Post-Partum Urinary Incontinence
By: Zara Salman
Incontinence is any bowel or bladder activity that results in lifestyle alterations, emotional changes or feelings of discomfort.
Women usually get incontinence during pregnancy as the baby compresses the bladder. Childbirth places a lot of stress on the vaginal canal and pelvic floor muscles and can also cause nerve damage around the bladder.
Two types of incontinence experienced by women who have been or are pregnant are stress and urge incontinence. Stress is urine leakage after laughing, coughing, sneezing, running, jumping or lifting weights. Urge incontinence is due to an overactive bladder. patients have the sudden urge to go even when the bladder is empty.
The pelvic floor muscle is called the pubococcygeus. This is part of a sling that stretches from the pubic bone to the front of the tail bone and back. It hangs against the bottom of the vagina, bladder, uterus and rectum. When you pee, these muscles relax to allow urine to flow. Tightening the muscle on the other hand closes the lower urethra and keeps urine in the bladder.
There are several different treatment options for this condition.
The most common are pelvic floor muscle exercises, or Kegel exercises. Kegels help to decrease urinary leakage during coughing, laughing or sneezing. One method to locate these muscles, is for a woman to imagine she has a tampon in her vagina that is about to fall out and try to tighten it. Another method is to sit on the toilet, begin urinating, and then stop urinary flow. Making sure the bladder is empty, tighten and hold the muscles for 8 seconds followed by a period of relaxation for 10 seconds. This is repeated 10 times. It is recommended to do them 3 times daily.
A frequently used therapy is biofeedback. Biofeedback, by definition, is a way to visualize or hear things that are happening in the body. An example is checking body weight by using a scale. For incontinence purposes, a computer graph and audible tones show the muscles that are being exercised and their strength. Because it does nothing to the muscles, the patient is in control. The therapist can use this information to set up an individualized exercise program for the patient. Two small sensors are placed on either side of the anus and another pair across the abdomen. The pair on the abdomen are placed to allow the woman to see when she is incorrectly using her abdominal muscle instead of the pelvic floor muscle. There is an average of four sessions 30 minutes in duration. The patient is required to practice at home.
An alternative option is an injection of collagen to the tissues around the urethra. They swell up and close the base of the bladder preventing urine from leaking. Young active women are not candidates for this treatment as the collagen eventually dissolves and is not permanent.
Reconstruction surgery is something to consider if the pelvic tissues or sphincter muscles have collapsed.
A new innovation called the NeoControl chair uses magnetic waves to stimulate strong contractions in the pelvic floor. A 1999 study from the journal of Urology reported some positive findings regarding NeoControl. Researchers at Emory University of Atlanta studied 83 women, aged 35-83 who were diagnosed with stress incontinence. Participants had to use the chair 20 minutes two times a week for 6 weeks. Results found 34% of women who used the chair had no leakage and the overall incidence rate decreased from 3.3 to 1.7 daily.
Medical devices are available that can be inserted into the vagina such as the Kegel fit. These stop bladder leakage by strengthening and toning the pelvic floor muscles through electrical impulses.
A Pessary can also be used. This is a silicon ring placed in the vagina during the day. It supports the pelvic organs.
Bladder sling surgery is the best option for frequent leakage. It is a minimally invasive procedure where the surgeon inserts a U-shaped, mesh sling that permanently supports the urethra. This is not for women who want to be pregnant again.
Another procedure is an abdominal suspension where stitches are placed on both sides of the urethra through a horizontal skin incision on the bikini line. These stitches are attached to a ligament that lies on the pelvic bone. The result is resupport of the bladder or a lift into normal position.
Lifestyle changes are an easy way to help women regain control of their bladder. These changes are to limiting certain foods like caffeine, alcohol, carbonated beverages, and spicy foods which can irritate the bladder and cause it to contract easier. Smoking cessation saves the bladder from nicotine acting on the muscles causing it to spasm. Weight loss decreases the constant pressure on the pelvic floor muscles.
Certain medication have proven to help symptoms of urinary incontinence when used with exercise and behavioral strategies. Medications used to treat urge incontinence are anticholinergics, estrogen replacement therapy (ERT), and tricyclic antidepressants (TCA).
Anticholinergics like oxybutynin and tolterodine work by decreasing bladder contractions and relaxing smooth muscle. The result is an increase in bladder capacity, decreased leakage and increased time between voiding.
Premarin, a conjugated estrogen, functions by restoring the urethral mucosa, increasing vascularity, tone and responsiveness of urethral muscle, and increases alpha adrenergic receptors of urethra. This leads to improved internal sphincter function, decreased incontinence with increased intra-abdominal pressure, decreased irritative voiding symptoms and decreased frequency of urination especially at night.
Tricyclic antidepressants imipramine, nortriptyline, and doxepin, reduce daytime and nighttime leakage.
In addition to ERTs and TCA, medications for stress incontinence include alpha adrenergic agonists pseudoephedrine and antidiuretic hormone. a
In conclusion, even though about one third of women in the United States are affected by this condition, postpartum incontinence is manageable with a variety of treatment options.