed to collagen, which is decreased during pregnancy).
- Assisted delivery, especially with the use of forceps. Research shows that there is less injury and urinary incontinence noted with the use of ventouse in comparison.
- Maternal age; the higher the age the higher the association with urinary incontinence.
- Parity; incontinence is more common with parous women, however of note is that the highest risk of incontinence is with the first delivery, then 10% risk increase with each subsequent birth.
- Vaginal delivery definitely predisposes women to a higher risk of incontinence and most women will be incontinent for a few weeks; however most will be normal within a year.
What can help?
“Pelvic floor muscle training or kegels exercise are by far the best way to combat the problem postpartum, although the research differs as to how much of the exercises should be done. However, these can be done anywhere, and one way to remember to do them is to pick an anchor which will remind you to do them. For example, when stopping at a robot or boiling the kettle: each time you do one of these activities, do some pelvic floor exercises too,” says Dr Makhubo.
She suggests that physiotherapy can also help in some cases. “A physiotherapist will give you cones or a pessary that can be used to squeeze and strengthen the pelvic floor muscle.” Dr Makhubo also encourages lifestyle modifications, such as drinking less coffee and alcolhol and stopping smoking. Decreasing BMI can also help improve incontinence issues. “If lifestyle modifications have been made and incontinence persists, then medical treatments can be offered,” she says. “The last resort is surgery.”
Medical treatment and surgical options
- Estrogen creams, duloxetene and even botox can help to alleviate incontinence.
- Medical devices:
- A vaginal pessary, which can be used for prolapses. It is a ring-like device and acts as a support for the bladder. A disposable urethral insert may also be prescribed and serves as a leakage barrier.
- Bulking agents:
- Bulking agents are injected into the urethra to help plump up the tissues where urine is released from the bladder and help to hold it in.
- Surgery: The underlying principle of surgery is to support the urethra, so that the bladder can work effectively.
- “Retropubic urethropexy ( Burch’s Colposuspension ) is used most common surgery for this condition. It is an abdominal procedure, where the pubocervical fascia is attached to a copper ligament or to the pubic symphysis (pelvic bone),” explains Dr Makhubo. “This helps lift the anterior vaginal wall and tissues surrounding the urethra and bladder, which helps to alleviate incontinence.
- Slings: There are various kinds of slings and they are all made of mesh. The use of mesh has been approved by the FDA and the South African Urogynaecology Society endorses and supports the use of this method for incontinence. A ‘hammock’ is created using mesh and tissue to support your urethra and can be done under local anaethesia.
- Pubovaginal slings, mid-urethral slings, mini-slings and micro-slings are used as a means to help incontinence, but implanting mesh where it is needed, in and around the urethra. These range from being quite invasive to non-invasive. Your care provider will help you decide on the best approach for you.