Just what is Post-partum Stress Urinary Incontinence (SUI) and how does it affect women?
WORDS RACHEL LIM
Motherhood speaks to Dr Crystal Chin Hsuan, consultant obstetrician and gynaecologist, HAFcare OG Clinic, Thomson Medical Centre; Professor Peter Lim, Andrology, Urology and Continence Centre, Gleneagles Hospital; Dr Siow Woei Yun, specialist in urology & consultant, Raffles Urology Centre; and Associate Professor Han How Chuan, head and senior consultant, Department of Urogynaecology, KK Women’s and Children’s Hospital, to find more about Stress Urinary Incontinence (SUI).
What is SUI?
SUI is a symptom of involuntary urine loss associated with exertion, such as coughing, sneezing, laughing, or any physical activity that puts pressure on the bladder.
In Singapore, about 13 per cent of women develop SUI during pregnancy and about 5 per cent continue to have SUI after childbirth. However, the figures are probably higher due to under-reporting.
According to Prof Lim, pregnancy and childbirth are the major causes of SUI in women because they cause stretching and weakening of the ligaments, nerves and pelvic floor muscles that normally work together to support the bladder and keep the urethra closed so urine doesn't leak.
What Increases the Risk of SUI?
Doctors agree that age, multiple pregnancies, vaginal delivery, and obesity increase the risk of SUI. Assoc Prof Han and Dr Chin also mention that prolonged labour and forceps-assisted deliveries increase the risk. Dr Han adds that having a big baby (more than 3.8kg) makes you more susceptible to SUI.
Pelvic floor exercises during and after childbirth help to improve pelvic muscle tone and hence to prevent or improve SUI symptoms, asserts Dr Chin. She also brings up how adjusting various lifestyle habits can help. For instance, smoking may cause airway irritations and chronic cough, which may in turn cause or worsen SUI symptoms. Prof Lim also agrees that excessive weight is an additional risk factor to SUI, so keeping your BMI within 18-23kg/m2 for Asians is advisable. Lastly, avoiding beverages that irritate the bladder such as caffeinated drinks and alcohol, can be helpful as well.
There is a range of treatment options for SUI depending on its severity.
Mild SUI: Prof Lim describes behavioural modification such as fluid and dietary management, bladder training and timed or prompted voiding, as well as pelvic floor exercises, as a way to manage mild SUI. The pros are low or even no cost, no downtime, no need for anaesthesia, no side effects, and subsequent pregnancies are not affected. However, this takes time to be effective, and one has to keep up the exercises and lifestyle modifications to retain the benefits.
Pelvic floor exercises can also be supported by additional measures.
Assoc Prof Han cites the use of vaginal cones or electrical stimulation to improve SUI symptoms; while Dr Chin mentions the use of biofeedback.
All these methods seek to strengthen and target the pelvic floor muscles, helping them to exercise and squeeze.
Moderate SUI: When symptoms do not respond to behavioural modification and pelvic floor exercises, injectable bulking agents (IBAs) are another option, Prof Lim points out. They are injected into the supportive tissues beneath the urethra to bulk them up and stiffen them so that they offer more support. This is effective, minimally invasive and cost-effective compared to surgery, and can last a relatively long time. The cons are that they still require a trip to the hospital as they need to be done in an operating room; they are not as long lasting as surgery; and depending on the choice of IBA, there is a limit to the number of follow-up injections that can be administered. Subsequent babies may also have to be delivered via C-section.
Laser treatment such as Photothermal technology is also possible. This technology stimulates collagen remodelling and the synthesis of new collagen fibres. This then causes the shrinking and tightening of the vaginal mucosa tissue and collagen-rich endopelvic fascia, greatly improving continence function. The latest models have robotic scanners which ensure uniform delivery of energy to the entire vaginal canal for increased patient comfort. This method is minimally invasive, virtually painless, can be done in a clinic, does not require downtime, and natural delivery is still an option in subsequent births. You would, however, require an annual maintenance top-up laser treatment.
Severe SUI: The final option would be a surgical procedure. There are a variety of surgical options dependent on how the individual patient presents. Dr Chin relates how tension-free vaginal tape is becoming the commonest type of continence surgery with a good success rate of up to 90 per cent. Most operations to treat SUI are now done as laparoscopic or ‘keyhole’ surgeries. The key benefit is that surgery is a very long-lasting solution to most cases of SUI, and in very severe cases it may be the best option. The cons are invasive, expensive, requires hospitalisation, and subsequent babies would have to be delivered by caesarean section.
One is never destined to suffer from SUI. Having a variety of treatment options offers the possibility of tailoring therapy to the needs of each patient. Talk to a gynaecologist if SUI is disturbing and disrupting your daily life.