Urinary incontinence in women after childbirth: reasons for how to treat

Urinary incontinence after childbirth is an important and often missed form of maternal morbidity. This pathology can be both in pregnant women, and after the birth of a child, but in the second case, treatment can be more difficult. It is important that every woman knows the main causes and risk factors of this pathology.

Epidemiology

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

[1], [2], [3],

Causes of the urinary incontinence after childbirth

There are various reasons why a woman can suffer from urinary incontinence after childbirth. The muscles of the bladder can be weakened after permanent stretching of the pelvis during pregnancy. This causes the urethra to lose control while holding the urine.

Urinary incontinence is often associated with vaginal delivery, especially with the first vaginal birth. Many clinical studies have attempted to detect a special obstetric event that causes urinary incontinence. The obvious cause may be large children and "difficult births", which are complicated by surgical interventions. Prolapse of the pelvic organ (cystocele, rectocele and uterine prolapse) and anal incontinence are also complications of physiological birth.

Each woman should have sufficient information to determine which set of risks she prefers for herself and her child. In the general situation, when there is no additional risk for the child, obstetric tactics should focus on reducing maternal morbidity, including postpartum urinary incontinence. Young mothers are likely to benefit from routine screening of symptoms and an early discussion of healthy bladder habits and proper muscle methods as part of their postpartum care. Obstetrical care should include an assessment of the maternal outcome of this birth, including the full range of pelvic floor injuries that are known to be associated with childbirth.

Therefore, the causes of this pathology are most often limited to pathology in childbirth. If a woman has an epidural or spinal anesthetic, then it can cause sensations of numbness of the bladder. This can last several hours after anesthesia or several days. In the first few hours after birth, a woman will not be able to accurately sense all organs, both because of anesthesia, because of the very process of delivery. The presence of a catheter in a caesarean section may make it difficult to control the bladder and may be one of the reasons for further complications.

The main causes of urinary incontinence after childbirth can be identified as follows:

1. The pelvic nerves that control the function of the bladder can be injured during prolonged or severe vaginal delivery.
2. childbirth with forceps can lead to pelvic floor injuries and anal sphincter muscles.
3. prolonged depression during vaginal delivery also increases the likelihood of pelvic nerve damage and bladder control problems that may follow.
4. vaginal physiological births (although even women who have chosen a cesarean section may be prone to incontinence);
5. invasive application of instruments in childbirth.

[4]

Risk factors

The risk factors for this disease are as follows:

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

[5], [6], [7]

Pathogenesis

The pathogenesis of urinary incontinence after childbirth, as a frequent problem, consists in the features of the structure and innervation of urine.

The sphincter of the bladder is the muscular valve located on 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. Usually every 2-4 hours - a woman should urinate. Drinking beverages with caffeine, products using artificial sweeteners, acid products and alcohol can irritate the bladder and make it go more often, so avoiding can help control the urgency and reduce the frequency. The sphincter of the bladder relaxes when the urinary bladder is filled with urine, and the sphincter muscles help keep the bladder closed until you are ready to urinate. Other body systems 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 be emptied. All these nerves and muscles must work together so that the bladder can function normally.

During pregnancy, the expanding uterus puts pressure on the bladder. Muscles in the sphincter of the bladder and in the pelvis can be overloaded with additional stress or pressure on the bladder. Urine can leak from the bladder when there is additional pressure, for example, when doing sports or any movements.

[8], [9], [10],

Symptoms of the urinary incontinence after childbirth

Pregnancy comes with a share of joys and discomfort. One of such 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 under stress. Urinary incontinence when coughing, when sneezing after childbirth, refers to stress factors that can provoke a sphincter relaxation. Such stress factors primarily affect the innervation of the bladder, and then there is an involuntary discharge of urine. A healthy functional pelvic floor has a balance between the ability to contract and the ability to relax. The pelvic floor, which is too relaxed or too compressed, is dysfunctional and can cause such symptoms.

Another kind of incontinence is under the influence of physical activity. Urinary incontinence during jumping or during physical exertion 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 on the background of the stimulus. A woman can skip urine when she coughs, sneezes, laughs or moves fast. The amount of urine can vary from a few drops to a sufficient amount. The first signs appear more often immediately after childbirth. If you miss a small amount of urine in the first days after birth, do not worry, as this can normalize in the first few days. If this is observed for several weeks, then this is a serious pathology.

Complications and consequences

The consequences and complications of untimely seeking help can be serious. This can lead to the fact that women feel lonely and isolated, affect relationships and careers, and may be an obstacle in having sex.

[11], [12], [13]

Diagnostics of the urinary incontinence after childbirth

Gynecological or proctologic examination can diagnose the causes and type of incontinence in order to provide targeted treatment and prevent incontinence.

Diagnosis should begin with an anamnesis. And every doctor should remember that not every woman can make complaints about urinary incontinence. Some patients may simply not say these symptoms, considering them normal, or they may just be embarrassed. Therefore, the doctor on examination should ask the woman about the possible symptoms. If a woman talks about the presence of symptoms of incontinence, you need to find out under what conditions it occurs and how long it lasts.

Analyzes should be carried out necessarily to exclude infection of the urinary tract. It is compulsory that a woman should pass a general urine test that allows to exclude infection and localize the pathological process, for example, to clarify the process in the bladder or in the kidneys. Also, laboratory tests should include serum creatinine, which can be increased if there is urine retention (overflow vesicle) caused by obstruction of the bladder outlet or denervation of the detrusor.

Instrumental diagnostics is also carried out to exclude associated conditions. For this purpose, most often begin with ultrasound diagnosis. This method allows you to determine whether there are changes in the bladder and kidneys, and whether there are abnormalities on the part of the uterus.

[14], [15], [16], [17]

Differential diagnosis

Differential diagnoses of urinary incontinence are diverse. Sometimes there is more than one factor contributing to the further complication of diagnosis and therapy. It is necessary to distinguish these different etiologies, since each condition requires another, but often overlapping, therapeutic approach. Urinary incontinence after childbirth needs to differentiate with urinary tract infection and cystitis in women. It is also necessary to exclude multiple sclerosis, neoplasms of the spinal cord, birth injuries of the spinal cord and concomitant diseases, spinal epidural abscess, vaginitis.

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

Symptoms and signs of a urinary tract infection are: urination disorder, frequency of urination, discomfort in the bladder area, side pain and sensitivity in the musculoskeletal area (may be present with cystitis), fever, chills and malaise. The main differential sign of urinary tract infection is the detection of pyuria or changes in the general urine analysis. Therefore, with incontinence, a urinalysis is always performed, and if there are changes, this indicates an infection.

Urinary incontinence in the postpartum period can be due to various pathological processes of the spinal cord, including trauma. Regardless of the pathogenesis, this can lead to a significant impairment of motor, sensory or autonomic function. Therefore, in the presence of any similar symptoms, it is necessary to exclude a spinal cord injury.

Vaginitis (inflammation of the vagina) is the most common gynecological disease that occurs in the office. This is a diagnosis based on the presence of symptoms of abnormal discharge, vulvovaginal discomfort. Every day, a woman from the vagina releases mucus as a way to maintain a normal healthy environment. Change in quantity, color or smell; irritation; or itching or burning can be caused by an imbalance of healthy bacteria in the vagina, which leads to vaginitis. Pronounced symptoms of vaginitis can cause frequent urination and incontinence. Studies that can be performed in cases of suspected vaginitis include sowing on flora from the vagina. Therefore, when incontinence is also recommended to conduct this study for the purpose of differential diagnosis.

[18], [19], [20], [21], [22], [23]

Treatment of the urinary incontinence after childbirth

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

Since this problem does not have any violations in its development at the biochemical level, the drugs are not used.

The first thing to consider in this issue is dietary changes.

Some foods and drinks are believed to contribute to bladder incontinence. Such products include: alcoholic drinks, carbonated drinks (with or without caffeine), coffee or tea (with or without caffeine). Other changes include consuming less liquid after dinner and enough fiber to avoid constipation. Also, avoid drinking too much.

If some mothers also smoke after birth, the researchers still prove the connection between incontinence and smoking cigarettes. Therefore, this factor should be deleted.

Pessary is the most common device used to treat urinary incontinence. This is a hard ring that the doctor or nurse inserts into the vagina. The device is pressed against the wall of the vagina and urethra. This helps reposition the urethra to reduce leakage of urine under tension.

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

Vitamins can only be used for the doctor's prescription, given that the woman is breastfeeding.

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

In gynecological applications, electrotherapy can ideally complement traditional physiotherapy. It should only be used after delivery. This therapy supports the stability of the pelvic floor and the controlled coordination of the sphincters of the urethra and pelvic floor muscles. The electrotherapeutic device sends electrical impulses to stimulate the nerve cells and strengthens the muscles of the pelvic floor and bladder, which were strained during childbirth. A small electrode is inserted into the vagina to send electrical impulses to the muscles of the pelvic floor. The electrode can also be attached to the skin to stimulate the pelvic floor.

The electrotherapy device also allows combining biological feedback and electrical stimulation. This is called electrostimulation, caused by EMG. The patient should actively contract the muscles of the pelvic floor, and electrostimulation provides an additional electrical impulse when reaching a predetermined threshold. The goal is to constantly increase this threshold until the patient can fully compress the muscles without support.

Alternative therapies and homeopathy have little evidence of effectiveness, so they are used very rarely.

Surgical treatment is most effective for people with stress incontinence who have not been helped by other methods of treatment.

The most effective and initial stage of treatment can be physical exercises. Exercises for urinary incontinence after childbirth that have proven effectiveness are Kegel exercises. The main principle of the action of such exercises is training the control of the muscles, performing the exercises every day. It is proved that they treat and prevent incontinence.

You can start doing exercises shortly after the birth of your child. Kegel exercises also help blood circulation around the vaginal area (perineum), and this will help any swelling, bruising heal. If you stop exercising, your muscles may weaken over time, and the symptoms may recur.

How to do Kegel exercises to strengthen the pelvic floor?

Make sure that you are relaxed and breathe freely, with your stomach raised, when you inhale, and with the stomach pulling in when you exhale. Together with the inhalation you have to squeeze the muscles of the press and the pelvic floor. You should feel the compression around your vagina and anus. Try not to tighten the buttocks or upper abdominal muscles, and make sure that you do not hold your breath, but breathe smoothly. Do not worry if you can not hold the compression for long. Gradually increase the time when you squeeze the muscles of the pelvic floor. Try to hold the squeeze for four or five seconds.

Regularly practicing the exercises, you must hold the squeeze for 10 seconds with normal breathing. Rest and wait at least 10 seconds before squeezing again. Women who perform Kegel exercises regularly, can get the first results in four to six weeks.

Prevention

Prevention of this problem still exists. Although you can not do anything to solve the problem itself, there are simple measures that you can apply to avoid incontinence. Here are a few measures that can be used to prevent stress incontinence after childbirth:

1. Doctor's assessment:

Allow your doctor to carefully examine you after giving birth and examine your condition to manage any chance of urinary tract infection.

2. Kegel exercises are useful not only during pregnancy, but also help to strengthen the pelvic muscles after childbirth and can prevent incontinence at every next pregnancy.

Women should try to stay in shape and perform Kegel exercises even before the birth to help prevent urinary incontinence. Kegel exercise is the basic exercise that can be done at any time and anywhere. What you are trying to do is isolate your pubococcygeus muscles and hold them in the squeezing position, count for 3-5 seconds, let go and relax for 5 seconds. You must do this in 5 repetitions a day.

[24], [25], [26], [27], [28], [29]

Forecast

The prognosis of recovery in this pathology is higher in young women after the first birth. In 7% of new mothers, the symptoms are eliminated immediately after the beginning of the complex treatment. But even complex treatment was inadequate for many mothers who give birth repeatedly.

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

[30], [31], [32]