Postpartum Urinary Incontinence

Postpartum urinary incontinence is involuntary leakage of urine after childbirth, most commonly stress incontinence from pelvic floor and urethral sphincter weakness.

• It affects about a quarter to a third of women in the first months after birth. Most improve by 6 to 12 months.
• Stress incontinence (leakage on cough, sneeze or exertion) is commonest. Urgency incontinence and mixed types also occur.
• Risk factors are vaginal delivery, instrumental delivery, obstetric anal sphincter injury, large infant, prolonged second stage, high body mass index, and incontinence in pregnancy.
• Obstetric fistula is a distinct and serious cause, especially after obstructed labour.

Leakage pattern points to the type.

• Stress: leakage on coughing, laughing, sneezing, lifting or exercise.
• Urgency: sudden strong urge with leakage before reaching the toilet, frequency and nocturia.
• Mixed: features of both.
• Continuous leakage day and night, especially after obstructed or prolonged labour, suggests a vesicovaginal or ureterovaginal fistula.
• Overflow: dribbling with a palpable bladder suggests retention.
• Associated faecal incontinence or prolapse symptoms.
• Differential diagnosis: obstetric fistula, overflow incontinence from retention, urinary tract infection, vaginal discharge mistaken for urine, ureteric injury and neurological injury.
• Complications: perineal skin irritation, urinary tract infection, reduced quality of life, social isolation, and persistence into later life.

Diagnosis is by history, examination and exclusion of fistula and infection.

• History of onset, type, volume, pad use and bowel symptoms.
• Bladder diary for 3 days.
• Urinalysis and culture.
• Pelvic examination: pelvic floor muscle strength (Oxford grading), prolapse, perineal scars, and a cough stress test with a full bladder.
• Post-void residual by bladder scan.
• Dye test (methylene blue instilled into the bladder with a tampon in the vagina) if fistula is suspected. Cystoscopy and imaging for confirmation and mapping.
• Urodynamic assessment for persistent or complex symptoms.

First-line treatment is pelvic floor muscle training.

• Supportive: supervised pelvic floor exercises (three sets of 8 to 12 contractions daily, held for up to 8 seconds, for at least 3 months), weight loss if overweight, avoid constipation, reduce caffeine and fluid before bed, and timed voiding.
• Bladder training for urgency, gradually lengthening the interval between voids.
• Pharmacological: for urgency incontinence persisting after 3 months of training, oxybutynin 2.5 to 5 mg two to three times daily or solifenacin 5 mg once daily, avoided in breastfeeding where possible. Topical vaginal oestrogen may help for atrophic changes in breastfeeding women.
• Antibiotics only for confirmed infection.
• Procedures: for persistent stress incontinence beyond 6 to 12 months, urethral bulking or mid-urethral sling. Fistula repair (surgical) after catheter drainage for 4 to 6 weeks for small fresh fistulae.
• Special groups: women with obstetric anal sphincter injury need combined assessment of urinary and bowel function.
• Red flags: continuous leakage (fistula), retention with overflow, haematuria, severe pain, neurological symptoms and no improvement after 3 to 6 months.
• Follow-up: review at 6 weeks and 3 months, then at 6 to 12 months. Refer to gynaecology or urology if not improving.