Bryceland, Linda(University of Liverpool (University of Chester), 2007-08)
Objectives To determine obstetric, maternal and fetal variables that increase the risk of postnatal urinary and anal incontinence. To establish how anal and urinary incontinence impact on Quality of Life (QoL) with particular reference to sexual psychology. Finally, to ascertain the extent of disclosure of incontinence problems to partners and health professionals. Design A longitudinal, prospective, repeated measures, cohort study using five data sources. Data was collected in the last trimester of pregnancy, at 6 weeks postnatal, 6 months postnatal and finally at one year postnatal. Setting Wirral University Teaching Hospital NHS Foundation Trust. Participants Primiparous women with no pre-existing disease (N=516). Participants were recruited after a normal 20 week obstetric ultrasound scan. Results Stress incontinence was reported by 39.7% antenatally, 28.2% at 6 weeks postnatal, 31% at 6 months and 26.5% at one year postnatal. Urge incontinence was reported by 23.5% antenatally, 21.2% at 6 weeks, 21.4% at 6 months and 16.4% at one year postnatal. Anal incontinence at one year postnatal was reported by 9.39%. Those participants under the age of 20yrs had higher rates of postnatal urge incontinence (p<.001) possibly associated with increased rates of infection in this group. BMI>30 was associated with higher rates of antenatal stress incontinence but was not significant in the postnatal period. BMI<20 was associated with an increase in postnatal urge incontinence. Prolonged periods of time in labour without bladder emptying was associated with increased rates of both urinary incontinence (OR 2.36) and anal incontinence (p=.026). Forceps delivery was associated with postnatal stress incontinence (OR 2.41). Although caesarean section appeared protective against urinary incontinence initially, long-term data show a progressive increase in reported rates of urinary incontinence even after elective caesarean section. Elective caesarean section was protective for anal incontinence. Faecal incontinence was significantly higher (OR 3.26) in the group who had their labour induced (12.1%) compared to those who had a spontaneous labour (4.6%). Perineal trauma was not associated with anal incontinence. However, it was associated with urinary incontinence throughout the postnatal year with anal sphincter disruption having the highest rates of stress incontinence (p<.005). Birth weight, duration of labour, feeding method, epidural anaesthesia and smoking were not significant. Overall, urinary incontinence appears to be a regressive condition, although the impact on QoL is cumulative and seems to increase over time. Some participants had a progressive, deteriorating condition which appears to be associated with a higher BMI or >6 hours from bladder emptying to delivery of the baby. Urinary and anal incontinence had a detrimental effect on all QoL domains. Those reporting nocturnal enuresis, pain, intercourse incontinence and urge incontinence were effected the most. The greatest impact is on the emotion domain. Only 8.7% with urinary incontinence and 9.7% with anal incontinence discussed their symptoms with a health professional. Discussion with a partner was 32.8% and 21.4% respectively. The most common reasons for non-disclosure were embarrassment, fear of not being taken seriously and not wanting to waste the time of the health professional. Those participants who did disclose tended to have multiple symptoms. Pregnancy and childbirth appear to have a detrimental impact on sexual psychology, irrespective of continence status. Those who reported incontinence appear to have less sexual depression than the continent group suggesting the adoption of defense mechanisms to preserve the sexual Self. Conclusion Generally, urinary incontinence is a regressive condition. Risk factors for a progressive condition have been identified. Younger pregnant women appear to be more prone to infection which can sensitise the bladder and result in long term urinary incontinence. Prolonged periods of time in labour without voiding increases the risk of urinary and anal incontinence and is associated with a deterioration of symptoms over time. Whilst for all other modes of delivery the rate of UI decreased over time, in the elective CS group, the rate of UI increased steadily throughout the postnatal year. These findings support previous studies and suggest a degree of under-recognition or under-reporting of anal sphincter trauma leading to dysfunction. The impact of incontinence on quality of life domains shows clear evidence that the condition has a detrimental impact on many aspects of an individuals well being. Those women reporting intercourse incontinence had the greatest impact on QoL domains. Few women seek help for their condition and a number of personal and organisational factors have been highlighted which contribute to keeping incontinence both secret and taboo. It is clear that what incontinent women think is affecting the way they feel and ultimately their behaviour. Psychological defence mechanisms are employed to justify their inaction.
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