Urinary incontinence in women after childbirth: causes, how to treat

Postpartum urinary incontinence is an important and often overlooked form of maternal morbidity. This pathology can occur both in pregnant women and after the birth of the child, but in the second case, treatment may be more difficult. It is important for every woman to know the main causes and risk factors for this pathology.

Epidemiology

Statistics show that urinary incontinence is a widespread problem. Almost half of all women have this problem after childbirth. Unfortunately, despite the fact that incontinence is something that many new mothers suffer from, it remains an issue that is not discussed or prevented. Research has shown that a third (33%) of women who have had urinary incontinence after childbirth were embarrassed to discuss it with their partner, and almost half (46%) felt uncomfortable talking to their doctor about it.

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Causes postpartum urinary incontinence

There are various reasons why a woman may suffer from urinary incontinence after childbirth. The bladder muscles may become weak after the constant stretching of the pelvis during pregnancy. This causes the urethra to lose control, holding the urine.

Urinary incontinence is often associated with vaginal birth, especially first-time vaginal births. Many clinical studies have attempted to identify a specific obstetric event that causes urinary incontinence. Obvious causes include large babies and “difficult births” complicated by surgical interventions. Pelvic organ prolapse (cystocele, rectocele, and uterine prolapse) and anal urinary incontinence are also complications of normal birth.

Each woman should have sufficient information to determine what combination of risks she prefers for herself and her baby. In the general situation where there is no additional risk to the baby, obstetric management should focus on reducing maternal morbidity, including postpartum urinary incontinence. New mothers are likely to benefit from routine symptom screening and early discussion of healthy bladder habits and proper muscle techniques as part of their postpartum care. Obstetric care should include assessment of the maternal outcome of this birth, including the full range of pelvic floor injuries known to be associated with childbirth.

Therefore, the causes of this pathology are most often limited to pathology during childbirth. If a woman had epidural or spinal anesthesia, it can cause a feeling of numbness in the bladder. This can last for several hours after anesthesia or several days. In the first few hours after birth, a woman will not be able to accurately feel all the organs, both because of the anesthesia and because of the birth process itself. The presence of a catheter during a cesarean section can make it difficult to control the bladder and can become one of the causes of further complications.

The main causes of urinary incontinence after childbirth are as follows:

1. The pelvic nerves that control bladder function can be injured during prolonged or difficult vaginal delivery.
2. Forceps births can cause injury to the pelvic floor and anal sphincter muscles.
3. Prolonged pushing during vaginal delivery also increases the likelihood of pelvic nerve damage and the bladder control problems that may follow.
4. vaginal physiological birth (although even women who choose cesarean section may be prone to incontinence);
5. invasive use of instruments during childbirth.

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Risk factors

The risk factors for this disease are as follows:

1. excess weight in women;
2. genetic predisposition;
3. a large fetus in the uterus, requiring additional effort;
4. Mothers who have had many children have less elasticity of the pelvic floor.

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Pathogenesis

The pathogenesis of the development of urinary incontinence after childbirth, as a common problem, lies in the peculiarities of the structure and innervation of urine.

The urinary sphincter is a muscular valve located at the bottom of the bladder. It works to control the flow of urine. A healthy bladder empties 5 to 9 times a day and no more than once at night. Typically, every 2 to 4 hours is when a woman should urinate. Drinking caffeinated beverages, foods with artificial sweeteners, acidic foods, and alcohol can irritate the bladder and cause you to go more often, so avoiding them can help control the urgency and reduce frequency. The urinary sphincter relaxes when the bladder is full of urine, and the sphincter muscles help keep the bladder closed until you are ready to urinate. Other systems in the body also help control the bladder. Nerves from the bladder send signals to the brain when the bladder is full; nerves from the brain signal the bladder when it needs to empty. All of these nerves and muscles must work together to keep the bladder working properly.

During pregnancy, the expanding uterus puts pressure on the bladder. The muscles in the urinary sphincter and pelvic area can become overloaded with additional stress or pressure on the bladder. Urine may leak from the bladder when there is additional pressure, such as during exercise or any movement.

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Symptoms postpartum urinary incontinence

Pregnancy comes with its share of joys and discomforts. One of these common problems is that most women have stress urinary incontinence.

There are different types of urinary incontinence after birth. Stress urinary incontinence is classified as involuntary loss of urine during stress. Incontinence of urine when coughing, sneezing after birth refers to stress factors that can provoke relaxation of the sphincter. Such stress factors primarily affect the innervation of the bladder, and then involuntary leakage of urine occurs. A healthy functional pelvic floor has a balance between the ability to contract and the ability to relax. A pelvic floor that is too relaxed or too contractile is dysfunctional and can cause such symptoms.

Another type of incontinence is under the influence of physical activity. Incontinence of urine during jumping or during physical activity after childbirth develops against the background of muscle weakness and relaxation of the sphincter, and the violation of innervation here is of secondary importance.

Symptoms of this pathology are the appearance of a small amount of urine or complete urination against the background of an irritant. A woman can miss urine when coughing, sneezing, laughing or moving quickly. The amount of urine can vary from a few drops to a sufficient amount. The first signs often appear immediately after childbirth. If you miss a small amount of urine in the first days after childbirth, do not worry, as this can normalize in the first few days. If this is observed for several weeks, then this is already a serious pathology.

Complications and consequences

The consequences and complications of not seeking help in a timely manner can be serious. It can leave women feeling lonely and isolated, affect relationships and careers, and can be a barrier to having sex.

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Diagnostics postpartum urinary incontinence

A gynecological or proctological examination can diagnose the cause and type of incontinence to provide targeted treatment and prevention of urinary incontinence.

Diagnostics should begin with collecting anamnesis. And every doctor should remember that not every woman can complain of urinary incontinence. Some patients may simply not mention these symptoms, considering them normal, or may simply be embarrassed. Therefore, during the examination, the doctor should ask the woman about possible symptoms. If a woman says that she has symptoms of incontinence, then it is necessary to find out under what conditions this occurs and how long it lasts.

Tests must be performed to rule out urinary tract infection. A woman must undergo a general urine test, which allows to rule out infection and localize the pathological process, for example, to clarify whether the process is in the bladder or kidneys. Also, laboratory tests should include the level of serum creatinine, which can be elevated if there is urinary retention (overflow bladder) caused by obstruction of the bladder outlet or detrusor denervation.

Instrumental diagnostics are also performed to exclude concomitant conditions. For this purpose, ultrasound diagnostics is most often used. This method allows determining whether there are changes in the bladder and kidneys, as well as whether there are any disorders in the uterus.

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Differential diagnosis

The differential diagnoses of urinary incontinence are varied. Sometimes there is more than one factor, further complicating the diagnosis and treatment. Distinguishing between these different etiologies is important because each condition requires a different, but often overlapping, therapeutic approach. Postpartum urinary incontinence should be differentiated from urinary tract infection and cystitis in women. Multiple sclerosis, spinal cord neoplasms, birth trauma to the spinal cord and associated diseases, spinal epidural abscess, and vaginitis should also be excluded.

Urinary tract infections are common, especially in the postpartum period. Cystitis (inflammation of the bladder) represents the majority of these infections. Related terms include pyelonephritis, which refers to an upper urinary tract infection; bacteriuria, which describes bacteria in the urine; and candiduria, which describes yeast in the urine.

The symptoms and signs of a urinary tract infection are: difficulty urinating, frequency of urination, discomfort in the bladder area, flank pain and tenderness in the musculoskeletal area (may be present in cystitis), fever, chills and malaise. The main differential sign of a urinary tract infection is the detection of pyuria or changes in the general analysis of urine. Therefore, in case of incontinence, a urine analysis is always performed, and if there are changes, then this indicates an infection.

Urinary incontinence in the postpartum period can occur with various pathological processes of the spinal cord, including trauma. Regardless of the pathogenesis, this can lead to a significant deterioration in motor, sensory or autonomic function. Therefore, if any such symptoms are present, it is necessary to exclude spinal cord trauma.

Vaginitis (inflammation of the vagina) is the most common gynecologic condition seen in the office. It is a diagnosis based on the presence of symptoms of abnormal discharge, vulvovaginal discomfort. Every day, a woman secretes mucus from the vagina as a way to maintain a normal healthy environment. Changes in the amount, color, or odor; irritation; or itching or burning can be caused by an imbalance of healthy bacteria in the vagina, leading to vaginitis. Severe symptoms of vaginitis can cause frequent urination and incontinence. Investigations that may be performed in cases of suspected vaginitis include vaginal culture. Therefore, incontinence is also recommended for differential diagnosis.

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Treatment postpartum urinary incontinence

What to do about urinary incontinence after childbirth? Urinary incontinence after childbirth is not something you should just accept as a normal function. It can affect your mental health if symptoms continue, so do not wait too long to seek help and begin treatment.

Since this problem does not have any biochemical disturbances in its development, medications are not used.

The first thing to consider with this problem is dietary changes.

Certain foods and drinks are thought to contribute to bladder incontinence. These include: alcoholic beverages, carbonated drinks (with or without caffeine), coffee or tea (with or without caffeine). Other changes include drinking less fluid after lunch and getting enough fiber to avoid constipation. Also, avoid drinking too much.

If some mothers continue to smoke after birth, then researchers are still proving a link between incontinence and cigarette smoking. Therefore, this factor must be excluded.

A pessary is the most common device used to treat urinary incontinence. It is a rigid ring that a doctor or nurse inserts into the vagina. The device presses against the wall of the vagina and urethra. This helps reposition the urethra to reduce urine leakage during straining.

Some people with urinary incontinence may not respond to behavioral treatments or medicine. In this case, electrical stimulation of the nerves that control the bladder may help. This treatment, called neuromodulation, can be effective in some cases. The doctor will first place a device outside your body to deliver the impulse. If it works well, the surgeon will implant the device.

Vitamins can only be used as prescribed by a doctor, taking into account that the woman is breastfeeding.

Physiotherapy treatment can also be widely used. Biofeedback can lead to conscious control of the pelvic floor muscles and support voluntary contraction of the bladder muscles. A small electrode is inserted into the vagina to measure muscle activity. Acoustic and visual feedback indicates whether the correct muscles are controlled and the intensity of their contraction (can also be combined with electrotherapy). Some electrotherapy devices, such as the STIWELL med4, have a biofeedback function that displays contractility via electromyography. Even minute progress in therapy has been shown to motivate the patient.

In gynecological applications, electrotherapy can ideally complement traditional physical therapy. It should be used exclusively after childbirth. This therapy maintains pelvic floor stability and controlled coordination of the urethral sphincters and pelvic floor muscles. The electrotherapy device sends electrical impulses to stimulate nerve cells and strengthens the pelvic floor and bladder muscles that were tense during childbirth. A small electrode is inserted into the vagina to send electrical impulses to the pelvic floor muscles. The electrode can also be attached to the skin to stimulate the pelvic floor.

The electrotherapy device also allows for a combination of biofeedback and electrical stimulation. This is called EMG-induced electrical stimulation. The patient must actively contract the pelvic floor muscles, and the electrical stimulation provides an additional electrical impulse when a predetermined threshold is reached. The goal is to continually increase this threshold until the patient can fully contract the muscles without support.

Traditional medicine and homeopathy have little evidence of effectiveness and are therefore rarely used.

Surgery is most effective for people with stress urinary incontinence who have not responded to other treatments.

The most effective and initial stage of treatment may be physical exercises. Exercises for urinary incontinence after childbirth, which have proven effectiveness, are Kegel exercises. The main principle of such exercises is training the control of muscle work, doing exercises every day. It is proven that they treat and prevent incontinence.

You can start doing exercises soon after your baby is born. Kegel exercises also help blood circulation around the vaginal (perineal) area, and this will help any swelling, bruising, and bruising heal. If you stop exercising, your muscles may weaken over time, and symptoms may recur.

How to do Kegel exercises to strengthen the pelvic floor?

Make sure you are relaxed and breathing freely, with your belly lifted as you inhale and your belly pulled in as you exhale. As you inhale, you should squeeze your abdominal and pelvic floor muscles. You should feel a contraction around your vagina and anus. Try not to tighten your buttocks or upper abdominal muscles, and make sure you are not holding your breath but breathing evenly. Don’t worry if you can’t hold the contraction for long. Gradually increase the amount of time you squeeze your pelvic floor muscles. Try to hold the contraction for four or five seconds.

When practicing the exercises regularly, you should hold the contraction for 10 seconds while breathing normally. Rest and wait at least 10 seconds before contracting again. Women who perform Kegel exercises regularly can see the first results in four to six weeks.

Prevention

Prevention of this problem does exist. Although there is nothing you can do to solve the problem itself, there are simple measures you can take to try to avoid incontinence. Here are some measures that can be taken to prevent stress incontinence after childbirth:

1. Doctor's rating:

Let your doctor examine you closely after delivery and review your condition to manage any chances of urinary tract infection.

2. Kegel exercises are not only beneficial during pregnancy, but also help strengthen pelvic muscles after childbirth and may prevent incontinence in any subsequent pregnancies.

Women should try to stay fit and do Kegel exercises even before giving birth to help prevent urinary incontinence. Kegel exercise is a basic exercise that can be done anytime, anywhere. What you are trying to do is isolate your pubococcygeus muscles and hold them in a squeezing position, count for 3-5 seconds, release and relax for 5 seconds. You should do this 5 times a day.

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Forecast

The prognosis for recovery from this pathology is higher in young women after their first birth. In 7% of new mothers, symptoms are eliminated immediately after the start of comprehensive treatment. But even comprehensive treatment was insufficient for many mothers who give birth again.

Urinary incontinence after childbirth is a fairly common pathology that can cause discomfort. Many factors play a role in the development of this disease, but the risk is higher in women with traumatic childbirth and problems with the pelvic floor. Treatment of the pathology is physiotherapy with active physical exercises. The effectiveness of any treatment methods is assessed individually.

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