Long-term Impact of Mode of Delivery on Stress Urinary Incontinence and Urgency Urinary Incontinence: A Systematic Review and Meta-analysis

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Abstract

Context

Stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) are associated with physical and psychological morbidity, and large societal costs. The long-term effects of delivery modes on each kind of incontinence remain uncertain.

Objective

To investigate the long-term impact of delivery mode on SUI and UUI.

Evidence acquisition

We searched Medline, Scopus, CINAHL, and relevant major conference abstracts up to October 31, 2014, including any observational study with adjusted analyses or any randomized trial addressing the association between delivery mode and SUI or UUI ≥1 yr after delivery. Two reviewers extracted data, including incidence/prevalence of SUI and UUI by delivery modes, and assessed risk of bias.

Evidence synthesis

Pooled estimates from 15 eligible studies demonstrated an increased risk of SUI after vaginal delivery versus cesarean section (adjusted odds ratio [aOR]: 1.85; 95% confidence interval [CI], 1.56–2.19; I ² = 57%; risk difference: 8.2%). Metaregression demonstrated a larger effect of vaginal delivery among younger women ( p = 0.005). Four studies suggested no difference in the risk of SUI between spontaneous vaginal and instrumental delivery (aOR: 1.11; 95% CI, 0.84–1.45; I ² = 50%). Eight studies suggested an elevated risk of UUI after vaginal delivery versus cesarean section (aOR: 1.30; 95% CI, 1.02–1.65; I ² = 37%; risk difference: 2.6%).

Conclusions

Compared with cesarean section, vaginal delivery is associated with an almost twofold increase in the risk of long-term SUI, with an absolute increase of 8%, and an effect that is largest in younger women. There is also an increased risk of UUI, with an absolute increase of approximately 3%.

Patient summary

In this systematic review we looked for the long-term effects of childbirth on urinary leakage. We found that vaginal delivery is associated with an almost twofold increase in the risk of developing leakage with exertion, compared with cesarean section, with a smaller effect on leakage in association with urgency.

Take Home Message

We found that over the long term, vaginal delivery is associated with an almost twofold increase in the risk of developing leakage with exertion, compared with cesarean section, with a smaller effect of leakage in association with urgency.

Related collections

Most cited references 41

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A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trøndelag.

Y S Hannestad, S Hunskaar, H Sandvik … (2000)

The aim was to assess the prevalence of any urinary leakage in an unselected female population in Norway, and to estimate the prevalence of significant incontinence. The EPINCONT Study is part of a large survey (HUNT 2) performed in a county in Norway during 1995-97. Everyone aged 20 years or more was invited. 27,936 (80%) of 34,755 community-dwelling women answered a questionnaire. A validated severity index was used to assess severity. Twenty-five percent of the participating women had urinary leakage. Nearly 7% had significant incontinence, defined as moderate or severe incontinence that was experienced as bothersome. The prevalence of incontinence increased with increasing age. Half of the incontinence was of stress type, 11% had urge and 36% mixed incontinence. Urinary leakage is highly prevalent. Seven percent have significant incontinence and should be regarded as potential patients.

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Urinary incontinence after vaginal delivery or cesarean section.

Guri Rortveit, Anne Kjersti Daltveit, Yngvild S Hannestad … (2003)

It is uncertain whether women who deliver by cesarean section have an increased risk of urinary incontinence as compared with nulliparous women and whether women who deliver vaginally have an even higher risk. We studied 15,307 women enrolled in the Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) study, which involved a community-based cohort. The data base for this study was linked to data from the Medical Birth Registry of Norway. We included women who answered questions related to urinary incontinence, were younger than 65 years of age, and had had no deliveries, cesarean sections only, or vaginal deliveries only. The prevalence of any incontinence was 10.1 percent in the nulliparous group; age-standardized prevalences were 15.9 percent in the cesarean-section group and 21.0 percent in the vaginal-delivery group. Corresponding figures for moderate or severe incontinence were 3.7 percent, 6.2 percent, and 8.7 percent, respectively; figures for stress incontinence were 4.7 percent, 6.9 percent, and 12.2 percent, respectively; figures for urge incontinence were 1.6 percent, 2.2 percent, and 1.8 percent, respectively; and figures for mixed-type incontinence were 3.1 percent, 5.3 percent, and 6.1 percent, respectively. As compared with nulliparous women, women who had cesarean sections had an adjusted odds ratio for any incontinence of 1.5 (95 percent confidence interval, 1.2 to 1.9) and an adjusted odds ratio for moderate or severe incontinence of 1.4 (95 percent confidence interval, 1.0 to 2.1). Only stress and mixed-type incontinence were significantly associated with cesarean sections. The adjusted odds ratio for any incontinence associated with vaginal deliveries as compared with cesarean sections was 1.7 (95 percent confidence interval, 1.3 to 2.1), and the adjusted odds ratio for moderate or severe incontinence was 2.2 (95 percent confidence interval, 1.5 to 3.1). Only stress incontinence (adjusted odds ratio, 2.4; 95 percent confidence interval, 1.7 to 3.2) was associated with the mode of delivery. The risk of urinary incontinence is higher among women who have had cesarean sections than among nulliparous women and is even higher among women who have had vaginal deliveries. However, these findings should not be used to justify an increase in the use of cesarean sections. Copyright 2003 Massachusetts Medical Society

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Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.

E Hodnett, David Hannah, S Hewson … (2000)

For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies. At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat. Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35). Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

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Author and article information

Contributors

Kari A.O. Tikkinen

Journal

Journal ID (nlm-ta): Eur Urol

Journal ID (iso-abbrev): Eur. Urol

Title: European Urology

Publisher: Elsevier Science

ISSN (Print): 0302-2838

ISSN (Electronic): 1873-7560

Publication date PMC-release: 1 July 2016

Publication date (Print): July 2016

Volume: 70

Issue: 1

Pages: 148-158

Affiliations

[a ]Department of Obstetrics and Gynecology, Kuopio University Hospital, Kuopio, Finland

[b ]Department of Obstetrics and Gynecology, Kanta-Häme Central Hospital, Hämeenlinna, Finland

[c ]Department of Epidemiology and Biostatistics, Imperial College London, London, UK

[d ]Department of Urogynecology, Imperial College London, London, UK

[e ]Department of Urology, North Shore-LIJ Lenox Hill Hospital, New York, NY, USA

[f ]Institute for Bladder and Prostate Research, New York, NY, USA

[g ]Department of Obstetrics and Gynecology, University of Turku and Turku University Hospital, Turku, Finland

[h ]Department of Urology, University of Fukui Faculty of Medical Sciences, Fukui, Japan

[i ]Department of Clinical Practice Guidelines, National Center for Health Technology Excellence, México, Mexico

[j ]Department of Anesthesiology, Botucatu Medical School, São Paulo State University, São Paulo, Brazil

[k ]Department of Obstetrics and Gynecology, King Saud bin Abdulaziz University for Health Sciences, and King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia

[l ]Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

[m ]Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland

[n ]Pharmaceutical Science Master Courde, University of Sorocaba, São Paulo, Brazil

[o ]School of Pharmaceutical Sciences, Department of Drugs and Medications, Paulista State University, São Paulo, Brazil

[p ]Department of Obstetrics and Gynecology, St. Mary's Hospital, London, UK

[q ]Department of Urology, Päijät-Häme Central Hospital, Lahti, Finland

[r ]Department of Obstetrics and Gynecology, South Karelia Central Hospital, Lappeenranta, Finland

[s ]Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada

[t ]Chinese Cochrane Centre, West China Hospital, Sichuan University, Chengdu, China

[u ]Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

[v ]Department of Medicine, McMaster University, Hamilton, Ontario, Canada

[w ]Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland

Author notes

[* ]Corresponding author at: Department of Urology, University of Helsinki and Helsinki University Hospital, Haartmaninkatu 4, 00029 Helsinki, Finland. Tel. +358 50 5250971. kari.tikkinen@ 123456gmail.com

Article

Publisher ID: S0302-2838(16)00156-1

DOI: 10.1016/j.eururo.2016.01.037

PMC ID: 5009182

PubMed ID: 26874810

SO-VID: d333e8bc-3f97-4ef8-a44a-067038676d91

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Long-term Impact of Mode of Delivery on Stress Urinary Incontinence and Urgency Urinary Incontinence: A Systematic Review and Meta-analysis

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Abstract

Context

Objective

Evidence acquisition

Evidence synthesis

Conclusions

Patient summary

Take Home Message

Related collections

RNA drug delivery

Most cited references 41

A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trøndelag.

Urinary incontinence after vaginal delivery or cesarean section.

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.

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