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
Objective: To determine the prevalence of and risk factors for
urinary and fecal incontinence four months after vaginal delivery.
Methods: All patients who had vaginal deliveries at a tertiary care
hospital over a three-month period were approached during their
postpartum hospital stay regarding participation in the study.
Participants underwent a telephone interview at four months after
their delivery to determine the presence and type of any
incontinence.
Results: Of 632 patients, 145 (23%) had stress incontinence,
77 (12%) had urge incontinence, 181 (29%) had any urinary
incontinence and 23 (4%) had fecal incontinence. In univariate
analysis, stress incontinence was found to be increased in
patients ³ 30 years of age (26.2%) compared with patients
< 30 years of age (19.3%) (RR 1.4; 95% CI 1.0–1.8, P = 0.05).
Urge incontinence was increased in patients who had a forceps
delivery (21%) compared with no forceps delivery (9%) (RR 2.2;
95% CI 1.4–3.6, P = 0.005), an episiotomy (32.4%) compared with
no episiotomy (18.7%) (RR 1.9; 95% CI 1.2–2.9, P < 0.01) and a
longer second stage of labour (108 min vs. 77 min, P = 0.01). The
prevalence of any urinary incontinence was increased with forceps
delivery (15.5%) compared with no forceps delivery (8.7%) (RR
1.5; 95% CI 1.1–2.1, P = 0.01) and maternal age of ³ 30 years
(34.1%) compared to < 30 years (23.5%) (RR 1.5; 95% CI
1.1–1.9, P = 0.003). In multivariate analysis, the two variables that
remained significant for any urinary incontinence were maternal
age ³ 30 years (P < 0.01) and forceps delivery (P < 0.01). There
were no identified risk factors for fecal incontinence.
Conclusion: Urinary incontinence is common in women at four
months post partum. Fecal incontinence is less common. Maternal
age and forceps assisted delivery were risk factors for urinary
incontinence.
Key Words: Stress urinary incontinence, urge urinary incontinence,
fecal incontinence, vaginal delivery
Competing Interests: None declared.
Received on March 13, 2008
Accepted on April 16, 2008
36 l JANUARY JOGC JANVIER 2009
Résumé
Objectif : Déterminer la prévalence et les facteurs de risque de
l’incontinence urinaire et fécale, quatre mois à la suite d’un
accouchement vaginal.
Méthodes : Sur une période de trois mois, au sein d’un hôpital de
soins tertiaires, nous avons sollicité la participation de toutes les
patientes y ayant connu un accouchement vaginal et s’y trouvant
dans le cadre de leur hospitalisation postpartum. Les participantes
se sont soumises à une entrevue téléphonique, quatre mois à la
suite de l’accouchement, en vue de déterminer la présence et le
type de toute incontinence, le cas échéant.
Résultats : Sur les 632 patientes, 145 (23 %) connaissaient une
incontinence à l’effort, 77 (12 %) connaissaient une incontinence
par impériosité, 181 (29 %) connaissaient une incontinence
urinaire (quel qu’en soit le type) et 23 (4 %) connaissaient une
incontinence fécale. Dans le cadre de l’analyse univariée, il a été
constaté que l’incontinence à l’effort connaissait une hausse chez
les patientes de ³ 30 ans (26,2 %), par comparaison avec les
patientes de < 30 ans (19,3 %) (RR, 1,4; IC à 95 %, 1,0–1,8,
P = 0,05). L’incontinence par impériosité connaissait une hausse
chez les patientes qui avaient subi un accouchement par forceps
(21 %), par comparaison avec celles qui n’avaient pas subi un tel
accouchement (9 %) (RR, 2,2; IC à 95 %, 1,4–3,6, P = 0,005); une
épisiotomie (32,4 %), par comparaison avec celles qui n’en
avaient pas subi une (18,7 %) (RR, 1,9; IC à 95 %, 1,2–2,9,
P < 0,01); et un deuxième stade du travail prolongé (108 min, par
comparaison avec 77 min, P = 0,01). La prévalence de
l’incontinence urinaire (quel qu’en soit le type) connaissait une
hausse en présence d’un accouchement par forceps (15,5 %), par
comparaison avec l’absence d’une telle intervention (8,7 %) (RR,
1,5; IC à 95 %, 1,1–2,1, P = 0,01), et en présence d’un âge
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.
Conclusion : L’incontinence urinaire est courante chez les femmes
dont l’accouchement remonte à quatre mois. L’incontinence fécale
est moins courante. L’âge maternel et l’accouchement par forceps
étaient des facteurs de risque en ce qui concerne l’incontinence
urinaire.
J Obstet Gynaecol Can 2009;31(1):36–41
 Prevalence and Risk Factors for Urinary and Fecal Incontinence Four Months After Vaginal Delivery
INTRODUCTION
aginal delivery is an established risk factor for urinary
V and fecal incontinence,1–5 while delivery by Caesarean
section appears to be protective.1–3,6-8 Urinary and fecal
incontinence reduce quality of life and may lead to increased
health care costs and medical interventions.9 The preva-
lence of urinary incontinence in the postpartum period
ranges from 0.3% to 38%.1–3,10 This range is derived from
studies with differing definitions of urinary incontinence
and variable follow-up periods. In addition, many studies
have focused primarily on the development of stress or any
urinary incontinence, while only a few studies examined the
prevalence of postpartum urge incontinence.1,2,11
Risk factors for incontinence after vaginal delivery, includ-
ing parity, age, birth weight, forceps-assisted delivery, and
maternal age, have been found in some studies but not in
others.1,2,12–15 Risk factors for postpartum urge inconti-
nence have been poorly evaluated.12
The prevalence of postpartum fecal incontinence has been
more consistently reported to range between 4% and 5.5%
after vaginal delivery.4,16,17 While anal sphincter disruption
appears to be an established risk factor for fecal inconti-
nence, other factors such as episiotomy and instrumental
delivery are more controversial.4,17
The primary aim of this study was to determine the preva-
lence of stress, urge, and mixed urinary incontinence, as
well as fecal incontinence, at four months after vaginal
delivery. We also identified demographic or obstetrical risk
factors for these conditions. The effect of delivery by
Caesarean section was not reviewed in this study.
MATERIALS AND METHODS
This was a prospective, cohort study undertaken at a tertiary
care obstetrical hospital in Edmonton, Alberta. All patients
who underwent a spontaneous or operative vaginal delivery
at the Royal Alexandra Hospital between January 1, 1999,
and March 31, 1999, were approached during their
postpartum admission for recruitment into the study. Inclu-
sion criteria included having a singleton vaginal delivery,
proficiency in English, and a permanent residence with a
telephone. Patients were excluded if they had pre-
pregnancy urinary or fecal incontinence, drug or alcohol
abuse (which might affect a subject’s ability to complete the
questionnaire and the follow-up survey), or incontinence
due to a medical, cognitive, or mobility impairment. Rele-
vant demographic and obstetrical data were collected from
prenatal records and hospital charts. At four months post
partum, a telephone interview was conducted to determine
the presence and type of incontinence.
Maternal demographic, clinical, and obstetrical factors iden-
tified as independent variables were maternal age, birth
weight, parity, weight gain during pregnancy (BMI was not
consistently available), length of second stage of labour,
postpartum urinary tract infection, mode of delivery, degree
of obstetrical tear, breech delivery, epidural use, and
episiotomy. Neonatal risk factors were limited to birth
weight. The telephone interview consisted of a 19-item
questionnaire designed to determine the presence,
frequency, and severity of stress and urge urinary inconti-
nence, or fecal incontinence. These were standardized ques-
tionnaires used by the tertiary care urogynaecology unit at
the time of the study; validated tools for assessment of
pelvic floor symptoms were not widely used or available.
The timing of follow-up at four months post partum was
selected to allow the urinary tract to return to pre-pregnancy
structure and function; most women have return of normal
function within two to three months of delivery.18–20
Incontinence of urine was defined as urinary leakage at least
once in a two week interval. Questions related to stress
incontinence described urinary leaking with activities such
as coughing, laughing, sneezing, bending, lifting, bouncing,
or exercising. Urge incontinence was defined as urinary
leaking associated with a strong desire to urinate. Fecal
incontinence was defined as leakage of liquid or solid stool
at least once every two weeks. Patients were also questioned
regarding urinary frequency, pad use, nocturia, pre-
pregnancy and antepartum incontinence (part of the
screening questions), weight gain during pregnancy, and
postpartum urinary tract infections. A pilot test of the ques-
tionnaire was conducted with 30 postpartum subjects to
ensure the questions were specific and easy to understand.
Categorical variables including age (arbitrarily divided into
< 30 years or ³ 30 years), mode of delivery, episiotomy, use
of epidural analgesia, and postpartum urinary tract infection
were assessed using chi square or Fisher exact tests. Ratio
variables including parity, weight gain during pregnancy,
and birth weight were assessed by a Student t test. The rank
variable of obstetrical tear was assessed using a Mann-
Whitney U test. Logistic regression was used to examine
factors affecting the presence of urinary incontinence and
included all factors with a P value £ 0.10 on univariate analy-
sis. All statistical analyses were performed using SPSS for
Windows version 11.5 (SPSS Inc., Chicago IL).
Ethics approval for the study was obtained from the
University of Alberta Health Research Ethics Board.
RESULTS
A total of 717 patients were recruited into the study.
Eighty-four patients were excluded because of pre-existing
JANUARY JOGC JANVIER 2009 l 37
WOMEN'S HEALTH

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

38 l JANUARY JOGC JANVIER 2009

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

JANUARY JOGC JANVIER 2009 l 39

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
incontinence
Variable P
Stress incontinence
Maternal age 0.02*
Urge incontinence
Maternal age 0.01*
Length second stage of labour 0.082
Any incontinence
Maternal age < 0.01*
Forceps < 0.01*
* denotes statistical significance
innervates both striated sphincters involved in urinary and
fecal continence.4,5
A maternal age of ³ 30 years was found to be significant on
multivariate analysis for stress incontinence. Although uri-
nary incontinence increases with advancing age in the gen-
eral population,21 postpartum urinary incontinence has not
been consistently associated with advancing maternal age.
Persson et al.13 demonstrated that age ³ 25 years at the time
of first delivery was a risk factor for future incontinence sur-
gery, but several short-term studies, all with less than one
year of follow-up, failed to find a relationship between uri-
nary incontinence and maternal age.1,3,14,16 Nevertheless,
Hatem et al.15 found that, in primiparous women, maternal
age > 35 years was associated with fecal incontinence and
with concomitant fecal and urinary incontinence, but not
with the development of urinary incontinence alone.
Urge urinary incontinence in the postpartum period has
been less well studied. The prevalence of urge incontinence
in this study is consistent with other reports.2,11 While
maternal age, forceps-assisted delivery, episiotomy, and
length of second stage were identified as risk factors for
urge incontinence in univariate analysis, only maternal age
remained significant after multivariate analysis. Studies
identifying risk factors for postpartum urge urinary in
continence are limited.6,11,12 However, head circumference
> 38 cm and concomitant stress incontinence have been
reported as risk factors, although these were not specifically
examined in our study.11,12
Many studies examining potential risk factors for
postpartum incontinence include any form of incontinence
in their analyses. We found that two variables, maternal age
³ 30 years and forceps-assisted delivery, were significantly
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
and pelvic floor damage occurring during a forceps delivery.
However, a few long-term studies failed to show this
increased association with forceps delivery.3,11,21 Our find-
ings support the conclusion that forceps-assisted delivery
has a detrimental effect on the urinary continence mecha-
nism in the short term.
Our observed rate of fecal incontinence (a prevalence of
4%) after vaginal delivery is consistent with several stud-
ies.6,10,16,17 Several studies have established anal sphincter
lacerations as risk factors for fecal incontinence,5,22,23
although we did not find this relationship in our study. Only
recognized third and fourth degree tears were reported in
our study, and occult sphincter injuries may have been
missed. Also, the number of patients with reported fecal
incontinence was small (n = 23, 4%), and this limited our
analysis. Sultan et al. reported a small percentage of patients
with an intact perineum at delivery who were shown on
ultrasound assessment to have internal anal sphincter
defects.4 Forceps delivery as a risk factor for fecal inconti-
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
identified in our study, and therefore risk factor analysis was
not possible. Often fecal incontinence manifests at a time
distant from the injury; therefore, longer follow-up of these
patients, which we are pursuing, may be useful.
CONCLUSION
Urinary incontinence in previously continent patients is
common after vaginal delivery. While we found that stress
incontinence was the most common type of incontinence
present at four months post partum, a significant number of
women also developed urge incontinence. The two types of
urinary incontinence are inter-related, as are urinary and
fecal incontinence. Increased maternal age stands alone as
the most significant risk factor for any urinary incontinence.
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