Antenatal Prediction of Postpartum Urinary and Fecal Incontinence

CHALIHA, CHARLOTTE MA, MBBChir; KALIA, VEENA PhD; STANTON, STUART L. FRCS, FRCOG; MONGA, ASH MRCOG; SULTAN, ABDUL H. MD, MRCOG

Original Research

Objective: To investigate the effect of pregnancy and delivery on continence and to assess whether physical markers of collagen weakness can predict postpartum urinary and fecal incontinence (including incontinence of flatus).

Methods: In a prospective, longitudinal study in a London teaching hospital, 549 nulliparas were interviewed after 34 weeks' gestation and again 3 months postpartum regarding urinary and fecal symptoms before and during pregnancy and after delivery. Family histories of incontinence, prolapse, and collagen abnormalities were recorded also. Physical examination was done to assess markers of collagen weakness such as striae, hernia, varicose veins, and joint mobility.

Results: The prevalence of urinary incontinence before, during, and after pregnancy was 3.6%, 43.7%, and 14.6%, and rates of fecal incontinence were 0.7%, 6.0%, and 5.5%, respectively. Fecal urgency was more common in women who had spontaneous and instrument-assisted vaginal deliveries (n = 413) compared with cesareans (n = 131) (7.3% versus 3.1%; P = .046). Postnatal urinary or fecal dysfunction was not related to antenatal body mass index, smoking, race, striae, varicose veins, hemorrhoids, or family history of incontinence. Higher joint-mobility scores were associated with incontinence of flatus (P = .021) but not with other urinary or fecal symptoms.

Conclusion: Although collagen weakness was previously implicated in the pathogenesis of incontinence, physical markers in this study could not predict postpartum urinary and fecal incontinence. Either those markers were not representative of collagen weakness, or a larger study with longer follow-up is necessary.

Urinary and fecal incontinence can have a devastating effect on a woman's quality of life. Vaginal delivery has been implicated as a predisposing factor, and this might increase demand for cesarean deliveries to protect pelvic-floor function. The high prevalence of postpartum symptoms independent of parity suggests that there might be an individual predisposition to pelvic-floor weakness and consequent incontinence. Although collagen abnormalities have been associated with increased joint mobility, prolapse, and urinary incontinence,1–6 their relation to fecal incontinence is not fully understood.7,8

Increased joint mobility is believed to indicate systemic alterations in collagen during pregnancy, as in women with varicose veins, and is associated with stretching of the pelvic ligaments during pregnancy.9 If collagen abnormalities predispose to incontinence, they might be inherited defects detectable by family histories. Identification of obstetric variables that can increase the risk of pelvic-floor trauma in women with inherent risks of incontinence might enable modification of obstetric practice and appropriate counseling. The aim of this study was to evaluate the use of physical markers of collagen weakness in predicting postpartum fecal and urinary incontinence and to identify associated obstetric risk factors.

Clinical markers of collagen weakness such as striae, hernia, joint hypermobility, and varicose veins do not predict postpartum incontinence.

Urogynecology Unit, St. George's Hospital, London; Princess Anne Hospital, Southampton; and Mayday University Hospital, Surrey, United Kingdom.

Address reprint requests to: Charlotte Chaliha, MA, MBBChir, Urogynecology Unit, Department of Obstetrics and Gynecology, St. George's Hospital, Cranmer Terrace, Blackshaw Road, London SW17 0RE, United Kingdom

Supported by the South Thames Project Grant Scheme.

The authors thank Professor Martin Bland for advice regarding statistical analysis of the data.

Received August 27, 1998. Received in revised form April 2, 1999. Accepted April 8, 1999.

© 1999 The American College of Obstetricians and Gynecologists