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WOMEN'S HEALTH

WOMEN'S HEALTH

Prevalence and Risk Factors for Urinary and


Fecal Incontinence Four Months After Vaginal
Delivery
Sandra A. Baydock, MD,1 Catherine Flood, MD,1 Jane A. Schulz, MD,1 Dianna MacDonald, PT,1
Deborah Esau, BScPT,1 Sandra Jones, BPT,1 Craig B. Hiltz, MSc²
1
Department of Obstetrics and Gynecology, University of Alberta, Edmonton AB
2
Consultant Statistician, Department of Obstetrics and Gynecology, University of Alberta, Edmonton AB

Abstract Résumé
Objective: To determine the prevalence of and risk factors for Objectif : Déterminer la prévalence et les facteurs de risque de
urinary and fecal incontinence four months after vaginal delivery. l’incontinence urinaire et fécale, quatre mois à la suite d’un
Methods: All patients who had vaginal deliveries at a tertiary care accouchement vaginal.
hospital over a three-month period were approached during their
Méthodes : Sur une période de trois mois, au sein d’un hôpital de
postpartum hospital stay regarding participation in the study.
soins tertiaires, nous avons sollicité la participation de toutes les
Participants underwent a telephone interview at four months after
patientes y ayant connu un accouchement vaginal et s’y trouvant
their delivery to determine the presence and type of any
dans le cadre de leur hospitalisation postpartum. Les participantes
incontinence.
se sont soumises à une entrevue téléphonique, quatre mois à la
Results: Of 632 patients, 145 (23%) had stress incontinence, suite de l’accouchement, en vue de déterminer la présence et le
77 (12%) had urge incontinence, 181 (29%) had any urinary type de toute incontinence, le cas échéant.
incontinence and 23 (4%) had fecal incontinence. In univariate
analysis, stress incontinence was found to be increased in Résultats : Sur les 632 patientes, 145 (23 %) connaissaient une
patients ³ 30 years of age (26.2%) compared with patients incontinence à l’effort, 77 (12 %) connaissaient une incontinence
< 30 years of age (19.3%) (RR 1.4; 95% CI 1.0–1.8, P = 0.05). par impériosité, 181 (29 %) connaissaient une incontinence
Urge incontinence was increased in patients who had a forceps urinaire (quel qu’en soit le type) et 23 (4 %) connaissaient une
delivery (21%) compared with no forceps delivery (9%) (RR 2.2; incontinence fécale. Dans le cadre de l’analyse univariée, il a été
95% CI 1.4–3.6, P = 0.005), an episiotomy (32.4%) compared with constaté que l’incontinence à l’effort connaissait une hausse chez
no episiotomy (18.7%) (RR 1.9; 95% CI 1.2–2.9, P < 0.01) and a les patientes de ³ 30 ans (26,2 %), par comparaison avec les
longer second stage of labour (108 min vs. 77 min, P = 0.01). The patientes de < 30 ans (19,3 %) (RR, 1,4; IC à 95 %, 1,0–1,8,
prevalence of any urinary incontinence was increased with forceps P = 0,05). L’incontinence par impériosité connaissait une hausse
delivery (15.5%) compared with no forceps delivery (8.7%) (RR chez les patientes qui avaient subi un accouchement par forceps
1.5; 95% CI 1.1–2.1, P = 0.01) and maternal age of ³ 30 years (21 %), par comparaison avec celles qui n’avaient pas subi un tel
(34.1%) compared to < 30 years (23.5%) (RR 1.5; 95% CI accouchement (9 %) (RR, 2,2; IC à 95 %, 1,4–3,6, P = 0,005); une
1.1–1.9, P = 0.003). In multivariate analysis, the two variables that épisiotomie (32,4 %), par comparaison avec celles qui n’en
remained significant for any urinary incontinence were maternal avaient pas subi une (18,7 %) (RR, 1,9; IC à 95 %, 1,2–2,9,
age ³ 30 years (P < 0.01) and forceps delivery (P < 0.01). There P < 0,01); et un deuxième stade du travail prolongé (108 min, par
were no identified risk factors for fecal incontinence. comparaison avec 77 min, P = 0,01). La prévalence de
l’incontinence urinaire (quel qu’en soit le type) connaissait une
Conclusion: Urinary incontinence is common in women at four hausse en présence d’un accouchement par forceps (15,5 %), par
months post partum. Fecal incontinence is less common. Maternal comparaison avec l’absence d’une telle intervention (8,7 %) (RR,
age and forceps assisted delivery were risk factors for urinary 1,5; IC à 95 %, 1,1–2,1, P = 0,01), et en présence d’un âge
incontinence. maternel de ³ 30 ans (34,1 %), par comparaison avec un âge
maternel de < 30 ans (23,5 %) (RR, 1,5; IC à 95 %, 1,1–1,9,
P = 0,003). Dans le cadre de l’analyse multivariée, l’âge maternel
de ³ 30 ans (P < 0,01) et l’accouchement par forceps (P < 0,01)
constituaient les deux variables qui demeuraient significatives peu
importe le type d’incontinence urinaire. Aucun facteur de risque
d’incontinence fécale n’a été identifié.
Key Words: Stress urinary incontinence, urge urinary incontinence, Conclusion : L’incontinence urinaire est courante chez les femmes
fecal incontinence, vaginal delivery dont l’accouchement remonte à quatre mois. L’incontinence fécale
Competing Interests: None declared. est moins courante. L’âge maternel et l’accouchement par forceps
étaient des facteurs de risque en ce qui concerne l’incontinence
Received on March 13, 2008 urinaire.
Accepted on April 16, 2008 J Obstet Gynaecol Can 2009;31(1):36–41

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Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery

INTRODUCTION Maternal demographic, clinical, and obstetrical factors iden-


tified as independent variables were maternal age, birth
aginal delivery is an established risk factor for urinary
V and fecal incontinence,1–5 while delivery by Caesarean
weight, parity, weight gain during pregnancy (BMI was not
consistently available), length of second stage of labour,
section appears to be protective.1–3,6-8 Urinary and fecal postpartum urinary tract infection, mode of delivery, degree
incontinence reduce quality of life and may lead to increased of obstetrical tear, breech delivery, epidural use, and
health care costs and medical interventions.9 The preva- episiotomy. Neonatal risk factors were limited to birth
lence of urinary incontinence in the postpartum period weight. The telephone interview consisted of a 19-item
ranges from 0.3% to 38%.1–3,10 This range is derived from questionnaire designed to determine the presence,
studies with differing definitions of urinary incontinence frequency, and severity of stress and urge urinary inconti-
and variable follow-up periods. In addition, many studies nence, or fecal incontinence. These were standardized ques-
have focused primarily on the development of stress or any tionnaires used by the tertiary care urogynaecology unit at
urinary incontinence, while only a few studies examined the the time of the study; validated tools for assessment of
prevalence of postpartum urge incontinence.1,2,11 pelvic floor symptoms were not widely used or available.
The timing of follow-up at four months post partum was
Risk factors for incontinence after vaginal delivery, includ- selected to allow the urinary tract to return to pre-pregnancy
ing parity, age, birth weight, forceps-assisted delivery, and structure and function; most women have return of normal
maternal age, have been found in some studies but not in function within two to three months of delivery.18–20
others.1,2,12–15 Risk factors for postpartum urge inconti-
nence have been poorly evaluated.12 Incontinence of urine was defined as urinary leakage at least
once in a two week interval. Questions related to stress
The prevalence of postpartum fecal incontinence has been incontinence described urinary leaking with activities such
more consistently reported to range between 4% and 5.5% as coughing, laughing, sneezing, bending, lifting, bouncing,
after vaginal delivery.4,16,17 While anal sphincter disruption or exercising. Urge incontinence was defined as urinary
appears to be an established risk factor for fecal inconti- leaking associated with a strong desire to urinate. Fecal
nence, other factors such as episiotomy and instrumental incontinence was defined as leakage of liquid or solid stool
delivery are more controversial.4,17 at least once every two weeks. Patients were also questioned
The primary aim of this study was to determine the preva- regarding urinary frequency, pad use, nocturia, pre-
lence of stress, urge, and mixed urinary incontinence, as pregnancy and antepartum incontinence (part of the
well as fecal incontinence, at four months after vaginal screening questions), weight gain during pregnancy, and
delivery. We also identified demographic or obstetrical risk postpartum urinary tract infections. A pilot test of the ques-
factors for these conditions. The effect of delivery by tionnaire was conducted with 30 postpartum subjects to
Caesarean section was not reviewed in this study. ensure the questions were specific and easy to understand.
Categorical variables including age (arbitrarily divided into
MATERIALS AND METHODS < 30 years or ³ 30 years), mode of delivery, episiotomy, use
This was a prospective, cohort study undertaken at a tertiary of epidural analgesia, and postpartum urinary tract infection
care obstetrical hospital in Edmonton, Alberta. All patients were assessed using chi square or Fisher exact tests. Ratio
who underwent a spontaneous or operative vaginal delivery variables including parity, weight gain during pregnancy,
at the Royal Alexandra Hospital between January 1, 1999, and birth weight were assessed by a Student t test. The rank
and March 31, 1999, were approached during their variable of obstetrical tear was assessed using a Mann-
postpartum admission for recruitment into the study. Inclu- Whitney U test. Logistic regression was used to examine
sion criteria included having a singleton vaginal delivery, factors affecting the presence of urinary incontinence and
proficiency in English, and a permanent residence with a included all factors with a P value £ 0.10 on univariate analy-
telephone. Patients were excluded if they had pre- sis. All statistical analyses were performed using SPSS for
pregnancy urinary or fecal incontinence, drug or alcohol Windows version 11.5 (SPSS Inc., Chicago IL).
abuse (which might affect a subject’s ability to complete the
Ethics approval for the study was obtained from the
questionnaire and the follow-up survey), or incontinence
University of Alberta Health Research Ethics Board.
due to a medical, cognitive, or mobility impairment. Rele-
vant demographic and obstetrical data were collected from RESULTS
prenatal records and hospital charts. At four months post
partum, a telephone interview was conducted to determine A total of 717 patients were recruited into the study.
the presence and type of incontinence. Eighty-four patients were excluded because of pre-existing

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WOMEN'S HEALTH

Table 1. Characteristics
Peripartum variables included a mean duration of second
stage of labour of 81 minutes (range 0–651), and mode of
Characteristic n (range) delivery included spontaneous vaginal delivery (536,
Mean maternal age 29 (17–43) 84.8%), forceps-assisted delivery (68, 10.8%), vacuum-
Median parity 1 (0–8) assisted delivery (96, 15.2% ). Some patients underwent a
Mean birth weight, grams 3302 (930–5070)
delivery that was both vacuum-assisted and forceps-
Mean weight gain in pregnancy, pounds 31.5 (19–80)
assisted, and were included in both groups because of the
Mean length 2nd stage, minutes 80.5 (0–651)
small numbers.

Postpartum UTI n (%)


A total of 143 patients complained of stress urinary inconti-
nence (23%), 77 patients complained of urge urinary incon-
No 600 (94.9) tinence (12%), and 181 patients complained of any type of
Yes 32 (5.1) urinary incontinence (29%). Twenty-three (4%) com-
Forceps delivery n (%) plained of fecal incontinence. There was a significant
association between the two types of urinary incontinence
None 564 (89.2)
(P < 0.01). For example, a patient with stress urinary incon-
Low/outlet 18 (2.8)
tinence was more likely to have urge urinary incontinence
Mid 42 (6.6)
than a patient without stress incontinence. Fecal inconti-
Rotation 2 (0.4) nence showed a significant association with stress or urge
Breech 5 (0.8) incontinence (P < 0.01 and P = 0.02, respectively).
No data 1 (0.2)
The results of the univariate analysis for the development of
Vacuum delivery n (%) stress urinary incontinence are summarized in Table 2. The
None 536 (84.8) only variable identified as statistically significant was maternal
Low 66 (10.4) age ³ 30 years (RR 1.5; 95% CI 1.01–1.8; P = 0.05). The
Mid 30 (4.8) results of the univariate analysis for the development of
urge urinary incontinence are summarized in Table 3. Sig-
Degree obstetrical tear n (%)
nificant variables included maternal age ³ 30 years (RR 1.5;
0 225 (35.6) 95% CI 1.01–2.3; P = 0.05), forceps-assisted delivery
1 113 (17.8) (RR 2.2; 95% CI 1.4–3.6; P = 0.001), episiotomy (RR 3.5;
2 218 (34.4) 95% CI 2.3–5.2; P < 0.001) and increased length of second
3 66 (10.5) stage (108 minutes, SD 111, vs. 77 minutes, SD 87; P = 0.01).
4 9 (1.5) The results of the univariate analysis for the development of
No data 1 (0.2) any urinary incontinence are summarized in Table 4. Signifi-
Epidural use n (%) cant variables included maternal age ³ 30 years (RR 1.5;
95% CI 1.1–1.9; P = 0.003) and forceps-assisted delivery
No 335 (53.0)
(RR 1.5; 95% CI 1.1–2.1, P = 0.01). No risk factors for fecal
Yes 297 (47.0)
incontinence were identified.
Episiotomy n (%)
Multivariate analysis was used to evaluate risk factors (Table 5).
None 503 (79.6) For stress urinary incontinence, we performed logistic
Midline 88 (13.9) regression analysis controlling for maternal age, epidural
Mediolateral 41 (6.5) use, and forceps-assisted delivery. Only a maternal age
³ 30 years was significant (P = 0.02).
incontinence and one because of active perianal Crohn’s In the analysis for urge urinary incontinence, we controlled
disease. The final analysis included data from 632 patients. for maternal age, length of second stage of labour,
forceps-assisted delivery, and episiotomy. The only risk fac-
Baseline and delivery characteristics of study participants tor that remained significant after multivariate analysis was
are shown in Table 1. The demographic variables of the maternal age ³ 30 years. When we examined risk factors for
study group included a mean maternal age of 29 years any urinary incontinence, we controlled for maternal age,
(range 17–43), a median parity of 1 (range 0–8), a mean forceps-assisted delivery, and birth weight. In this analysis,
birth weight of 3316 g (range 980–5070 g), and a mean both maternal age ³ 30 years (P = 0.004) and forceps
maternal weight gain of 14.0 kg (range–8.5 to 35.7 kg). delivery (P = 0.008) remained significant.

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Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery

Table 2. Risk factors for stress urinary incontinence

Variable SUI (143), n (%) No SUI (489), n (%) RR 95% CI P

Maternal age
< 30 years 63 (44.1) 264 (54.0) 1.4 1.0–1.8 0.05
³ 30 years 80 (55.9) 225 (46.1)
Forceps delivery
Yes 21 (14.6) 46 (9.0) 1.5 1.0–2.1 0.09
No 122 (84.4) 443 (91.0)
Epidural use
Yes 77 (54.0) 220 (45.0) 1.3 1.0–1.8 0.07
No 66 (46.0) 269 (55.0)

SUI: stress urinary incontinence

Table 3. Risk factors for urge urinary incontinence

Variable UUI (77), n (%) No UUI (555), n (%) RR 95% CI P

Maternal age
< 30 years 32 (41.6) 295 (53.2) 1.5 1.0–2.3 0.07
³ 30 years 45 (58.4) 260 (46.8)
Forceps
Yes 16 (20.8) 51 (9.2) 2.2 1.4–3.6 0.005
No 61 (79.2) 504 (90.8)
Episiotomy
Yes 25 (32.4) 104(18.7) 1.9 1.2–2.9 < 0.01
No 52 (67.6) 451(81.3)
Length of 2nd stage, 108 (SD 111) 77 (SD 87) NA NA 0.01
minutes (SD)

UUI: urge urinary incontinence

DISCUSSION
Our study population was heterogeneous for parity and
mode of delivery, with 10.8% of our population undergoing
This study was designed to determine the prevalence of uri- a forceps-assisted delivery. Other studies confirm forceps
nary and fecal incontinence following vaginal delivery and delivery increases the prevalence of urinary incontinence in
to evaluate risk factors for these conditions. The reported the first six months after delivery.3,16
prevalence of urinary incontinence after vaginal delivery
varies from 0.3% to 38%.1–3,10 Viktrup et al. reported a
prevalence as low as 0.3% in primiparous women at three A significant association between the two types of urinary
months post partum.1 Other studies show a prevalence of incontinence was found in our study. The presence of stress
urinary incontinence during the first six months post par- urinary incontinence increased the likelihood of a woman’s
tum ranging from 21% to 38%,1,3,10,16 which is consistent also having urge urinary incontinence. Mixed urinary incon-
with our results (29% prevalence of any urinary inconti- tinence is a common entity in women, but the specific
nence). Patients were included in the study by Viktrup et al.1 number of women developing urge incontinence is
only if they met the strict International Continence Society’s reported in only a few studies.2,11 Although the etiology of
definition of incontinence, although 6% admitted to any stress urinary incontinence in the postpartum period may
urinary incontinence at three months post partum. The be related to pudendal nerve disruption,4,5 the etiology of
study population in the study by Viktrup et al. also consisted urge incontinence remains unclear. We also found a signifi-
only of primiparous women, none of whom had a cant association between urinary and fecal incontinence,
forceps-assisted delivery.1 which has biological plausibility since the pudendal nerve

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WOMEN'S HEALTH

Table 4. Risk factors for any urinary incontinence

Variable UI (181), n (%) No UI (451), n (%) RR 95% CI P

Maternal age
< 30 years 77 (42.5) 250 (55.4) 1.5 1.1–1.9 0.003
³ 30 years 104 (57.5) 201 (44.6)
Forceps
Yes 28 (15.5) 39 (8.7) 1.5 1.1–2.1 0.02
No 153 (84.5) 412 (91.3)
Birth weight, 3374 (498) 3273 (563) NA NA 0.07
grams (SD)

UI: urinary incontinence

Table 5. Multivariate analysis of risk factors for urinary length of second stage were identified as risk factors for
incontinence urge incontinence in univariate analysis, only maternal age
remained significant after multivariate analysis. Studies
Variable P
identifying risk factors for postpartum urge urinary in
Stress incontinence continence are limited.6,11,12 However, head circumference
Maternal age 0.02* > 38 cm and concomitant stress incontinence have been
Urge incontinence reported as risk factors, although these were not specifically
Maternal age 0.01* examined in our study.11,12
Length second stage of labour 0.082
Many studies examining potential risk factors for
Any incontinence
postpartum incontinence include any form of incontinence
Maternal age < 0.01*
in their analyses. We found that two variables, maternal age
Forceps < 0.01*
³ 30 years and forceps-assisted delivery, were significantly
* denotes statistical significance associated with any urinary incontinence. Several authors
have noted an increased rate of incontinence in forceps-
assisted delivery3,14,16; this may be related to increased nerve
innervates both striated sphincters involved in urinary and and pelvic floor damage occurring during a forceps delivery.
fecal continence.4,5 However, a few long-term studies failed to show this
A maternal age of ³ 30 years was found to be significant on increased association with forceps delivery.3,11,21 Our find-
multivariate analysis for stress incontinence. Although uri- ings support the conclusion that forceps-assisted delivery
nary incontinence increases with advancing age in the gen- has a detrimental effect on the urinary continence mecha-
eral population,21 postpartum urinary incontinence has not nism in the short term.
been consistently associated with advancing maternal age.
Our observed rate of fecal incontinence (a prevalence of
Persson et al.13 demonstrated that age ³ 25 years at the time 4%) after vaginal delivery is consistent with several stud-
of first delivery was a risk factor for future incontinence sur- ies.6,10,16,17 Several studies have established anal sphincter
gery, but several short-term studies, all with less than one lacerations as risk factors for fecal incontinence,5,22,23
year of follow-up, failed to find a relationship between uri- although we did not find this relationship in our study. Only
nary incontinence and maternal age.1,3,14,16 Nevertheless, recognized third and fourth degree tears were reported in
Hatem et al.15 found that, in primiparous women, maternal our study, and occult sphincter injuries may have been
age > 35 years was associated with fecal incontinence and missed. Also, the number of patients with reported fecal
with concomitant fecal and urinary incontinence, but not incontinence was small (n = 23, 4%), and this limited our
with the development of urinary incontinence alone. analysis. Sultan et al. reported a small percentage of patients
Urge urinary incontinence in the postpartum period has with an intact perineum at delivery who were shown on
been less well studied. The prevalence of urge incontinence ultrasound assessment to have internal anal sphincter
in this study is consistent with other reports.2,11 While defects.4 Forceps delivery as a risk factor for fecal inconti-
maternal age, forceps-assisted delivery, episiotomy, and nence has been previously reported.4,17 No patients with

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Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery

fecal incontinence who had forceps-assisted deliveries were 9. Handa VL, Zyczynski HM, Burgio KL, Fitzgerald MP, Borello-France D,
Janz NK, et al. The impact of fecal and urinary incontinence on quality of
identified in our study, and therefore risk factor analysis was life 6 months after childbirth. Am J Obstet Gynecol 2007;197:636.e1–6.
not possible. Often fecal incontinence manifests at a time 10. Morkved S, Bo K. Prevalence of urinary incontinence during pregnancy and
distant from the injury; therefore, longer follow-up of these postpartum. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:394–8.
patients, which we are pursuing, may be useful. 11. Viktrup L, Lose G. Lower urinary tract symptoms 5 years after the first
delivery. Int Urogynecol J Pelvic Floor Dysfunct 2000;11:336–40.
CONCLUSION
12. Rortveit G, Daltveit A, Hannestad Y, Hunskaar S. Vaginal delivery
Urinary incontinence in previously continent patients is parameters and urinary incontinence: the Norwegian EPINCONT study.
Am J Obstet Gynecol 2003;189:1268–74.
common after vaginal delivery. While we found that stress
incontinence was the most common type of incontinence 13. Persson J, Wolner-Hanssen P, Rydhstroem H . Obstetric risk factors for
stress urinary incontinence: a population-based study. Obstet Gynecol
present at four months post partum, a significant number of 2000;96(3):440–5.
women also developed urge incontinence. The two types of
14. Burgio K, Zyczynski H, Locher J, Richter H, Redden D, Wright K. Urinary
urinary incontinence are inter-related, as are urinary and incontinence in the 12-month postpartum period. Obstet Gynecol
fecal incontinence. Increased maternal age stands alone as 2003;102:1291–8.
the most significant risk factor for any urinary incontinence. 15. Hatem M, Pasquier JC, Fraser W, Lepire E. Factors associated with
postpartum urinary/anal incontinence in primiparous women in Quebec.
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