Vaginal Delivery as Leading Risk Factor
The article reports pelvic floor exercise treatment success rates of 56% in patients with stress urinary incontinence (1) based on the result of a meta-analysis of four studies including a total of 165 women. Furthermore, the authors state that mental disorders are more common among patients with bladder dysfunction than among other women. However, the question is how often these abnormalities result from the feeling of insecurity these patients develop in response to their incontinence problem. The patient population referred to in the article were Swedish women aged 20 to 59. Prolapse of the reproductive organs was found in 31% of the women of this patient population, typically after childbirth. However, the article reports the following figures: Two pregnancies with vaginal delivery result in an eightfold increase in the odds of developing incontinence (2). Symptomatic prolapse is twice as common after vaginal delivery compared with cesarean section in every stage of birth (14.6% vs. 6.3%). To complement this, here are the data of the German Federal Statistical Office (Destatis: Statistics of hospital diagnosis, 077): In 35% of vaginal deliveries, tears require surgical treatment. This corresponds to 295 000 women versus 225 000 with cesarean section. Damaged connective tissue structures after childbirth can only partly be detected by examination of the perineal region (2). As pelvic floor exercises are primarily aimed at muscle strengthening, they have little effect on these injuries. The editors of the textbook state in their editorial that “surgical techniques can only repair a small proportion of these anatomical changes“. It has to be asked whether conservative incontinence treatment can achieve better results.
An Australian/New Zealand study (3) collected data on this question at 3 months, 6 years and 12 years after index birth. At 12 years, 53% still reported urinary incontinence. In 38%, urinary incontinence was persistent, i.e. it had been previously reported.
Three out of four patients with incontinence at 3 months after index birth still reported incontinence at 12 years. According to a US study (4), the risk of pelvic organ prolapse doubles after the second vaginal delivery.
Conclusion: The therapeutic options available to treat pelvic floor dysfunction are limited.
Prof. Dr. med. Dipl. Psych. J. Matthias Wenderlein
Universität Ulm, Germany
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Jundt K, Peschers U, Kentenich H: The investigation and treatment of female pelvic floor dysfunction. Dtsch Arztebl Int 2015; 112: 564–74 VOLLTEXT|
|2.||Hofmann R, Wagner U, eds.: Inkontinenz- und Deszensuschirurgie der Frau. Springer 2015 CrossRef|
|3.||Mac Arthur C, Wilson D, Herbison P, et al.: Urinary incontinence persisting after childbirth: extent,delivery history,and effects in a 12-year longitudinal cohort study. BJOG. 2015 Apr 2. [Epub ahead of print] CrossRef MEDLINE|
|4.||Shveiky D, Kudish Bi, Iglesia CB, et a.l: Effects of bilateral salpingo-oophorectomy at the time of hysterectomy on pelvic organ prolaps: results from the Women’s Health Initiative trial. Menopause 2015; 22: 483–8 CrossRef MEDLINE|