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| Your Baby, Your Bladder and Your Bowels | |||||||||||||||||||||||||||||||
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PREGNANCY,
CHILDBIRTH AND INCONTINENCE WHAT
CHILDBIRTH DOES TO THE PELVIC FLOOR
Causes Although there is evidence of denervation of the pubococcygeus muscle in cases of urinary stress incontinence, there is increasing interest in the part played by mechanical trauma and recent work suggests that nerve damage is not a major factor in the development of genuine stress incontinence (2). Some workers, using MRI imaging, point to damage to urethro-pelvic ligaments as a cause (3). However, others claim that urethro-pelvic ligaments do not exist and have found degeneration of the levator ani muscle in 45% of stress-incontinent patients (4). Another study suggests that denervation injury during childbirth might not only cause weakness but lack of synchronisation of the levator ani muscles (5). Faecal incontinence Childbirth is a major factor in faecal incontinence. Research suggests that pelvic and pudendal nerve damage during vaginal delivery leads to progressive denervation of the pelvic floor and eventually to weakness of the pelvic floor and anal sphincter. In Mr Sultan's study of anal sphincter disruptions, 202 women were investigated antenatally and 150 of them again three months after delivery (mean 49 days). Of the 23 who had had Caesareans, none had anal symptoms and there were no new anal sphincter defects. Results from the vaginal deliveries (79 primiparae, 48 multiparae) showed that 13% of primiparae and 23% of multiparae had symptoms of urgency and/or faecal incontinence three months after delivery. In some cases the defects in the internal and external anal sphincters were not new but had existed antenatally. This was so in 40% of multiparae. Only 4% of multiparae developed a new defect. However, in primiparae, 35% developed a new defect after delivery, suggesting that most sphincter damage occurs with the first vaginal delivery. So after vaginal delivery, 13% of primiparae antenatally and 23% of multiparae developed defaecatory symptoms for the first time. Anal ultrasound revealed no sphincter defects among primiparae, but among the multiparae there were five external anal sphincter defects and 13 internal sphincter defects, and 10 had defects in both sphincters - a total of 28 defects. Obstetric factors In this study (6), the only single independent obstetric factor to be associated with sphincter defects was forceps delivery. Data suggests that delivery by vacuum extractor is significantly less likely to cause serious maternal injury compared to forceps (7,8). Mr Sultan added that nerve damage tends to recover with time. Episiotomy There is no evidence for the benefits usually claimed for episiotomies (TABLE 2) and the reali-ties are considerably different (TABLE 3). At best episiotomy may shorten the second stage of labour but it has not been shown to improve perinatal morbidity or mortality, and is related to increased risk of tears to the anal sphincter.
In our study (9), said Mr Sultan, we interviewed 75 doctors and 75 midwives, of whom only 7% (all of whom were midwives) could name the muscles divided during an uncomplicated episiotomy. None of the doctors could name the muscles and one claimed the muscle was the gluteus maximus! There was also considerable inconsistency in defining third-degree tears. "Asked for their views of the training they had received to perform their first episiotomy unsupervised, our respondents felt it was unsatisfactory. Only 20% of doctors thought it was of a good standard. Midwives need to 'see five and do five' and only then are allowed to repair episiotomies, whereas there are no such recommen-dations for doctors." (For recommendations for perineal repair, see TABLE 4.)
"Since at least half of women with a third degree tear still have symptoms after repair (10), it is time for a randomised trial to establish the best perineal repair method," said Mr Sultan.
THE MIDWIFE AND CONTINENCE Midwives have many opportunities to educate women on the promotion of continence, said Maureen Hulme, a freelance midwife educa-tionalist. These range from schools (last year, for example, in the Anglia/Oxford Region, midwives in 13 out of 19 units took part in health education on pregnancy and childbirth to senior schoolgirls [Changing Childbirth Review, 1996]), to the ante-natal booking consultation and the puerperium.
At present midwives have little information on the long-term effects of deliveries. Once mothers are discharged from midwifery care it is rare for midwives ever to hear of them again. This is an area where longitudinal research could provide useful information for clinical practice, said Mrs Hulme. Midwives accept that providing pelvic floor exercises is part of the total package of midwifery care, although teaching is time-consuming and a randomised controlled trial is needed to show that these exercises can help in the promotion of continence. Midwives also need to make sure mothers are doing them correctly. "Mary Dolman, a continence adviser, tells me it is not uncommon to find that women are actually bearing down when they think that they are pulling up the muscles," said Maureen Hulme. Midwives examine mothers for up to 28 days after the birth and routinely ask whether bowel and bladder function are normal. However, there may be a discrepancy between midwives' and mothers' view of what is normal. Some women, having seen their mothers and grandmothers putting up with incontinence after childbirth, may think this is a natural consequence. More detailed questioning may be needed to pick up early signs of incontinence. Many women are embarrassed by the topic and some fear that urine tests will reveal information about sexual activity. EPIDURALS: THE DANGER OF OVERDISTENSION Epidural anaesthesia has been used sporadically as a form of pain relief in labour from the 1960s onwards, said Mr Vic Khullar, Registrar in Obstetrics and Gynaecology at the Whittington Hospital, London. According to a recent survey in South East Thames region, it is used by 15% of women, though the rate between individual units varies from 0-40%. Epidemiological studies suggest that women have fewer symptoms of stress incontinence three months postpartum than women who have used other forms of pain relief, possibly because epidurals may have a protective effect in relaxing the pelvic floor. However, epidural anaesthesia is associated with retention of urine (which in some cases may even become chronic), and bladder distension. As the anaesthetic wears off, bladder sensation is the last sensation to be regained. This means that even though a woman may be able to walk about perfectly normally, she may not be aware that her bladder is full. After an epidural the mean number of hours before women realise they have a full bladder is 6-7 hours, and sometimes 8 or 9 hours. The distension is worsened by the diuresis that occurs during the first eight hours after delivery, which often amounts to over one litre of urine. "We recommend, therefore, that women should be catheterised for eight hours after delivery if epidural anaesthesia has been used," concluded Mr Khullar. Professor Linda Cardozo said this was a particular hobby-horse of hers. She has a number of women referred to her with the worst possible bladder dysfunction and it relates to one single episode of overdistension of the bladder associ-ated with childbirth. Usually these women have had an instrumental delivery or a Caesarean section under epidural and it has gone unnoticed that their bladder is becoming fuller and fuller without it being relieved. "I think this is a very important area where midwives, health visitors and physio-therapists can have a significant impact," she said. In response to questions, Mr Khullar said he thought it was kinder to the woman to have a Foley's indwelling catheter following epidural, rather than intermittent catheterisation. The length of time it takes for an epidural to wear off is not related to the length of time it has been in situ. Professor Cardozo said a bladder that has been seriously overdistended needs to be rested. "Allay the women's anxieties and let her go home and carry on looking after the baby. She should have two weeks of free drainage with a suprapubic catheter before starting a clamping regimen, ensuring that when she does release her catheter she doesn't have more than about 50Oml in her bladder at any time." TREATMENT OF INCONTINENCE "'Squat' toilets are an excellent way for women to exercise their perineum and pelvic floor musclesand control their urinary stream from the age of 2½-3 years onwards. Reports from the developing world suggest that urinary incontinence is much less in women who squat," said Mr Stuart Stanton, Chairman of the Continence Foundation and Consultant Urogynaecologist at St George's Hospital, London. Urinary incontinence sometimes develops in childhood, not just from congenital abnormalities like spina bifida but from subtle changes in collagen. Young girls aged nine or 10 years old can present with symptoms on heavy exercise such as trampolining. We need to reach the school population in our continence education and to realise that children this age can have incontinence. After summarising the extent (TABLE 5) and causes (TABLE 6) of incontinence, Mr Stanton emphasised the need to change women's attitude that urinary incontinence is something to be endured and persuade them to seek treatment. Far too many women put up with incontinence for far too long.
How Can We Prevent Incontinence? Management of labour "Many women doctors and obstetricians in training are electing to have a Caesarean for their first delivery to protect their urinary and anal sphincters. We need to get ahead of this trend because the patients are beginning to think that what's good for the doctors must be good for them too," said Mr Stanton. We need to draw up a risk profile of patients who would benefit from an elective Caesarean and offer this if there is a risk their urinary continence would be compromised by vaginal delivery. "If assistance is needed for a vaginal delivery, ventouse extraction is preferable to forceps," he added. General preventive measures include weight reduction where necessary, and avoiding chronic straining, heavy lifting and constipation.
Pelvic floor exercises "The literature shows some benefit from pelvic floor exercises (PFE) although we don't know their exact role," Mr Stanton said. There are many approaches to PFEs, including isolated muscle exercises, vaginal cones, electronic stimulation and biofeedback. "The difficulty about PFEs is that they're not really proven prior to the onset of stress incontinence, except for use of squat toilets. I don't believe that exercises, however assiduously done, will lead to a cure or improvement rate greater than 70%, and this needs to be explained to the patient." However, PFEs are a good initial substitute for surgery and may well suit some patients so that surgery is never required. "They're ideal if you're deferring surgery, for example between deliveries, but exercises do have to be done regularly and you have to continue with them," he said. "Bladder retraining is useful for certain situations, particularly in patients with uninhibited bladder contractions, namely detrusor (bladder muscle) instability. The aim is to reduce the frequency and urgency by lengthening the time between voids. That involves explanation, a fixed time to void which is gradually lengthened, simple charting, a limit of two litres of fluid a day and perhaps antispasmodic drugs. And, of course, support from nursing, paramedical and medical staff, and the chance to meet a cured patient, are all important aids. " Pads and catheters "Pads are often indicated where incontinence is mild and other methods have failed, and also for the frailer, infirm patient. There are all sorts available. The better pad has a gel and hydrophobic membrane so once urine has escaped on to the pad it doesn't leak back on to the skin. These pads absorb an extraordinary amount of urine and are very good for encouraging mobility in the patient," said Mr Stanton. Tampons Mr Stanton said a simple tampon can be used for the woman who has incontinence under certain physical activities such as playing tennis. When inserted in the vagina it elevates the bladder neck as a space-occupying mass. It should not be used all the time or it will lead to excoriation, but many women manage with these on a daily basis and it is a cheap method. Other vaginal devices One device is like a long bow, with string tags to remove it. When inserted into the vagina it exerts pressure on the posterior part of the urethra. Trials abroad indicate that the device has some appli-cation. [Note: this device is the Conveen Continence Guard from Coloplast.] Vaginal cones These are an excellent form of pelvic floor exercise. They weigh between 20-100 gm and the patient starts with the lightest and has to contract the pelvic floor muscles to prevent the cone being released from the vagina. "The vaginal cone works directly on the pelvic floor muscles - it is no good using the abdominal muscles because that simply extrudes the cone," explained Mr Stanton. Some patients are totally unable to contract their pelvic floor muscles enough to hold in even the lightest cone and for them the device is not of use. But for patients who can contract these muscles and exercise with the cone for at least an hour a day in separate intervals of time, this is a good method and also gives the woman a sense of progress as she graduates from the lighter cones to a higher weight. The success rate ranges from 45%-75% of patients cured or improved, but these exercises do have to be continued and practised daily. Electrified pessaries are also available. They are placed in the vagina to stimulate the pelvic floor muscles, and are switched off when voiding. Urethral devices Mr Stanton showed illustrations of a device which can be placed in the urethra itself. The device is inflated by a simple syringe to anchor it, and has a lip to prevent it being drawn into the bladder. Studies suggest it can lead to a reduction in in-continence but at the expense of urinary tract infection, some discomfort and perhaps migration to the bladder. [Note: this device is no longer available.] Drug Treatment Despite interest in oestrogen to treat urinary disorders, this appears to be of no benefit for stress incontinence, though there is possibly some benefit for urgency, frequency and recurrent urinary tract infection. Oestrogen enhances the quality of life, perhaps making the patient subjectively less aware of stress incontinence or prolapse, but has no benefit for stress incontinence on its own (11). Periurethral Injections A new device which can be used for mild stress incontinence is collagen, available as Contigen from Bard, a purified bovine collagen which is injected round the bladder neck where it prevents premature bladder neck opening (12). The collagen is a protein so patients have to be tested for allergy first. It is injected periurethrally, which can be done as a day case, usually under local anaesthetic. It is bio-compatible and leads to cure or improvement in about 70% of patients. This may decline after about three years but reinjection is possible. SEX AND THE BLADDER Linda Cardozo, Professor of Urogynaecology, King's College Hospital, London, began by stressing how anatomically close the genital and urinary tracts are to each other in adult women. They are separated by only a narrow band of tissue so it is not surprising that sex affects the urinary tract and urinary tract disorders affect sex. Ultrasound study of the lower urinary tract during intercourse shows considerable stretching of the upper vagina and indentation of the blad-der, suggesting that the trauma of sexual intercourse accounts for post-coital urinary symptoms. A variety of urinary problems may be related to sexual dysfunction. The types of urinary incontinence which most commonly cause sexual problems are firstly stress incontinence and secondly detrusor (bladder muscle) instability, although women with the latter have great sexual dysfunction. This may be because they are more anxious or because the detrusor instability is less predictable than sphincter weakness. Other causes of sexual dysfunction include post-coital urethritis or cystitis (often called honeymoon cystitis in younger women). The contraceptive diaphragm is associated with a very high incidence of recurrent urinary tract infection. In the older woman, atrophic changes of vulva, vagina and urethra may be responsible.
In one study, 1:4 incontinent women attending for urodynamic assessment were incontinent when having sexual intercourse - a very high proportion, although the proportion in the general population is not known. The reaction of these women, and sometimes of their partners, is embarrassment, shame, lack of self-esteem and decrease in libido. Incontinence may occur at various different times during intercourse: on penetration, at orgasm or throughout. Pain may be a feature, and may be superficial from the urinary dermatitis or deeper if there is some other pelvic pathology. Generally women with genuine stress incontinence due to weakness of the urethral sphincter mechanism tend to leak during penetration, whereas women with unstable bladders which contract uninhibitedly, like a young child's, tend to leak at orgasm. In a study of 340 women, many took a long time to present for help. 61% took more than two years and nearly one-quarter took more than five years.
Surgery Few studies have addressed the effect of incontinence surgery on sexual intercourse. Colposuspension is currently the most popular operation, but there is a low but noticeable incidence of dyspareunia following this type of operation, which may be related to a change in the angle of the vagina. As one partner put it, he should have been given a map of the new contours! In more advanced reconstructive urology (unless done for cancer), results often show an improvement in sexual intercourse because of the improvement in incontinence. Urinary Catheters These can produce urethral trauma and pain. For preventing sexual problems, clean, intermittent self-catheterisation is preferable to indwelling catheters. Asked about the best positions to use for intercourse when there was urinary incontinence, Professor Cardozo said that so far there is no evidence from a randomised controlled trial. See TABLES 7, 8.
BOWEL PROBLEMS AFTER CHILDBIRTH Ultrasound has revolutionised our understanding of the damage done to the bowel by childbirth and our ability to treat it effectively, said Dr Michael Kamm, Consultant Gastroenterologist at St Mark's Hospital, Harrow. Nerve damage is responsible for only a very small percentage of faecal incontinence related to childbirth, but structural damage is much more common than we realised. Of patients with third degree tears, 85% have persistent structural damage and as many as half have symptoms of faecal incontinence. "When we looked at 62 women with faecal incontinence, for whom the only known predisposing factor was childbirth, 90% had ultra-sonal evidence of structural damage, always in close proximity to the vagina. The internal sphincter was affected in two-thirds of patients, and 60% had evidence of damage to both internal an external sphincters," said Dr Kamm.
To illustrate the problem, he presented the case of a 33-year-old woman incontinent of both liquid and solid stools after a forceps delivery four months previously (forceps delivery is the greatest single predictor of maternal morbidity). The history is important, he stressed. Passive incontinence, ie passing stools without realising it, suggests internal sphincter damage, whereas urge incontinence correlates more closely with external sphincter disruption.
The patient was unable to cope with normal activities, had become quite severely depressed and was unable to look after the baby. The perineal body appeared intact, but Dr Kamm stressed that this can be misleading as it is almost impossible to tell from clinical examination alone whether the deep tissues of the anal sphincter muscles are disrupted. This is why ultrasound examination and anal pressure tests are so important. She was given a surgical anterior overlap repair but was anxious and inhibited about defaecating. To help her regain confidence, she was given pelvic floor biofeedback exercises to retrain her to use her muscles in the normal way. Seven months later the baby is back at home, she can defer defaecation, is continent and has a good intact repair. Women may present soon after delivery with an immediate onset of bowel incontinence, or they may present in middle age. The latter group have either developed symptoms after childbirth but never sought help, or have genuinely developed symptoms for the first time in middle age. The second group also have structural damage but there may be other factors such as hormonal or other changes associated with ageing. Treatment
Results from operative repairs are encouraging, especially in women who present early after childbirth. One study showed an 80% improvement rate after sphincter repairs. When the problem is a simple mechanical one the solution is usually an operation, but loperamide is an excellent drug when there is no structural damage. With some patients there is also a place for drugs, behaviour techniques, physiotherapy, and biofeedback techniques to re-teach women to use their muscles. Constipation One of the less recognised problems of childbirth is the onset of severe constipation afterwards. Though probably not common, this is a very real problem when it occurs. "It may be due to a mixture of factors such as pelvic nerve damage, pain or haematoma, or perhaps the major physical event of childbirth has altered women's understanding of how to undertake these normal physiological processes," said Dr Kamm. "Our approach is to educate the patient in how the normal pelvic muscles should function during defaecation. We use biofeedback, using equipment supplied by Hollister, involving electrodes placed round the anal canal. This is a complex technique and is heavily dependent on therapists. We have an expert team of a clinical psychologist, pelvic floor specialist physiotherapist, specialist nurse and clinical scientist." In answer to questions, Dr Kamm said it was generally better to postpone a repair until child-bearing is complete, but if a repair is wanted before this then a Caesarean delivery would probably be appropriate. On irritable bowel syndrome, he said that patients with this condition often have detrusor instability as well and can be managed effectively with antispasmodics and biofeedback to retrain the muscles. Asked about the effects of an episode of overdistension of the rectum, Dr Kamm said these were probably not very great in adults. THE PHYSIOTHERAPIST'S ROLE There is evidence that pelvic floor exercises (PFEs) are effective, said Jeanette Haslam, Senior Physiotherapist, Chorley & South Ribble Health Authority. One study showed that women who did ante-natal exercises had the strongest pelvic floors postnatally, and that those with the lowest pelvic floor power were the most likely to have stress incontinence (13). A Danish study showed better pelvic floor power after antenatal exercises (14) Another study showed higher postpartum scores for pelvic floor strength among women who exercised antenatally, while women with the lowest scores were those with stress incontinence (15). Finally, Jeanette Haslam cited a very recent major study of over 2,000 women with an over-70% response rate (16). In this study the two factors which directly correlated with not becoming stress incontinent after childbirth were not more than two Caesarean sections, and practising PFEs daily in the third trimester. Giving written and verbal instructions, however, is not enough; as one study showed, 51% of woman are doing the exercises ineffectively and worse still, 25% are actually doing possible harm by bearing down (17). "I urge every health professional who sees a woman's perineum to assess the pelvic floor muscles by asking her to do a quick contraction, and to refer women who can't do it to a physio-therapist," said Ms Haslam. She also recommends teaching women to check the effectiveness of their own exercises (TABLE 9).
To promote continence, antenatal education should include advice on fluids, avoiding and treating constipation, correct posture, lifting and handling, relaxation, pain control and general fitness. Aerobic or jogging-type exercises involving bouncing through the joints should be avoided. Aquanatal exercises are ideal. Jeanette Haslam recommends that postnatal pelvic floor exercises should begin when the patient is pain-free, which will vary between individuals. Pulsed electromagnetic energy and ice packs can help with pain - although the latter cause vasoconstriction, the subsequent vasodilation is useful. Quick flicks of the pelvic floor may help relieve pain and help healing. Bouncing about, sit-up exercises or abdominal exercises which cause bearing down are bad for the pelvic floor. In general, the women we should be particularly concerned about are: CYSTITIS The need to treat cystitis promptly in pregnancy was stressed by Mr Julian Shah, Consultant Urologist and Senior Lecturer in Urology at the Institute of Urology and Nephrology, London. Bacteria multiply very rapidly, doubling every 20 minutes, and it is important to prevent upper urinary tract infection developing or there is a risk of pyelonephritis, pre-eclampsia, hypertension, harm to the fetus and premature delivery. Cystitis occurs in 12% of pregnant women.
He advocated a short, sharp shock of antibiotics. Patients with recurrent urinary tract infection should be allowed to keep antibiotics at home and self-treat when they feel the symptoms. "GPs who say differently are wrong, and you may need to educate them," said Mr Shah. Hygiene is important, and he recommended Angela Kilmartin's treatment of washing the perineum with soap and water after defaecation, followed by filling a Schweppes bottle with water and pouring the contents over the perineum from front to back to wash the bacteria away. Showers or bidets are not nearly so effective, he said. Careful hygiene and early diagnosis and treatment are also important in the puerperium. The more babies a woman has had the more likely she is to suffer urinary tract infection, and the risk increases with catheterisation. Cranberry juice genuinely works for cystitis, perhaps because it acidifies the urine. Finally, said Mr Shah, urinary tract infection is more common in lower socioeconomic groups and these patients need our help with extra counselling. THE PRIMARY HEALTH CARE NURSE'S RESPONSIBILITY "Primary health-care nurses should put continence promotion high on their list of priorities and help reduce the incidence in women of all ages," said Jane Dowse, Continence Adviser for Lifespan NHS Healthcare Trust and Education Officer of the Association for Continence Advice. Many women may feel more inclined to talk to the nurse about incontinence than the GP, and nurses have a vital role in prevention, advice and referral, by asking key questions and taking prompt action to treat the problem.
"If nurses or health visitors do not feel competent to give continence advice because of lack of training, they should seek out that training." Ms Dowse added that the local continence advisory service was usually ready to help both professionals and patients. Health visitors and school nurses "Health visitors have a vital role in encouraging mothers to continue with their pelvic floor exercises, and ensuring they understand how to do these," said Ms Dowse. The postnatal check is another opportunity to pick up any problems with bladder or bowel, and the health visitor can also raise the subject when women bring their babies to clinic or at health education sessions. "Several other speakers have stressed the importance of continence education in schools and school nurses are the key professionals here," said Mrs Dowse. Practice and family planning nurses She also feels the practice nurse and family planning nurse could play a bigger part in promoting continence. Opportunities for early detection, advice and referral can arise particularly during family planning clinics, pre-conceptual consultations and well women clinics, and when giving general health advice. MEDICO-LEGAL AND ETHICAL ISSUES One of the issues which particularly interested the audience was preserving the patient's confidentiality. What if the patient did not want information about her incontinence or sexual problems to be accessible to other health professionals or clerical staff? Susan Parker, Head of Nursing Services at The Medical Defence Union Ltd, said clients should be reassured that "members of the primary care team, as well as administrative staff - who should be bound by a confidentiality clause - will only share such information with their relevant professionals colleagues if, in their clinical judgement, it is necessary." She added that with any procedure, nurses and midwives must ask themselves: "Am I competent to do this?" They will be judged by current knowledge, and ignorance is no defence. THE WAY FORWARD "The key to urinary and faecal continence in connection with childbirth is to be aware of the pelvic floor, but the message has never been put across in a systematic way," said Mr Paul Abrams, Consultant Urologist, Southmead Health Services NHS Trust, Bristol, and Honorary Secretary of the International Continence Society. He suggested a campaign to include loo stickers and leaflets, perhaps with descriptive cartoons, in women's toilets and in schools and sports clubs. Pelvic floor exercises need to be better and more thoroughly taught; he suggests contracting for five seconds then relaxing for 10 seconds, 10 times every hour during the day for six weeks, although starting at a realistic level that the woman can cope with and building up gradually.
We also need to consider how to motivate women to exercise. Many women do not understand what the pelvic floor is, and this should preferably be taught antenatally, with good diagrams and perhaps aids to awareness like the perineometer or vaginal cones to get the woman interested, It is time to review who should repair tears. Should it be a consultant? And, if it involves the anal sphincter or, even worse, the anal canal itself, should a coloproctologist repair this very serious injury? Care on busy postnatal wards needs a protocol to protect the patient from overdistension of the bladder and ensure good bowel care. Midwives should be aware that legal action could result if a patient is left with permanent bladder damage because of urinary retention after epidural anaesthesia. An integrated care plan is needed for the woman who remains incontinent after childbirth. This should involve proper assessment of the pelvic floor and pelvic floor rehabilitation, with surgical intervention a final resort. About one-third of women, if instructed properly, no longer want an operation for stress incontinence.
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