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clinmed/2000090001v1 (November 14, 2000)
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Antenatal screening for postpartum urinary incontinence in nulliparous women: results of a pilot study.

Douglas G Tincello MD MRCOG#, Lecturer
Elisabeth J Adams MD MRCOG, Urogynaecology Subspecialist Trainee
David H Richmond MD FRCOG, Consultant Gynaecologist

 

# Department of Obstetrics & Gynaecology, University of Liverpool and Urogynaecology Department, Liverpool Women’s Hospital, Crown Street, Liverpool L8 7SS

 

Corresponding author and address for reprints:

Dr DG Tincello MD MRCOG
University Department of Obstetrics & Gynaecology
Liverpool Women’s Hospital
Crown Street
Liverpool L8 7SS
Tel: 0151 702 4114
Fax: 0151 702 4024

e-mail: tincello{at}liv.ac.uk

 

 

Abstract

Objectives

To examine the utility of joint mobility scoring as a screening test for predicting post-partum urinary incontinence.

Design

Prospective observational cohort study.

Setting

Antenatal clinics and urodynamic clinic of a large tertiary referral teaching hospital.

Participants

150 nulliparous Caucasian women. Women from different ethnic groups and those with a history of prolapse, incontinence surgery or connective tissue diseases were excluded. 103 women were followed up until at least 21 days after delivery.

Main outcome measures

Joint mobility score at 20 weeks. Reported incidence of urinary incontinence at 32 and 38 weeks gestation and postnatally at the end of the study period (42 days). Maximum daily perineal pad use.

Results

Antenatal incontinence occurred in 43.7% of subjects. Postpartum incontinence occurred in 12.6% with a prevalence of 2.9% at study end. Total joint mobility was normally distributed with no differences between continent and incontinent women. Elbow hyperextension (>180° ) was associated with postnatal incontinence at the end of the study (Odds ratio 12.2; 95%CI 1.3, 114.2).

Conclusion

Elbow hyperextension carries an estimated relative risk of postnatal urinary incontinence of 12. The small size of the study necessitates caution in interpretation of this finding, but it appears to have potential value as a simple, independent screening tool for women at high –risk of postnatal incontinence. Confirmation of this finding in a large sample with longer follow up is important and will allow prospective randomised trials to evaluate the benefits of suggested antenatal interventions to be performed on high-risk women.

 

Introduction

Urinary incontinence is reported to affect 40% of women in the community.1,2 Francis3 first examined the incidence of pregnancy related incontinence and found an overall incidence during pregnancy of 53% in nulliparous women, with the gestation of onset equally spread between the three trimesters of pregnancy. 9% of affected women had long-term continence problems following delivery. Recent research has focused on the impact of obesity,4 parity,5 operative vaginal delivery,6 episiotomy, and the duration of labour on the incidence and severity of postnatal incontinence.7,8 The risk of both urinary and faecal incontinence is increased

by a combination of pelvic floor trauma,9 and occult damage to the pudendal nerves.10,11 Caesarean section appears to reduce the incidence of pudendal nerve damage and incontinence,7,8 but only if performed before labour or in the early stages of labour.12 The impact of pregnancy per se has not been examined so thoroughly.

There have been calls for the development of antenatal scoring systems to identify women at high risk of incontinence.13 Identification of high-risk women could provide the opportunity to study the effects of antenatal pelvic floor physiotherapy or even elective Caesarean section. Joint hypermobility is an indirect marker of connective tissue laxity14 and is more common in women with urogenital prolapse.15 A role for connective tissue laxity in the aetiology of pregnancy incontinence, either constitutional or as a result of the relaxing effect of circulating progesterone, is a theoretically attractive concept and joint hypermobility is a simple assessment to make in clinical practice. We formulated the hypothesis that joint hypermobility in early pregnancy would be associated with an increased risk of pregnancy related urinary incontinence. The results of a prospective cohort study of women in their first pregnancy are reported.

Patients & Methods

Consecutive nulliparous women attending an antenatal clinic at 20 weeks gestation were recruited. Basic demographic data were recorded including age, height, weight, general health and medical history. Women were asked to detail any pre-pregnancy or current pregnancy incontinence and any family history of uterovaginal prolapse or urinary incontinence. Women known to have connective tissue disease or those of non-Caucasian origin were excluded.

Joint mobility score (JMS) was calculated by scoring 5th metacarpophalangeal joint extension, abduction of the thumb, elbow hyperextension and the ability to touch toes, according to the method of Beighton.14 Details of the scoring system are summarised in Table 1.

Women were reviewed at 32 and 38 weeks gestation and again at 3, 7, 21 and 42 days following delivery, either in person or by telephone. A history of urinary incontinence (involuntary urinary leakage after coughing, sneezing or similar activity) and pelvic floor muscle exercise (PFME) was sought from the patient and the frequency of leakage and exercise recorded. The number of perineal continence pads used was also recorded. Significant urinary leakage was defined as leakage more than once a day requiring more than one perineal pad per day to control.

We did not attempt to obtain urodynamic diagnoses or objective measures (pad tests) in any of the recruited women because we considered that recruitment and symptom reporting would be adversely affected by the inclusion of a cystometry confirm the diagnosis. Secondly we have found that subjective measures and quality of life issues are regarded as the most significant variables among patients, nurses and medical staff involved in continence care (unpublished data). Delivery details were extracted from the hospital notes. The information recorded included gestation at delivery, mode of delivery, perineal trauma or episiotomy, induction of labour, epidural use, length of first and second stage, and birthweight. All women gave informed written consent to participate and the local authority ethics committee approved the study.

Sample size calculations were based on an assumed incidence of antenatal incontinence of 55%.3 Hypermobility occurs in approximately one third of our hospital population (unpublished data). To detect an increase in incidence to 75% among the women with hypermobility would require 147 subjects at 80% power.16 This sample size would also detect an increase of postnatal urinary incontinence from 24%7 to 50%.

Data were stored and analysed using the SPSS software package, version 9 (SPSS Inc., Chicago). Data are presented as mean (SD) or median (range). Data were compared by t-test, Mann-Whitney U test, Kruskall-Wallis test or Chi square test as appropriate. Univariate odds ratios for postnatal incontinence were calculated for potentially relevant variables (data not shown). The variables examined were: JMS (total and components of the score), family history of incontinence/prolapse, body mass index (BMI), antenatal PFME, induction of labour, maternal age, epidural for pain relief, birthweight, length of first and second stages, mode of delivery, forceps or ventouse delivery, any vaginal delivery, and episiotomy. Variables with significant univariate odds ratios were included in stepwise backward logistic regression analyses with postnatal incontinence as the dependent variable.

Results

150 nulliparous women were recruited at a median of 20 weeks (16-26). 39 women (26%) withdrew before delivery, and eight women (5.3%) withdrew before day 21 visit. These data from these women are not included in the analysis. Basic demographic and obstetric details of the subjects are shown in Table 2.

45 women (43.7%) reported antenatal urinary incontinence which resolved in 93% of women. 20 (19.4%) women reported significant leakage with a median daily frequency of leakage episodes of 3 (2-7) and median maximum daily pad use of 1 (0-7). 13 women (12.6%) reported postnatal incontinence but only 3 women (2.9%) had significant leakage at the end of the study. The changes in incontinence during the study are indicated in the flowchart, see Figure 1:



31 women (20.7%) performed PFME before conception. PFME were performed by 67 women (44.7%) during pregnancy, more than once a day by 22 women (14.7%).

JMS at recruitment was normally distributed with a mean of 4.8 (± 2.0). No differences in mean JMS were detected between continent and incontinent women (data not shown). 28 (27%) women had elbow hyperextension (a component of total JMS).

Univariate analysis identified pre-pregnancy incontinence as a significant risk factor for antenatal incontinence (OR 8.9, 95% CI 1.0 to 78.6). A history of incontinence before pregnancy, elbow hyperextension (>180° ), and vaginal delivery were significantly associated with postnatal incontinence in univariate analysis. Logistic regression showed elbow hyperextension to be associated with a significantly higher risk of postnatal incontinence in the whole group (OR 12.2, 95% CI 1.3 to 114.2) and in the vaginal delivery group (OR 11.6, 95% CI 1.2 to 110.0). Vaginal delivery was identified as a significant risk factor but the OR was infinite, because all cases of incontinence occurred in the vaginal delivery group.

Discussion

This study supports the findings of others that the incidence of antenatal urinary incontinence is common, affecting between 30% and 50% of women.3,17 All published studies have demonstrated that antenatal incontinence resolves in the majority of women and the prevalence of postpartum incontinence is of much greater significance in terms of potential morbidity.

Our data demonstrated a lower incidence of postpartum urinary incontinence than the work of others (12% to 38%)7,18 although Chaliha et al19 also showed a 5% incidence of new postnatal incontinence. We were unable to demonstrate the previously documented associations of forceps delivery,6 perineal trauma, high birthweight20,21 and prolonged second stage in our study,7,8,13 probably as a consequence of the small sample. An association with vaginal delivery was demonstrated. None of our patients who were delivered by Caesarean section reported postnatal incontinence.

A significant association between elbow hyperextension and the risk of developing postnatal urinary incontinence independent of any recognised risk factors was demonstrated. The assessment of elbow hyperextension is extremely simple to perform and identifies women with an estimated 12-fold increased risk of postnatal incontinence. We recognise that the confidence intervals of the relative risk are wide, and advise caution in estimating the magnitude of the association we have identified.

This finding is in contrast to the work of Chaliha et al19 who used joint hypermobility to screen for urinary and faecal incontinence and found no associations with either condition. However, they concentrated on the total score and did not examine each component separately. Our data for total joint mobility score is identical to theirs, with a comparable normal distribution in the continent and incontinent women.

An explanation of the association between elbow hyperextension and postnatal incontinence is difficult to derive. There must be a generalised laxity of connective tissue represented by elbow hypermobility which increases the impact of the trauma of delivery. Although increased tissue laxity may be thought to allow easier passage of the fetus through the vagina, it will also allow greater stretching of the pudendal nerves and increase the likelihood of long term damage, which is thought to be a major component in the aetiology of incontinence.11,12 It is unclear whether elbow hyperextension at 20 weeks gestation represents an inherited laxity of tissue or one acquired secondary to the connective tissue remodelling effects of relaxin and progesterone.22

If it is now possible to screen for increased risk of postnatal incontinence, one is left with the difficulty of managing these patients. The options which have been suggested include properly taught pelvic floor physiotherapy performed antenatally,7 or elective Caesarean section to avoid injury to the pudendal nerves and pelvic floor.13 Elective abdominal delivery is known to avoid occult damage to the anal sphincter but other factors such as operative morbidity, cost and long term quality of life must also be considered. A small randomised trial of antenatal physiotherapy demonstrated a reduction in postpartum symptoms for up to six months.23 Unblinded studies of PFME have shown a reduction in postnatal incontinence and an increase in pelvic floor muscle strength.24,25 It remains to be seen whether PFME are effective at reducing postnatal incontinence in high risk women. Large randomised controlled trials of antenatal physiotherapy and other prophylactic interventions are needed in order to answer these questions.

In conclusion, we have demonstrated that elbow hyperextension in the second trimester is a simple, easily performed, and potentially sensitive screening test for postnatal urinary incontinence. There is now an urgent need to confirm these findings in a larger group of women with longer follow up and then to develop evidence based principles of management for patients found to be at high risk of postnatal urinary incontinence.

 

Word count: 1,687

Authorship

Douglas Tincello designed the research study, obtained ethical committee approval, recruited patients, analysed the data and wrote the manuscript. He is guarantor of the study. Elisabeth Adams recruited patients, assisted in data analysis, and was involved in writing and revising the manuscript. David Richmond contributed to design of the research study, data analysis and revision of the manuscript.

Katie Booth contributed to the study by assisting with recruitment, data collection and patient follow up. Vicky Cording assisted by collecting delivery details from the hospital notes.

 

Source of funding

None

Conflict of interest

None

 

References

1. Jolleys JV. Reported prevalence of urinary incontinence in women in a general practice. BMJ 1988; 296: 1300-2.

2. Locher JL, Burgio KL. Epidemiology of incontinence. In: Ostergard DR, Bent AE, eds. Urogynecology & Urodynamics Theory & Practice, 4th ed. Baltimore: Williams & Wilkins, 1996: 67-73.

3. Francis WJA. The onset of stress incontinence. J Obstet Gynaecol Brit Emp 1960; 67: 899-903.

4. Rasmussen KL, Krue S, Johansson LE, Knudsen HJ, Agger AO. Obesity as a predictor of postpartum urinary symptoms. Acta Obstet Gynecol Scand 1997; 76: 359-62.

5. Marshall K, Thompson KA, Walsh DM, Baxter GD. Incidence of urinary incontinence and constipation during pregnancy and postpartum: survey of current findings at the Rotunda Lying-In Hospital. Br J Obstet Gynaecol 1998; 105: 400-2.

6. Meyer S, Schreyer A, De Grandi P, Hohlfeld P. The effects of birth on urinary continence mechanisms and other pelvic-floor characteristics. Obstet Gynecol 1998; 92: 613-8.

7. Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol 1996; 103: 154-61.

8. Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol 1998; 105: 156-61.

9. Sultan AH, Kamm MA, Bartram CI, Hudson CN. Anal sphincter trauma during instrumental delivery. Int J Gynaecol Obstet 1993; 43: 263-70.

10. Sultan AH, Hudson CN. Anal-Sphincter Disruption During Vaginal Delivery. New Eng J Med 1993; 329: 1905-11.

11. Sultan AH, Kamm MA, Hudson CN. Pudendal nerve damage during labour: prospective study before and after childbirth. Br J Obstet Gynaecol 1994; 101: 22-8.

12. Fynes M, Donnelly VS, O'Connell PR, O'Herlihy C. Caesarean delivery and anal sphincter injury. Obstet Gynecol 1998; 92: 496-500.

13. Sultan AH, Stanton SL. Preserving the pelvic floor and perineum during childbirth - elective Caesarean section? Br J Obstet Gynaecol 1996; 103: 731-4.

14. Beighton P, Grahame R, Bird H. Joint hypermobility: Methods of quantification and epidemiology. Orthopade 1984; 13: 19-24.

15. Norton PA, Baker JE, Sharp HC, Warenski JC. Genitourinary prolapse and joint hypermobility in women. Obstet Gynecol 1995; 85: 225-8.

16. Altman DG. Clinical Trials. In: Altman DG, ed. Practical Stastistics for Medical Research, 1st ed. London: Chapman & Hall, 1991: 440-476.

17. Stanton SL, Kerr Wilson R, Grant Harris V. The incidence of urological symptoms in normal pregnancy. Br J Obstet Gynaecol 1980; 87: 897-900.

18. Morkved S, Bo K. Prevalence of urinary incontinence during pregnancy and postpartum. Int Urogynecol J 1999; 10: 394-8.

19. Chaliha C, Kalia V, Stanton SL, Monga A, Sultan AH. Antenatal prediction of postpartum urinary and fecal incontinence. Obstet Gynecol 1999; 94: 689-94.

20. Hojberg KE, Salvig JD, Winslow NA, Lose G, Secher NJ. Urinary incontinence: prevalence and risk factors at 16 weeks of gestation. Br J Obstet Gynaecol 1999; 106: 842-50.

21. Groutz A, Gordon D, Keidar R, Lessing JB, Wolman I, David MP, et al. Stress urinary incontinence: prevalence among nulliparous compared with primiparous and grand multiparous premenopausal women. Neurourol Urodyn 1999; 18: 419-25.

22. MacLennan AH, Nicolson R, Green RC. Serum relaxin in pregnancy. Lancet 1986; ii: 241-3.

23. Sampselle CM, Miller JM, Mims BL, Delancey JO, Ashton-Miller JA, Antonakos CL. Effect of pelvic muscle exercise on transient incontinence during pregnancy and after birth. Obstet Gynecol 1998; 91: 406-12.

24. Morkved S, Bo K. The effect of post-natal exercises to strengthen the pelvic floor muscles. Acta Obstet Gynecol Scand 1996; 75: 382-5.

25. Morkved S, Bo K. The effect of postpartum pelvic floor muscle exercise in the prevention and treatment of urinary incontinence. Int Urogynecol J 1997; 8: 217-22.

 

What this paper adds

Work in recent years has identified pregnancy and childbirth as major risk factors for subsequent urinary incontinence. Specifically, vaginal delivery, operative delivery and a prolonged labour all increase the risk of postnatal urinary incontinence. Less is known about whether there is a constitutional factor or factors which may predispose individuals to increased risk independently from the trauma of delivery. Effective interventions for the treatment of incontinence are available but there is little evidence to confirm their effectiveness at prevention. A method of identification of "high-risk" individuals has been advocated to allow appropriate interventions be offered.

This study has identified elbow hyperextension (>180°) as a potentially useful screening tool for the identification of women at high risk of postnatal incontinence. Confirmation of these data is required in a larger study. The use of this screening tool will allow prospective trials of available and novel interventions to be performed. The efficacy and cost effectiveness of these interventions as prophylaxis can then be assessed, and resources can be targeted against the women at highest risk.

Table 1 Scoring system for joint hypermobility

 

Score

 

0

1

2

3

5th Metacarpo-phalangeal joint

30° or less

31-60°

61-90°

More than 90°

Approximation of thumb-tip to radius with wrist flexed

More than 10 cm

6 –10 cm

0- 5 cm

Touching

Elbow hyperextension in supination

Up to 180°

More than 180°

--

--

Toe touching with knees extended

Fingertips to mid shin

Fingertips to ankles

Touching toes

Palms flat on floor

After Beighton et al14. Maximum score is 10; 7 or more represents hypermobility.

 

Table 2. Demographic details of patients recruited

 

Mean (± SD), or no (%)

Age

26.4 (± 5.6)

Family history of incontinence

19 (12.6)

Family history of prolapse

8 (5.3)

Body mass index

 

< 20

18 (11.9)

20-24

73 (48.3)

25-29

38 (25.2)

>30

20 (13.2)

Unknown

2 (1.3)

Mode of delivery:

 

Spontaneous vaginal

92 (60.9)

Forceps

9 (6.0)

Ventouse delivery

25 (16.6)

Elective Caesarean section

2 (1.3)

Emergency Caesarean section

22 (14.6)

Birthweight (kg)

3.466 (± 0.496)

Induction of labour

33 (21.9)

Epidural in labour

65 (43.0)

Episiotomy

43 (28.5)

 





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