Postpartum Incontinence

Symptoms – The most common type of incontinence after (and before) childbirth is stress incontinence: the leaking of urine when coughing, sneezing, crying, lifting and exercising, all of which put pressure on the bladder.

Causes – “Think of a bucket. Each time you pour something into it, it comes closer to overflowing. It’s the same with incontinence: As you add predisposing factors, you’re more likely to end up with a problem,” explains Jerome Weiss, M.D., director of the Pacific Center for Pelvic Pain and Dysfunction in San Francisco and president of the International Pelvic Pain Society.

Among the risk factors for incontinence:
Diastasis recti, or separation of the abdominal muscles – In this common “side effect” of pregnancy, the growing fetus stretches the mother’s abdominal wall until it separates down the middle. “In 60 percent of new mothers, the separation heals on its own,” says Kotarinos. If not, this sagging support may lead to incontinence, low back pain and prolapsed (fallen) pelvic organs – in days or even decades to come.
A damaged pudendal or levator ani nerve – This can weaken the pelvic muscles that the nerve “feeds.” Nerves typically have trouble healing.
Stretching, weakening and tearing of pelvic muscles during pregnancy and childbirth – In general, muscles heal better than nerves.
Add these together, and you’ve got the perfect recipe for incontinence, Dr. Weiss explains: “To control urination, you use the muscles around your bladder and urethra. When they weaken for any reason, you have less control. Even if you seem fine right now, hormonal changes during menopause can cause thinning and weakening of the urethra. Add in pre-existing muscle weakness from childbirth, and you can develop incontinence.”
Treatment – Again, your physical therapist will evaluate you and choose techniques suited to your circumstances. Her bag of therapeutic tricks includes:
• Abdominal exercises – Diastasis recti calls for specialized exercises; traditional sit-ups will not help, Kotarinos explains. As your abdominal muscles heal, your physical therapist will introduce more-standard strengthening exercises.• Hands-on techniques – Examples include trigger-point release, myofascial manipulation and connective tissue manipulation. The goal, explains Weiss, is to “eliminate any trigger points and normalize muscle functioning before introducing strengthening exercises.” Women with healthier muscles may not need manual manipulation, according to Kotarinos.• Kegel exercises – Among their many perks, Kegels strengthen “pelvic floor” muscles, the support structure for the bladder and other organs. Many physical therapists add biofeedback to help patients isolate the muscles that control urination. Again, daily practice is critical.
If you have trouble recruiting the correct muscles, perhaps because of extreme weakness or nerve damage, Perlis says your therapist may “jump-start” your muscles with electrical stimulation – a safe, controllable, therapeutic current.
• Vaginal cones – Vaginally insert a weighted “cone,” then try to keep it in place – automatically, you contract and strengthen your pelvic muscles. Your therapist may give you a set of graded (lighter to heavier) cones for gradual strengthening at home.
Incontinence PT typically involves fewer, and less frequent, visits than vaginal-pain PT. Kotarinos and Perlis both say that, after four to six weeks, patients leak substantially less or go “dry.”
Confirming their success, several clinical studies show that Kegels plus biofeedback reduces leaking episodes by 80 percent. (Drugs had about 10 percent less success – and more side effects.)
Other treatment options include medication and surgery, but “you really need to go through conservative measures before surgery,” says Weiss. “Even after surgery, you’ll need Kegels to prevent further problems.”