Urinary incontinence after birth

Short answer: Leaking urine when you cough, sneeze, laugh or run is common after birth, and it affects roughly one woman in three. Being common does not mean that nothing can be done about it, and it does not mean that living with it for years is simply how things are. Nor should you assume that leaking will clear up completely on its own. In pelvic floor muscle training the strongest evidence sits in prevention rather than in treatment. An assessment begins with a conversation, and an internal examination is not compulsory.

Being common and being normal are two different things

A woman who notices leaking for the first time after giving birth usually tells nobody. When she does say something, one sentence tends to come back at her: it happens to everyone who has had a baby. There is truth in that sentence, because the situation genuinely is widespread. The problem is that the sentence stops there. Prevalence is a statement about frequency and nothing more. Whether anything can be done about the symptom is a separate question, and it cannot be read off a frequency figure.

Those two meanings get muddled, and that is the main reason women stay quiet. Raising something that happens to so many people feels like complaining. So instead of asking the question, a woman rearranges her life around the answer she never got. She starts carrying a spare pad. At the gym she skips anything with jumping in it, and she leaves the trampoline to her child. She uses the toilet just before leaving the house, in case, and she laughs with her knees pressed together. Each of these adjustments is small on its own, and the sum of them grows without being noticed. After a while the routine built around the symptom takes up more room in her day than the symptom itself does.

Wind incontinence, faecal incontinence, a sensation of downward pressure and a feeling of something bulging are named here in the same plain way. Seeing your own situation written down under its own name is the first sign that it is something you are allowed to talk about.

How common it is

Reviews that have looked at urinary incontinence after birth report that around one woman in three is affected. The figures those reviews give shift noticeably depending on the region studied, on how leaking was defined and on how long after the birth the measurement was taken. That is why a rough figure is more useful here than a precise one, and why no exact rate is given on this page.

For a woman reading this, the information is reassuring, because it shows that what is happening to her is neither rare nor strange. The same figure can be read the other way, as though something so frequent were not worth discussing. That second reading is the wrong one, because prevalence tells you that a great many women are asking the same question, and that the question has a professional home rather than a private one. For any one woman the rate is not what matters. What matters is how often the leaking happens, which situations bring it on, and how far it has narrowed her daily life.

What happens over time

The first question most women ask is whether this will settle by itself. What can be said with confidence is this: complete resolution on its own should not be assumed. Some reduction has been reported over the early months, but that reduction has not been shown to hold in every woman. Data describing the course over time in numbers could not be verified for this guide, so no numerical timeline is given here.

In some women the leaking really does stop by itself. In others an early improvement is followed by the symptom returning, and in others again it never eases at all. Which group you are in cannot be worked out in the first few weeks.

Waiting has a cost of its own, and that cost usually goes unmeasured. As the months pass, avoidance habits settle in, pads become routine, and the situation stops being a problem that can be raised and turns into a fixed feature of life. None of this is the woman's fault. Nobody told her it was something that could be assessed, and habits of that kind take root in exactly that gap.

The difference between waiting and starting early raises the question of when it is possible to begin after the birth. The committee opinion of the American College of Obstetricians and Gynecologists on physical activity in pregnancy and after birth sets out one principle: exercise routines may be resumed gradually once it is medically safe to do so. Light activity such as walking, and pelvic floor exercises too, may begin as soon as they are medically safe. That opinion does not give a number of weeks that applies to everyone. Whether it is safe is judged by the physician, who takes into account the mode of birth and any medical or surgical complications.

The fact that years have gone by since the birth is not a barrier to assessment. The same steps apply to a woman who comes two years, five years or longer afterwards. The length of time changes how expectations and the programme are set, but it does not change whether an assessment is worth doing.

The types of urinary incontinence and how they look in daily life

Working out at which moments the symptom appears is one of the first jobs of the assessment, because the programme is built on that answer. Naming the type as a diagnosis is the physician's work. What physiotherapy does is establish under which load and during which movement the leaking shows up. Your own account is the main source here. Exactly when does it happen? Is there a sense of urgency beforehand? How much comes away?

Some women do not recognise themselves in that table. In one woman the leaking may appear only on tired days or during one particular movement. Others are troubled mainly by a feeling that the bladder has not emptied fully, and if that feeling persists it needs a physician's assessment.

There is a further picture that sits outside those three headings and has to be mentioned separately: urine seeping continuously, without any effort or urgency and without being noticed. This is not a picture for physiotherapy to take on. It calls for assessment by a physician directly, because there can be separate causes underneath it.

How pregnancy and birth set this up

The pelvic floor is the layer of muscle and connective tissue that closes the lower opening of the pelvis, and the muscles that hold the urethra (the tube that carries urine out of the body) closed when it needs to be closed sit there. Through pregnancy that layer carries a rising load. The weight of the growing uterus, the changing distribution of pressure inside the abdomen, and the way the tissues stretch differently under hormonal influence all work at the same time. During birth the area is stretched markedly. Stitches, a long pushing stage (the second stage of labour) or a birth in which vacuum or forceps were used can add to that load.

Women who give birth by caesarean section also experience urinary incontinence. The mode of birth is therefore not treated as decisive on its own, because pregnancy itself is a period that loads this region. A caesarean is abdominal surgery and its healing timetable runs differently from that of a vaginal birth, but the pelvic floor has already spent the pregnancy under load.

The mechanism behind the leaking varies from one woman to the next. In some the muscle is too tense to release, and in that picture more contraction work can make things worse. In another woman the strength is adequate but the timing has gone, so the contraction arrives late at the moment of a cough. How those distinctions are drawn is set out in detail on the what the pelvic floor is page.

Where the evidence is strong and where it is weak

The broadest review available in this field is a Cochrane review that pooled forty-six studies from twenty-one countries and more than ten thousand women. Its conclusions do not fit into one sentence, because they change according to which group a woman belongs to.

In pregnant women who were not yet leaking, pelvic floor muscle training given during pregnancy reduced the risk of urinary incontinence at three to six months after birth by around a third, and that finding was rated as high-quality evidence. This is the strongest part of the picture. The same review also reports a reduction in risk in late pregnancy, and together these two results are the main reason for starting pelvic floor work during pregnancy.

The review's second finding is discussed far less often. In women who were already leaking during pregnancy, no evidence was found that pelvic floor muscle training given in pregnancy reduced incontinence in late pregnancy or after the birth, and the quality of the evidence in this area was rated between very low and low. For a woman who is already leaking, both the approach and the timing are set differently, because the aim here is to deal with a symptom that is already present rather than to lower a risk.

The gap in the evidence concerns one thing only: the effect of training given during pregnancy on women who were already leaking. It does not extend to the effect of a programme built after the birth on the basis of an assessment. Since no verified source answers that question in this guide, no claim of benefit is made for it here. What can be done is to assess the symptom and the capacity to carry load for the individual woman.

No difference was found in labour or birth outcomes between the women who were given pelvic floor muscle training in pregnancy and those who were not, and only two adverse events were reported across the whole set of studies. On safety, then, the review speaks clearly. There is no finding that doing this work in pregnancy has a negative effect on the birth.

There are also questions these studies simply do not answer: how long one woman's symptom will last, what will have happened after a given number of sessions, or what the outcome will be. What they report is a change in group averages, and that is not a promise to any individual.

Wind and faecal incontinence

Urinary incontinence is not the only thing that happens after birth. Wind incontinence and faecal incontinence occur as well, and they are the symptoms least likely to be voiced. Many women never raise them even with their own physician, because they have no idea how common they are.

The evidence here is weaker. Eight studies in the Cochrane review looked at faecal incontinence as an outcome. Across those studies the benefit of pelvic floor muscle training given during pregnancy and after birth was either uncertain or not demonstrated, with the quality of evidence rated between very low and moderate. For this symptom, then, there is no reliable picture of benefit of the kind that exists for the prevention of urinary incontinence.

Wind and faecal incontinence can be signs of an injury during birth to the closing muscle around the anus (the sphincter, the ring-shaped muscle that keeps the bowel outlet shut). These symptoms therefore need to be assessed by a physician. Physiotherapy comes in after that assessment and works within the frame it sets.

“I do my Kegels and nothing has changed”

Behind that sentence there is usually a sense of personal failure. What is being described, though, is generally a piece of work that has never been assessed. An exercise instruction handed over without anyone checking whether the contraction is being made with the right muscle leaves the result to chance.

When the expected change does not appear, these are the things worth checking.

• Nobody has ever checked whether the right muscle is being found. Some women believe they are contracting when they are in fact pushing the area downwards. Because the movement cannot be seen from outside, this can carry on unnoticed for months.
• The breath is being held during the contraction. Holding the breath raises pressure inside the abdomen and increases the load on the area, so the work ends up pulling against its own purpose.
• The abdomen and buttocks are contracting along with it. A movement made by squeezing the buttocks or drawing the stomach in does not stand in for the pelvic floor doing its own work.
• Only the contraction has been practised and the release never has. Releasing is a separate skill, and in a tense picture it is the one that is missing. Contracting harder in that situation can make the symptom worse.
• No progression has been built in. The same number of repetitions is kept up in the same position for months. The work needs to move from lying on the back to sitting, to standing and to carrying load, because leaking happens while you are on your feet and not while you are lying down.
• Timing has not been practised. Bringing the contraction in just before the pressure rises, at the moment of a cough or a sneeze, is a skill separate from strength and is worked on separately.

Telling which of these applies takes an assessment from outside, and that is the work an assessment does.

How the assessment runs

The assessment starts with taking a history. You are asked when the leaking happens, when it started, how the pregnancy and the birth went, whether any stitches were needed, what your bowel habits are like, and how much lifting and carrying your day involves. Noting down over a few days when the leaking occurs and in what circumstances makes the picture concrete and makes the symptom easier to separate out.

Then come the examination of the trunk and the functional tests. How the breath is used, how the abdominal wall behaves under load, and the pattern of sitting and standing are all looked at. Every one of these steps can be carried out without an internal assessment.

An internal assessment comes up only after it has been discussed and agreed between you and the physiotherapist. If it is going to be done, what will be looked at is explained beforehand, verbal consent is asked for, and it is not done if the woman does not want it. The assessment can be stopped at any stage. The door of the room stays closed, a cover is available, separate time is given for dressing and undressing, and a woman who wishes may have a family member or a friend in the room with her. The physiotherapist carrying out the assessment is a woman and the appointments are one to one. The detail of these steps is on the what the pelvic floor is page.

Appointments are made in advance and run one to one for sixty minutes. For anyone who wants to understand how the process works before deciding, a free fifteen-minute introductory call can be arranged. Consultations can be held in English. The address is Erzene Mahallesi 113 Sokak No: 1/3, Bornova. Evka 3 metro station is in the same neighbourhood, at the eastern end of the M1 line.

What is worked on in a programme

A programme is written according to what the assessment found, and it is not the same for any two women. The contraction strength of the muscle and how long it can be held, the capacity to release, the position in which control is lost and the movement that brings on the symptom together set the starting point.

Work usually begins in the position where control is easiest to achieve, then moves to sitting, standing, walking and carrying load. Releasing is practised as a subject in its own right. Timing at the moment of a cough or a sneeze is given separate attention. The loads that cannot be put down are counted in from the start: carrying the baby and the pushchair, lifting the car seat, picking up an older child. Those are the real loads that fall outside the programme and land on the pelvic floor every day.

Constipation and the habit of straining belong to the programme as well. Straining at every visit to the toilet applies repeated pressure to the area. Going to the toilet often, just in case, can over time lead the bladder to signal at smaller volumes, and that habit is assessed too.

How many sessions will be needed cannot be stated on the first day. What determines the length is the nature of the symptom, how long it has been going on, the capacity of the muscle to contract and release at the outset, any accompanying pain, and how well the home programme fits into daily life. Building the home programme around the time a woman can genuinely set aside matters as much as the time spent in the clinic.

When to see a physician first

Making a diagnosis, requesting imaging or tests and prescribing medication are outside a physiotherapist's remit. A physiotherapy programme is built inside the limits the physician has set.

If you have recently moved to Turkey, the route here is worth spelling out, because it may differ from the one you are used to. Most people start with the family physician (aile hekimi) at their local family health centre, who looks at the complaint and can send them on to obstetrics and gynaecology, to urology, or to physical medicine and rehabilitation. Booking a state hospital outpatient clinic directly is also possible, and in the private route the specialist is usually booked directly. Waiting times differ between the two routes, and which one suits you depends on your insurance and your circumstances.

If any of the findings below is present, a physician should be seen before a physiotherapy appointment.

• Burning or pain when passing urine. If fever or pain in the side or lower back comes with it, a physician should be seen without delay.
• Urinary tract infections that keep coming back.
• Blood in the urine.
• Urine seeping continuously, without any effort or urgency and without being noticed.
• Postnatal bleeding that restarts after it had stopped, or increases unexpectedly.
• Downward pressure, a sensation of something bulging, or the feeling of tissue coming down through the vagina.
• Wind incontinence and faecal incontinence.
• Being unable to pass urine at all, or a persistent feeling that the bladder is not emptying.
• Progressive weakness or numbness in the legs, or loss of sensation in the area you sit on. This picture calls for urgent assessment.
• A sudden and marked increase in leaking, or a new symptom appearing abruptly.
• Severe pain during intercourse, or bleeding after intercourse.

For anything that worries you and is not on this list, asking a physician is equally reasonable. If describing the symptom out loud feels difficult, writing it down and handing it over is another way through. Having been brushed off once before is not a reason to leave the subject closed.

Where to go next in this guide

What the pelvic floor does, the difference between a muscle that is weak and one that is too tight, and the steps of the assessment are set out on the what the pelvic floor is page. Which movements are suitable during pregnancy, the weekly activity recommendation and the warning signs that mean exercise should stop are on the exercise in pregnancy page.

The gap along the midline of the abdomen, how it is measured and what the evidence does and does not say about it are covered on the separation of the abdominal muscles page. How the level of activity can be raised from walking to running, and the criteria used when returning to running, are on the returning to exercise after birth page. Appointment and travel details are on the contact page.