Postpartum stress urinary incontinence

Case Study - Pelvic floor muscle training can be effective with the right guidance says Joanne Townsend.

Stress urinary incontinence (SUI) - involuntary leakage on effort or exertion - has been estimated to occur in six to 43 per cent of women post delivery.

Pregnancy and childbirth can result in trauma to the supporting structures of the urethra, bladder and pelvic floor muscles, and damage to the nerve supply of the sphincter or levator ani muscle.

Risk factors include urinary incontinence during the antenatal period, a prolonged second stage of labour, instrumental delivery, perineal tear and epesiotomy, and obesity. Although many bladder and bowel problems resolve between eight and 24 weeks postpartum, for some women urinary incontinence will persist.

Assessment
Sarah described wetting from urine loss through her sanitary towels and underwear. This started immediately postpartum and she reported no previous urinary symptoms.

She did not take regular medication, had no previous surgical or gynaecological history and no faecal symptoms.

A urine dipstick test was performed to exclude other conditions, such as UTI and diabetes.

Because women can experience urinary retention postpartum, post-void residual volume was measured by ultrasound.

Sarah also completed a frequency volume chart over three days and underwent vaginal examination.

Vaginal examination is an essential part of the assessment of any woman presenting with SUI, to establish the condition of the pelvic floor muscles (PFM). PFM function and strength can be graded using the modified Oxford scale (see box, opposite page). Evidence shows that verbal instructions and leaflets alone are not sufficient to teach women to correct the right muscles.

Although she reported poor sensations locating her PFM, on examination Sarah could contract her PFM sufficiently and was graded three using the modified Oxford scale.

Treatment options
Women scoring three or above on the modified Oxford scale are considered potential candidates for pelvic floor muscle training. This training improves and strengthens urethral stabilisation, helping the patient to regain continence. When contracted correctly and with enough strength, the PFM squeeze can create an inward lift, tightening the urethra, vagina and rectum.

Lifestyle interventions, including weight loss and fluid management, may also be recommended in postpartum women.

Sarah was provided with a full explanation of her PFM training regimen, concentrating on strength and duration of each contraction.

In addition, Sarah was taught 'the knack', where PFM are contracted in anticipation of any leak-provoking activity.

NICE guidelines on the management of urinary incontinence in women suggest a minimum of eight contractions, three times a day.

A useful aid to compliance is to associate the exercises with another daily activity such as breastfeeding.

To help locate and recruit the PFM, some women, particularly those with an Oxford score below three benefit from biofeedback and electrical stimulation.

Follow-up
Researchers have demonstrated a significant weakness in PFM six weeks postpartum, with an element of improvement at 12 weeks, following a PFM training regimen. A systematic review found that continuation of the regimens for 48 hours, three months and five months also significantly reduced SUI, and individual programmes were more successful than group sessions.

Repeat vaginal examinations at follow-up appointments may assist with compliance. Failure to respond to supervised PFM training may indicate a need for urodynamic investigation.

Outcome
After 12 weeks of supervision, Sarah felt in control of her SUI. She declined further follow-up appointments and was given a telephone point of contact.

P Joanne Townsend is a urogynaecology nurse specialist at the University Hospitals of Leicester NHS Trust and a member of the NICE guideline development group on the management of urinary incontinence

This article was first published in MIMS Women's Health, April 2007. To register to receive copies see www.hayreg.co.uk/specials/

CASE STUDY - SARAH AFTER GIVING BIRTH

Sarah, who is 26 years old, was referred to the urogynaecology department 12 weeks after the birth of her first child. Her 7Ib 10degz daughter was born after a 12-hour delivery, with forceps and an episiotomy.

Since the delivery, Sarah reported that she had leaked urine while laughing, coughing and bending. She found this extremely embarrassing and had confided in her health visitor.

Sarah was given verbal instructions about pelvic floor muscle training and leaflets at her antenatal classes. Her health visitor reinforced this information, but due to Sarah's lack of improvement, she was referred to the local hospital.

Implications for practice

  • The prognosis for women with SUI after childbirth is good. Many have the potential to respond to PFM training supervised by a specialist practitioner.
  • Evidence confirms that PFM training during the first pregnancy reduces the prevalence of SUI at three months postpartum; longer-term effects are inconsistent and the impact of subsequent pregnancies unknown.
  • Antenatal and postnatal PFM training is recommended.
  • With the emphasis on swift discharge after birth, women need to undertake PFM training as soon as they feel able.
  • Informing women that SUI should not be accepted as a consequence of birth and giving them a point of contact after hospital discharge may prevent referral for SUI in later life.

Oxford scale

0 No contraction

1 Flicker

2 Weak

3 Moderate

4 Good

5 Strong

References

  • Mantle J, Haslam J, Barton S. Physiotherapy in obstetrics and gynaecology. Butterworth Heinemann, London, 2004.
  • Joanna Briggs Institute. A pelvic floor muscle exercise programme for urinary incontinence following childbirth. Nurs Stand 2006; 20: 46-50.
  • Laycock J, Chiarelli P. Pelvic floor assessment and re-education. Proc Int Continence Soc 1989; 99: 206-7.
  • Chiarelli P, Murphy B, Cockburn J. Acceptability of a urinary continence promotion programme to women in postpartum. BJOG 2003; 110: 188-96.
  • Miller J M, Ashton-Miller J A, DeLancey J O. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc 1998; 46: 870-4.
  • NICE. The management of urinary incontinence in women. Clinical Guideline 40. NICE, London, 2006.
  • P Dougherty M C, Bishop K R, Abrams R M et al. The effect of exercise on the circumvaginal muscles in postpartum women.
  • J Nurse Midwifery 1989; 34: 8-14.

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