Urinary incontinence during pregnancy and after delivery - effect of pelvic floor muscle training in prevention and treatment
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The primary aim of this thesis was to increase knowledge about the prevention of or treatment for urinary incontinence related to pregnancy and delivery. To achieve this we evaluated the effect of pelvic floor muscle training both during pregnancy and postpartum in the prevention and treatment of urinary incontinence. In addition, we studied the prevalence of urinary incontinence related to pregnancy and delivery, and compared the pelvic floor muscle strength and thickness in continent and incontinent nulliparous pregnant women. Included in this thesis are five studies, based on data from two study populations: - one population of parous women who were followed from eight weeks to 12 months after delivery (study I - a cross sectional study, study II - a matched controlled intervention study, study III - a follow up study) - one population of nulliparous women who were followed from 20 weeks of pregnancy to three months after delivery (study IV - a randomised controlled trial, study V - a case control study) The primary outcome measure was self reported symptoms of urinary incontinence. Other outcomes were assessments of pelvic floor muscle strength (measured by vaginal squeeze pressure) and pelvic floor muscle thickness (assessed using perineal ultrasound). In the intervention studies the women in the training groups followed a specially designed pelvic floor muscle exercise course. They trained once per week for 60 minutes in groups led by a physiotherapist. In addition the women were encouraged to perform 8-12 intensive pelvic floor muscle contractions at home twice per day. The training program for women in the postpartum training groups lasted 8 weeks (study II), and in pregnant women (study IV) the program lasted 12 weeks. The respective control groups received the usual education and information given by the hospital, the midwife or the general practitioner. The prevalence of stress urinary incontinence (study I) was nearly the same at 8 weeks postpartum (38%) as it was in pregnancy (42%). The results of the intervention studies (studies II, III, and IV) showed a statistically significantly lower prevalence of urinary incontinence in the groups of women who followed the pelvic floor muscle training courses either during pregnancy or after delivery [32% (pregnancy), 14% (four months postpartum), 16% (one year postpartum)] than did the women in the control groups [48% (pregnancy), 28% (four months postpartum), 31% (one year postpartum)]. These results support the hypothesis that pelvic floor muscle training can both prevent and treat urinary incontinence. Other results support the hypothesis that pelvic floor muscle strength training during pregnancy and postpartum increases pelvic floor muscle strength. The statistically significant difference in pelvic floor muscle strength and thickness between continent and incontinent pregnant nulliparous women (study V) indicates that pelvic floor muscle strength and thickness are related to the risk for incontinence. This thesis suggests that pregnant and postpartum women should be encouraged to perform pelvic floor muscle exercises to prevent and/or treat urinary incontinence. Health services for women during pregnancy and after delivery should be increased, and strategies to prevent and treat urinary incontinence need to be implemented.