Title Page Stress incontinence 4 years postdelivery 1

Title Page Stress incontinence 4 years postdelivery 1 Stress a Authors: retrospective urinary incontinence cohort Arnaud Xavier survey Fritel, Fauconnier, four MD years after the first delivery: Institution: Université Jean-Louis Caroline Levet * INSERM Service de Pierre-et-Marie-Curie, Unité Gynécologie Bénifla, 149, MD Recherches et Obstétrique, Paris, épidémiologiques France. Hôpital Rothschild en santé AP-HP, Correspondence: Gynécologie Dr et santé Xavier des FRITEL femmes, & Obstétrique Paris, France. périnatale CHD 97405 France Tel: Félix Saint-Denis Guyon Fax: +33.262.905.540 +33.262.907.730 cedex, Réunion Headline: E-mail: Stress incontinence x-fritel@chd-fguyon.fr 4 years postdelivery

Stress a retrospective urinary incontinence cohort survey Stress four incontinence years after 4 the years first postdelivery delivery: 2 Abstract Background: after Methods: 669 primiparous the first A retrospective delivery Our women aim and was who cohort analyze to estimate delivered survey its risk the in was factors. prevalence our conducted department of stress a French 1996 urinary a university singleton incontinence in hospital. vertex four The years position sent incontinence Results: four 307 between years women four after 37 years the and replied, after indexed 41 weeks 274 the delivery. first had of amenorrhea delivery. moved The and main 88 were outcome did included. not respond. measure A mailed Four was years stress questionnaire after urinary the was delivery, logistic pregnancy regression prevalence (OR 18.7; analysis, of 95% stress CI the urinary 3.6 96.4), independent incontinence urine risk leakage factors was during 29% were (89/307). the urine first leakage pregnancy According before (OR to multiple 2.5; first first 95% 30 delivery Conclusion: years CI 1.3 4.8), (OR at the 0.3; first duration 95% delivery CI 0.1 0.9). of (OR first 2.4; labor 95% 8 CI hours 1.4 4.2) (OR 3.1; and 95% cesarean CI 1.7 5.7), section at mother's first age > from during a multifactorial the Our first results pregnancy), condition. suggest prolonged The that main stress labor risk urinary factors and incontinence vaginal are: age, delivery. previous following incontinence pregnancy (before arises Keys-words Stress urinary incontinence; pregnancy; delivery; cesarean section.

Abbreviations BMI: body mass index Stress incontinence 4 years postdelivery 3 CI: n: OR: P: number probability confidence odds ratio interval SUI: stress urinary incontinence

Introduction Stress urinary incontinence Stress (SUI) incontinence is common 4 years in women postdelivery but its pathophysiology remains 4 poorly that urinary who vaginal elucidated incontinence delivery (1, favored is 2). two As times long pelvic as more obstetrics floor frequent disorders has in been women (3). taught, Three who months it delivered has commonly after vaginally the first been delivery, than assumed The had aim remains a cesarean of this uncertain study (4). However, was (1, 5). determine long after the the prevalence first delivery, of SUI the four impact years of the after mode the first of those delivery to identify and women analyze at its high risk risk factors. who may Knowing benefit these from factors preventive before measures. the first delivery may help Materials after considered We used and the Methods weeks. 37 to 41 a first weeks database delivery of amenorrhea of if the our women maternity to a living had ward not singleton previously identify a delivered women vertex position. who a fetus gave of This birth, more birth in than 1996, was presentation) Data The study the and mother delivery population (date (length comprised of birth, of labor, height, 669 type women weight of delivery, meeting before conception), duration these inclusion of active the pregnancy criteria. second stage, (term, 22 birth September questions Information weight) were on collected continence at the time was of the obtained first delivery. 1996 and urinary addressed 2000. If symptoms no urinary response leakage during was the before received, preceding and a during second four from weeks. the and a first questionnaire even When pregnancy, third a woman mailing mailed pregnancies answered was in sent. since yes The to

the questionnaire entry question (6), about (Do you the Stress have frequency, involuntary incontinence the amount loss 4 years of and urine?) postdelivery the circumstances she was asked, of using leakage, a validated if she 5 wore the each study Our responding pads outcome is for available incontinence woman. of interest from the and was authors if SUI leakage four upon was years request. a after problem Informed the first her. delivery consent The questionnaire (hereafter was obtained termed used from for current following Incontinence index developed SUI). question: was A by categorized Do Sandvik you was have considered et in al three loss (7), of which levels to urine have had (slight, during current been moderate physical shown SUI if or she exertion, correlate severe) replied cough using well affirmatively with or the sneeze? severity the 48- to the hour delivery, contractions The pad following test. to body to mass delivery), variables index duration (BMI), were tested birth of active weight, as potential second duration stage risk of factors: (from labor mother's (from onset the of age onset expulsive at the of first delivery first delivery), since mode 1996, of urinary first delivery, leakage third-degree before the first perineal pregnancy tear at and the urinary first delivery, leakage a second during efforts considered. pregnancy. Because were compared an episiotomy women was not systematically reached and non-responders performed, this factor for the was different not the test confounding Responders variables with current collected SUI at were the time compared of their to first those delivery. regression. Univariate analysis was performed using Student's t-test without quantitative for the variables different and variables. analysis for qualitative (8). Variables As the data. impact were Multivariate introduced of cesarean analysis into section the was model was performed the when main P question using < 0.25 stepwise according we planned logistic to univariate to introduce the χ²

it leakage into the before logistic the regression first pregnancy Stress model incontinence and independently urinary leakage 4 years of univariate postdelivery during the analysis first pregnancy results. Urinary were 6 likelihood considered variables. threshold of The independent P < final 0.05. model The variables. included coefficients Quantitative only in variables the final variables model associated were with dichotomized estimated current using SUI into at the qualitative from method; the adjusted odds ratios their confidence intervals (CI) were the StatView the model's 5.0 software coefficients (SAS Institute and their Inc., standard Cary, deviations. NC, USA). All analyses were performed maximum calculated with Results questionnaire, (0.1%) letters. From If woman we the exclude 669 273 had women (40.8%) died the and 274 included letters 88 women (13.2%) were in who the returned women study, did not we did stamped receive received not respond no the 307 longer questionnaire, despite (45.9%) at this two responses address, the "reminder" response one to our was 307 were responders, 77.7% older (307/395). the 274 We women searched not for reached difference and the concerning 88 non-responders potential risk (Table factors I). Responders among rate The prevalence and less likely of any to urinary have had incontinence a cesarean section was 5% at (16/304) first delivery. before the first pregnancy, the 22% with amount, urinary urinary (68/303) incontinence bother incontinence during and pads was the associated first categorized four pregnancy years with after as slight and leakage the 32% first for are 62 (99/307) delivery, reported women, four circumstances, in moderate years Table later. II. for The frequency, 21, For degree severe the 99 of for women and unknown for 8. 8,

pregnancy Among for the 1489 (16%), (29%) during Stress women the incontinence with first pregnancy current 4 SUI, years incontinence postdelivery 23 (26%), immediately had started before after the the first first 7 for delivery protective 34 Univariate (39%), for pads 20 often (23%) because comparisons for and 19 of (22%) later SUI. between for and 32 all (36%). the of risk the SUI time factors occurred for present 5 (6%). rarely Twenty women for 31 (22%) with (35%), current women sometimes SUI wore delivery those current with SUI no and SUI BMI, are given birth weight, in Table active III. No second significant stage association 20 min, third-degree was found between tear, second and cesarean, (P and 30% mode (49/166) of first after delivery. spontaneous The prevalence childbirth of and current 31% (34/110) SUI was after 19% forceps (6/31) after at = 0.45; The following χ² test). variables were included in the logistic regression model (Table IV): delivery urinary delivery, leakage duration during of labor, first cesarean pregnancy. section, The urinary risk of current leakage SUI before increased the first with pregnancy, urinary age and section leakage labor at 8 before hours, the first the and delivery. first mother's pregnancy, age > urinary 30 years. leakage The risk during of current the first SUI pregnancy, was lower duration with cesarean of

Discussion Only 46% of the women Stress included incontinence responded 4 years to the postdelivery mailed questionnaire. This low 8 response likely Indeed, moved that during the rate growth West can the Berkshire mostly three of the years nuclear be perineal explained following family management by necessitated the the delivery change trial (9). a of larger found address Wilson home, that of et 49% 41% al., as previously of who of their sent women. subjects a reported. It had is questionnaire not more they associated experienced frequently 6 with years delivered fewer SUI. after urinary In by delivery our cesarean. disorders. population, had It a 53% This the possible response hypothesis non-responders that rate these is (10). in women were agreement We slightly assume did with not younger that reply our moving data. because and had is Thus, observed. Urinary the real leakage risk associated preceding with the age first and pregnancy mode of was delivery the strongest might be risk higher factor than among that we incontinence 8.6 15.9). subjects. Recently, before Wilson pregnancy et al. and (10) the reported risk of SUI a strong 6 years association after delivery between (OR urinary 11.7; 95% our 15% pregnancy nulliparous Pertinently, Canadian Alnaif students and Drutz 15 19 (11) old. observed This urinary a incontinence preceding prevalence CI and the bladder could neck. be a sign of the poor quality of the connective tissue supporting the urethra of population 3.0 5.5, factor Like for respectively), Viktrup SUI study four (4,345 (1) years and we women, after Wilson found the urinary 20 59 et first al. delivery. (10) years leakage (OR old) Foldspang 3.0; during and 95% also pregnancy CI et identified 1.7 5.4 al. (12) to an and conducted be association a OR significant 4.1; a 95% general between risk IC urinary 4.6). In leakage addition, during King and pregnancy Freeman and (13) SUI showed at the time that bladder-neck of the inquiry mobility (OR 3.4; measured 95% CI 2.6 during

the an alteration first pregnancy of the was urethra a risk and Stress factor bladder incontinence for neck postpartum support, 4 years SUI. as postdelivery Landon It is possible et al. (2) that found pregnancy fascia induces tensile 9 strength individuals subsequently of serum during relaxin with returns pregnancy SUI (a hormone to (14). prepregnancy to Joint that be laxity reduced. affects levels increases collagen It is (15). known during metabolism) Kristansson that pregnancy, collagen et to al. be metabolism but (16) associated it found not a is known with higher modified SUI level it during However collected Urinary pregnancy. between this leakage information result has before to retrospectively or interpreted during the cautiously first (1, 10, pregnancy 12, because, 17). seems The like relationship to the be other an early that studies, risk we observed factor. partially urinary leakage before or during the first pregnancy and current SUI might we current Use SUI of explained forceps our study. by and a the recall However, duration bias (18). use of the of active forceps second is a controversial stage were not risk associated factor, with with be authors 21). expulsive Because finding of a the link disparity with postpartum of obstetrical urinary practices, incontinence it is possible (19, 20), that and forceps others and not prolonged (4, some Mother's efforts age are at first poor delivery markers was of the a significant difficulty risk of the factor, delivery. according to our analysis. 12, Because = age at first questionnaire delivery + 4 years), was mailed it is not at the possible same to date conclude for each whether women it (age is the at age questionnaire (22) risk delivery of urinary or at the incontinence time of the to questionnaire be increased that for a is second important. delivery Foldspang after 40 et years. al. (12) Persson found at the the et first age on pelvic at observed the connective first an delivery. increased tissue It would risk and urethra of be later interesting support urinary to incontinence is the determine same at whether surgery all ages. with the effect increasing of pregnancy maternal al.

A preponderant In our cohort, effect a second of the Stress delivery first pregnancy incontinence was not associated 4 pelvic years floor postdelivery with disorders an increased is likely risk of (22, current 23). SUI. 10 primiparous the Højberg long-term Postpartum et al. and protective (24) urinary 16% reported for incontinence effect multiparous urinary of a cesarean incontinence is women. less common is less prevalences certain. after a For cesarean of the 4% 278 for (4, women nulliparous, 17, 19, questioned 25 27). 14% But for Viktrup not nulliparity, significant. (1) pelvic five MacLennan years floor after dysfunction their et al. first included was delivery, significantly 1,546 the women relationship associated over 15 between with years cesarean old cesarean (5). section Compared and SUI (OR was to by 2.5), difference questioned incontinence spontaneous between vaginal cesarean delivery and spontaneous (OR 3.4) and delivery instrumental was not delivery significant. (OR Wilson 4.3), but et the respectively), 4,242 rates but women a between significant six cesarean years difference after and delivery, vaginal did exist deliveries and for found second for (33 primiparas difference versus 46%) (33 for urinary versus and third 38%, al. (10) deliveries cesarean associated the section (26 with versus vaginal to 11,299 49%). deliveries who Rortveit delivered (OR et 2.4). al. vaginally (28) Evaluation compared (1 to using 4669 times). ultrasound women SUI who was showed delivered significantly that, by after significantly first cesarean delivery, associated (13, bladder-neck 25, 29). with According a lower mobility risk to was our of SUI increased multivariate long after after analysis, the vaginal first a delivery. cesarean But and was it unchanged is not after known SUI. because surgical It whether is intervention. possible less increasing elastic that Pertinently, women tissue, the the number requiring Rortveit more of difficult cesareans et al. questioned cervix have could dilatation more lower 27,900 inflexible the is, women long-term thereby connective of necessitating all prevalence ages tissue, and of found that parity was no longer associated with SUI after 65 years (23).

risk Women of developing complaining SUI later. of Stress urine For these incontinence leakage women, before 4 it years or seems during postdelivery legitimate their first to pregnancy propose antenatal are at higher pelvic 11 floor determines multifactorial premature exercises, their to condition propose which potential have prophylactic in protective which been shown pregnancy effect. cesareans to prevent Our and to findings labor prevent postpartum seem suggest SUI to before have incontinence that their SUI a randomized own results (30). impacts. from However, trial a Our it findings questioned need early to be during confirmed their pregnancy, by a prospective or even study better before which conceiving. women will be examined and

Acknowledgment The authors thank Mrs. Janet Stress Jacobson incontinence for editorial 4 years assistance. postdelivery 12

References Stress incontinence 4 years postdelivery 13 12 Neurourol Viktrup Landon CR, L. Urodyn The Crofts risk 2002; CE, of lower Smith 21: urinary 2 9. ARB, tract Trowbridge symptoms EA. five Mechanical years after properties the first delivery. 3 during Contemp pregnancy: Rev Obstet a possible Gynaecol factor 1990; in 2: the 40 6. development of stress incontinence of of fascia 1773. DuCoudray AM. Abrégé de l'art des accouchements. Châlons-sur-Marne: Bouchard, urine. 45 incontinence disorders Wilson MacLennan PD, and Herbison AH, three their Taylor months relationship RM, AW, after Herbison Wilson to delivery. gender, GP. DH, Obstetric Br age, Wilson J Obstet parity D. practice and Gynaecol The mode prevalence and 1996; of the delivery. prevalence of 103: pelvic 154 61. Br of floor J Obstet urinary 6 Gynaecol Jackson S, 2000; Donovan 107: J, 1460 70. 7 Female testing. Sandvik Br Lower H, J Seim Urol Urinary A, 1996; Vanvik Brookes Tract 77: 805 12. A, Symptoms Hunskaar S, Eckford questionnaire: S. S, A Swithinbank severity development index L, for Abrams epidemiological and P. psychometric The Bristol 8 of Urodyn Mickey female 2000; RM, urinary Greenland 19: incontinence: 137 45. S. The impact comparison of confounder with 48-hour selection pad-weighing criteria on tests. effect Neurourol surveys 9 estimation. 1987; Sleep J, 295: Grant 749 51. Am A. J Epidemiol West Berkshire 1989; perineal 129: 125 37. management trial: three year follow up. BMJ

10 Wilson PD, Herbison P, Stress Glazener incontinence C, McGee 4 years M, MacArthur postdelivery C. Obstetric practice and 14 11 urinary secondary Alnaif B, incontinence Drutz school HP. teenage The 5 7 prevalence years girls: after questionnaire of delivery. urinary study Neurourol and fecal and review incontinence Urodyn of 2002; the literature. in 21: Canadian 289 91. 12 Urogynecol Foldspang A, J 2001; Mommsen 12: 134 8. S, Djurhuus JC. Prevalent urinary incontinence as a correlate Int 13 pregnancy, 209 12. King JK, Freeman vaginal RM. childbirth, Is antenatal and obstetric bladder techniques. neck mobility Am a J risk Public factor Health for postpartum 1999; 89: of 14 15 stress incontinent Falconer incontinence? C, Ekman G, Br Malmström J Obstet Gynaecol A, Ulmsten 1998; U. 105: Decreased 1300 7. Peripheral Schauberger joint women. CW, laxity Rooney Obstet increases BL, Gynecol Goldsmith in pregnancy 1994; L, 84: Shenton but 583 6. does D, not Silva correlate collagen PD, Schaper with synthesis serum A. Obstetrics: relaxin in stress- 16 17 levels. stress Kristansson Am J P, Obstet Samuelsson Gynecol E, 1996; von Schoultz 174: 667 71. Acta Hvidman Obstet urinary L, Gynecol Foldspang incontinence Scand A, Mommsen in 2003; pregnancy. 82: S, 556 63. Nielsen Acta B, Obstet Svärdsudd JB. Postpartum Gynecol K. Reproductive Scand urinary 2001; incontinence. hormones 80: 1125 30. and 18 19 Obstet Farrell Viktrup Gynecol SA, L, Lose Allen Scand 2001; G. VM, Do 97: 2001; Baskett fertile 350 6. 80: women TF. 952 5 Parturition remember and the urinary onset of incontinence stress incontinence? primiparas. Acta

20 Arya LA, Jackson ND, Stress Myers incontinence DL, Verma A. 4 years Risk postdelivery of new-onset urinary incontinence after 15 21 forceps 1318 24. Meyer S, and Hohlfeld vacuum P, delivery Achtari in C, primiparous Russolo A, De women. Grandi Am P. J Birth Obstet trauma: Gynecol short 2001; and 185: 22 term floor Persson effects parameters. J, Wølner-Hanssen of forceps Br J Obstet delivery P, Gynaecol Rydhstroem compared 2000; with H. 107: Obstetric spontaneous 1360 5. risk delivery factors for on stress various urinary pelvic long 23 incontinence: Rortveit G, Hannestad a population-based YS, Daltveit study. AK, Obstet Hunskaar Gynecol S. Age- 2000; and 96: type-dependent 440 5. 24 parity 98: Højberg 1004 10. KE, urinary Salvig incontinence: JD, Winsløw the NA, Norwegian Lose G, EPINCONT Secher NJ. Urinary study. Obstet incontinence: Gynecol effects 2001; of 25 prevalence 842 50. Viktrup L, Lose and risk G, Rolff factors M, at Barfoed 16 weeks K. of The gestation. symptom Br of J Obstet stress incontinence Gynaecol 1999; caused 106: 26 pregnancy mechanisms Meyer S, Schreyer or and delivery other A, De in pelvic-floor primiparas. Grandi P, characteristics. Hohlfeld Obstet Gynecol P. The Obstet effects 1992; Gynecol 79: of birth 945 9. 1998; urinary 92: 613 8. continence by 27 28 postpartum Chaliha Rortveit C, G, Kalia urinary Daltveit V, and Stanton AK, fecal Hannestad SL, incontinence. Monga YS, A, Hunskaar Obstet Sultan AH. Gynecol S. Urinary Antenatal 1999; incontinence prediction 94: 689 94. after of 29 delivery mobility Peschers or following U, cesarean Schaer vaginal G, section. Anthuber delivery. N Engl C, Delancey Obstet J Med 2003; Gynecol JOL, 348: Schuessler 1996; 900 7. 88: B. 1001 6. Changes in vesical vaginal neck

30 Reilly ET, Freeman RM, Stress Waterfield incontinence MR, Waterfield 4 years postdelivery AE. Steggles P, Pedlar F. Prevention 16 of a 2002; randomised postpartum 109: 68 76. controlled stress incontinence trial of antenatal in primigravidae pelvic floor with exercises. increased Br bladder J Obstet neck Gynaecol mobility:

responders Table I. Analysis concerning of the differences potential Stress incontinence risk among factors 4 responders, for years SUI. postdelivery Values women are not means reached [standard non- 17 deviation] (n) Risk for factor qualitative for quantitative data assessed Responders (n data = 307) assessed with χ² test. with Not (n analysis = reached 274) of variance Non-responders (n = and 88) percentages Age BMI, Birth at weight, kg/m² delivery, g yr 3240 29.3 21.3 [384] [4.4] [2.9] 3253 28.2 21.1 [4.4] [2.9] [400] 3241 28.9 21.3 [430] [4.7] [3.2] 0.92 0.01 0.62 P Labor, Active Cesarean Forceps 2nd h section stage, min 11.1 10.1 6.2 [2.3] [7.5] (31) 10.6 17.5 6.5 [2.5] [7.9] (48) 10.9 17.0 6.6 [2.3] [7.9] (15) 0.21 Third-degree tear 36.2 1.3 (111) (4) 31.3 1.1 (3) (86) 44.3 1.1 (1) (39) 0.97 0.08 0.69 0.03

Table based II. on Characteristics 99 incontinent of Stress women urinary incontinence responding incontinence 4 to years the four postdelivery questionnaire. years after the first delivery 18 Circumstances Frequency Urinary stress urge other incontinence circumstances of leakage 89.9 64.6 %(n) less 1 than of once leakage a 22.2 (89) every to 3 times per month week (64) unknown day 41.4 (22) Amount drops 29.3 11.1 10.1 (41) small 8.1 (29) more of leakage (11) unknown amount 69.7 (10) (8) Bothered not 23.2 3.0 4.0 (69) moderately by all incontinence (23) a little (3) unknown lot 17.2 (4) Use none 54.5 15.2 10.1 (17) 3.0 (54) 1 of pads for incontinence (15) unknown to or 6 more per week per day 74.7 16.2 4.0 5.1 (10) (3) (74) (16) (4) (5)

Table delivery. III. Univariate Risk factors analysis for Stress stress using incontinence urinary the χ² incontinence test. 4 years Values postdelivery (SUI) are percentages four years after (n). the first 19 Age BMI Risk at factor > delivery 27 kg/m² > 30 yr. Yes 53.9 (n (48) = 89) SUI No 36.7 4.6 (n(10) = (80) 218) 0.005 0.34 P Cesarean Labor Birth weight 4000 g 2.2 (2) 1.4 (3) 0.58 Forceps Active 2nd 8 h stage 41.6 (37) 21.1 (46) 0.0002 Third 20 min 16.9 (15) 19.3 (42) 0.62 section 6.7 (6) 11.5 (25) 0.21 Leakage degree tear 38.2 2.2 (34) (2) 35.3 0.9 (77) (2) 0.63 0.35 Second during before pregnancy 40.2 16.1 (35/87)* (14/87)* 15.3 0.9 (33/216)* (2/217)* <0.0001 * Missing delivery values 69.6 (53) 61.0 (133) 0.81 correspond to questions not completed.

Table Adjusted IV. odds Risk factors ratios estimated for Stress stress incontinence by urinary logistic incontinence regression 4 years postdelivery four analysis. years after the first delivery. 20 Leakage Risk factor before Odds 18.7 ratio 95% 3.6 96.4 CI P Labor Age at the during 1st delivery the 1st > pregnancy 30 yr 2.4 2.5 1.4 4.2 1.3 4.8 0.002 0.005 0.0005 Cesarean 8 at h the 1st delivery 3.1 0.3 1.7 5.7 0.1 0.9 0.0002 0.04