|Year : 2019 | Volume
| Issue : 2 | Page : 139-144
Persistence of transient urinary incontinence after delivery in obese women: a cross-sectional study
Doaa M Saleh
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University for Girls, Cairo, Egypt
|Date of Submission||06-Dec-2018|
|Date of Decision||03-Apr-2019|
|Date of Acceptance||20-Jun-2019|
|Date of Web Publication||23-Oct-2019|
Doaa M Saleh
Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University for Girls, Cairo, 11717
Source of Support: None, Conflict of Interest: None
Aim Urinary incontinence (UI) is a prevalent condition that can affect up to 50% of the global female population. Recently, it was reported that obesity can affect the risk of postpartum persistent UI. In this study, we aimed to investigate the risk of obesity on the persistence of postpartum persistent UI.
Patients and methods We conducted a cross-sectional study on 84 obese women and a similar number of control group during their first year after delivery. The Arabic version of the The International Consultation on Incontinence Modular Questionnaire was used. Data analysis was carried out using SPSS version 22 for Microsoft Windows.
Results There were no statistically significant difference between study groups in terms of demographic and clinical characteristics. Concerning UI before urination, the proportion of obese women with UI before urination was significantly higher than the proportion in the nonobese group (54.8 vs. 19%; P<0.001). In addition, there was highly significant difference between two groups in term of stress UI during cough or sneezing (P<0.001). However, there was no significant difference between two groups in terms of UI during sleep and all time UI (P>0.05).
Conclusion This study showed that obesity is a significant, independent risk factor for persistent UI after delivery. Nevertheless, further large-scale studies are still needed to confirm our findings.
Keywords: delivery, obesity, urinary incontinence
|How to cite this article:|
Saleh DM. Persistence of transient urinary incontinence after delivery in obese women: a cross-sectional study. Al-Azhar Assiut Med J 2019;17:139-44
|How to cite this URL:|
Saleh DM. Persistence of transient urinary incontinence after delivery in obese women: a cross-sectional study. Al-Azhar Assiut Med J [serial online] 2019 [cited 2019 Nov 22];17:139-44. Available from: http://www.azmj.eg.net/text.asp?2019/17/2/139/269756
| Introduction|| |
Urinary incontinence (UI) is defined as the involuntary loss of urine in response to a wide range of predisposing factors. The condition is a major public health concern. According to previous epidemiological data, the prevalence of UI may be as high as 50% in the general female population . UI is a troublesome disorder that affects women of all ages, especially who are involved in high impact activities; previous reports indicated that stress urinary incontinence (SUI) negatively impacts mental stress status, social functions, family life, interpersonal relations, and sexual contacts . On the other hand, childbearing and vagina delivery were reported to be significant contributors for the development of postpartum UI. The anatomical injury after vaginal delivery (VD) is one of the main risk factors for pelvic floor dysfunction and subsequent incontinence ; moreover, the pelvic floor dysfunctions may occur as a consequence of impairment in neural control during pregnancy . Though UI during pregnancy and in the immediate postpartum period is transient, a considerable proportion of women were reported to suffer long-term existence of this condition; therefore, it is critical to identify potentially modifiable risk factors for postpartum persistent UI . Multiparity, gestational age greater than 37 weeks, incontinence during pregnancy, and constipation were previously identified as major risk factors for postpartum persistent UI .
Recently, a growing body of evidence has reported that obesity may be one of the main risk factors for the development of SUI . It is postulated that the significant increase in abdominal pressure may lead to subsequent increase in bladder pressure and urethral mobility; in turn, UI disorders and overactive bladder develop progressively. The effect of obesity may even become aggravated by the associated anatomical and hormonal changes in pregnancy and childbirth ,. Nevertheless, the current published literature is insufficient to confirm these findings. Therefore, we conducted the present cross-sectional study to investigate the risk of obesity on the persistence of postpartum SUI.
| Patients and methods|| |
We confirm that this study run in concordance with the Declaration of Helsinki principles and the guidelines of the International Committee of Medical Journal. The study’s protocol gained the approval of the Local Ethics and Research Committee of Alzahra University Hospital and family medicine outpatient clinics. A written informed consent was obtained from every eligible woman before study enrollment.
Study design and patient selection
The present study was a descriptive cross-sectional study that was conducted through the period from January to July 2015. Primiparous women, aged between 18 and 40 years old, who suffered from transient SUI during pregnancy for the first time were included. Eligible women were classified according to their BMI into two groups with equal number of patients: group I which included obese women (postpartum BMI≥30 kg/cm2) and group II which included nonobese women (postpartum BMI<30 kg/cm2). We excluded women with predisposing factors of stress incontinence other than obesity like diabetes, pre-existing stress incontinence before pregnancy, or previous urogynecological surgery. A nonprobability consecutive sampling technique was used to recruit eligible women.
We collected the following data from every participating woman: demographic characteristics, UI during pregnancy, duration since delivery, weight during delivery, lactation status, mode of delivery, complications during labor, and fetal characteristics. Then, each eligible women had an interview to fulfill the Arabic version of the International Consultation on Incontinence Modular Questionnaire (ICIQ). The ICIQ comprises three scored items and an unscored self-diagnostic item. It allows the assessment of the prevalence, frequency, and perceived cause of UI, and its impact on everyday life .
Data entry, processing, and statistical analysis were carried out using Microsoft Excel 2007 (Microsoft Corporation, New York, New York, USA) and statistical package for the social sciences (SPSS Inc., Chicago, Illinois, USA) version 22 for Microsoft Windows. Quantitative data were described in terms of mean±SD, while qualitative data were expressed as frequencies (number of cases) and relative frequencies (percentages). Comparisons between quantitative variables were done using unpaired Student’s t-test for parametric data or Mann–Whitney rank sum test for nonparametric data. χ2-Test was performed for categorical variables. A P value of less than 0.05 was considered statistically significant.
| Results|| |
This study included 84 obese women who have got childbirth 3–12 months and a similar number of nonobese women. The mean age in the obese group was 24.40±4.526 years, while the mean age of the nonobese group was 23.87±4.871 years (P=0.46). Regarding women’s characteristics, there were no statistically significant difference between two groups regarding the mode of delivery, postpartum duration, complications of pregnancy, history of lactations, type of contraceptive method, usage of drugs, or sport activities (P>0.05). Notably, only 30 women in both groups had a history of pelvic floor exercise during pregnancy (P=0.54). [Table 1] shows the baseline demographic and clinical characteristics of the included patients.
Regarding the findings of ICIQ, the average score of Q1 (frequency of UI) was significantly higher in the obese group than the nonobese group (2.4±1.7 vs. 0.93±1.4, respectively; P<0.001); the proportion of women who scored 4 or 5 in the Q1 (frequency of UI) was significantly higher in the obese group than the nonobese group (44 vs. 9.5%; P<0.001). Similarly, greater proportion of obese women had Q2>4 (amount of UI) than nonobese women (36 vs. 12%; P<0.001); the average score of Q2 (amount of UI) was significantly higher in the obese group than the nonobese group (2.2±1.8 vs. 0.86±1.7, respectively; P<0.001). Fifty-four percent of obese women had Q3≥5 (impact of UI on health-related quality of life) compared with 13% in the nonobese women (P<0.001). Overall, the ICIQ score was significantly higher in obese women than nonobese women (8.8±6.4 vs. 3.2±5.1, respectively; P<0.001; [Table 2]). Concerning the frequency of postpartum persistent UI before urination, there was highly significant difference between two groups, as 19% of women in the nonobese group have urgency UI compared with 54.8% in the obese group (P<0.001; [Figure 1]). Similarly, 21.4% of women in the nonobese group had stress UI with coughing or sneezing and 45.2% in the obese group had stress UI with coughing or sneezing (P<0.001; [Figure 2]). Moreover, there was significant difference between two groups in terms of IU during sport as 1.2% in the nonobese group had UI during sport compared with 9.5% in the obese group (P=0.016). However, there was no significant difference between two groups in terms of UI during sleep and all time UI (P>0.05).
|Table 2 International Consultation on Incontinence Modular Questionnaire data of the included women|
Click here to view
| Discussion|| |
The current published literature shows that there are a number of modifiable risk factors for postpartum persistent UI; however, there is a scarcity in the published reports regarding the role of obesity on the persistence of postpartum UI. This study demonstrated that women with BMI higher than 34 kg/cm2 had statistically significant higher frequency and severity of postpartum UI than nonobese women; obese women had higher incidence of urgency UI, SUI, and UI during sport. Moreover, the ICIQ showed that a higher proportion of obese women suffered from negative impact of SUI on health-related quality of life than nonobese women.
Over the past few decades, obesity has been established as an independent risk factor for UI, presumably through its role in elevated bladder pressure and urethral mobility, which predispose to UI disorders. The effect of obesity may even become aggravated by the associated anatomical and hormonal changes in pregnancy and childbirth ,. Our results showed that obesity is a risk factor for postpartum persistent UI; obese women had higher incidence of urgency and stress UI than women without obesity. In concordance with our findings, Rasmussen et al.  reported that obesity is a potent risk factor for several urinary symptoms after pregnancy and delivery, and a substantial number of women still have problems 6–18 months postpartum. Another report showed that readily presented overweight during pregnancy increased the risk of postpartum persistent UI, while weight loss postpartum may be important for avoiding incontinence and regaining continence 6 months postpartum . Ruiz de Vinaspre Hernández et al.  also found that high BMI and weight retention at 6 months postpartum increase the risk of UI, whereas postpartum weight loss decreases the risk of UI even if other UI risk factors coexist. A more recent report showed similar results ,.
Given this significant impact of obesity on UI, it was suggested that weight reduction interventions may reduce the incidence and severity of persistent postpartum UI. A previous randomized, controlled trail by Subak et al.  showed that there is a significant negative correlation between weight loss and the risk of SUI. Another randomized, controlled trial demonstrated the positive effects of weight loss that 5% or greater weight loss leads to a statistically significant improvement in both SUI and quality of life .
Pelvic floor exercises are one of the mainstay conservative measures for the prevention and treatment of UI; the current available evidence shows that pelvic floor muscle exercise helps women with all types of UI, particularly women with SUI . Moreover, it was reported that pelvic floor exercise significantly improves the physical, mental, and social functioning of women with UI . With regard to the role of pelvic floor exercise on postpartum UI, a previous systematic review of the published evidence showed that both antenatal and postpartum pelvic floor exercise led to significant reduction in the incidence of postpartum persistent UI . Despite this established role of pelvic floor exercise, only 19% of the women in the obese group and 15.5% of the women in the nonobese group had undergone pelvic floor exercise, with no statistically significant difference. Such findings call for more effort to raise the awareness about the beneficial role of antenatal and postpartum pelvic floor exercise on the prevention of postpartum UI.
VD can be complicated by perineal tear, due to laceration or episiotomy, and pudendal neuropathy with subsequent nerve dysfunction. On the other hand, cesarean delivery is not associated with perineal damage or stretch injury . Thus, a growing body of evidence has proposed a significant association between VD and increased risk of postpartum UI . However, we found no significant association between the mode of delivery and the proportion of women with persistent postpartum UI in the study groups. Therefore, further investigations are needed to evaluate whether the mode of delivery is an independent predictors of postpartum UI or not.
We acknowledge that this study has a number of limitations. The study was cross-sectional in nature with no follow-up of the included women, so we could not study the change in the SUI frequency and severity over time. Moreover, it was reported that many of the ICIQ items do not reflect the SUI-related effects on the quality of life adequately . Another limitation is that the study was conducted in one center only which may affect the generalizability of our findings.
| Conclusion|| |
This study showed that obesity is a significant, independent, risk factor for persistent UI after delivery. Obese women have a higher risk of persistent UI during different stressful situation and they are more liable to health-related quality of life problems than nonobese women. Nevertheless, further large-scale studies are still needed to confirm our findings.
Doaa M. Saleh shared the concept and design of the study, acquisition of data or analysis and interpretation of data, drafting the article and revising it critically for important intellectual content, and final approval of the version to be published. The authors confirm that the manuscript has been read and approved, the requirements for authorship have been met, and that each author believes that the manuscript represents honest work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Markland AD, Richter HE, Fwu CW, Eggers P, Kusek JW.Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008. J Urol 2011; 186:589–593.
Wesnes SL, Hunskaar S, Bo K, Rortveit G. The effect of urinary incontinence status during pregnancy and delivery mode on incontinence postpartum. A cohort study. BJOG 2009; 116:700–707.
Raz R, Stamm W. A controlled trial of intravaginal oestriol in postmenopausal women with recurrent urinary tract infection. J Obstet Gynaecol (Lahore) 1994; 14:753–756.
Jundt K, Peschers U, Kentenich H. The investigation and treatment of female pelvic floor dysfunction. Dtsch Arztebl Int 2015; 112:564–574.
Viktrup L, Rortveit G, Lose G. Does the impact of subsequent incontinence risk factors depend on continence status during the first pregnancy or the postpartum period 12 years before? A cohort study in 232 primiparous women. Am J Obstet Gynecol 2008; 199:e1–e4.
Wesnes SL, Lose G. Preventing urinary incontinence during pregnancy and postpartum: a review. Int Urogynecol J 2013; 24:889–899.
Bump RC, Sugerman HJ, Fantl JA, McClish DK. Obesity and lower urinary tract function in women: effect of surgically induced weight loss. Am J Obstet Gynecol 1992; 167:392–399.
Noblett KL, Jensen JK, Ostergard DR. The relationship of body mass index to intra-abdominal pressure as measured by multichannel cystometry. Int Urogynecol J 1997; 8:323–326.
Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: A brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004; 23:322–330.
Rasmussen KL, Krue S, Johansson LE, Knudsen HJ, Agger AO. Obesity as a predictor of postpartum urinary symptoms. Acta Obstet Gynecol Scand 1997; 76:359–362.
Wesnes SL, Hunskaar S, Bo K, Rortveit G. Urinary incontinence and weight change during pregnancy and postpartum: a cohort study. Am J Epidemiol 2010; 172:1034–1044.
Ruiz de Vinaspre Hernández R, Rubio Aranda E, Tomás Aznar C. Urinary incontinence and weight changes during pregnancy and post partum: a pending challenge. Midwifery 2013; 29:e123–e129.
Ruiz de Viñaspre Hernández R, Rubio Aranda E, Tomás Aznar C. Urinary incontinence 6 months after childbirth. Med Clin (Barc) 2013; 141:145–151.
Pizzoferrato AC, Fauconnier A, Quiboeuf E, Morel K, Schaal JP, Fritel X. Urinary incontinence 4 and 12 years after first delivery: risk factors associated with prevalence, incidence, remission, and persistence in a cohort of 236 women. Neurourol Urodyn 2014; 33:1229–1234.
Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence: epidemiology and clinical research update. J Urol 2009; 182:S2–S7.
Auwad W, Steggles P, Bombieri L, Waterfield M, Wilkin T, Freeman R. Moderate weight loss in obese women with urinary incontinence: a prospective longitudinal study. Int Urogynecol J 2008; 19:1251–1259.
Price N, Dawood R, Jackson SR. Pelvic floor exercise for urinary incontinence: a systematic literature review. Maturitas 2010; 67:309–315.
Bø K, Herbert RD. There is not yet strong evidence that exercise regimens other than pelvic floor muscle training can reduce stress urinary incontinence in women: a systematic review. J Physiother 2013; 59:159–168.
Harvey MA. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can 2003; 25:487–498.
Leeman LM, Rogers RG. Sex after childbirth: postpartum sexual function. Obstet Gynecol 2012; 119:647–655.
Dabiri F, Yabandeh AP, Shahi A, Kamjoo A, Teshnizi SH. The effect of mode of delivery on postpartum sexual functioning in primiparous women. Oman Med J 2014; 29:276–279.
[Figure 1], [Figure 2]
[Table 1], [Table 2]