L'incontinenza urinaria dopo il parto

1. Unità operativa di
UROGINECOLOGIA
Clinica Ostetrico-Ginecologica “L. Mangiagalli”
Università degli Studi di Milano
L' INCONTINENZA URINARIA DOPO IL PARTO
Memorial uroginecologico LORENZO SPREAFICO
Convegno Nazionale sul PAVIMENTO PELVICO
Montecchio Emilia 14-15settembre2014
PAOLA PIFAROTTI

2. Delivery-related pelvic floor trauma is a
reality, not a myth.
Delivery-related pelvic floor trauma is a
reality, not a myth.
There is little doubt that some women suffer significant trauma to pelvic floor structures as a
consequence of (successful or unsuccessful) attempts at vaginal childbirth. Trauma might
affect the pudendal nerve or its branches, the anal sphincter, the puborectalis-
pubococcygeus complex, and/or pelvic fascial structures.
It is much less clear, however, whether such trauma is
clinically relevant

3. THE PELVIC FLOOR ATTACHMENTS
• An evolutionary solution for support ofAn evolutionary solution for support of
visceral organsvisceral organs
• Pelvic floor musclesPelvic floor muscles
oppose gravity andoppose gravity and
increased abdominalincreased abdominal
pressurespressures

5. 12/01/14
The Biomechanics of Vaginal Birth and Common
Sequelae

6. BIOMECHANICS OF THE LEVATOR MUSCLES
Ashton-Miller JA, Annu Rev Biomed Eng 2009

7. Jing D, J Biomech 2012
BIOMECHANICS OF THE LEVATOR MUSCLES

8. BIOMECHANICS OF THE LEVATOR MUSCLES

9. PELVIC FLOOR DYSFUNCTIONPELVIC FLOOR DYSFUNCTION
Stress urinary incontinence
Pelvic organ prolapse
Anal incontinence
Clinical signsClinical signs

11. Population group: 859 primiparous women who delivered live born babie
The prevalence of urinary incontinence during pregnancy was 3.3 times higher compared with a
control group of nulliparous women. After 1 year, the difference was reduced, but still 2.5 times
higher in the primiparous group. The symptoms and impact on quality of life seemed to be mild to
moderate in both groups.
The prevalence of urinary incontinence during pregnancy was 3.3 times higher compared with a
control group of nulliparous women. After 1 year, the difference was reduced, but still 2.5 times
higher in the primiparous group. The symptoms and impact on quality of life seemed to be mild to
moderate in both groups.
STRESS INCONTINENCE

12. - Two decades after one birth, vaginal delivery was associated with a 67% increased risk of UI, and
UI > 10 years increased by 275% compared with caesarean section.
- It is necessary to perform eight or nine caesarean sections to avoid one case of UI.
- Weight control is an important prophylactic measure to reduce UI. Current BMI was the most
important BMI-determinant for UI, which is important, as BMI is modifiable.
- Two decades after one birth, vaginal delivery was associated with a 67% increased risk of UI, and
UI > 10 years increased by 275% compared with caesarean section.
- It is necessary to perform eight or nine caesarean sections to avoid one case of UI.
- Weight control is an important prophylactic measure to reduce UI. Current BMI was the most
important BMI-determinant for UI, which is important, as BMI is modifiable.
STRESS INCONTINENCE

13. 12/01/14
STRESS INCONTINENCE

14. Sintomi uroginecologici e dispareunia
124 (38.7%) 79 (42.7%)
10 (3%) 8 (4.3%)
18 (5.6%) 16 (8.6%)
50 (15.6%) 42 (22.7%)
PV TC
0.05
Pre-gravidanza
Terzo trimestre
di gravidanza
11 (3.4%) 9 (5%)
1 (0.3%) 2 (1%)
34 (10.6%) 23 (12.5%)
PV

15. Follow-up a 6 mesi
Follow-up 6 mesi
(media±DS)
Parto
vaginale
Taglio
cesareo
P
PGI-S score 0.6±0.6 0.2±0.7 0.0001
PGI-I score 2.9±1.2 2.6±1.1 0.01
ICIQ-SF score 1.6±3.1 0.6±1.9 0.0008
W-IPSS score 3.5±3.8 2.6±3.3 0.04
P<0.0001 P=0.002 P=0.03
Pifarotti et al.2014 (unpublished)

16. IUS
- età e BMI materno,
- peso neonatale,
- episiotomia,
utilizzo di ventosa
ostetrica,
-esecuzione di manovre
di Kristeller
- uso di analgesia
peridurale
-durata periodo espulsivo
-IUS in gravidanza
età >35 anni: probabilità di
sviluppare IUS a 6 mesi 3.9 volte
superiore
Correlazione positiva tra IUS in
gravidanza e IUS a 6 mesi dal
parto (P<0.0001).
il PV aumenta il rischio di IUS a 6
mesi di 4.5 volte rispetto al TC, pur
considerando il peso del bambino e
il BMI della madre.
Analisi multivariata
Pifarotti et al.2014 (unpublished)

20. PELVIC FLOOR DYSFUNCTIONS are a public health
problem of enormous magnitude 1 in every 10
women will requires surgery
Each year in US 11% women will require surgery for
pelvic floor dysfunction
Olsen AL et al, Epidemiology of surgically managed pelvic organ prolapse and urinary
incontinence. OBSTET GYNECOL 1997; 89:501-6
OBS/GYN are the physicians responsible for the
care of PF dysfunction.
CONCLUSIONS

21. The hidden epidemic of pelvic floor dysfunction: Achievable
goals for improved prevention and treatment;
DeLancey JO, AM J OBSTET GYNECOL. 2005; 192, 1288-95
HOW?:
Improving prevention  by careful management of the
late 2nd
stage of labor
Improving treatment by understanding the reasons
behind an op failure , so that the treatment can be
specific
PFMR
WHAT NEEDED?
 Advanced imaging and NEW TECHNOLOGIES for PF study and
have a multidisciplinary approach
For prevention and treatment of antenatal and
postnatal SUI

22. Tutti i nostri sforzi hanno lo scopo di
minimizzare i danni che potrebbero alterare in
modo significativo il pavimento pelvico di
queste pazienti per migliorare la loro futura
qualità di vita
CONCLUSIONS