Stress Urinary Incontinence Postpartum

This is probably the hardest thing I’ve had to write. It’s taken a long time to read the studies and put together something I hope other women find helpful. Please be kind, this is my personal experience and it was a difficult one. I wanted to write this because during that challenging time I didn’t speak to anybody about it and mentally suffered. I’ve always been active and enjoy high impact exercise, the prospect of not being able to go back to this symptom free devastated me. I felt very alone and let down by my body. If you’re reading this and thinking “oh my god it’s me!” Please know this. Things will get better.

So this post is about my absolute rock bottom shitty day 44 Postpartum (PP). That’s right, not day 3 or 4, day 44. That was the day I realised I had Stress Urinary Incontinence (SUI) and it absolutely broke my heart. It all starts with a moderately amusing story about our French Bulldog Louis. Louis has a mind of his own when it comes to cats. He LOVES them but the feeling is most certainly not reciprocated. Ordinarily this wouldn't be an issue, that was until day 44. We did our normal walk and were coming to the end of the country park when all of a sudden Louis spotted a cat. He took off after it with not a care in the world. I had to run and catch him as he was heading towards a road. Without a thought I sprinted off after him as I have always done. Even at 32 weeks pregnant I ran after him on Woodbury Common as he confused a horse for a cat and wanted to say hello. I caught him with no issue. This time it didn’t play out like that. I became very aware of a really odd sensation down there. A sort of dull ache like an openness, I’m finding it hard to explain. Either way I was aware I was leaking. Not a lot but enough. If you think about drawing up 3ml in a syringe it doesn’t seem a lot but when we’re talking about transference on to clothes it looks a lot. It was a horrible feeling, something inside me died. Not of embarrassment, it was about 1900 and nobody was around. I was wearing black leggings (every single postpartum woman’s best friend) and nobody was remotely aware of what was happening but me. I was just so disappointed in my body and felt like it had let me down. I realise now this was cruel of me. Back to Louis who had thankfully stopped well before the road. I clipped him back on to his lead and we walked home. When we got home I opened the front door took Louis’ collar off and walked upstairs as my husband called up to me whilst cradling Theodora “How was your walk?”

-“Yeah great.” I replied and tears started to fill my eyes. I got into our family bathroom closed the door turned the shower on and sobbed. Big ugly snotty sobs. I got undressed got in the shower and the snotty sobs continued. I was mortified. All I could think was- Well that’s it you’ll never box jump again. Double unders are out of the window, running is a no. All the high impact stuff I love, (not strictly true, anybody who’s worked out with me will know I despise running). My mind then started racing. What if exerting any Inter Abdominal Pressure (IAP) results in leaking. Will I be able to lift symptom free? Will I be able to row or do burpees symptom free? OH MY GOD IF I CAN’T ROW OR DO BURPEES, WHAT AM I GOING TO DO?! Cue extreme sobbing still standing in the shower. I know the thought of not doing either of those things may delight some people but I love a bit of PE. I’m fully aware I became symptomatic at the mid to top end of the spectrum, high impact activity. Some women experience leaking with much less impact or carrying out daily functional tasks. Let’s have a look at some of the research around pre and post natal urinary incontinence.

So, the science bit, Urinary Incontinence (UI) is identified as the unintentional release of urine and is a condition that affects 25%- 45% of women world wide (Abrams et al 2017). Read those percentages again, let that sink in. If you’re reading this and feeling alone in dealing and/or rehabbing from UI you’re not. This figure of course is not solely reflective of postpartum women. Bø et al (2015) suggest UI affects 35-49% of young and perimenopausal women. Which is a slightly more reflective demographic but remember you don’t have to have been pregnant or given birth vaginally to have UI. There are several different types of UI, below is a table identifying the different types.

(Rigby 2014)

I didn’t have any form of UI during my pregnancy or pre pregnancy. I was religious in completing my Pelvic Floor Muscle Exercises (PFME’s) from the day I found out I was pregnant. I was aware this wouldn’t make me immune from UI but it gave me the best possible chance of minimising it. Completing PFME’s is one thing but completing them correctly is quite another and most certainly a post in its own right (I promise it’s on the way)! In 2006 a Cochrane review was completed by Hay-Smith & Dumoulin. Their subject studies were non pregnant women who were experiencing UI. Having subjects who were not pregnant mitigates against some of the contributing factors pregnancy brings. Things like mass hormone fluctuation which can affect connective tissue strength thus potentially contributing to UI. I’ll be touching on this again later. The Cochrane review recommends that PFMEs should be used as a first-line conservative treatment for UI. NICE (2006) recommend 8 contractions three times a day. Come on ladies! It’s not even 10! Just 8 contractions three times a day, make the time. The gold standard would be a ten second hold of the contraction but realistically anything from 5-8 seconds is a great start. Associate the exercises with a mundane task and get them done every day. I try and do mine when I’m doing the following:

• Brushing my teeth

• Feeding my daughter (not that this is mundane in any way)

• Waiting for the kettle to boil

• Waiting for the shower to get warm

• When I’m stood waiting for Louis to come back from one of his jollies

• When I’m putting away my daughter’s toys at the end of he day

• When I’m trying to get my daughter down to sleep

I could go on forever on the topic of PFME’s how to do them/ best practice/ mental imagery, and I will but on a separate post. There are varying reports on the percentage of women who experience UI during pregnancy. Mørkved & Bø (1999) stated that it is 42%, while Chiarelli & Campbell (1997) found that 64% of pregnant women experience some degree of UI. So why do women develop UI during pregnancy? This isn’t fully understood remember all women and their pregnancies are unique. Cooper and Cook (2011) describes the increase in intra- abdominal pressure caused by the enlarged uterus. Kapoor and Freeman (2007) found hormone levels may effect connective tissue strength and urethral resistance. Kennaway (2020) states that SUI is the result of urethral sphincter muscle weakness and anatomical shortcomings in urethral support. When you take these factors into consideration and combine functional movements like jumping, running and moving with weight we are adding ground reaction forces and testing the pelvic floor further. Hay (1993) estimated maximal ground reaction forces and reported running to be 3-4 times the subjects body weight and jumping to be 5-12 times body weight. Ground reaction force is the force exerted by the ground on a body in contact with it. This extends to everything we do from walking to going up the stairs. The force will always be there just at different pressures. Think of how many times we increase and decrease this pressure on a daily basis. It’s not just ground reaction forces that can overexert the pelvic floor. Increases in Intra Abdominal Pressure (IAP) can also do the same. Sneezing, Coughing and Laughing would all be examples of this that are not related to physical movement as such. I think a lot of people worry about IAP when thinking about sit ups and planks, the things you may think generate lots of pressure. Bø & Nygaard (2019) found coughing generates higher IAP than most exercises. The contributing factors for SUI are multifactorial, Chaitow (2012) identifies the most common being;

• Pregnancy

• Vaginal Delivery

• Pelvic Surgery

• Lifestyle Features (including high impact activities)

• Obesity

• Ageing

• Neurological Disorders.

That’ll be four ticks for me then. The pelvic floor forms the bottom part of that functional cylinder with the Diaphragm making the top and the (transversus abdominis) deep abdominal muscle at the front and the deep spinal muscles (multifidus) forming the back part. THIS ladies and gentlemen is your core. It’s a muscular system that works in synergy. The core is not (just) your six pack muscles. If it’s one thing to remember today as well as doing your PFME’s it’s that your core is bigger than one ascetic muscle group that everybody wants for the summer.

Moving on from anatomy and physiology to hormones. Let’s not underestimate the huge role hormones play in pregnancy and postpartum, especially if you are breastfeeding. Unfortunately there are limited amounts of research available around the effects of hormones on UI postpartum. There are however more studies regarding hormonal fluctuation in peri-menopausal women. Perimenopause refers to the transitional years prior to a woman beginning the menopause. During these years less oestrogen is produced. This is obviously not the same as as a lady who has just given birth but bare with me. La Leche League Canada (2016) describe lower estrogen levels post labour and how breastfeeding can extend the time frame of decreased oestrogen levels. We know through previous studies on perimenopause how oestrogen can affect the urethral and vaginal structure causing atrophy. Think of a structure not affected by atrophy as a grape and the same structure but with the affects of atrophy looking more like a raisin. In short a lack of estrogen can cause structures that were previously plump and squashy to become less so. When looking at the functional role of the urethra and its supporting structures, if atrophy is affecting their function this could in turn cause UI. Findings regarding the role in hormonal changes and SUI are inconsistent (Stothers & Friedman 2011). The lack of evidence is frustrating (and has made this bit hard to put together)! Oestrogen depletion is something I have discussed with my Obstetrics and Gynaecological Registrar as we felt it’s something I may have been suffering with.

Progress… This is something everybody wants to know. I think it gives a bit of hope if you’re just starting your rehab journey. I have good news! Obviously it helps being in the pelvic health field and having knowledge around regression and progression of exercises. I really did suffer with SUI and talked at length with my Obs and Gynae Reg. Topical estrogen cream was discussed and I was given a prescription as I was still exclusively breastfeeding which we felt may have been affecting my oestrogen levels. That was at around 16 weeks PP. As I’ve mentioned running was’t great, I hadn’t tried box jumps or any lifting with a barbell. The thought of double unders was a million miles away. I returned to Crossfit classes at Crossfit Exmouth at exactly 20 weeks PP. Everything was scaled. I was super wobbly and to be perfectly honest a little scared! I had worked hard with my PFME’s and included pilates into my daily exercise routine up to this point. I’m pleased to say running is now fine, box jumps are fine and single skips are fine, all lifting is okay it’s just building up to getting back to double unders symptom free. I will get there. I’m still exclusively breastfeeding my daughter, although feeds have dropped off dramatically now she is weaning and eating everything in sight. So there may still be some positive effects as my hormones continue to level out.

This has been a very humbling journey for me. I’ve been privileged to meet some fantastic sports women along the way who are on their own rehab journeys. Some of whom have spurred me on to write this blog (thank you, you know who you are). I don’t want women to feel they can’t return to exercise or do the things they love. UI is one of the single biggest barriers for women causing huge emotional upset. As Abrams et al (2015) found, UI has a significant impact on quality of life. I’ll never forget a friend telling me the latest update from her Obs and Gynae appointment. She was told (by a man if that makes any difference).

“You’ve had two children, what do you expect?”

*My reply in the gym to her retelling the story- “BETTER, I EXPECT BETTER”. There may also have been several expletives thrown in for good measure.

This is not an easy route of rehabilitation by any stretch of the imagination. It’s frustrating (many objects have been thrown around in our home gym,) upsetting and progress can be slow. But progress is progress. Techniques can be taught, exercises can be done and time can be taken. These things can’t be rushed. I think if my friend’s conversation at her appointment had gone a little more like this…

“ You’ve had two children, what do you expect? It’s going to take time assessment and the right clinician to work with you towards your goals.”

Her experience may have been a very different one. Don’t give up. Don’t be unkind to yourself. This is rehabilitation, the same as we would rehabilitate from a sprained ankle, hip surgery or a rotator cuff tear. Your body just needs the right assessment to establish diagnosis and goals, cues, exercises and time. Your mind needs a bit of positivity and encouragement. Remember those numbers, you’re not on your own. Big love V x

References;

• Abrams P., Smith A. P. & Cotterill N. (2015) The impact of urinary incontinence on health-related quality of life (HRQoL) in a real-world population of women aged 45- 60 years: results from a survey in France, Germany, the UK and the USA. BJU International. 115 (1), 143-152.

• Abrams P., Cardozo L., Wagg A. & Wein A. (eds) (2017) Incontinence, 6th end, Vol. 1. International Continence Society, Bristol.

• Bø K., Berghmans B., Mørkved S & Van Kampen M. (2015) Evidence Based Physical Therapy for the Pelvic Floor: Bridging Science and Clinical Practice, 2nd end. Churchill Livingstone, Edinburgh.

•  Bø, K., Nygaard, I.E. (2019) Is Physical Activity Good or Bad for the Female Pelvic Floor? A Narrative Review.Sports Med 50, 471–484 (2020). https://doi.org/10.1007/s40279-019-01243-1

• Chaitow L. & Lovegrove Jones R. (eds) (2012) Chronic Pelvic Pain and Dysfunction: Practical Physical Medicine, 1st end. Churchill Livingstone, Edinburgh.

• Chiarelli P. & Campbell E. (1997) Incontinence during pregnancy: prevalence and opportunities for continence promotion. Australian and New Zealand Journal ofObstetrics and Gynaecology 37 (1), 66–73. Accessed online at; https://rdcu.be/b3EK4

• Cooper H.E & Cooke T. (2011) Antenatal pelvic floor muscle exercises for the prevention and treatment of urinary incontinence in the antenatal and early postnatal period: a critical appraisal of the evidence.Journal of the Association of Chartered Physiotherapists in Women’s Health, Autumn 2011, 109, 5–13. Accessed online at; https://pogp.csp.org.uk/system/files/coopercook_hr.pdf

• Hay JG. Citius, altius, longius [faster, higher, longer]: the bio- mechanics of jumping for distance. J Biomech. 1993;26(Suppl 1):7–21.

• Kapoor D. S. & Freeman R. M. (2007) Pregnancy, child- birth and urinary incontinence. In: Therapeutic Manage- ment of Incontinence and Pelvic Pain: Pelvic Organ Disorders, 2nd edn (eds J. Haslam & J. Laycock), pp. 143–146. Springer-Verlag, Berlin.

• Kennaway B. (2020) Is pelvic floor muscle training enhanced by supplementary transversus abdomens recruitment in the treatment of female urnary incontinence? A review of the evidence and reflection on current practices. Journal of Pelvic Obstetric and Gynaecological Physiotherapy, Spring 2020, 126, 16-28.

• La Leche League Canada. (2016) Breastfeeding and the hormones of sexuality. Accessed online at; https://www.lllc.ca/thursdays-tip-breastfeeding-and-hormones-sexuality

• Mørkved S. & Bø K. (1999) Prevalence of urinary inconti- nence during pregnancy and postpartum. International Urogynecology Journal and Pelvic Floor Dysfunction 10 (6), 394–398.

• National Institute for Health and Care Excellence 2006. Urinary incontinence and pelvic organ prolapse in women: management. Accessed online at; https://www.nice.org.uk/guidance/ng123/chapter/ Recommendations#physical-therapies

• Rigby D. (2014). Urinary incontinence and comorbidity. Australian Journal of Pharmacy. 95. 60-62. Accessed online at;https://www.researchgate.net/figure/Types-of-urinary-incontinence_tbl1_286674626

• Stothers, L., Friedman, B. Risk Factors for the Development of Stress Urinary Incontinence in Women.Curr Urol Rep 12, 363 (2011). Accessed online at; https://doi.org/10.1007/s11934-011-0215-z