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risk factors for urinary incontinence relevant to women

director: Diane K. Newman, RNC, MSN, CRNP, FAAN

Pregnancy and Childbirth

The urinary system may change during pregnancy in ways that affect urinary control in some women. Trauma (injury) during and after delivery of a baby, from stretching or compression of the pelvic floor muscles, can cause damage to the pudendal and pelvic nerves that serve the pelvis, uterus and bladder. A woman who has had one vaginal birth is more than two and a half times as likely to report stress or urge urinary incontinence. Even during a first pregnancy, 50 percent of women experience problems with bladder control, especially during the third trimester. These problems often become more pronounced with each successive pregnancy. 

The greatest damage from delivery of the baby through the vagina (vaginal delivery) occurs during the second stage of labor. When the baby’s head encounters the muscles of the pelvic floor, the mechanical process of stretching and compressing the nerves to the bladder, urethra and pelvis causes nerve damage. Depending on the size and weight of the baby and length of labor, damage occurs to the soft tissue of the muscle and nerves and may cause tears in ligaments that support the urethra and bladder muscles. As baby’s head crowns, the significant downward pressure further stretches the nerves.

Episiotomies, anesthesia and the use of forceps all may cause incontinence. Urinary incontinence that begins after delivery usually stops in the next 3-6 months, however, it may recur and persist after additional pregnancies.  Women often report difficulty with contracting their pelvic muscles after childbirth.

It has been suggested that elective cesarean delivery would significantly decrease, but not eliminate, the conditions of pelvic organ prolapse and urinary incontinence. Unlike health care services in countries such as Great Britain and France, the U.S. health care system does not promote pelvic muscle rehabilitation immediately after childbirth, although the data strongly suggests that this is a crucial time when pelvic floor muscle and nerve damage occur. 

Sampselle, CM, Miller, JM, Mims, BL, Delancey, JOL et al. (1998) Effect of Pelvic muscle exercise on transient incontinence during pregnancy and after birth.Obstet & Gynecol;91(3):406-412.

Thom, DH, Van Den Eeden, SK, Brown, JS. (1997) Evaluation of parturition and other reproductive variables as risk factors for urinary incontinence in later life.Obstet & Gynecol;90(6):983-98.

Menopause

Menopause is a risk factor for urinary incontinence since decreasing estrogen levels can cause  weakness in the bladder, urethra and pelvic muscles. Sensitivity and responsiveness to estrogen have been found in cells of the pelvic muscles and in other tissues of the pelvic area. While these findings may suggest that replacing estrogen could cure or lessen incontinence, studies have not supported this hypothesis. Weakness in the walls of the urethra prevents a “tight seal” from forming and stress urinary incontinence can occur. During and after menopause, many women complain of urgency (strong urge sensation to urinate), frequency (urinating more than 8 times a day, dysuria (difficulty urinating) and UI. The use of estrogen pills, vaginal estrogen cream or a vaginal ring may decrease urine leakage and relieve bladder symptoms for many women.

Brown, JS, Seeley, DG, Fong, J., Black, DM, Ensrud, KE, Grady, D. (1996) Urinary incontinence in older women: who is at risk? Obstet Gynecol;87:715-21.

Fantl JA, Bump, RC, Robinson, D, McClish DK, & Wyman, JF (1996) Estrogen therapy in the  management of urinary incontinence.  Obstetrics & Gynecology. 88(1), 12-18.

Pelvic muscle weakness

Pelvic muscle weakness in women can cause pelvic organ prolapse. Relaxation of the pelvic muscles increases rapidly after menopause and may progress with aging, in general. Even with estrogen hormone replacement after menopause, continued pelvic relaxation can occur. It is unknown whether the change in pelvic muscles during aging is related to earlier nerve damage caused by vaginal delivery or to other diseases and problems.

Women who have pelvic organ prolapse may develop a cystocele (dropped bladder) or uterine prolapse (dropped uterus), may complain of urinary urgency and frequency, describe a dripping or bulging feeling in their vagina, or feel as though they are sitting on a tennis ball. Childbirth, heavy lifting, and chronic straining during bowel movements may contribute to pelvic prolapse. 

A common treatment for pelvic organ prolapse is the use of an intravaginal device called a pessary, which comes in many sizes and shapes. In the past, pessaries were made of rubber or soft plastic, but today, they are usually made of silicone material with internal moldable steel reinforcement. A pessary is inserted into the vagina and rests against the cervix in a way similar to a diaphragm used for birth control. The pessary should be removed and cleaned every 3 to 6 weeks depending upon the presence and amount of unusual discharge, type of pessary and a woman’s comfort. For ease of removal, choose one of the following positions that is most comfortable: standing with one leg raised on a stool, squatting down, sitting on a toilet, lying down with legs separated and knees bent. Pessaries can create negative side effects including back pain, foul-smelling vaginal discharge or bleeding. Vaginal estrogen cream may be prescribed before a pessary is fitted, as it will prevent ulceration and breakdown of vaginal tissue.

Although pessaries have been used primarily for pelvic organ prolapse (POP), these devices have also been used to prevent exercise-related UI.

Fritzinger, K., C.M., Newman, D.K., Dinkin, E. (1997) "Use of a Pessary for the Management of Pelvic Organ Prolapse" Lippincott’s Primary Care Practice. 1(4):431-436.

Newman, DK.  (2000) “New Technology for Women for Stress Incontinence”. Contemporary OB/GYN: April 15:69-70,74-75, 79-83.

Nygaard, I. (1995) “Prevention of exercise incontinence with mechanical devices.”  Journal Reprod Med.  40:89.

Pelvic Surgery

Women that have had a hysterectomy (surgical removal of the uterus) experience a forty percent increased risk of urinary incontinence. The reasons for the association between hysterectomy and UI are not known but may be related to loss of  support for the bladder, scarring of the urethra, or injury to the pelvic nerves. Removal of a women’s uterus is a very common, and often unnecessary procedure. In the United States, more than 600,000 women have hysterectomies every year.

Brown, JS, Saways, G, Thom, DH. (2000) Hysterectomy and urinary incontinence: a systematic review  The Lancet;356, August 12:535-539.

Last updated: February 2007

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