Elsevier

Seminars in Perinatology

Volume 30, Issue 5, October 2006, Pages 267-271
Seminars in Perinatology

Urinary Incontinence: Is Cesarean Delivery Protective?

https://doi.org/10.1053/j.semperi.2006.07.007Get rights and content

About half of all women develop transient urinary incontinence during pregnancy. Three months postpartum, the prevalence and incidence rates of urinary incontinence are 9% to 31% and 7% to 15%, respectively. Antenatal incontinence increases the risk of postpartum incontinence, which in turn increases the risk of long-term persistent incontinence. After the first delivery, women delivered vaginally have two-fold more incontinence than those delivered by cesarean. The protective effect of cesarean on urinary incontinence may dissipate after further deliveries, decreases with age, and is not present in older women. Data are mixed about whether cesarean done before labor confers greater protection than cesarean done after labor. To understand the true impact of cesarean delivery on urinary incontinence, future studies must compare incontinence by planned (not actual) delivery modes, consider a woman’s entire reproductive career, focus on leakage severe enough to be problematic, consider other bladder symptoms as well as incontinence, and take into account other risk factors, particularly antepartum urinary incontinence.

Section snippets

Factors Important in Framing this Discussion

In evaluating the literature about cesarean delivery and UI, several points are important to consider. Comparing outcomes between vaginal delivery and cesarean delivery is NOT the same as comparing outcomes between planned vaginal and planned cesarean deliveries. Currently, 30% of planned vaginal deliveries in the U.S. result in cesarean deliveries instead. A cesarean delivery conducted after the onset of labor, and in particular, after the onset of the second stage of labor, may have a

UI During and After Delivery

Nulligravid pregnant women leak more often than nulliparous counterparts.3 Indeed, numerous studies reveal that 15% to 65% of women report UI symptoms during and shortly after pregnancy (Table 1). Thus, pregnancy itself causes UI, transient in some but lasting in others.

This is relevant, because antepartum UI increases the risk for postpartum UI. For example, Foldspang followed 1232 women 12 to 120 months postpartum.4 Of the 16% that had antenatal UI, 67% reported postpartum UI, compared with

Cesarean Delivery and Postpartum UI

The best data to inform the discussion about cesarean delivery on request is that which separates out cesarean deliveries done before and after the onset of labor. However, given the dearth of such information, data on cesarean deliveries in general will also be reviewed to provide the reader with as broad a picture as possible. Several prospective studies evaluated the risk of postpartum UI by delivery type, grouping all cesarean deliveries together. In 3405 primiparas 3 months postpartum,

Cesarean Delivery and UI After Multiple Deliveries

The studies described above generally assessed UI outcome after one delivery. Although these data are important, they do not reflect the reality of childbearing in the U.S. Scant data evaluates risk prospectively after more than one delivery. Foldspang initially evaluated women postpartum after one delivery and found a marked decrease in UI after cesarean delivery (all types) than after vaginal delivery (12% versus 28%, respectively).4 However, in 642 women that had a second delivery, cesarean

Cross-Sectional Studies

In addition to cohort studies, there are cross-sectional studies that address the difference in UI based on delivery type. These studies generally evaluate women more remote from delivery and thus include middle-aged or older women, rather than young postpartum women. In these studies, there are often no differences in UI prevalence by delivery type. In 2625 women ages 49 to 61 years, 15% had severe UI (“often/all the time”).20 Nulliparous women had a lower prevalence of severe UI (7%), but

Cesarean Delivery and the Risk of Future Surgery

Data are mixed about whether cesarean deliveries impact the risk of future surgeries for urinary incontinence or pelvic organ prolapse. Most studies group both conditions together, and most do not differentiate between types of cesarean. In a nested case-control study in which an historical cohort was linked with a current morbidity database, women who first delivered between 1952 and 1966 were evaluated.24 Cases included 352 women that had surgery for UI or pelvic organ prolapse; this group

Sister Studies

Studies comparing sisters aim to evaluate the role of delivery type in UI prevalence, controlling for potential genetic contributions. Although one study of older sisters (mean age 61 years) does not specifically address the issue of cesarean delivery, the results speak to the impact of childbirth on UI.29 In this study, 143 postmenopausal sister pairs were enrolled; one sister was nulliparous and one parous. The prevalence of UI was the same in both groups: 47.6% in nulliparous and 49.75 in

Randomized Trial

Only one randomized trial has assessed the difference in pelvic floor symptoms after planned elective cesarean delivery or planned vaginal birth: the Term Breech Trial.31 Questionnaires were completed 3 months postpartum by 1596 women from 110 centers around the world. Three months postpartum, women in the planned cesarean delivery group reported less UI than those in the planned vaginal birth group (4.5% versus 7.3%; RR 0.62, 95% CI 0.41-0.93). Other outcomes did not differ. However, by 2

Conclusion

The following key points summarize current knowledge about the role of cesarean delivery on UI:

  • Vaginal delivery increases the short-term risk of UI in young and middle-aged women more than cesarean delivery.

  • Most women with UI have mild incontinence.

  • Nulliparous women also develop UI.

  • Mode of delivery no longer plays a role in the development of UI in older women; older nulliparous women are as likely to have UI as older parous women.33

  • Nearly eight in nine women deliver babies, usually via the

Acknowledgments

This work is supported in part by K24 HD42469-01 from the National Institutes of Child Health and Human Development. The sponsor had no role in data collection, data analysis, data interpretation, or in the writing of the report.

References (36)

  • R.P. Goldberg et al.

    Delivery mode is a major environmental determinant of stress urinary incontinence: results of the Evanston-Northwestern Twin Sisters Study

    Amer J Obstet Gynecol

    (2005)
  • M.E. Hannah et al.

    Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial

    Am J Obstet Gynecol

    (2004)
  • J.S. Brown et al.

    Prevalence of urinary incontinence and associated risk factors in postmenopausal women

    Obstet Gynecol

    (1999)
  • S. Iosif

    Stress incontinence during pregnancy and the puerpium

    Int J Gynaecol Obstet

    (1981)
  • T.H. Dimpfl et al.

    Incidence and cause of postpartum urinary stress incontinence

    Eur J Obstet Gynaecol Reprod Biol

    (1992)
  • D. Thom

    Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type

    J Am Geriatr Soc

    (1996)
  • S. Hunskaar et al.

    Epidemiology of faecal and urinary incontinence and pelvic organ prolapse

  • A. Foldspang et al.

    Risk of postpartum urinary incontinence associated with pregnancy and mode of delivery

    Acta Obstet Gynecol Scand

    (2004)
  • Cited by (34)

    • Caesarean section on maternal request for non-medical reasons: Putting the UK National Institute of Health and Clinical Excellence guidelines in perspective

      2013, Best Practice and Research: Clinical Obstetrics and Gynaecology
      Citation Excerpt :

      On the other hand, caesarean section may reduce the incidence of SUI, but cohort studies and meta-analyses differ significantly in estimating the numbers of caesarean section needed to prevent one case of SUI.68 Again, the protective effect of a caesarean section decreases with age, dissipates with future vaginal births,69 and is abolished after three consecutive planned caesarean section70 or if the caesarean section is carried out after the onset of labour.12 In fact, in women aged 50–64 years, the prevalence of SUI was found to be high irrespective of the route of delivery (28.6% after caesarean section and 30% after vaginal births).71

    • Factors involved in the persistence of stress urinary incontinence from pregnancy to 2 years post partum

      2011, International Journal of Gynecology and Obstetrics
      Citation Excerpt :

      Specifically, it has been reported that up to 32% of primigravid women develop this symptom during pregnancy [2]. Although most women recover their pre-pregnancy continence status within 8 weeks of delivery [3], a significant percentage of women have persistent symptoms in the postpartum period. The prevalence of persistent SUI varies widely from 5% to 92% [4–7].

    • Significant Linkage Evidence for a Predisposition Gene for Pelvic Floor Disorders on Chromosome 9q21

      2009, American Journal of Human Genetics
      Citation Excerpt :

      Risk factors typically focus on defects in the pelvic floor musculature or connective tissue weakness. Childbirth is the most studied risk factor;3 vaginal delivery, especially with forceps, increases the risk of urinary incontinence, but cesarean delivery is not entirely protective.4 Other risk factors include increased age, smoking, and chronic increased intra-abdominal pressures such as occupational lifting, obesity, and chronic constipation.3

    • Levator ani denervation and reinnervation 6 months after childbirth

      2009, American Journal of Obstetrics and Gynecology
    • Birth and the pelvic floor

      2022, Journal fur Urologie und Urogynakologie
    View all citing articles on Scopus
    View full text