Congratulations! You're pregnant. It's an exciting time in life. Along with the joy and anticipation of bringing a baby into the world, you may find that pregnancy includes some unwelcome experiences like morning sickness, stretch marks, or LBL (light bladder leakage.) We asked urogynocogist Robert A. Starr, MD from Beaumont Hospital in Royal Oak, MI to shed some light on LBL during and after pregnancy.
"It's very common. There are things that can be done about it. And it demands open communication," said Dr. Starr. "We are getting better as physicians, nurses, and health care providers at asking patients about urinary leakage, though I think there's room for us to improve as providers." If you've been reluctant to talk about LBL, it may help to know that you are not alone. One in three women experiences LBL. Dr. Starr encourages women to be proactive, and discuss it, because there are some effective options available to you.
LBL during pregnancy tends to happen for a combination of reasons according to Dr. Starr. Some women are genetically predisposed to it. Others are not. Race and age can be factors. Smoking is known to contribute to LBL, and it's considered taboo during pregnancy. Also, pulmonary conditions like asthma and chronic coughing can weaken the pelvic floor because of continuous pressure. Anything that increases pressure in the pelvis may contribute to those unwanted trickles and drips.
"The weight of the growing uterus on the bladder is probably a factor that leads to some leakage throughout pregnancy," said Dr. Starr, "When LBL is present before a pregnancy the symptoms can sometimes worsen and persist after delivery."
Dr. Starr explained that LBL results from weakened pelvic floor muscles, stretching or injury to the pelvic nerves that feed those muscles, and connective tissue damage. In some women, stretching, or tearing combined with other factors result in a higher likelihood of LBL.
"In any given woman the size of the baby in relation to the size of her own bony pelvis can be a factor. The length of time the woman pushes may contribute to urinary incontinence too," said Dr. Starr.
During a vaginal birth there are moments in obstetrics when some assistance is necessary. When the expectant mother is exhausted, or there are issues with the fetal heart rate, it may be necessary to speed up the delivery. Forceps, or vacuum assisted delivery may be the best option for a patient at the time, though it is associated with a little higher risk of developing urinary incontinence afterwards. "That's why it is not done routinely." said Dr. Starr.
An episiotomy (a surgical incision during childbirth to facilitate delivery) was once thought to be a protective measure against pelvic floor injury. "Now we know that when it's done routinely it increases the risk to pelvic floor muscles," said Dr. Starr, "There's been a very big swing away from using routine episiotomies. It is now used only when needed."
Some women experience pelvic organ prolapse, a condition where organs, such as the uterus, fall down or slip out of place. Urinary incontinence is often a symptom. Dr. Starr helps women who aren't ready to have anything surgical done to correct it, because they planned to have more children.
In some instances he had patients work with a physical therapist to maximize pelvic floor strength with pelvic exercises.
"Another thing that has been helpful in select patients is a non-surgical approach using a specialized device called a pessary," said Dr. Starr. Pessaries are usually made of medical grade silicon. They come in different styles, sizes and shapes and work as a mechanical device. When properly fitted, they are inserted in the vagina and seat themselves in the pelvis. It helps lift up the uterus off the bladder when it is relaxed and falling down, relieving some of the pressure, fullness and heaviness. Incontinence style pessaries are designed to put additional pressure against the bladder opening or bladder neck.
"Even though it's not common to use during pregnancy, I've had patients with pretty traumatic symptoms who have benefited from this. We use it to help relieve the symptoms of the prolapse, the pressure and fullness, and it's been reasonably successful in reducing some of the leaking they've had as well," said Dr. Starr.
Once the uterus grows large enough, sometime between the first and second trimester, it is too big to slide down. Then, typically the pessary is no longer effective or necessary. "At that point we'll stop using it. In the first trimester it could be a nice approach for select patients," Dr. Starr said.
Women have asked Dr. Starr, "How is it that I'm 10, 15, 20 years down the road from pregnancy, and we're talking as if my bladder leakage is related to child birth?" Childbirth is one of multiple factors that combine to lead to delayed LBL. "I read one study that said up to one third of patients who deliver vaginally may develop some degree of incontinence up to 3 to 6 months after childbirth," said Dr. Starr.
"For those who seem to have a delayed onset, it may be caused by injury to the pelvic floor muscles, or nerves. We don't talk a lot about what happens to pelvic floor nerves. Sometimes small branches of the nerves that feed these muscles can be injured. Gradually over time, the muscle can slowly atrophy. That's why we think there is some delay in experiencing bladder leakage."
So, what can you do during pregnancy to help reduce or prevent LBL? Dr. Starr suggests modifying the things that are changeable. Some modifications are straight forward: stop smoking (especially during pregnancy) and get coughs and sneezing under control. Here are two more helpful changes to put in place:
Pelvic floor muscle exercise, such as Kegels and core strengthening, can be rewarding for women who experience LBL. "It is helpful for women who experience stress incontinence and even urge incontinence," said Dr. Starr, referring to the two most common types of LBL. It's especially helpful under the guidance of a physical therapist or nurse practitioner who's trained to help women understand and maximize the benefit of those types of exercises. Dr. Starr points out, "It may not always cure incontinence, but often time's symptoms can be markedly improved."
When asked whether it's safe to do pelvic exercises during pregnancy, Dr. Starr said, "It certainly won't hurt anything. There's no risk to the pregnancy, and no risk to the mother. From a practical standpoint, pelvic floor exercise is a part of good pelvic floor heath. If you do it effectively during pregnancy, you set the stage for doing the exercises postpartum and beyond when we know it can be a difference maker in terms of reducing or preventing leakage."
"Certainly, pregnancy is no time for dieting," Dr. Starr said, "Though, it is a time when good nutrition and managing weigh gain is important." If you don't have a good track record in this area, it may be helpful to work with a nutritionist to get a handle on healthy eating and learn how to track your weight gain. When a woman's weight exceeds a certain threshold, it can begin having a negative impact on pelvic floor health and adds to the likelihood of urinary incontinence.
Since vaginal childbirth is more strongly associated with prolapse and urinary incontinence, expectant moms have asked whether having an elective caesarian section is a better route to go than delivering vaginally. This has drawn so much attention that The National Institutes of Health (NIH) sponsored a study. Experts were brought together from many different disciplines, including clinicians and basic scientists, to analyze the literature.
Dr. Starr explained, "Right now, based on everything we know, the scientific data on this topic is not sufficient to justify elective caesarian section. There are so many things to balance including the potential risk of a major surgery. So, we don't recommend elective caesarian section on this basis alone."
Pregnancy is the time to reach out to your friends. When you start comparing notes with the women in your life, you'll soon find that there is a wealth of information and support available to you. It just takes one woman to get the conversation about light bladder leakage started.
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