Urinary incontinence during and after pregnancy is very common because pregnancy and the postpartum period are well-established risk factors for urinary leakage. There are two main types of urinary incontinence: urge incontinence and stress incontinence. Although both types of incontinence result in urinary leakage, we need to think of them as being unrelated and distinct because they are treated and managed very differently.
Stress incontinence is not emotional stress, but rather physical stress. Think of the bladder as being like a balloon made out of muscle. Anytime pressure is placed on top of the bladder (or balloon), a little bit of urine will come out down below. This most commonly happens with exercising, lifting, coughing, dancing or laughing. The cause of this is thought to be a slight shift in anatomy, which can occur both during and after pregnancy. Management options for stress urinary incontinence consist of pelvic floor physical therapy, a pessary, Poise Impressa™ or surgical intervention.
Pelvic floor physical therapy is done by physical therapists that specialize in the pelvic anatomy and conditions. They instruct patients using ultrasound, biofeedback and internal examinations to make sure that the pelvic floor exercises are being done effectively. Contracting the correct pelvic floor muscles is not as easy as it might seem, though. It can be like trying to wiggle your ears. The connection between the mind and the muscle needs to be established. Pelvic floor physical therapists act like coaches by teaching you how to contract or relax the pelvic floor muscles as needed. Many people are surprised at how much this helps with post-pregnancy back pain as well.
Another treatment option for stress incontinence is a pessary. A pessary is a vaginal device made out of medical grade silicone. It is placed inside the vagina and puts upward pressure against the urethra to make urine leakage less likely. Pessaries are placed inside the vagina at a doctor’s office, but can be maintained easily at home. They are very low risk and can be left inside the vagina for up to 3 months at a time. Healthy, able-bodied people usually remove, wash and replace the pessary often enough to feel clean, but not so frequently that the device becomes a burden.
The Poise Impressa™ device is a cross between a tampon and a pessary. It has an applicator like a tampon, however, it does not feel like a tampon. The Poise Impressa™ device has silicone arms that spring up and put pressure underneath the urethra, similar to a pessary. This decreases the amount of urine leakage with activity. The Poise Impressa™ device can only stay in for up to 8 hours at a time, similar to a tampon.
The next option for stress urinary incontinence treatment is surgery. There are several different options depending on the person's needs and the surgeon’s skill set. The following surgeries are designed to decrease urinary leakage with activity: mid-urethral mesh slings, fascial slings, peri-urethral bulking agents and the Burch urethropexy. The risks and benefits of each of these surgical procedures vary and should be individualized. The rule of thumb for undergoing anti-incontinence procedures is to wait one year after breastfeeding has been completed. This allows time for your body to return to baseline. The majority of people that experience stress incontinence during or after pregnancy will not leak urine long-term.
The other common type of urinary leakage is urge incontinence. Urge incontinence is when you leaks urine involuntarily with the urge to urinate. You can’t get to the restroom fast enough or simply can’t hold it. Occasionally, you will start to leak urine when pulling down your pants to sit on the toilet. An overwhelming urge to urinate can be triggered by hearing or feeling water running or approaching home after being out for a while. The act of putting the key in the front door can produce a powerful urge to go to the bathroom (key-in-lock phenomenon).
Urge incontinence is first treated with behavioral management. With urge incontinence, the bladder and the brain do not do a good job communicating with each other. As a result, voiding every 2 hours during the day helps keep the bladder empty and can result in a decrease in urinary leakage. Avoiding caffeine and nicotine can also help reduce the urge to urinate. Nicotine affects the bladder muscle and makes it “twitchy” which can cause both urinary frequency and urgency. There is a theory that the habit of going to the bathroom frequently during pregnancy (very normal because a baby is sitting on the bladder) should be continued after delivery. Distraction techniques can also be used in the time in between voids if urinary frequency is a problem. Urinating every 2-4 hours during the day is considered normal.
Once behavioral modification is optimized, medical intervention may be needed. Most medications for urge incontinence take 4-6 weeks to become effective. It is best to wait until after breastfeeding is completed before starting medication. If satisfaction is not achieved after trying several medications, advanced therapies can be considered. Advanced therapies for urge incontinence include Botox injections in the bladder, sacral nerve stimulation (InterStim™) and percutaneous tibial nerve stimulation.
In the time during and after pregnancy, there are a lot of factors at play. Urinary incontinence during pregnancy or immediately after pregnancy resolves in the majority of people. There are many changes associated with pregnancy that contribute to urinary leakage such as hormonal changes, anatomic changes, weight gain and fluid shifts. It takes approximately one year after delivery and/or breastfeeding to go back to baseline. During this time, nonsurgical options are preferred. If you are experiencing leakage, talk to your doctor. Know that there is help if leakage becomes a persistent problem.
But above all, do not feel embarrassed. You are not alone.
Dr. Doyle graduated in 2007 from the University of Texas Medical Branch and completed her OB-GYN residency at the University of Texas Medical Branch in Galveston, TX 2011. Dr. Doyle completed her FPMRS fellowship in 2014 at the University of Rochester and started at the University of Rochester as our newest division member in 2014. Dr. Doyle is building her practice and has special interests in improving the quality of life for cancer survivors with pelvic floor disorders. She is also interested in fellowship research and developing tools to augment FPMRS research.
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