Introduction

Incontinence in pregnancy is not highlighted as a problem, as it is overlooked by other pressing problems and their events. There are a lot of physiological changes that happen during pregnancy, in the lower genital tract, that increases the risk of incontinence. There is a 50% hike in the glomerular filtration rate in the kidney with increase in the urine output to 90-100 ml per hour. The renal calyces also dilate predominantly on the right side. Renal blood flow increases by 30% with the pressure from the gravid uterus decreasing the functional capacity of the kidney.

Discussion

One of the main causes for the incontinence is the pudendal damage secondary to childbirth. There can also be incontinence in pregnancy due various other reasons. In the Nun study, 50% of the sample surveyed complained of incontinence, of which 30% had SI, 24% had UI, and 35% had mixed symptoms. So it’s thought that neuromuscular damage and collagen deficiency are the main contributors to the increased incidence of urinary incontinence in these women. Apart from the intrinsic damage in pregnant women, there is pregnancy related trauma that aggravates the risk. Progesterone is found to increase the detrusor over-activity and this is the cause of increased incontinence in women during their luteal phase, pregnancy, and those who are on the oral contraceptive pill. In a prospective study, 32% of 305 primiparas developed stress incontinence during pregnancy and 7% after delivery. One year after delivery, only 3% reported SI. However 5 years later, 19% of these women, with no symptoms after the first delivery, developed SI later. So it is crucial to identify these high risk women in their antenatal period and offer them support and guidance.

The key issues in identifying women at risk of developing incontinence are Obesity, Multiparty, Vaginal delivery, regional anesthesia, women with excessive bladder neck mobility, prolonged second stage, big baby, episiotomy and other tears and women who have instrumental delivery. In addition there is evidence of other risk factors, such as preconceptional incontinence and antenatal bladder neck mobility, which indicates possibility of pelvic floor weakness in the development of incontinence. This should alert us to foresee the problems that may arise in them.

Studies have confirmed that forceps delivery doubles the incidence of incontinence. Forceps and ventouse deliveries have been associated with bladder and bowel complication rates of up to 50% at 5 years and pose a particular risk of injury to the anal sphincter mechanism in primiparous vaginal delivery. Caesarean section does prevent the risk of incontinence but less so than at three months post partum, with a relatively greater effect with increasing parity. Elective caesarean section has become safe for the mother and the baby, those performed at second stage of labor has considerable morbidity. At term, 4% of women with otherwise uncomplicated pregnancies require instrumental or caesarean section in the second stage of labor. Randomized control trials has confirmed, routine episiotomy, which was once recommended, is out of fashion in preventing incontinence reflecting poor sexual function in patients, with little help in protecting the pelvic floor strength. Breast-feeding is found to increase the risk though transiently due to varieties of hormonal changes. Smoking is also found to increase the risk primarily due to associated chronic bronchitis and recurrent coughing with poor tissue healing. Obesity is a major risk factor as it is hypothesized that excessive weight places extra pressure on the pelvic floor impending the outlet. Antenatal incontinence is a significant indicator of postpartum and future incontinence. So identifying women at risk will help in counseling and providing them with preventive strategies.

Incontinence usually occurs within the initial 3-6 months after delivery, though in some cases it may occur even later. Identifying these high-risk women is crucially important as they can be focused and treated at an early stage. Those who have longer duration of symptoms in the post partum period are at risk of developing long-term symptoms later in life. Identifying and counseling these women will make them to be aware of the anticipated problems and to get early help. Referral to a physiotherapist with an early start of pelvic floor exercises will prevent any need for surgery in these women.

Pelvic floor exercises have good outcomes and are found to be successful in 56 – 75% of cases. It increases the muscle strength and hypertrophy thereby improving urethral compression and support. It is recommended as the first line treatment for stress incontinence. It is ideally recommended for women with mild to moderate incontinence, for those where surgery is inappropriate and for those women wishing future pregnancy. The main factor associated with success seems to be the compliance and motivation rather than age and severity of disease. Other factors associated with compliance depend on the perception of their ability to contract pelvic floor, severity of incontinence and life style changes. It crucially depends on the therapist – patient relationship and possibility to use other methods.

Conclusions

Having known that incontinence is a chronic health problem that reduces the quality of life and has a lot of implications on the social, domestic, physical and leisure activities, it is vitally important to identify the problems in the antenatal groups and encourage them to rectify the problem thereby preventing future disease. It is the responsibility of the patient’s family physician and obstetrician, liaising with the physiotherapist, in identifying the risk as part of the antenatal care and impose least damage in labor to allow the pelvic floor recover to it’s best.

References

1. Kegel AH Progressive resistance exercise in the functional restoration of the Perineal muscles. AM J Obstet Gyn 1948;56: 238-248.

2. Shing-Kia Determining the reliability of Ultrasound measurements and the validity of the formula for ultrasound estimation of post void residual volume in post partum women. Neurology and Urodynamics 22:255-260(2003).

3. IngridE Stress Incontinence. Clinical Gynecological series Experts view. Vol 104 no3 Sept 2004.

4. Erica Symptoms of SI 1 year after child birth: Prevalence and predictors in a national Swedish sample Acta Obs Gynae Scand 2004;83:928-936

Obtained from: http://www.ispub.com/ostia/index.php?xmlFilePath=journals/iju/vol3n2/pregnancy.xml

From UroToday

by G. Alessandro Digesu, MD

From KSFY.com

By Nancy Naeve Brown

Story Created: Sep 2, 2009 at 3:56 PM CDT

Story Updated: Sep 3, 2009 at 9:13 AM CDT

Urinary incontinence is a problem for half the women in this country.  It’s a problem you don’t have to suffer with. There are trained specialists in this field at Avera McKennan who can not only treat you, but cure you.

For a lot of women, sneezing, coughing, laughing and exercising can also mean a little leaking.

Avera Urogynecologist Dr. Matthew Barker says that falls into the “stress urinary incontinence” category. It happens most often in women younger than 60 years old. Urge incontinence is different, as is the therapy to treat it, and as we age, the chances of suffering from it also increase.

Dr. Matthew Barker with Avera Urogynecology Specialists says, “Urge incontinence is the involuntary leaking of urine because the bladder contracts at an abnormal time. Women describe it as not being able to make it to the toilet as they are opening the door or on a long car ride. Their bladder gets full causing it to contract.”

Treatment varies for each patient, but Dr. Barker says it can include, medication, surgery, bladder retraining and/or physical therapy.

Staci Wietfeld is a physical therapist at Avera McKennan Rehabilitation Services. She says, “A lot of men and women who have leakage can have it do to weakness in the pelvic floor muscles. So we work to strengthen those weak muscles just like any other part of the body that’s weak.”

We also may make modifications to their diet and/or their fluid intake. We may also help by using different modalities, like electrical stimulation, to jump start the pelvic floor muscles.”

Dr. Barker says, “It’s interesting how prevalent urinary incontinence is, yet how infrequent women will seek out care for this. People think it’s something you live with. The sanitary pads business is a $6 billion industry in itself just for urinary incontinence. It’s important for women to understand there are people with special training who can improve their quality of life.”

While incontinence is common, it is not normal. See a specialist and get back to living life without leakage.

Found at: WebMD

Workouts and romance may both trigger ‘accidents,’ but stress incontinence treatments can bring relief.

By Kathleen Doheny
WebMD Feature

Reviewed by Brunilda Nazario, MD

Stress incontinence has an annoying way of showing up at the most inopportune times.

You’re jogging along, feeling great — and then you realize your running shorts are damp with urine. Later that night, during a romantic rendezvous with your partner, a trickle of urine appears again, definitely spoiling the moment.

Lest you think stress urinary incontinence is a problem only of middle-aged or elderly women, think again. Surprisingly, young women actually have more stress incontinence during sex than older women, according to Amy Rosenman, MD, a gynecologist at Santa Monica — UCLA Medical Center, Santa Monica, Calif., and co-author of The Incontinence Solution.

When incontinence occurs during intimate moments, women feel anxious, Rosenman says, even if they are in stable marriages. This could even lead to sexual dysfunction.

The same anxiety can occur during a workout, where you may end up with an embarrassing wet spot on your pants for the world to see.

Stress Incontinence Due to Weak Pelvic Floor Muscles

The problem, whether the stress incontinence occurs during exercise or sex, has a common denominator, says Beverly Whipple, PhD, RN, professor emerita at Rutgers, The State University of New Jersey, and a sexuality researcher.

“Stress incontinence is related to the strength of the pelvic floor muscles,” Whipple says. The weaker those muscles are, the more likely you are to have symptoms of stress incontinence — leaking urine during physical activity, such as exercise, sex, sneezing, laughing or jumping–in the absence of bladder contraction.

While many women experience minor leakage from time to time, at any age, if it becomes more frequent or interferes with your normal routine, you should tell your doctor. There is an array of very effective treatments for stress incontinence. Stress urinary incontinence is the most common cause of urinary incontinence in younger women and the second most common cause in older women.

If you have had several pregnancies and childbirths, your pelvic muscles and tissues may have gotten stretched and damaged. With age, the muscles can weaken, too, although stress incontinence is not an inevitable part of aging. Excess weight can also weaken pelvic floor muscles and cause stress incontinence.

Kegels Can Help Stress Incontinence

Strengthening the muscles of the pelvic floor is crucial, experts agree.

One recommended way to do that is through Kegel exercises, according to the American Academy of Family Physicians (AAFP).

First, some anatomy: at the bottom of the pelvis, many muscle layers stretch between your legs, attaching to the pelvic bones at the front, back and sides. If you think of the muscles you would use to stop the flow of urine, those are the ones you will be targeting when doing your Kegels.

The how-to’s: Pull in or squeeze the muscles, pretending you are trying to stop urine flow. You should hold that squeeze for about 10 seconds. Follow that by a 10-second rest. How many? Try three to four sets of 10 squeezes a day, recommends the AAFP.

The beauty of Kegels, most experts find, is that they can be done anytime and just about anywhere — sitting in your car or at your desk or watching television or while talking on the phone. No one will know what you are doing unless you tell them. But to ensure proper form, ask your doctor or nurse to describe to you exactly how to do them correctly.

If you do Kegels correctly and often, you can expect to leak less, Rosenman says.

Typically, bladder control improves after 6 to 12 weeks of daily Kegels, according to the AAFP. But you may notice improvement in stress incontinence after just a few weeks.

Kegels and Vaginal Weights for Stress Incontinence

Another way to prevent stress incontinence is to use vaginal weights. Vaginal weights can help you to isolate the pelvic floor muscles while doing your Kegel exercises. They come in various sizes and are inserted into the vagina using a cone. As you progress, you insert heavier weights.

Vaginal weight kits are sold online and over the counter.

Biofeedback for Stress Incontinence

Biofeedback, as the name implies, uses monitors and “feeds back” information to patients about body processes, including control of the pelvic floor muscles.

In one study of 14 women with stress incontinence, a 12-week program of pelvic floor training with biofeedback gave favorable results, according to a report published in the International Brazilian Journal of Urology. The number of leakage episodes decreased from about eight a day to 2.5 among study participants, the researchers report.

Self-Help Products for Stress Incontinence

If your stress incontinence is not severe, you may get by with urinary incontinence products such as pads and panty liners. You might want to consider rubberized bed sheets.

Another stress incontinence treatment option is a device called a pessary, which is inserted into the vagina to help elevate the bladder neck and keep urine from leaking.

Medications, Surgery for Stress Incontinence

If your stress incontinence becomes more severe or if it interferes with your lifestyle and kegel exercises and other self-help measures fail, your doctor may suggest medications or surgery.

Medications can help tighten muscles at the bladder neck and urethra, preventing urine from leaking and relieving stress incontinence.

In one operation for stress incontinence, surgical threads are used to help support the bladder neck. In another procedure, called a “sling” operation, the surgeon uses strips of material, either natural or synthetic tissue, to support the bladder neck. Bulking material such as collagen is sometimes used around the bladder opening for women with stress incontinence

Talking to Your Doctor About Stress Incontinence

Your doctor should routinely ask you about your bladder function to determine if you are having stress incontinence or urge incontinence (also called overactive bladder), Rosenman says.

If your doctor does not ask, Rosenman advocates the straightforward approach. Try something like: “I’m having some problems with my bladder.” At that point, if your doctor does not pepper you with questions about how often you experience symptoms, and how long it has been going on, Rosenman suggests asking for a referral to another doctor or to a specialist, such as a urogynecologist. A urogynecologist is a gynecologist who has extra training in urology.

Talking to your partner about stress incontinence is not simple, either, Rosenman acknowledges. But she tells women it may be the most important thing they can do to help their relationship. Communicating well about the problem, she writes in her book, will lead to greater affection and trust. And getting the problem out in the open is often a relief, she says.

In addition to good communication and effective treatments, Rosenman says some simple measures can help women with stress incontinence enjoy a better sex life. Among other tips, she tells them to always empty the bladder before intercourse and to cut back a bit on fluids before intercourse. Don’t dehydrate yourself, but don’t overdo the fluids, she says. And she encourages experimentation to find positions that are more comfortable, reducing overall anxiety.

In getting more comfortable with talking about stress incontinence, you might also take a cue from two famous Olympic athletes from the U.S. — speed skater Bonnie Blair and gymnast Mary Lou Retton. In recent years, both have spoken publicly about their experiences with incontinence, raising awareness that the problem exists and, more importantly, that treatments can improve or eliminate the problem.

Found at the Minot Daily News

The Souris Valley Care Center in Velva and the Good Samaritan Nursing Home in Mohall have begun a new physical therapy program to treat urinary incontinence and other related problems.

The program focuses on simple exercises individuals can do to help with urinary incontinence without the use of surgery or drugs. Physical therapists from Souris Valley Care Center, Krista Becker and Teressa Brock, have completed several courses of specialized training for the program.

“We have established the main exercises (to help with urinary incontinence) into our exercise program. There’s also a tremendous amount of information we can give someone, so they can make educated choices,” Brock said.

Incontinence, Becker said, is the second most prevalent reason individuals enter a nursing home, next to dementia. Preventing and easing the incontinence problem can help individuals stay at home longer.

The program isn’t focused solely on the elderly, either, but on men, women, and children of all ages who suffer with the problem.

“It can happen to anyone. It can happen in children, athletes, and women who are pregnant, postpartum, premenopausal, or menopausal,” Becker said.

“It happens in people who exercise a lot. There are even aerobics instructors, people who do a lot of jumping, who have to wear a pad when they teach. You always picture an older person, and it’s not,” Brock said.

The program can also help those who have pelvic pain, prolapses, or pelvic surgeries as well as those who have Parkinson’s, Multiple Sclerosis, or other peripheral neuropathies, cancer patients, children over age 6 with bowel and bladder problems, and chronic constipation sufferers.

Individuals will learn the exercises through a series of one to four physical therapy sessions, and will continue to practice the exercises at home. The exercises work to strengthen the pelvic floor muscles, called the pelvic rotator cuff. Brock said individuals are usually eager to continue practicing the exercises.

“People are usually very motivated. They’re willing to stand on their head if they think it would help. After they come in, they’re so glad they did,” Brock said.

In addition to the exercises, Brock and Becker offer information on lifestyle changes such as dietary changes that will help with preventing incontinence.

“We educate them about bladder irritants, such as caffeine, carbonated beverages, citric foods, acidic foods like spaghetti sauce, spicy foods, and chocolate,” Becker said.

“Sometimes, people will find there are one or two things they are sensitive to, so they might want to eat those foods more sparingly,” Brock said.

Along with the program, Becker and Brock will offer community presentations on preventing urinary incontinence. They have already presented at several assisted living facilities in Minot, and hope to continue presenting in other areas in northwest North Dakota. They are in the process of securing grant money for community presentations.

“We have specific programs, and a general program for going into group meetings called “Bones, Bottoms, and Balance.” It’s a little less stressful than saying, ‘We’re going to talk about incontinence prevention.’ They’re interested, and it’s a way to talk to them about it without scaring them and making them too embarrassed,” Brock said.

Found at Doctor’s Guide Channels

By Laura Gater

CHICAGO — September 5, 2008 – Initiation of weight loss should be considered a first-line approach to the treatment of overweight and/or obese women with urinary incontinence (UI), researchers reported at the American Urogynecologic Society 19th Annual Scientific Meeting (AUGS).

Overweight is a strong risk factor for UI, and weight loss results in improved continence, said study presenter Rena Wing, MD, The Miriam Hospital, Providence, Rhode Island, in a presentation on September 4.

The Program to Reduce Incontinence by Diet and Exercise (PRIDE) is a multicentre, randomised clinical trial including 338 overweight and obese women (BMI 25-30 kg/m²) experiencing up to 10 episodes of UI per week. The cohort had a mean age of 53 years and mean weight of 97 kg.

According to patients’ reports on 7-day voiding diaries, 22% of the women experienced stress incontinence, 43% had urge incontinence, and 35% experienced mixed UI.

Although the main objective was to determine the effect of weight loss on UI among obese and overweight women at 18 months, the study’s secondary objective was to evaluate the association between the magnitude of weight loss and frequency of incontinence episodes.

The women were randomised to either an intensive 6-month weight loss program that included diet, exercise, and behavioural modification followed by a 12-month weight maintenance program or to a structured education program.

Overall, 86% of the women completed the 18-month trial. The mean weight loss at 18 months in the intervention and control groups was 6.5 kg and 1.7 kg, respectively.

Although there were large within-group differences in weight loss and UI improvement, differences at 18 months between the intervention and control groups were not significant in decreased total incontinence (61% vs 55%), stress incontinence (70% vs 64%), or urge incontinence (55% vs 50%).

However, when the researchers combined the 2 treatment groups, there was a strong dose-response relationship between magnitude of weight loss and UI improvement. The decreases in UI frequency by type were significant at 6 months (P = .02), at 12 months (P < .01), and at 18 months (P = .40).

The cohort analysis concluded that greater weight loss was associated with a greater decrease in UI frequency. There was no difference between the groups in the use of the UI behavioural techniques in the UI behavioural training booklet.

A modest weight loss of just 5% can have a marked impact on UI, and participation in a behavioural weight loss program was an effective short- and long-term treatment for UI in overweight and obese women, concluded Dr. Wing.

[Presentation title: Weight Loss Improves Urinary Incontinence in Overweight & Obese Women Through 18 Months. Paper 16]

Found at the health experiment.

NEW YORK (Reuters Health) – In pregnant women, pelvic floor muscle training for bladder-control problems, though beneficial initially, is ineffective over the long term, research shows.

Stress-related urinary incontinence “is a risk factor for long-term leaage but not necessarily enough to require surgery,” Dr. Robert M. Freeman from Derriford Hospital, Plymouth, UK told Reuters Health. Performing exercises before delivery designed to strengthen the pelvic floor muscles “does not seem to give good long-term results, and this is probably due to poor compliance,” Freeman noted.

The findings are based on 230 women who participated in two studies of the effectiveness of pelvic floor muscle training for preventing stress urinary incontinence after pregnancy.

At 3 months after pregnancy, significantly fewer women who perform

ed pelvic floor muscle exercises reported post-delivery urinary incontinence, compared with women who did not perform these exercises (19 percent versus 33 percent).

Eight years later, however, urinary incontinence was reported by a similar percentage of women in the pelvic floor muscle training group and the control group (35 percent and 39 percent, respectively).

More than two-thirds of the women in the training group reported that they still performed pelvic floor muscle training at 8 years, and more than a third said they were performing the exercises at least twice a week.

Despite these reports, the investigators say, incontinence rates did not differ between those performing pelvic floor exercises at least twice weekly and those performing the exercises less frequently.

“We are concerned that a lot of the evidence for both (before delivery

and after delivery) pelvic floor muscle training suggests poor long-term effect,” Freeman said. “We believe that compliance is the major issue, and this can only be improved by education.”

SOURCE: BJOG: An International Journal of Obstetrics and Gynaecology, July 2008.

Found at Secret Womens Business

Sometimes we women put up with a lot of unnecessary discomfort because we are too embarrassed to talk about it or we think nothing can be done about it. One of the most common things that women tend to put up with is incontinence. A little incontinence for a short time after the birth of your baby is normal and common but if the problem does not go away then you need to speak to your doctor.

A study of 4,000 women by Kaiser Permanent which was funded by the National Institute of Health revealed that 1 in 3 women have problems with incontinence. Other research shows that 11% of women end up having surgery for a pelvic floor disorder. It is important to consult your doctor as the problem may be able to be rectified without surgery.

There may be medication that you can take and I am sure your doctor will advise you about the correct way to do pelvic floor exercises and hopefully the need for surgery will never arise. If you are one of the 11% who needs surgery there have been advances in this procedure which makes it much less invasive and can be done with laporoscopic surgery.

Incontinence is an embarrassing discomfort and is not something you should just ‘put up with’, so visit your doctor and start getting advice and treatment now. Remember, like everything else, early treatment is always the wisest option.

This is an excerpt from an article found here at WebMD.

When Pee Ruins Your Socks and Your Shoes

It’s not just rumor, it’s really true. Pregnancy and incontinence go hand in hand.

“I can remember during my first pregnancy I went for a walk, something made me sneeze — and I felt this gush of urine. I tried to get home as quickly as I could, but another sneeze brought a second gush and, well, it wasn’t long before I felt the warm trickle of pee down my leg, heading straight into my socks and shoes. I felt like I was 7 years old again,” says Quarty.

The problem, says Macaulay, is your growing uterus pressing on your bladder, making it hard to hold even a small amount of fluid.  While drinking less during the day can help if you’re out and about, Macaulay says that also means having to drink more fluids in the evening — which not only means up-all-night trips to the bathroom, but also the possibility of wetting the bed.

A better solution: Get going on those Kegel exercises — muscle-toning movements that help increase urinary control. “Don’t wait until after pregnancy — do them now,” says Macaulay. In the meantime, try wearing a sanitary napkin or incontinence pad for the times when sneezing takes you by surprise.

Found at: The Beacon News

Urinary incontinence affects millions of Americans. Unfortunately, many people do not seek help or treatment and live with this often embarrassing condition.

Because of differences in the pelvic region and childbirth, women are more likely than men to have issues with urinary incontinence. However, men can suffer from urinary incontinence. Three types of urinary incontinence are stress, urge and overflow incontinence.

Stress incontinence is urine leakage that happens during activity that causes pressure on the bladder such as laughing, lifting, coughing or sneezing. Stress incontinence is often seen in women who have had multiple pregnancies and vaginal childbirths, or who have pelvic organ prolapse. Urge incontinence or overactive bladder, is urine leakage that is an involuntary loss of urine following an urge to urinate that cannot be halted. Overflow incontinence occurs when the bladder does not empty properly and is characterized by the constant dribbling of urine and small frequent voids.

To help you determine if you have a bladder control problem ask yourself the following questions:

• Do you frequently have a strong, sudden urge to urinate?

• Do you sometimes not make it to the bathroom in time?

• Do you go to the bathroom more than eight times in 24 hours?

• Do you get up two or more times through the night to urinate?

• Do you experience a loss of urine during physical exertion?

• Do you experience a loss of urine when you sneeze or laugh?

If you answered “yes” to any of the above questions, you may have a treatable condition.

Treatment of urinary incontinence includes both non-surgical and surgical options. Most bladder control problems can be successfully treated without surgery. Some things that people can do to include:

Keep a bladder diary — Bladder diaries help show the causes of bladder control trouble by tracking when and what triggers your bladder weakness.

Modify your diet — Identify fluid and food issues that can alter your bladder function. For example, reducing caffeine or quitting smoking can help reduce how often you have incontinence problems.

Try pelvic floor exercises — Strengthening muscles that help hold the organs in place may help reduce stress and urge incontinence.

Biofeedback — Massage, exercise, water therapy and ultrasound help identify and correct musculoskeletal problems that contribute to pelvic pain or incontinence.

There are numerous medications, non-surgical and minimally invasive techniques available to help reduce incontinence. To help diagnose and treat your incontinence issue, consult a physician for a complete evaluation.

Dr. Brett J. Vassallo is a urogynecologist with Rush-Copley Comprehensive Pelvic Medicine and Continence Center in Aurora.