Stress urinary incontinence (SUI) can certainly mar the joy of motherhood. If you leak when you laugh, sneeze, cough or bounce on a trampoline with your three-year-old, you are likely to suffer from SUI. According to Professor Peter Lim from the Andrology, Urology and Continence Centre at Gleneagles Hospital, post-partum SUI is more common than many people might think.
SUI is classified as mild, moderate or severe, according to the amount of leakage and how easily leakage occurs. For example, occasional small leaks triggered by strong sneezing, laughing fits or heavy lifting would be classified as mild. More frequent or larger leaks caused by the occasional sneeze, running for a bus or lifting a heavy shopping bag might rate as moderate. If leakage is heavy or caused by almost any normal physical exertion such as walking upstairs or even standing for a long time or getting up after sitting for a prolonged period it would be classified as severe.
Professor Lim reveals,“About a third of first-time mothers will experience SUI in the third trimester and most women will have some SUI in the first three to six months after birth. In Singapore, it is difficult to give an accurate figure of the number of women affected by SUI because it is largely under-reported, but it is thought to be 12 to 20 percent with the highest incidence found among those over 65.”
Many women, especially older women may have SUI but never seek medical attention either because they are too embarrassed to confide in their doctors about it, or they simply believe it is an unavoidable part of ageing and they think nothing short of surgery can fix it because they are unaware of the modern non-surgical treatment options.
Says Professor Lim, “Another misconception is that it is hereditary. There are no obvious genetic indicators of a hereditary factor to SUI, and just because your mother had it and suffered with it for years does not mean that you will.”
“Some women wonder if there is some way they could have prevented it but the answer is no. There is no way to guarantee you won’t have SUI after childbirth so there is no fault or blame. While maintaining a healthy weight and exercising (especially Kegels) during your pregnancy and after birth may reduce the chances of having SUI, they don’t guarantee it.”
He adds, “Most new mothers tend to experience some mild to moderate SUI after giving birth but it usually clears up within a few months to a year if they do their Kegel pelvic floor exercises (PFEs) to strengthen the muscles and ligaments of the pelvic floor. Second and third births may cause more serious or longer lasting problems.”
About Pregnancy and SUI
“Pregnancy and childbirth are the major causes of SUI in women because they cause stretching and weakening of the ligaments, nerves and pelvic floor muscles that normally work together to support the bladder and keep the urethra closed so urine doesn’t leak,” explains Professor Lim.
“The extent and severity of the stretching and weakening of the supportive structures of the pelvic floor and urinary tract will determine the severity of SUI in pregnant women and women who have given birth. Some risk factors may increase the incidence of SUI, such as being overweight or obese, if the baby is particularly large or the mother very petite, or if forceps or suction are used delivery, or if there is any tearing during delivery. Not doing Kegel exercises after birth can also slow recovery of the pelvic floor muscles and lead to SUI.”
Opt for C-sections to avoid SUI?
Many studies have been conducted to establish if vaginal delivery tends to increase the incidence of SUI compared to C-section delivery, reveals Professor Lim. “It seems that the prevalence of post-partum SUI is similar after spontaneous vaginal delivery and C-sections performed for obstructed labour. However an elective C-section with no labour does seem to reduce the instance of SUI significantly. Although there does appear to be a reduced incidence of SUI, expectant mothers should keep in mind that C-sections come with their own risk factors, especially for first-time mothers planning on more children. Several studies have also shown that mothers who had, had caesarean sections were just as likely to develop SUI in later life as mothers who had given birth naturally.”
Professor Lim advises, “There are a range of treatment options for SUI depending on its severity and no single procedure or intervention is optimal for all patients. Having a variety of treatment options offers the possibility of tailoring therapy to the desires and needs of the individual patient.”
The first option, especially for mild or post-partum SUI, would be behavioural modification such as fluid and dietary management, bladder training and timed or prompted voiding combined with PFEs like Kegels. It comes with pros such as no downtime, side effects or additional costs while not affecting future pregnancies. However, it takes time for behavioural modification to be effective and one has to keep up with the exercises and lifestyle modifications to retain the benefits.
For mild or moderate SUI not responding to behavioural modification and PFEs, injectable bulking agents (IBA) are another option, such as glutaraldehyde cross-linked bovine collagen, pyrolytic carbon-coated beads and polytetrafluoroethylene. They are injected into the supportive tissues beneath the urethra to bulk them up and stiffen them so that they offer more support. They are effective, minimally invasive and cost-effective compared to surgery and they can last a long time; although not for as long as surgery. However, they still require a trip to the hospital, and depending on the choice of IBA there is a limit to the number of follow-up injections that can be administered. Another consideration is that depending on the type and amount of bulking agent used, subsequent babies may have to be delivered via C-section.
The latest treatment for SUI, and one which Professor Lim thinks will soon revolutionise SUI treatment in Singapore, and may even become the new standard first line therapy as it has in the United States, is the Fotonasmooth IncontiLase laser treatment.
“IncontiLase is a non-ablative photothermal technology that works by thermally affecting the vaginal tissue, stimulating collagen remodelling and the synthesis of new collagen fibres around the opening to the urethral and the vaginal wall. This new and strengthened collagen causes the shrinking and tightening of the vaginal mucosa tissue and collagen-rich endopelvic fascia and subsequently gives greater support to the bladder and greatly improves continence function,” says Professor Lim.
The latest model of the FotonaSmooth gynaecological laser systems has a digitally controlled robotic scanner called the G-Runner which ensures uniform delivery of energy to the entire vaginal canal for optimised treatments and increased patient comfort. It is non-invasive in that it requires no incisions or injections and there are no cuts, abrasions or burns so no risk of wound infection. For the patient, it is virtually painless and does not need to be done in a hospital operating room. In fact it can be done in the urologist’s clinic and 20 minutes later the patient can walk out and continue with her day-to-day activities. Another big plus is that the patient can still give birth naturally if she decides to have another baby. There are no established cons to this treatment.
Surgery is the final option to counter SUI which women may not consider especially if they have been put off by older relatives. However, current surgical options are much less invasive than the techniques of even a couple of decades ago and there are a variety of surgical options depending on the condition.
Professor Lim says, “Most operations to treat SUI are now done as laparoscopic or ‘keyhole’ surgeries. Surgery is relatively safe, effective and a very long-lasting solution to most cases of SUI, and in very severe cases it may be the best option. However, it is invasive, expensive, and does require at least a night or two in hospital. As with any operation there is some risk involved, especially for older patients. This might also imply that subsequent births would have to be delivered by C-section.”