Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery

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1 WOMEN'S HEALTH WOMEN'S HEALTH Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery Sandra A. Baydock, MD, 1 Catherine Flood, MD, 1 Jane A. Schulz, MD, 1 Dianna MacDonald, PT, 1 Deborah Esau, BScPT, 1 Sandra Jones, BPT, 1 Craig B. Hiltz, MSc² 1 Department of Obstetrics and Gynecology, University of Alberta, Edmonton AB 2 Consultant Statistician, Department of Obstetrics and Gynecology, University of Alberta, Edmonton AB Abstract Objective: To determine the prevalence of and risk factors for urinary and fecal incontinence four months after vaginal delivery. Methods: All patients who had vaginal deliveries at a tertiary care hospital over a three-month period were approached during their postpartum hospital stay regarding participation in the study. Participants underwent a telephone interview at four months after their delivery to determine the presence and type of any incontinence. Results: Of 632 patients, 145 (23%) had stress incontinence, 77 (12%) had urge incontinence, 181 (29%) had any urinary incontinence and 23 (4%) had fecal incontinence. In univariate analysis, stress incontinence was found to be increased in patients of age (26.2%) compared with patients < 30 years of age (19.3%) (RR 1.4; 95% CI , P = 0.05). Urge incontinence was increased in patients who had a forceps delivery (21%) compared with no forceps delivery (9%) (RR 2.2; 95% CI , P = 0.005), an episiotomy (32.4%) compared with no episiotomy (18.7%) (RR 1.9; 95% CI , P < 0.01) and a longer second stage of labour (108 min vs. 77 min, P = 0.01). The prevalence of any urinary incontinence was increased with forceps delivery (15.5%) compared with no forceps delivery (8.7%) (RR 1.5; 95% CI , P = 0.01) and maternal age of (34.1%) compared to < 30 years (23.5%) (RR 1.5; 95% CI , P = 0.003). In multivariate analysis, the two variables that remained significant for any urinary incontinence were maternal age (P < 0.01) and forceps delivery (P < 0.01). There were no identified risk factors for fecal incontinence. Conclusion: Urinary incontinence is common in women at four months post partum. Fecal incontinence is less common. Maternal age and forceps assisted delivery were risk factors for urinary incontinence. Key Words: Stress urinary incontinence, urge urinary incontinence, fecal incontinence, vaginal delivery Competing Interests: ne declared. Received on March 13, 2008 Accepted on April 16, 2008 Résumé Objectif : Déterminer la prévalence et les facteurs de risque de l incontinence urinaire et fécale, quatre mois à la suite d un accouchement vaginal. Méthodes : Sur une période de trois mois, au sein d un hôpital de soins tertiaires, nous avons sollicité la participation de toutes les patientes y ayant connu un accouchement vaginal et s y trouvant dans le cadre de leur hospitalisation postpartum. Les participantes se sont soumises à une entrevue téléphonique, quatre mois à la suite de l accouchement, en vue de déterminer la présence et le type de toute incontinence, le cas échéant. Résultats : Sur les 632 patientes, 145 (23 %) connaissaient une incontinence à l effort, 77 (12 %) connaissaient une incontinence par impériosité, 181 (29 %) connaissaient une incontinence urinaire (quel qu en soit le type) et 23 (4 %) connaissaient une incontinence fécale. Dans le cadre de l analyse univariée, il a été constaté que l incontinence à l effort connaissait une hausse chez les patientes de 30 ans (26,2 %), par comparaison avec les patientes de < 30 ans (19,3 %) (RR, 1,4; IC à 95 %, 1,0 1,8, P = 0,05). L incontinence par impériosité connaissait une hausse chez les patientes qui avaient subi un accouchement par forceps (21 %), par comparaison avec celles qui n avaient pas subi un tel accouchement (9 %) (RR, 2,2; IC à 95 %, 1,4 3,6, P = 0,005); une épisiotomie (32,4 %), par comparaison avec celles qui n en avaient pas subi une (18,7 %) (RR, 1,9; IC à 95 %, 1,2 2,9, P < 0,01); et un deuxième stade du travail prolongé (108 min, par comparaison avec 77 min, P = 0,01). La prévalence de l incontinence urinaire (quel qu en soit le type) connaissait une hausse en présence d un accouchement par forceps (15,5 %), par comparaison avec l absence d une telle intervention (8,7 %) (RR, 1,5; IC à 95 %, 1,1 2,1, P = 0,01), et en présence d un âge maternel de 30 ans (34,1 %), par comparaison avec un âge maternel de < 30 ans (23,5 %) (RR, 1,5; IC à 95 %, 1,1 1,9, P = 0,003). Dans le cadre de l analyse multivariée, l âge maternel de 30 ans (P < 0,01) et l accouchement par forceps (P < 0,01) constituaient les deux variables qui demeuraient significatives peu importe le type d incontinence urinaire. Aucun facteur de risque d incontinence fécale n a été identifié. Conclusion : L incontinence urinaire est courante chez les femmes dont l accouchement remonte à quatre mois. L incontinence fécale est moins courante. L âge maternel et l accouchement par forceps étaient des facteurs de risque en ce qui concerne l incontinence urinaire. J Obstet Gynaecol Can 2009;31(1): JANUARY JOGC JANVIER 2009

2 Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery INTRODUCTION Vaginal delivery is an established risk factor for urinary and fecal incontinence, 1 5 while delivery by Caesarean section appears to be protective. 1 3,6-8 Urinary and fecal incontinence reduce quality of life and may lead to increased health care costs and medical interventions. 9 The prevalence of urinary incontinence in the postpartum period ranges from 0.3% to 38%. 1 3,10 This range is derived from studies with differing definitions of urinary incontinence and variable follow-up periods. In addition, many studies have focused primarily on the development of stress or any urinary incontinence, while only a few studies examined the prevalence of postpartum urge incontinence. 1,2,11 Risk factors for incontinence after vaginal delivery, including parity, age, birth weight, forceps-assisted delivery, and maternal age, have been found in some studies but not in others. 1,2,12 15 Risk factors for postpartum urge incontinence have been poorly evaluated. 12 The prevalence of postpartum fecal incontinence has been more consistently reported to range between 4% and 5.5% after vaginal delivery. 4,16,17 While anal sphincter disruption appears to be an established risk factor for fecal incontinence, other factors such as episiotomy and instrumental delivery are more controversial. 4,17 The primary aim of this study was to determine the prevalence of stress, urge, and mixed urinary incontinence, as well as fecal incontinence, at four months after vaginal delivery. We also identified demographic or obstetrical risk factors for these conditions. The effect of delivery by Caesarean section was not reviewed in this study. MATERIALS AND METHODS This was a prospective, cohort study undertaken at a tertiary care obstetrical hospital in Edmonton, Alberta. All patients who underwent a spontaneous or operative vaginal delivery at the Royal Alexandra Hospital between January 1, 1999, and March 31, 1999, were approached during their postpartum admission for recruitment into the study. Inclusion criteria included having a singleton vaginal delivery, proficiency in English, and a permanent residence with a telephone. Patients were excluded if they had prepregnancy urinary or fecal incontinence, drug or alcohol abuse (which might affect a subject s ability to complete the questionnaire and the follow-up survey), or incontinence due to a medical, cognitive, or mobility impairment. Relevant demographic and obstetrical data were collected from prenatal records and hospital charts. At four months post partum, a telephone interview was conducted to determine the presence and type of incontinence. Maternal demographic, clinical, and obstetrical factors identified as independent variables were maternal age, birth weight, parity, weight gain during pregnancy (BMI was not consistently available), length of second stage of labour, postpartum urinary tract infection, mode of delivery, degree of obstetrical tear, breech delivery, epidural use, and episiotomy. Neonatal risk factors were limited to birth weight. The telephone interview consisted of a 19-item questionnaire designed to determine the presence, frequency, and severity of stress and urge urinary incontinence, or fecal incontinence. These were standardized questionnaires used by the tertiary care urogynaecology unit at the time of the study; validated tools for assessment of pelvic floor symptoms were not widely used or available. The timing of follow-up at four months post partum was selected to allow the urinary tract to return to pre-pregnancy structure and function; most women have return of normal function within two to three months of delivery Incontinence of urine was defined as urinary leakage at least once in a two week interval. Questions related to stress incontinence described urinary leaking with activities such as coughing, laughing, sneezing, bending, lifting, bouncing, or exercising. Urge incontinence was defined as urinary leaking associated with a strong desire to urinate. Fecal incontinence was defined as leakage of liquid or solid stool at least once every two weeks. Patients were also questioned regarding urinary frequency, pad use, nocturia, prepregnancy and antepartum incontinence (part of the screening questions), weight gain during pregnancy, and postpartum urinary tract infections. A pilot test of the questionnaire was conducted with 30 postpartum subjects to ensure the questions were specific and easy to understand. Categorical variables including age (arbitrarily divided into < 30 years or ), mode of delivery, episiotomy, use of epidural analgesia, and postpartum urinary tract infection were assessed using chi square or Fisher exact tests. Ratio variables including parity, weight gain during pregnancy, and birth weight were assessed by a Student t test. The rank variable of obstetrical tear was assessed using a Mann- Whitney U test. Logistic regression was used to examine factors affecting the presence of urinary incontinence and included all factors with a P value 0.10 on univariate analysis. All statistical analyses were performed using SPSS for Windows version 11.5 (SPSS Inc., Chicago IL). Ethics approval for the study was obtained from the University of Alberta Health Research Ethics Board. RESULTS A total of 717 patients were recruited into the study. Eighty-four patients were excluded because of pre-existing JANUARY JOGC JANVIER

3 WOMEN'S HEALTH Table 1. Characteristics Characteristic n (range) Mean maternal age 29 (17 43) Median parity 1 (0 8) Mean birth weight, grams 3302 ( ) Mean weight gain in pregnancy, pounds 31.5 (19 80) Mean length 2nd stage, minutes 80.5 (0 651) Postpartum UTI n (%) 600 (94.9) 32 (5.1) Forceps delivery n (%) ne Low/outlet Mid Rotation Breech data 564 (89.2) 18 (2.8) 42 (6.6) 2 (0.4) 5 (0.8) 1 (0.2) Vacuum delivery n (%) ne Low Mid 536 (84.8) 66 (10.4) 30 (4.8) Degree obstetrical tear n (%) data 225 (35.6) 113 (17.8) 218 (34.4) 66 (10.5) 9 (1.5) 1 (0.2) Epidural use n (%) 335 (53.0) 297 (47.0) Episiotomy n (%) ne Midline Mediolateral 503 (79.6) 88 (13.9) 41 (6.5) incontinence and one because of active perianal Crohn s disease. The final analysis included data from 632 patients. Baseline and delivery characteristics of study participants are shown in Table 1. The demographic variables of the study group included a mean maternal age of 29 years (range 17 43), a median parity of 1 (range 0 8), a mean birth weight of 3316 g (range g), and a mean maternal weight gain of 14.0 kg (range 8.5 to 35.7 kg). Peripartum variables included a mean duration of second stage of labour of 81 minutes (range 0 651), and mode of delivery included spontaneous vaginal delivery (536, 84.8%), forceps-assisted delivery (68, 10.8%), vacuumassisted delivery (96, 15.2% ). Some patients underwent a delivery that was both vacuum-assisted and forcepsassisted, and were included in both groups because of the small numbers. A total of 143 patients complained of stress urinary incontinence (23%), 77 patients complained of urge urinary incontinence (12%), and 181 patients complained of any type of urinary incontinence (29%). Twenty-three (4%) complained of fecal incontinence. There was a significant association between the two types of urinary incontinence (P < 0.01). For example, a patient with stress urinary incontinence was more likely to have urge urinary incontinence than a patient without stress incontinence. Fecal incontinence showed a significant association with stress or urge incontinence (P < 0.01 and P = 0.02, respectively). The results of the univariate analysis for the development of stress urinary incontinence are summarized in Table 2. The only variable identified as statistically significant was maternal age (RR 1.5; 95% CI ; P = 0.05). The results of the univariate analysis for the development of urge urinary incontinence are summarized in Table 3. Significant variables included maternal age (RR 1.5; 95% CI ; P = 0.05), forceps-assisted delivery (RR 2.2; 95% CI ; P = 0.001), episiotomy (RR 3.5; 95% CI ; P < 0.001) and increased length of second stage (108 minutes, SD 111, vs. 77 minutes, SD 87; P = 0.01). The results of the univariate analysis for the development of any urinary incontinence are summarized in Table 4. Significant variables included maternal age (RR 1.5; 95% CI ; P = 0.003) and forceps-assisted delivery (RR 1.5; 95% CI , P = 0.01). risk factors for fecal incontinence were identified. Multivariate analysis was used to evaluate risk factors (Table 5). For stress urinary incontinence, we performed logistic regression analysis controlling for maternal age, epidural use, and forceps-assisted delivery. Only a maternal age was significant (P = 0.02). In the analysis for urge urinary incontinence, we controlled for maternal age, length of second stage of labour, forceps-assisted delivery, and episiotomy. The only risk factor that remained significant after multivariate analysis was maternal age. When we examined risk factors for any urinary incontinence, we controlled for maternal age, forceps-assisted delivery, and birth weight. In this analysis, both maternal age (P = 0.004) and forceps delivery (P = 0.008) remained significant. 38 JANUARY JOGC JANVIER 2009

4 Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery Table 2. Risk factors for stress urinary incontinence Variable SUI (143), n (%) SUI (489), n (%) RR 95% CI P 63 (44.1) 264 (54.0) (55.9) 225 (46.1) Forceps delivery 21 (14.6) 46 (9.0) (84.4) 443 (91.0) Epidural use 77 (54.0) 220 (45.0) (46.0) 269 (55.0) SUI: stress urinary incontinence Table 3. Risk factors for urge urinary incontinence Variable UUI (77), n (%) UUI (555), n (%) RR 95% CI P Forceps Episiotomy Length of 2nd stage, minutes (SD) 32 (41.6) 45 (58.4) 295 (53.2) 260 (46.8) (20.8) 51 (9.2) (79.2) 504 (90.8) 25 (32.4) 104(18.7) (67.6) 451(81.3) 108 (SD 111) 77 (SD 87) NA NA 0.01 UUI: urge urinary incontinence DISCUSSION This study was designed to determine the prevalence of urinary and fecal incontinence following vaginal delivery and to evaluate risk factors for these conditions. The reported prevalence of urinary incontinence after vaginal delivery varies from 0.3% to 38%. 1 3,10 Viktrup et al. reported a prevalence as low as 0.3% in primiparous women at three months post partum. 1 Other studies show a prevalence of urinary incontinence during the first six months post partum ranging from 21% to 38%, 1,3,10,16 which is consistent with our results (29% prevalence of any urinary incontinence). Patients were included in the study by Viktrup et al. 1 only if they met the strict International Continence Society s definition of incontinence, although 6% admitted to any urinary incontinence at three months post partum. The study population in the study by Viktrup et al. also consisted only of primiparous women, none of whom had a forceps-assisted delivery. 1 Our study population was heterogeneous for parity and mode of delivery, with 10.8% of our population undergoing a forceps-assisted delivery. Other studies confirm forceps delivery increases the prevalence of urinary incontinence in the first six months after delivery. 3,16 A significant association between the two types of urinary incontinence was found in our study. The presence of stress urinary incontinence increased the likelihood of a woman s also having urge urinary incontinence. Mixed urinary incontinence is a common entity in women, but the specific number of women developing urge incontinence is reported in only a few studies. 2,11 Although the etiology of stress urinary incontinence in the postpartum period may be related to pudendal nerve disruption, 4,5 the etiology of urge incontinence remains unclear. We also found a significant association between urinary and fecal incontinence, which has biological plausibility since the pudendal nerve JANUARY JOGC JANVIER

5 WOMEN'S HEALTH Table 4. Risk factors for any urinary incontinence Variable UI (181), n (%) UI (451), n (%) RR 95% CI P Forceps Birth weight, grams (SD) 77 (42.5) 104 (57.5) 250 (55.4) 201 (44.6) (15.5) 39 (8.7) (84.5) 412 (91.3) 3374 (498) 3273 (563) NA NA 0.07 UI: urinary incontinence Table 5. Multivariate analysis of risk factors for urinary incontinence Variable Stress incontinence 0.02* Urge incontinence 0.01* Length second stage of labour Any incontinence 0.01* Forceps 0.01* * denotes statistical significance innervates both striated sphincters involved in urinary and fecal continence. 4,5 A maternal age of was found to be significant on multivariate analysis for stress incontinence. Although urinary incontinence increases with advancing age in the general population, 21 postpartum urinary incontinence has not been consistently associated with advancing maternal age. Persson et al. 13 demonstrated that age 25 years at the time of first delivery was a risk factor for future incontinence surgery, but several short-term studies, all with less than one year of follow-up, failed to find a relationship between urinary incontinence and maternal age. 1,3,14,16 Nevertheless, Hatem et al. 15 found that, in primiparous women, maternal age > 35 years was associated with fecal incontinence and with concomitant fecal and urinary incontinence, but not with the development of urinary incontinence alone. Urge urinary incontinence in the postpartum period has been less well studied. The prevalence of urge incontinence in this study is consistent with other reports. 2,11 While maternal age, forceps-assisted delivery, episiotomy, and P length of second stage were identified as risk factors for urge incontinence in univariate analysis, only maternal age remained significant after multivariate analysis. Studies identifying risk factors for postpartum urge urinary in continence are limited. 6,11,12 However, head circumference > 38 cm and concomitant stress incontinence have been reported as risk factors, although these were not specifically examined in our study. 11,12 Many studies examining potential risk factors for postpartum incontinence include any form of incontinence in their analyses. We found that two variables, maternal age and forceps-assisted delivery, were significantly associated with any urinary incontinence. Several authors have noted an increased rate of incontinence in forcepsassisted delivery 3,14,16 ; this may be related to increased nerve and pelvic floor damage occurring during a forceps delivery. However, a few long-term studies failed to show this increased association with forceps delivery. 3,11,21 Our findings support the conclusion that forceps-assisted delivery has a detrimental effect on the urinary continence mechanism in the short term. Our observed rate of fecal incontinence (a prevalence of 4%) after vaginal delivery is consistent with several studies. 6,10,16,17 Several studies have established anal sphincter lacerations as risk factors for fecal incontinence, 5,22,23 although we did not find this relationship in our study. Only recognized third and fourth degree tears were reported in our study, and occult sphincter injuries may have been missed. Also, the number of patients with reported fecal incontinence was small (n = 23, 4%), and this limited our analysis. Sultan et al. reported a small percentage of patients with an intact perineum at delivery who were shown on ultrasound assessment to have internal anal sphincter defects. 4 Forceps delivery as a risk factor for fecal incontinence has been previously reported. 4,17 patients with 40 JANUARY JOGC JANVIER 2009

6 Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery fecal incontinence who had forceps-assisted deliveries were identified in our study, and therefore risk factor analysis was not possible. Often fecal incontinence manifests at a time distant from the injury; therefore, longer follow-up of these patients, which we are pursuing, may be useful. CONCLUSION Urinary incontinence in previously continent patients is common after vaginal delivery. While we found that stress incontinence was the most common type of incontinence present at four months post partum, a significant number of women also developed urge incontinence. The two types of urinary incontinence are inter-related, as are urinary and fecal incontinence. Increased maternal age stands alone as the most significant risk factor for any urinary incontinence. REFERENCES 1. Viktrup L, Lose G, Rolff M, Barfoed K. The symptoms of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol 1992;79: Wilson P, Herbison R, Herbison G. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol 1996;103: Farrell S, Allen V, Baskett T. Parturition and urinary incontinence in primiparas. Obstet Gynecol 2001;97: Sultan A, Kamm M, Hudson C, Chir M, Thomas J, Bartram C. Anal-sphincter disruption during vaginal delivery. N Eng J Med 1993;329: Snooks S, Swash M, Setchell M, Henry M. Injury to innervation of pelvic floor sphincter musculature in childbirth. Lancet 1984;2(8402): MacLennan A, Taylor A, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. BJOG 2000;107: Press JZ, Klein MC, Kaczorowski J, Liston RM, von Dadelszen P. Does Cesarean section reduce postpartum urinary incontinence? A systematic review. Birth 2007;34: Klein MC, Kaczorowski J, Firoz T, Hubinette M, Jorgensen S, Gauthier R. A comparison of urinary and sexual outcomes in women experiencing vaginal and Cesarean births. J Obstet Gynaecol Can 2005;27: Handa VL, Zyczynski HM, Burgio KL, Fitzgerald MP, Borello-France D, Janz NK, et al. The impact of fecal and urinary incontinence on quality of life 6 months after childbirth. Am J Obstet Gynecol 2007;197:636.e Morkved S, Bo K. Prevalence of urinary incontinence during pregnancy and postpartum. Int Urogynecol J Pelvic Floor Dysfunct 1999;10: Viktrup L, Lose G. Lower urinary tract symptoms 5 years after the first delivery. Int Urogynecol J Pelvic Floor Dysfunct 2000;11: Rortveit G, Daltveit A, Hannestad Y, Hunskaar S. Vaginal delivery parameters and urinary incontinence: the rwegian EPINCONT study. Am J Obstet Gynecol 2003;189: Persson J, Wolner-Hanssen P, Rydhstroem H. Obstetric risk factors for stress urinary incontinence: a population-based study. Obstet Gynecol 2000;96(3): Burgio K, Zyczynski H, Locher J, Richter H, Redden D, Wright K. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol 2003;102: Hatem M, Pasquier JC, Fraser W, Lepire E. Factors associated with postpartum urinary/anal incontinence in primiparous women in Quebec. J Obstet Gynaecol Can 2007;29(3): Meyer S, Schreyer A, Grandi P, Hohlfeld A. The effects of birth on urinary continence mechanisms and other pelvic-floor characteristics. Obstet Gynecol 1998;92: MacArthur C, Bick D, Keighley M. Faecal incontinence after childbirth. Br J Obstet Gynaecol 1997;104: Morin K. Urologic consequences of childbirth: a review of the literature. Urol Nurs 1994;14: Creasy RK, Resnik R. Maternal-fetal medicine. 5th ed. Philadelphia PA: Saunders; Lee SJ, Park JW. Follow up evaluation of the effect of vaginal delivery on the pelvic floor. Dis Colon Rectum 2000;43(11): Rortveit G, Dalveit A, Hannestad Y, Hunskaar S. Urinary incontinence after vaginal delivery or cesarean section. N Eng J Med 2003;348: Fenner D, Genberg B, Brahma P, Marek L, DeLancey J. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003;189: Tetzschner T, Sorenson M, Lose G, Christiansen J. Anal and urinary incontinence in women with obstetric anal sphincter rupture. Br J Obstet Gynaecol 1996;103: JANUARY JOGC JANVIER