Knocked Up Podcast - Urinary Incontinence After Childbirth Explained
Dr. Tzippora Ben-Harim, Head of Gynaecology at Women's Health Melbourne explains urinary incontinence after childbirth.
We are joined by Dr. Tzippora Ben-Harim, head of Gynaecology at Women's Health Melbourne, about urinary incontinence after childbirth. Urinary incontinence is common, affecting 1 in 3 to 1 in 4 women postpartum and occurs in two main forms: stress incontinence (leaking with coughing/sneezing) and urge incontinence (not making it to the toilet in time). The condition results from pressure on the pelvic floor during pregnancy, trauma from vaginal delivery, and postpartum oestrogen deficiency, particularly in breastfeeding women.
We discuss all types of treatment:
Conservative management including vaginal oestrogen therapy and pelvic floor physiotherapy satisfies most women's needs
Pessaries can provide temporary relief for those requiring additional support
Surgical options are typically reserved until family planning is complete due to risk of recurrence
Lifestyle modifications include reducing caffeine intake and maintaining proper hydration
Preventive measures include prenatal pelvic floor exercises and optimising general health before pregnancy
TRANSCRIPT
JORDI MORRISON: Hello and welcome to Knocked Up, the podcast about fertility and women's health. You're joined as always by me, Jordi Morrison, and Dr. Raelia Lew, CREI Fertility Specialist. Welcome, Raelia.
DR. RAELIA LEW: Hi, Jordi.
JORDI MORRISON: And today we're joined also by Dr. Tziporra Ben-Harim.
DR. TZIPORRA BEN-HARIM: Hello. Good morning.
JORDI MORRISON: So Dr. Tziporra Ben-Harim is the Head of Gynecology at Women's Health Melbourne. She's an experienced gynecologist and has done fellowship training in continent medicine in the Royal Women's Hospital in Melbourne and practices in all areas of gynecology across all age groups. Welcome, Tzippi.
DR. TZIPORRA BEN-HARIM: Thank you. Thank you for the invite.
JORDI MORRISON: Tzippi, we've got you on today to talk to us about urinary incontinence after childbirth. Not something that we've really touched on before. Can you explain to us what that means?
DR. TZIPORRA BEN-HARIM: Urinary incontinence is involuntary licking of urine. This is quite common, and we will discuss the postpartum period in which it's very prevalent. The estimate is 1 in 3 to 1 in 4, depending on different studies. We differentiate between licking with coughing and sneezing, and this falls under the category of stress urinary incontinence, when we need to go to the toilet, and this is urge incontinence, which means we need to go to the toilet and we don't quite make it. It can be either a few drops before we get to the toilet or the whole bladder gets empty. After having a baby, there is increase in both stress urinary incontinence and urge urinary incontinence.
JORDI MORRISON: And so Tzippi, this happens to a lot of women and obviously is so distressing. Why does it happen after you give birth?
DR. TZIPORRA BEN-HARIM: We can go through a few risk factors. The risk factors involve the pregnancy, the birth, and some factors that are for the patient herself. If we go through the pregnancy, basic fact of a pregnancy, as the uterus grows and the baby grows, puts pressure on the pelvic floor. So the pelvic floor is like a trampoline that the gynae organs, the bowel, and the urinary system are resting on. With the growing baby, there is more pressure on the pelvic floor. With regards to labor, some women have vaginal birth and some women have C-section. With vaginal birth, there is more trauma to the pelvic floor. Everything needs to be stretched. Vaginal births sometimes happen unassistedly, which means the woman... push the baby out and sometimes there is a need for assistance either for issues with mom she's getting exhausted and can't push the baby out or the baby is getting stressed. Procedures we do to expedite delivery like using forceps and vacuum increase the risk of urinary incontinence. The other element would be some trauma to the pelvic floor not just from passage of the baby but from needing to cut or from tearing, and this increases the risk of incontinence. Other factors which are worth mentioning, in the postpartum period, quite often there is estrogen deficiency. Women are breastfeeding, and the amount of estrogen in our system is reduced. The bladder and the vagina are quite sensitive to estrogen, they've got estrogen receptors, and the lack of estrogen makes women more prone to urinary incontinence.
JORDI MORRISON: Yeah, and shout out to one of our Alchemy products that you can research on the Alchemy website — is an intimate moisturizer that has estrogen in it, and that's a beautiful treatment for women who are breastfeeding if they're suffering symptoms of dry vagina, sore experience during intercourse, or incontinence. Why would using vaginal estrogen help with incontinence?
DR. TZIPORRA BEN-HARIM: A couple of things. So to say that vagina and bladder urethra are sensitive to estrogen, I encourage women to both use lubricant containing estrogen for intercourse but also estrogen as maintenance. Initially, we start with a daily course for two weeks and then we reduce it twice weekly. This is transient. So once they stop breastfeeding, their hormone system will recover. Estrogen will be produced again. Just to say that using vaginal lubricants that have estrogen and using vaginal estrogen is safe, including when breastfeeding. The absorption to the system is really minimal and has no impact on breastfeeding and other functions.
DR. RAELIA LEW: Yeah, it's very local and we know that from a lot of research because not only from women who are breastfeeding but also women who have menopause symptoms and use estrogen in the vagina in all its forms. It's been studied very widely around the world and we know that women who use estrogen in the vagina are not at risk of other systemic problems that can be sometimes associated when you use much more high dose oestrogen, say, for example, in an oral formulation, we just don't see those risks of things like blood clots and strokes or cancers associated with vaginal oestrogen use. And even sometimes women who've had something like a hormone-sensitive cancer, like a breast cancer, sometimes their oncologist, once they are past their initial treatment phase, are actually quite supportive of them using vaginal oestrogen creams to manage symptoms because it is, we think, very safe and local.
DR. TZIPORRA BEN-HARIM: Yeah, 100%.
JORDI MORRISON: So for someone at home who's experiencing these symptoms, at what stage should they contact a healthcare provider?
DR. TZIPORRA BEN-HARIM: To me, contacting a healthcare provider is if this symptom is impacting their quality of life. If this is now they're trying to reduce the fluid intake not to leak, or they walk out of home and they think, oh, where is the next toilet? They would plan their way according to the toilets. They would avoid socializing because they are embarrassed that maybe they will have an accident. So if all these things are playing on their mind, this is a good reason to go and chat with a healthcare provider. There are some initial tests that need to be done. We need to make sure that there is no urinary tract infection. We need to make sure that the bladder is actually emptying properly because sometimes the bladder can be over distended and we pass small amounts frequently, but actually a large volume stays behind. So we need to make sure that nothing like that is happening. And if that's the case, there are quite a few options for who to see. But I think seeing your GP first would be the way to go.
JORDI MORRISON: What happens if it's left untreated? Are there any long-term impacts?
DR. TZIPORRA BEN-HARIM: If it's not a urinary infection and it's not bladder that is not being emptied properly, there are not long-term consequences. I've seen women struggling with urinary incontinence for decades and decades, but the effect on their physical and psychological status is very important. This is about quality of life and not about quantity of life. This is not going to shorten the life expectancy, but still has a massive impact, and we're privileged enough that we can address that.
DR. RAELIA LEW: Yeah, and there's lots we can do. Even though for some women you'll never be exactly the same as before you were pregnant or gave birth to a baby, we can make really massive impacts on incontinence, particularly stress incontinence, both through physical therapy, medical therapies, and also some other therapies, including pessaries and also surgeries.
JORDI MORRISON: Tzippi, can you talk us through what your approach would be if you are meeting a woman for the first time? She's just had a baby maybe a couple of months ago. She's managed to get herself to your office, which in itself is a massive feat in those circumstances when you've got a newborn. There's so much struggle just even to leave the house sometimes. But this is really upsetting her and she wants your advice. What would you say to her at that first appointment?
DR. TZIPORRA BEN-HARIM: The first appointment will take a thorough history, will do an examination, make sure that there is no urinary tract infection, that the bladder is being emptied properly. Quite often, estrogen deficiency would be an element, will start estrogen. And the next step is conservative management, which... recommend seeing a physiotherapist. There is an option to do it independently, but the evidence is that comparing physiotherapists with self-practicing, it actually is beneficial to see a physio and get guidance and she will make, he or she will make sure that the exercises are doing properly. Could be also an element of commitment that when you go so very often to see a physio you will practice more regularly. So pelvic floor exercises like any exercises need to be practiced regularly, which means two, three times a day, 10 reps every time. And the evidence is that when you see a physiotherapist, you're more likely to be compliant with this plan.
JORDI MORRISON: Yeah, so I guess a pelvic floor is a muscle group and you've got to retrain it. It's like when you train for a marathon, you're not going to be able to run the marathon necessarily at your best time the first time you try. Maybe you won't even finish. But over time and sustained effort, you can get there. Tzippi's a runner, so she knows all about that. And she's had three babies.
DR. RAELIA LEW: Yeah, we all speak from experience here.
JORDI MORRISON: And so Tzippi, let's just say... your patient and she's made some improvements with her estrogen cream and her physiotherapy over the course of time and she's been dedicated and sustained that. What kind of percentage of women that you see feel that that's adequate and what kind of percentage maybe need to take help to the next level?
DR. TZIPORRA BEN-HARIM: Majority of women will be satisfied with the results of conservative management. The other thing to consider is that if someone comes in and they've just... the first baby, we would be reluctant to go surgically and manage because we know that very likely they will want again. Everyone is different and the circumstances can change, but very likely that you will want a second baby, and so the damage can accumulate with the pregnancies and the birth. It is better to defer surgical treatment until the family is complete. If we do surgical treatment early, there is a risk of recurrence after the next pregnancy or the next birth. And we know that the outcome is best in our first surgical management. We know that management of recurrent urinary incontinence is not as successful as the primary treatment.
DR. RAELIA LEW: I remember hearing that a lot when I was training as well, so I guess that hasn't really changed. But I suppose... pelvic floor muscles as a sling, our best chance of repairing them is on our first attempt because the tissues haven't been united again to reconstruct that area, whereas if we repair it and break it down, repair it and break it down, what we've got to work with in repairing the sling is tissues of lesser integrity. And I guess there's probably also an element of those who are going to get a good result get a good result. And those who unfortunately are not going to get a good surgical result are more likely to be the patients presenting for repeat surgeries, would you say, Tzippi?
DR. TZIPORRA BEN-HARIM: I agree with you. So in that aspect, nothing has much changed. The first repair is the best repair. That is also true for prolapse, for hernias. And it's a combination of women that are more likely to have recurrence, either their tissues to start with are weaker. This is something, it would have been nice to have this crystal ball and know who is going to have a recurrence and who isn't. But as a general rule, prefer deferring surgery until family is complete.
DR. RAELIA LEW: It's interesting that you say that. There are some women, for example, who have connective tissue concerns and we worry that they might have a tear and have a bad problem. And sometimes obstetricians might recommend cesarean birth for those women.
DR. TZIPORRA BEN-HARIM: Correct. So we are now in this time and in this day and age that women can choose how they birth. Elements to consider would be the consequences of pelvic floor damage, prolapse, and urinary incontinence, and having a cesarean section as a preventive measure to reduce the risk of pelvic floor damage. This is not a reason to have a C-section by itself. So the woman needs to take everything into consideration, her health, the baby's health, multiple factors in the decision, but definitely this is one of the factors to consider — the impact of pregnancy and childbirth on the pelvic floor.
DR. RAELIA LEW: Definitely. And Tzippi, if somebody has had severe symptoms, they've tried to do everything they can with physical therapies and topical therapies, and we don't want to do a surgery just yet because they might want to have another baby soon. So what you might do for patients in that circumstance?
DR. TZIPORRA BEN-HARIM: We've got pessaries that we can use. A pessary is a support device that stays in the vagina. Most women will be able to take it out and put it back in. We use it for prolapse and for urinary incontinence. It comes in different sizes and different shapes. Basically, the device gives support to the midsection of the urethra of the water pipe and then prevents the leakage. This is management of stress urinary incontinence because what can happen with stress urinary incontinence is when we do activities that increase the pressure in the abdomen, in the tummy, that gets the water pipe moving a bit, and this is enough to release urine. Putting that device will give support to the water pipe and reduce the chances of urinary incontinence.
JORDI MORRISON: And Tzippi, what's the success rate of a pessary for most women who use them?
DR. TZIPORRA BEN-HARIM: Success rates? Quite high, but it only works while it's there and sometimes over time women get tired of that, which is very understandable, and feel like, oh, eventually they want surgical treatment. So in my experience, long term, over time, women will decide either that the leakage is very small and they can't be bothered, or it's significant enough and they don't want to persevere with the pessary and they want surgical fix.
JORDI MORRISON: And what are the surgical options when it comes to incontinence?
DR. TZIPORRA BEN-HARIM: Surgical options have changed in the last 10 years. So before 2012 or 2013, mid-urethral sling was the most common treatment that we've used. So this is using a... mesh, a net, that sits under the water pipe like a hammock and basically provides support and prevent this movement of back and forth with increased intra-abdominal pressure. Initially, the mesh was used also for prolapse repair. In 2012, we had an FDA alert and the mesh got banned from prolapse repair and later the same thing happened for urinary incontinence. When we used it, results were quite good and complication rates were very small, very low, but regardless, that's where we are here today. What we do is either doing some vaginal procedures using a bulking agent into the urethra or abdominal procedures to reinforce some ligaments in the abdomen and hoist the urethra up.
JORDI MORRISON: We've talked a little bit about all the non-surgical options like seeing a pelvic physio and the pessaries. Are there any lifestyle changes that someone can do themselves that can make a real difference?
DR. TZIPORRA BEN-HARIM: We know that there are... coffee and tea that can irritate the bladder. Probably if you think about it, you have a nice cup of coffee, 15 minutes later you need to go to the toilet. So cutting down on coffee and tea would be beneficial. On the other hand, not limit fluid intake too much, so not to think, oh, I don't want to drink so much and go so often. We need to keep hydrated. Do pelvic floor exercises. Try and reduce high impact. As much as I'm in favor of running and exercising, first, strengthen the core muscles and then you can do some high impact. So defer running, jogging, weightlifting until the pelvic floor is stronger.
JORDI MORRISON: And in a preventative sense, is there something you can be doing during pregnancy that could prevent this from happening?
DR. TZIPORRA BEN-HARIM: We would recommend doing pelvic floor exercises in pregnancy. It's a good practice. It gets us to the finish line with stronger pelvic floor muscles. And it also is easier to know where the pelvic floor is after birth if we've practiced it before. As opposed to someone that has weak pelvic floor, has never practiced, and now is trying to learn to engage these muscles, can be challenging at times. And I'm going to come out with some controversial comments. I'm going to say them because they're true. If we have our babies at an older age, our tissues are not as stretchy and we're more likely to have a tear. If we have our babies and we are overweight... our babies are more likely to be larger, harder to push out, and we're more likely to have a tear. If we have gestational diabetes in pregnancy and we don't control it, our babies are likely to be larger and we're more likely to have a tear. So sometimes, obviously, in fertility as well, if we could wipe off 10 years and turn back time, everyone would do it in IVF because egg quality is also better when everything's easier about pregnancy at a younger age. But frustratingly, that's something we can't change. If we do have the choice to have our babies a little bit younger, our bodies are better at pregnancy and labour when we are younger compared to when we are older. So that's one factor that we can consider in planning when we have a baby. But if we optimise our general health, our metabolic health... and we ensure that we can control those factors the best of our ability, there will be impacts on our pelvic floor.
DR. RAELIA LEW: 100%. So when we do counseling before having a baby, we know that the section rate, even for women that are planning vaginal birth, goes up as we get older. And the same goes for the BMI. So at a BMI of 50, for example, there is some logic in offering an elective C-section and not trying vaginal birth because we know that the chances of an uneventful vaginal birth are quite low.
JORDI MORRISON: Listening to this, it really makes me think that your fertility patients have such a great opportunity because they are not going to spontaneously or unlikely to spontaneously get pregnant. They can really start seeing a pelvic physio early, start doing their Kegels early and consider their lifestyle factors in advance of even getting pregnant.
DR. RAELIA LEW: Yeah, in theory, that's true. But it's probably not what is at the forefront of their minds and probably might even be a bit triggering. I mean, it's hard to plan for your pregnancy when you're worried that you may not ever get pregnant. And a lot of fertility patients are in that mindset, unfortunately. Most of my patients will get pregnant and it would be a great time to plan. But usually that's not the focus at that point in time.
JORDI MORRISON: Tzippi, can you reflect on how women present to you when you first see them? And maybe just for, I guess, an element of hope and positivity, reflect on how they might change as they undertake intervention.
DR. TZIPORRA BEN-HARIM: I think we've come a very long way. So I've been practicing for a while. And if in the past women would suffer silently with all... of women's health. So for example, with heavy bleeding, with prolapse, with menopause symptoms, urinary incontinence is essentially the same. Women would suffer and come in quite late with severe symptoms. We've come a long way and now women know that they can reach out, that they can get help. I think they come in earlier than maybe 20 years ago. Just remember, if you're struggling, get help.
JORDI MORRISON: Thank you, Tzippi. To support Knocked Up, leave us a review or recommend to a friend. Join us on Instagram @knockeduppodcast and join Raelia at @drraelialew. And email us your questions to podcast at womenshealthmelbourne.com.au.
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
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