Presented at the NIH State-of-the-Science Conference: Prevention of Fecal and Urinary Incontinence in Adults - Bethesda, MD - December 10-12, 2007

In March of 2006, the National Institutes of Child Health and Human Development and the Office of Medical Applications of Research of the National Institutes of Health convened a State-of-the-Science Conference to explore more fully the currently available data on cesarean delivery (CD) on maternal request.¹ A systematic review of the literature pertaining to both neonatal and maternal outcomes with CD on maternal request and vaginal delivery was presented both by an expert panel and by RTI-International–University of North Carolina Evidence-Based Practice Center through the Agency for Healthcare Research and Quality. Furthermore, presentations by clinical experts in the various areas of neonatal and maternal healthcare complemented the panel’s presentations. For the maternal outcome of urinary incontinence (UI), level III (weak) data indicated that the rate of stress UI after elective CD was lower than after vaginal delivery; however, other covariates may influence these outcomes. For the outcome of anorectal dysfunction, including anal and fecal incontinence (FI), weak evidence suggested a reduced risk of anal incontinence in planned CD compared with unplanned CD or instrument-assisted vaginal deliveries. Existing evidence also demonstrated an association between sphincter disruption at the time of vaginal delivery and FI, especially when associated with midline episiotomy and instrument-assisted deliveries. This abstract provides an interim summary of an updated review of the literature on pregnancy and its effect on UI and FI.

UI has been attributed to pregnancy and childbirth, and its prevalence is common antenatally, with reported rates of 16%–65%.^2–6 UI during pregnancy may be a short-term condition for some women.^4,5 In a cohort of 523 women, Burgio and colleagues found a drop in the prevalence of UI from 60% to 11% by 6 weeks postpartum.⁵ However, the presence of antenatal UI has also been found to be a predictor of longer term postpartum UI.^3,5,7 Other covariates should be considered when looking at the effect of pregnancy on the development of both short- and long-term UI, including primiparity versus multiparous patients (effect of prior deliveries),^8,9 vaginal delivery versus CD,^7,10 and use of episiotomy and forceps5,^10,11 among other factors. More recently, a prospective multicenter cohort study, the Childbirth and Pelvic Symptoms (CAPS) study, comprising three cohorts of primiparous women: 407 vaginally delivered women, with clinically recognized anal sphincter tears (n=407); 390 vaginally delivered controls, without a clinically evident sphincter tear; and 124 CD controls who delivered prior to labor. All three cohorts were prospectively followed for symptoms of UI and FI. UI symptoms were assessed by using the Medical, Epidemiological, and Social Aspects of Aging questionnaire.¹² UI symptom prevalence did not differ between the sphincter tear and vaginal delivery control groups (at 6 weeks, 34.8% vs. 35.4%, p=0.76; at 6 months, 33.7% vs. 31.3%, p=0.66) or between the vaginal delivery control and CD cohorts at 6 weeks (35.4% vs. 25.0%, p=0.32) and 6 months (31.3% vs. 22.9%, p=0.44).

Curiously, as women age, the association of childbirth and UI appears to consistently decrease. In a large Norwegian study,⁹ the relationship of UI with parity was significant in younger women and absent in older women (>65 years).

To date, only one randomized trial has assessed the impact of planned vaginal delivery versus planned CD and its effect on UI.¹³ In that study, 1,596 women from 110 centers worldwide completed questionnaires addressing UI symptoms at 3 months postpartum, and approximately one-half of the original subjects completed these questionnaires 2 years postpartum. Furthermore, the questions at the 3-month time addressed stress UI symptoms within the last 7 days, and at the 2-year time addressed symptoms within the last 3–6 months. At 3 months postpartum, women in the planned CD group had less UI than those in the planned vaginal delivery group (4.5% vs. 7.3%, RR=0.62, 95% CI=0.41–0.93). No difference was seen at 2 years, with UI noted in 17.8% in the planned CD group versus 21.8% for the planned vaginal delivery group.

FI, the involuntary loss of solid or liquid stool, can significantly affect quality of life.¹⁴ Anal incontinence includes the involuntary loss of flatus. The prevalence of FI in community-dwelling women ranges from 0.4% to 18%, depending on the definition used and the population queried.¹⁵ Among the many causes of FI, obstetric-related sphincter tears—one of the primary causes—have been the focus of research, treatment, and prevention. As the long-term results of primary sphincter repair have been reported to be as low as 44%,16 research continues to investigate the relationship of obstetric delivery, sphincter tears, and the prevention of FI.

The Fecal Incontinence Postpartum Research Initiative undertook a population-based survey sent to women 3–6 months after delivery.¹⁷ Fourteen percent (1,192/8,774) of respondents reported symptoms of FI. Body mass index (BMI) greater than 30, time pushing, forceps-assisted delivery, fourth-degree tear, and current smoking were associated with FI. The Kaiser Permanente Continence Associated Risks Epidemiologic Study was a cross-sectional sample of 12,200 women aged 25–84 years.¹⁸ Using the validated Epidemiology of Prolapse and Incontinence Questionnaire, the overall prevalence of FI was 17%. Participants were then categorized into nulliparous, CD, or vaginally parous groups. The vaginally parous group had a higher prevalence of all pelvic floor disorder symptoms, including FI. Other recent studies have also continued to show an association between vaginal delivery and FI, especially with anal sphincter tear.^19,20

The association of third- and fourth-degree sphincter tear and FI was first reported more than 10 years ago.²¹ Sphincter tears may occur in up to 18% of deliveries²² and may not be recognized at the time of delivery in 23%–35% of primiparous women.^22,23 As noted above, the prospective multicenter CAPS study consisted of three cohorts of primiparous women: 407 women delivered vaginally, with clinically recognized anal sphincter tears (n=407); 390 controls who delivered vaginally, without a clinically evident sphincter tear; and 124 CD controls who delivered prior to labor.¹² The presence of FI was measured with use of the Fecal Incontinence Severity Index, assessing symptoms at 6 weeks and 6 months postpartum. Women sustaining a sphincter tear compared to the controls who delivered vaginally reported more FI at 6 weeks (27% versus 11%, OR=2.8, CI=1.8–4.3, attributable risk 15%) and at 6 months (17% versus 8%, OR=1.9, 95% CI=1.2–3.2, attributable risk 9%). Severity of FI was significantly greater in those women with a sphincter tear. Risk factors for FI in the group with sphincter tears of the CAPS cohort included Caucasian race, antenatal UI, fourth- versus third-degree tear, older age at delivery, and higher BMI.²⁴

A subset of CAPS patients underwent endoanal ultrasound studies, and they were queried about FI symptoms 6–12 months postpartum.²⁵ In the group with tears, the finding of internal sphincter tears was associated with greater FI symptoms. Women with combined tears (internal and external anal sphincter tears) had the highest degree of symptoms. The association of especially internal anal sphincter gaps by ultrasound postpartum, has been associated with greater FI symptoms in other studies as well^26,27 and has broadened the focus of anal sphincter repairs from just the external sphincter to include the internal sphincter.

Evidence regarding the use of mediolateral episiotomy to prevent sphincter tears is inconsistent,²⁸ and evidence on other interventions such as delivery posture²⁹ and perineal massage30 was inconclusive. The prevention of FI with use of CD has also not been conclusively proved.^12,31 The appropriate repair technique and association with FI has also been studied. A 2006 Cochrane review comparing overlapping and end-to-end repair did not find a difference in FI symptoms at 6 weeks and at 3, 6, and 12 months postpartum.³² Recently, immediate postpartum ultrasonography has demonstrated missed sphincter tear rates as high as 35%;³³ this finding has sparked interest in immediate postpartum ultrasound.

Written by: Richter H, M.D., Ph.D.

References

1. NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens Sci Statements. 2006;23:1–29.
2. Nygaard I. Urinary incontinence: is cesarean delivery protective? Sem Perinatology. 2006;30:267–271.
3. Hvidman L, Foldspang A, Mommsen S, Nielsen JB. Postpartum urinary incontinence. Acta Obstet Gynecol Scand. 2003;82:556–563.
4. Viktrup L, Lose G, Rolff M, Barfoed K. The symptom of stress incontinence caused by pregnancy or delivery in primiparas. Obstet Gynecol. 1992;79:945–949. 5. Burgio KL, Zyczynski H, Locher JL, Richter HE, Redden DT, Wright KC. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol. 2003;102:1291–1298. 6. Eason E, Labrecque M, Marcoux S, Mondor M. Effects of carrying a pregnancy and of method of delivery on urinary incontinence: a prospective cohort study. BMC Pregnancy Childbirth. 2004;4:4. 7. Foldspang A, Hvidman L, Mommsen S, Nielsen JB. Risk of postpartum urinary incontinence associated with pregnancy and mode of delivery. Acta Obstet Gynecol Scand. 2004;83:923–927. 8. Burgio KL, Locher JL, Zyczynski H, Hardin JM, Singh K. Urinary incontinence during a pregnancy in a racially mixed sample: characteristics and predisposing factors. Int Urogynecol J Pelvic Floor Dysfunct. 1996;7:69–73. 9. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol. 2001;98:1004–1010. 10. Chaliha C, Digesu A, Hutchings A, Soligo M, Khullar V. Cesarean section is protective against stress urinary incontinence: an analysis of women with multiple deliveries. Br J Obstet Gynecol. 2004;111:754–755. 80 11. Foldspang A, Mommsen S, Djurhuus JC. Prevalent urinary incontinence as a correlate of pregnancy, vaginal childbirth, and obstetric techniques. Am J Public Health. 1999;89:209–212. 12. Borello-France D, Burgio KL, Richter HE, Zyczynski H, Fitzgerald MP, Whitehead W, Fine P, Nygaard I, Handa VL, Visco AG, Weber AM, Brown MB; Pelvic Floor Disorders Network. Fecal and urinary incontinence in primiparous women. Obstet Gynecol. 2006;108:863–872. 13. Hannah ME, Hannah WJ, Hodnett ED, Chalmers B, Kung R, Willan A, Amankwah K, Cheng M, Helewa M, Hewson S, Saigal S, Whyte H, Gafni A; Term Breech Trial 3-Month Follow-up Collaborative Group. Outcomes at 3 months after planned cesarean vs planned vaginal birth for breech presentation at term: The International Randomized Term Breech Trial. JAMA. 2002;287:1822–1831. 14. Hunskaar S, Burgio K, Clark A, et al. Epidemiology of urinary (UI) and faecal (FI) incontinence and pelvic organ prolapse (POP). In: Abrams P, Cardozo L., Khoury S, Wein A, eds. Incontinence. 2005 ed. UK: Health Publications Ltd., 2005. 15. Macmillan AK, Merrie AE, Marshall RJ, Parry BR. The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature. Dis Colon Rectum. 2004;47:1341–1349. 16. Williams A. Third-degree perineal tears: risk factors and outcome after primary repair. J Obstet Gynaecol. 2003;23:611–614. 17. Guise JM, Morris C, Osterweil P, Li H, Rosenberg D, Greenlick M. Incidence of fecal incontinence after childbirth. Obstet Gynecol. 2007;109:281–288. 18. Lukacz ES, Lawrence JM, Contreras R, Nager CW, Luber KM. Parity, mode of delivery, and pelvic floor disorders. Obstet Gynecol. 2006;107:1253–1260. 19. McKinnie V, Swift SE, Wang W, Woodman P, O’Boyle A, Kahn M, Valley M, Bland D, Schaffer J. The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. Am J Obstet Gynecol. 2005;193:512–17; discussion 7–8. 20. van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH. Defecatory symptoms during and after the first pregnancy: prevalences and associated factors. Int Urogynecol J. 2006;17:224–230. 21. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993:329:1905–1911. 22. Fenner DE, Genberg B, Brahma P, Marek L, DeLancey JO. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol. 2003;189:1543–1549; discussion 1549–1550. 23. Pinta TM, Kylanpaa ML, Teramo KA, Luukkonen PS. Sphincter rupture and anal incontinence after first delivery. Acta Obstet Gynecol Scand. 2004;83:917–922. 81 24. Burgio KL, Borello-France D, Richter HE, Fitzgerald MP, Whitehead W, Handa VL, Nygaard I, Fine P, Zyczynski H, Visco AG, Brown MB, Weber AM; for The Pelvic Floor Disorders Network. Risk factors for fecal and urinary incontinence after childbirth: the Childbirth and Pelvic Symptoms Study. Am J Gastroenterol. 2007;102:1998–2004. 25. Richter HE, Fielding JR, Bradley CS, Handa VL, Fine P, FitzGerald MP, Visco A, Wald A, Hakim C, Wei JT, Weber AM; Pelvic Floor Disorders Network. Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears. Obstet Gynecol. 2006;108:1394–1401. 26. Mahony R, Behan M, Daly L, Kirwan C, O’Herlihy C, O’Connell PR. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol. 2007;196:217e1–217e5. 27. Nichols CM, Nam M, Ramakrishnan V, Lamb EH, Currie N. Anal sphincter defects and bowel symptoms in women with and without recognized anal sphincter trauma. Am J Obstet Gynecol. 2006;194:1450–1454. 28. Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst Rev. 2000;(2):CD000081. 29. Altman D, Ragnar I, Ekstrom A, Tyden T, Olsson SE. Anal sphincter lacerations and upright delivery postures—a risk analysis from a randomized controlled trial. Int Urogynecol J. 2007;18:141–146. 30. Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2006;(1):CD005123. 31. Nelson RL, Westercamp M, Furner SE. A systematic review of the efficacy of cesarean section in the preservation of anal continence. Dis Colon Rectum. 2006;49:1587–1595. 32. Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev. 2006;(3):CD002866. 33. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injury—myth or reality? BJOG. 2006;113:195–200.
5. xxx
6. xxx
7. xxx

UroToday.com Full Conference Coverage

Please log-in or register in order to submit comments.

Powered by AkoComment!