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Prevention of urinary and anal incontinence: role of elective cesarean delivery

Lal, Mira

Current Opinion in Obstetrics & Gynecology: October 2003 - Volume 15 - Issue 5 - pp 439-448
Urogynecology

Purpose of review: Currently, prophylactic elective cesarean to prevent incontinence is being promoted without robust evidence supporting it. This has created confusion among health personnel. Past research centered on defining the damaging effect of vaginal birth on continence whilst the limited research on elective cesarean considered it protective. Cesarean delivery has economic, obstetric, gynecological and psychosocial consequences, but incontinence is not uncommon with a persistent morbidity. There is confusion among health personnel about advocating elective cesarean delivery to prevent incontinence. Reviewing current research would facilitate obstetric thinking.

Recent findings: Multiplanar endosonography and three-dimensional magnetic resonance imaging scanning are reportedly better in delineating structural alterations in the continence mechanism following vaginal birth and could be applied to postcesarean incontinence. Incontinence can follow vaginal or elective cesarean delivery and the severity following either mode is comparable. Urinary incontinence can resolve, persist or start de novo and the primiparous prevalence is similar following cesarean or vaginal birth. Transient anal incontinence can manifest during pregnancy. Paradoxically, pelvic floor strengthening exercises are beneficial for pregnancy-related incontinence, yet urinary incontinence occurs in nulliparas notwithstanding a strong pelvic floor.

Summary: Improved imaging techniques should promote a better understanding of postcesarean incontinence. Since severe incontinence can occur after elective cesarean, its reportedly preventative role deserves more scrutiny. When incontinence occurs without labor, it is transient or shows exercise-related improvement; the role of elective cesarean delivery seems tenuous and needs careful evaluation. Current evidence does not support the routine use of elective cesarean to prevent incontinence so the delivery mode should continue to be dictated by obstetric considerations.

Department of Obstetrics and Gynaecology, Wordsley Hospital, Dudley Group of Hospitals NHS Trust, Stourbridge and University of Birmingham, Medical School, UK

Correspondence to Mira Lal MD MRCOG, Doctoral Research Fellow, Department of Obstetrics and Gynaecology, Wordsley Hospital, Stream Road, Stourbridge, West Midlands, DY8 5QX, UK Tel: +44 1384 440481/456111 ext 3308; fax: +44 1384 244 445; e-mail address: mira@miralal.freeserve.co.uk

© 2003 Lippincott Williams & Wilkins, Inc.