Postpartum Stress Incontinence

Postpartum stress incontinence is leakage of urine with coughing, sneezing, laughing, lifting or exercise, in the weeks to months after birth. It occurs in 20 to 30 percent of women at 3 months and results from stretching or injury to the pelvic floor muscles and the nerves and ligaments that support the urethra. It matters because it affects quality of life and may persist, and pelvic floor training cures or improves most women.

• Risk factors: vaginal birth, instrumental delivery, large baby, long second stage, perineal tears, obesity, incontinence in pregnancy, smoking, chronic cough, constipation.
• Most improve over the first 6 months.
• Caesarean section lowers but does not remove the risk.

Women have small leaks of urine during effort, with a dry bladder at rest and normal sensation. Urgency and large leaks suggest an overactive bladder.

• Leakage with cough, sneeze or lifting.
• Cough test shows spurt of urine on examination with a full bladder.
• Differential diagnosis: urge incontinence, mixed incontinence, overflow incontinence from retention, urinary fistula, urinary tract infection, urethral diverticulum.
• Complications: skin irritation, recurrent urinary infection, reduced exercise and social activity, depression, progression to prolapse, sexual dysfunction.

The approach is history, examination and a few simple tests.

• Bladder diary for 3 days; pad count; severity grading (leaks per day, pad use).
• Pelvic examination: pelvic floor muscle strength (Oxford scale 0 to 5), prolapse, perineal scars; cough stress test with a full bladder.
• Urine dipstick and culture; residual urine by ultrasound (to exclude retention); fasting glucose.
• Urodynamic tests only if symptoms are complex or surgery is planned.

The principle is pelvic floor muscle training first, with lifestyle measures, and surgery only if symptoms persist beyond 6 to 12 months and childbearing is complete.

• Supportive: pelvic floor muscle training: 8 to 12 contractions held for 6 to 8 seconds, repeated 3 times daily for at least 3 months, guided by a physiotherapist; the "knack" (contract before cough or lift); weight loss to a body mass index below 25 kg/m2; reduce caffeine and fizzy drinks; fluids 1.5 to 2 litres daily; treat cough and constipation; avoid straining; bladder training.
• Pharmacological: no drug is first line for stress incontinence; vaginal oestradiol 10 micrograms tablet at night for 2 weeks then twice weekly for 3 months if vaginal dryness and atrophy accompany breastfeeding; cefalexin 500 mg oral 6-hourly for 5 days for urinary infection.
• Procedures: continence pessary or vaginal tampon for sport; electrical stimulation or biofeedback with the physiotherapist; midurethral sling after 12 months and after childbearing is complete, in women who fail 3 to 6 months of supervised training.
• Special groups: women with a third or fourth degree tear or anal incontinence need combined pelvic floor and anorectal care; women with mixed or urge symptoms need bladder training before drugs.
• Red flags: haematuria, recurrent urinary infection, pain, constant dribbling (fistula), retention, neurological symptoms.
• Follow-up: review at 3 months after starting training with a repeat bladder diary; referral if no improvement by 6 months; annual review if symptoms persist.