Epidemiology
Female pelvic floor disorders include urinary incontinence, pelvic organ prolapse, and anal incontinence, as well as emptying disorders of the lower urinary and gastrointestinal tracts. These conditions can have a significant impact on a woman’s functioning and quality of life, and are associated with limitations that can negatively impact a woman’s wellness and health. With the aging population, female pelvic floor disorders are a significant issue from both an individual and public health perspective. This chapter reviews the epidemiology of risk factors for and psychosocial impact of the three most prevalent pelvic floor disorders: urinary incontinence, pelvic organ prolapse, and anal incontinence.
Urinary incontinence
In general, urinary incontinence can be characterized by the presence of specific symptoms, frequency of urine leakage, severity of leakage, degree of bother to the woman, and type of incontinence. Prevalence and incidence rates can vary widely depending on the definition used, as well as measurement and survey methods and population differences. Of note, although this chapter discusses the epidemiology of urinary incontinence, including urgency urinary incontinence, a more detailed discussion of the epidemiology and costs of overactive bladder, with and without incontinence, can be found in Chapter 31 .
Prevalence.
Prevalence rates reflect the total number of cases of disease in the population at a given time. For urinary incontinence, definitions used in the literature range from using the presence of leakage (yes/no) to using the frequency of leakage (daily, weekly, monthly, ever) to using symptom bother to determine prevalence. Different definitions can lead to variability in reported prevalence and incidence rates ( ).
A review of 21 studies by found the average prevalence of any incontinence for older women was 34%, and 12% for daily incontinence. For middle-aged and younger adults, the average prevalence of any incontinence was slightly lower, at 25%, in the same study. analyzed the National Health and Nutrition Examination Survey (NHANES) and used a more strict definition, defining incontinence as “at least weekly leakage or monthly leakage more than drops.” Based on this definition, the authors reported a prevalence of 15.7%. Also using NHANES data, reported a prevalence of 51% when incontinence was defined as any positive response. Table 6.1 summarizes the prevalence of urinary incontinence based on age group and varying definitions.
| Author | Definition Used | Prevalence (%) |
|---|---|---|
| All Ages | ||
| At least weekly leakage or monthly leakage more than drops | 15.7 | |
| Any leakage | 51.1 | |
| Middle Ages | ||
| (ages 40–59 years) | At least weekly leakage or monthly leakage more than drops | 17.2 |
| (ages 42–52 years) | At least monthly incontinence | 46.7 |
| (ages 40–59 years) | Any urine loss | 13.7 |
| Older Ages | ||
| (ages ≥60 years) | At least weekly leakage or monthly leakage more than drops | 23.3–31.7 |
| (ages ≥60 years) | Any urine loss | 20 |
| (ages 56–81 years) | Slight leakage Moderate leakage Severe leakage | 34 45 21 |
Prevalence rates also vary based on symptom severity. Again using NHANES data, reported that the prevalence of any urinary incontinence in women aged 50 to 59 years was 19.9% for “mild” incontinence, 16.5% for “moderate” incontinence, and 25% for “severe” incontinence. These prevalence rates remained stable from 2005 to 2010 ( ). Variable prevalence rates were also seen in other age groups based on symptom severity.
The type of urinary incontinence is also important when considering the prevalence of the condition, in addition to age ( Fig. 6.1 ). The prevalence of stress urinary incontinence ranges from 33% to 54%, of urgency urinary incontinence ranges from 12% to 16%, and of mixed urinary incontinence ranges from 19% to 50% in populations reporting any incontinence. Similar data are available from multiple countries documenting that these conditions are highly prevalent worldwide.
Incidence, remission, improvement, and progression.
Urinary incontinence is a dynamic condition, and symptoms may wax and wane. Incidence rates reflect the number of new cases of disease in the population during a specified period of time. The average one-year incidence ranges from 6.9% to 11.1% in the United States in women younger than 55 years ( ; ). The rate is higher in older women, estimated to be 13.8% over 1 year in women 54 to 79 years of age. Reported 1-year remission rates range from 4.6% to 9.1% ( ; ; ). In one meta-analysis by , age-specific incidence was less than 2/1000 person-years in women younger than 40 years, 5/1000 person-years at age 50 years, and 3/1000 person-years at 60 to 65 years, but then increased in later decades in life. In a study by that analyzed data from the Nurse’s Health Study, the authors reported that most women reported persistence or progression of urinary incontinence symptoms over time, with few (3%–11%) reporting remission. Younger women and those with less severe symptoms were more likely to report remission or improvement over 10 years. In a follow-up study, evaluated the natural history of urinary incontinence by subtype and found that most women with incident stress and urgency urinary incontinence continued to experience similar subtype symptoms over an 8-year time period. Women with more severe incident symptoms and obese women were more likely to have persistent symptoms or progress to mixed urinary incontinence over time. Only 4% to 12% reported resolution of their urinary incontinence over the time period.
Urinary incontinence during pregnancy and postpartum.
Stress urinary incontinence is common during pregnancy, with a prevalence ranging from 40% to 59%. In general, the severity may worsen throughout pregnancy. In postpartum women, stress urinary incontinence will resolve in many, and the prevalence is estimated to range from 15% to 30% ( ). In longitudinal studies, the cumulative incidence rate of urinary incontinence is estimated to be approximately 39% ( ). Up to 26% of women who report urinary incontinence during pregnancy will have persistent leakage in the postpartum period; the majority will have resolution. In a large cohort study by , women were followed annually for up to 5 years after their first delivery. During follow-up, the incidence of bothersome stress urinary incontinence was 2.5/100 woman-years, and for overactive bladder it was 1.7/100 woman-years. Urinary incontinence was more common in the vaginal birth group compared to those who received cesarean section, but the differences lessened as time from childbirth increased. reported that, following spontaneous vaginal delivery, the 15-year cumulative incidence of stress incontinence was 34.3%, and of overactive bladder was 21.8%. Compared with spontaneous delivery, cesarean delivery was associated with a significantly lower risk of developing either condition during the time period.
Costs.
The financial burden of urinary incontinence and overactive bladder syndrome is significant and includes direct and indirect costs. Direct costs include costs to the patient for routine care (absorbent products, laundry), medical visits, and treatments. Indirect costs include loss of productivity and costs of paid or unpaid caregivers, which are more difficult to measure ( Table 6.2 ). Many studies support that the largest cost item associated with urinary incontinence for both community-dwelling women, as well as those in nursing homes, remains routine care and supplies, with only a minimal proportion of the costs going to evaluation and treatment. Although most studies evaluate the direct costs because of accessibility of data, the economic impact of indirect costs should not be underemphasized.
| Type of Cost | Examples |
|---|---|
| Direct Costs | |
| Diagnostic and evaluation costs | Physician consultation and evaluation, laboratory, diagnostic procedures |
| Treatment costs | Surgery, medication, pelvic/behavioral therapy |
| Routine care costs | Nursing labor, supplies, laundry |
| Rehabilitation costs | Nursing, supplies |
| Incontinence consequence costs | Skin breakdowns, urinary tract infections, falls, nursing home/assisted living care |
| Indirect Costs | |
| Costs of unpaid caregivers | Time, loss of work |
| Loss of productivity | Missed time from work for diagnosis/treatment, missed time from work because of morbidity |
A study by estimated that the annual direct cost of urinary incontinence for women was $12.4 billion (2001 US dollars), and the largest cost category was routine care (70% of costs), followed by nursing home admissions (14%), treatment (9%), complications (6%), and diagnosis and evaluation (1%). Medicare spending on incontinence treatment continues to increase dramatically. For Medicare beneficiaries aged 65 years and older, used multiple national databases and reported that the expenditures for inpatient and outpatient medical care doubled from $128 million in 1992 to $234 million in 1998. They also estimated that 23% of incontinent women missed an average of 28.7 hours of work because of inpatient and outpatient care associated with urinary incontinence treatment. A systematic review by that focused on urgency urinary incontinence reported that the projected total cost including direct, indirect, and intangible costs would be $76.2 billion in 2015 and $82.6 billion in 2020 in the United States alone.
At the individual level, annual routine costs alone in 2005 were estimated to be $250 to $900 per woman ( ). Direct costs for incontinence management increase significantly with greater incontinence frequency. evaluated the impact of incontinence improvement on incontinence-associated costs and found that the mean cost for an individual decreased by 23% for each decrease of seven incontinence episodes per week. Because most of the cost associated with incontinence care is out of pocket, patients assume great financial responsibility in managing this condition.
Pelvic organ prolapse
Similar to incontinence, definitions for pelvic organ prolapse are also variable. The International Continence Society defines prolapse as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, and the apex of the vagina or vault. Most epidemiologic studies define prolapse based on either physical examination findings or patient symptom report.
Prevalence, incidence, remission, and progression.
Most population-based surveys define prolapse based solely on patient symptoms, commonly defined as an affirmative response to seeing/feeling a vaginal bulge. Using this definition, the prevalence of prolapse symptoms ranges from 2.9% to 8% in the United States ( ; ; ). These studies did not include physical examination information. Additional studies from the Women’s Health Initiative (WHI) including US women aged 50 to 79 years found the prevalence of any degree of prolapse based on examination alone of grades 1 to 3 prolapse to be 41.1% ( ; ). Table 6.3 presents the estimated prevalence of prolapse. Prevalence estimates based on examination findings alone are higher compared with those based on symptom reports alone.
| Study | Definition of Prolapse | Prevalence |
|---|---|---|
| Examination only | Stage 0 = 24% | |
| Stage 1 = 38% | ||
| Stage 2 = 35% | ||
| Stage 3 = 2% | ||
| Examination only | Any prolapse = 41.1% | |
| Cystocele = 34.3% | ||
| Uterine = 14.2% | ||
| Rectocele = 18.6% | ||
| Examination only | Cystocele = 24.6% | |
| Uterine = 3.8% | ||
| Rectocele = 12.9% | ||
| Symptoms only | 5.70% | |
| Symptoms only | 2.90% | |
| Symptoms only | 11.40% |
Data are limited for the incidence and remission of pelvic organ prolapse. Based on the WHI data, the incidence of grades 1 to 3 prolapse is estimated to be 9.3/100 woman-years for cystocele, 5.7/100 woman-years for rectocele, and 1.5/100 woman-years for uterine prolapse. The remission rates are estimated to be up to 9%, with cystocele having higher remission rates than rectocele. Prolapse progression ranged from 1.9% for uterine prolapse, to 9.5% for cystocele, and 14% for rectocele. Older, parous women are more likely to develop new or progressive prolapse than to regress. Progression and resolution appear to be dependent on baseline severity of prolapse.
After pregnancy and delivery, 31% of women have stage 2 prolapse. After delivery, 14% to 15% of women have prolapse at or below the hymen, and 5% have this after cesarean delivery. In a longitudinal study by , women were enrolled 5 to 10 years from their first delivery and followed annually for 4 to 9 years. The majority of women demonstrated worsening in pelvic support over time, and vaginal birth was associated with worse support 5 years from delivery and more rapid deterioration in apical support.
Costs.
There are limited cost analysis data available for pelvic organ prolapse. In 1997, the direct cost of pelvic organ prolapse surgery was estimated to be $1.0 billion based on national average Medicare reimbursement. Physician services accounted for 29% of costs, and hospitalization accounted for 71% ( ). A study using 2011 data from the Nationwide Inpatient Sample by reported that the mean cost per admission for inpatient pelvic organ prolapse surgery was $9035. Higher costs were associated with longer length of stay, patient comorbidities, and public hospitals. It is predicted that the annual economic cost of pelvic organ prolapse surgeries will grow at twice the rate of population growth because of aging populations in the United States and Europe over the next decades ( ). There are few data on the indirect costs or direct patient costs of pelvic organ prolapse.
Anal incontinence
Prevalence, incidence, and remission.
Anal incontinence includes the involuntary passage of gas, mucus, liquid, or solid stool. The prevalence and epidemiology of anal incontinence have been poorly documented, and many women are too embarrassed to report the condition. Most epidemiologic studies focus on fecal incontinence (any involuntary leakage of stool). Depending on the definition and reporting methods used, the prevalence of fecal incontinence in US women ranges from 2.2% to 24%. When defined as any leakage in the past year, the prevalence is estimated to be approximately 24% ( ). When defined as at least monthly leakage, the prevalence is estimated to be approximately 9% ( ).
estimated the prevalence of different types and frequencies of fecal incontinence in noninstitutionalized US women using NHANES data. The overall prevalence of fecal incontinence within the past month was 8.9%, and increased with age from 2.6% in 20- to 29-year-old women to 15.3% in women aged 70 years and older. The most common type of incontinence was watery/liquid stool (>20%), followed by hard stool and normal stool (∼9% for both). Some 51% of women reported leakage of gas in the past month, and 21% reported at least daily leakage of gas. A 2016 systematic review included 30 epidemiologic studies of fecal incontinence in community-based adults and reported a similar overall prevalence of fecal incontinence (liquid or solid stool incontinence occurring at least monthly) when identified during in-person or telephone surveys (8.3%–8.4%), but slightly higher prevalence when identified using mail surveys (11.2%–12.4%) ( ).
Data regarding the incidence, regression, and progression of anal incontinence are extremely limited. estimated the incidence and remission of fecal incontinence in Medicare beneficiaries. Defining fecal incontinence as any loss of bowel control during the previous year, the incidence rate at 4 years was approximately 18% in women, and the remission rate was 57%. The overall incidence rate for the development of more severe fecal incontinence, defined as monthly or greater incontinence, was 6.3%. A community-based study in women over 50 years of age reported new fecal incontinence (self-reported problems with stool leakage) over a 9-year period in 6.2% ( ).
Anal incontinence during pregnancy and postpartum.
During pregnancy, up to 10% of women present with anal incontinence, and the cumulative incidence rate is estimated to be 10.3% ( ). Of the women reporting anal incontinence during pregnancy, 29.7% reported persistent anal incontinence postpartum. Six months postpartum, fecal incontinence (liquid or solid stool) occurs before labor in 8% of primiparous women who deliver via vaginal delivery or cesarean birth. This rate increases to 17% in those who have anal sphincter laceration at time of their vaginal delivery ( ).
Costs.
reported the average lifetime cost to be approximately $17,166 per patient for treatment, follow-up, physician evaluation, and protective materials in 1996, and average surgical costs were $8555 per procedure. estimated the hospital cost of inpatient surgery alone for female fecal incontinence to be $6000 per surgical admission in 2003, totaling $24.5 million spent on hospital costs for surgery alone that year. This estimate did not include direct costs of physician services or any indirect costs. Women undergoing treatment for fecal incontinence at a tertiary care clinic self-reported an average annual total cost of $4110 (median = $1594) related to their fecal incontinence, including direct and loss of productivity costs ( ).
Coexisting pelvic floor disorders
Pelvic floor disorders often coexist in the same woman, although rates of coexistence differ across studies. In a study of community-dwelling women aged 25 to 84 years, 23.7% reported symptoms of one or more pelvic floor disorders (stress urinary incontinence, overactive bladder, pelvic organ prolapse, or anal incontinence), and 50% to 80% of those women had symptoms of at least two disorders ( ). In a racially-diverse cohort of middle-aged and older women, 34% reported symptoms of at least one pelvic floor disorder, and of those, 16% reported symptoms of more than one disorder ( ; Fig. 6.2 ). A large national registry study of women 20 years after single vaginal or cesarean delivery found that almost half had symptoms of a pelvic floor disorder, and approximately one third of those women had symptoms of two or more disorders. ( ). Coexisting pelvic floor disorders increase with age and vaginal delivery and are associated with increased frustration related to symptoms.
Future projections
It is projected that future demands for ambulatory care and surgical treatment for female pelvic floor disorders will increase. Using NHANES prevalence rates and US Census Bureau projections, estimated that the number of American women with at least one pelvic floor disorder will increase from 28.1 million in 2010 to 43.8 million in 2050. During this time period, the number of women with urinary incontinence will increase 55% from 18.3 million to 28.4 million. Fecal incontinence will increase 59% from 10.6 million to 16.8 million, and the number of women with prolapse will increase 46% from 3.3 million to 4.9 million.
Similar studies suggest a 35% increase in demand for new-patient visits for pelvic floor disorders between 2010 and 2013 ( ) and an increase in pelvic floor surgeries. In fact, project that the total number of women who will undergo stress urinary incontinence surgery will increase almost 50% from 210,700 in 2010 to 310,050 in 2050. Similarly, the total number of women who will undergo prolapse surgery is predicted to increase from 166,000 in 2010 to 245,970 in 2050. These estimates assume that the rates of surgery remain unchanged.
Causes and prevention of pelvic floor disorders
Causes of pelvic floor disorders are multifactorial, and it is difficult to understand the relative importance of each factor for a specific individual or population. However, it is useful to appreciate the impact of each factor on the development of pelvic floor disorders to potentially aid in disease prevention.
Race
The role of race as a predisposing risk factor for pelvic floor disorders remains unclear. Although some studies report that White women are at increased risk for stress urinary incontinence ( ; ; ; ), symptomatic pelvic organ prolapse ( ; ; ), and fecal incontinence ( ) this is not a consistent finding. specifically evaluated urinary incontinence prevalence among major racial and ethnic groups and found that the prevalence of all types of incontinence was highest in Hispanic women (36%), followed by White (30%), Black (25%), and Asian (19%) women. also found that a significantly higher proportion of White women reported stress incontinence compared to Black women (39% vs. 25%). However, other studies found no difference in pelvic floor disorders among racial/ethnic groups ( ). Large epidemiologic studies assessing fecal incontinence symptoms also found no difference by race ( ; ).
Most studies of pelvic floor disorders and race have been performed in predominantly White populations. Studies in a large, urban, racially diverse health system found the highest prevalence of stress urinary incontinence and overactive bladder in Hispanic women ( ; ). Black women had similar rates of stress urinary incontinence but higher rates of overactive bladder than White women in this population. Differences in these results compared to other studies may have occurred because the urinary incontinence conditions were identified using diagnosis codes (suggesting a treatment-seeking component), rather than from epidemiologic surveys.
Differences in physiologic makeup may predispose some racial and ethnic groups to pelvic floor disorders. For example, magnetic resonance imaging measurements of bony architecture and soft tissue show that White women have a wider pelvic inlet, wider outlet, and shallower anteroposterior outlet than African-American women ( ). When compared with White women, African-American women also demonstrated a 29% higher average urethral closure pressure during a maximum pelvic muscle contraction ( ).
Age
There is a significant increase in the prevalence of pelvic floor disorders with age, increasing from 9.7% (95% confidence interval [CI], 7.8%–11.7%) in women aged 20 to 39 years, to 26.5% (95% CI, 23.0%–29.9%) in women aged 40 to 59 years, to 36.8% (95% CI, 32.0%–41.6%) in women aged 60 to 79 years, to 49.7% (95% CI, 40.3%–59.1%) in women aged 80 years or older ( P < .001; ). For urinary incontinence, the prevalence increases from 17% to 32% for women aged 40 to 59 years versus women over 80 years of age. The incidence of urinary incontinence also increases with age, and remission is more likely in younger women ( ). reported that, for anal incontinence, the prevalence increases from 2.9% at ages 20 to 30 years to 16.2% in people aged 70 years or older.
Familial and genetic linkage
Epidemiologic evidence suggests that family history of prolapse is a risk factor for disease, and a meta-analysis including eight studies with over 1000 prolapse patients showed that women with prolapse are more likely to have family members with the same condition when compared with controls ( ). Family-based studies have shown there is an autosomal dominant inheritance of pelvic floor disorders. In addition, candidate gene studies, expression studies, and linkage studies have all been suggestive of a genetic contribution to pelvic organ prolapse ( ).
Candidate gene studies have focused on collagen and elastin biosynthesis, extracellular matrix metabolism, and hormone receptors. For example, it is understood that collagen is one of the main constituents of the connective tissue in the pelvic floor, with type I collagen being well organized and type III collagen being common in loose areolar tissue. It is unclear if changes in collagen types I and III content in pelvic support tissues are associated with pelvic organ prolapse, with some studies finding higher levels of type III collagen in women with prolapse and others finding no difference or lower levels ( ). Other research suggests that changes to the morphology and structure of collagen fibrils occur in women with pelvic organ prolapse. A meta-analysis of genetic epidemiology studies identified associations between a collagen type 3 alpha 1 genetic polymorphism and pelvic organ prolapse ( ).
Childbirth
Perhaps secondary to increased abdominal pressure and/or connective tissue changes, pregnancy itself has been shown to be a risk factor for pelvic floor disorders. However, the major inciting factor for pelvic floor disorders in parous women is likely childbirth. reported that the proportion of women reporting at least one pelvic floor disorder increased incrementally with parity, at 12.8%, 18.4%, 24.6%, and 32.4% for 0, 1, 2, and 3 or more deliveries, respectively ( P < .001). A Swedish nationwide matched cohort study of women 20 years after a single vaginal or cesarean delivery found that cesarean in comparison to vaginal delivery was associated with a 30% and 92% reduction in the prevalence of urinary incontinence and pelvic organ prolapse symptoms, respectively ( ; ).
To further evaluate the association between pelvic floor disorders and mode of delivery, conducted a longitudinal cohort study following women for 5 to 10 years from first delivery. When compared with cesarean delivery without labor, spontaneous vaginal birth was associated with higher odds of stress incontinence (odds ratio [OR] 2.9 [95% CI, 1.5–5.5]) and prolapse at or beyond the hymen (OR 5.6 [95% CI, 2.2–14.7]). Operative vaginal deliveries and perineal lacerations have also been associated with pelvic floor disorders. In the same cohort study, women who suffered anal sphincter laceration during vaginal delivery were most likely to report anal incontinence 5 to 10 years after first delivery compared with women who had vaginal delivery without sphincter laceration and cesarean delivery without labor ( ). Anal incontinence was similar between women who delivered by cesarean section and those who delivered vaginally without sphincter laceration.
The pathophysiologic mechanisms linking childbirth and later pelvic floor disorders are described in detail in Chapter 5 .
Constipation
Constipation and straining associated with constipation have been associated with pelvic floor disorders. In a meta-analysis of 16 observational studies identified a significant association between constipation and urinary incontinence in women (OR 2.46, 95% CI 1.79–3.38). Constipation is also more common in women with pelvic organ prolapse compared to women without prolapse ( ), and many providers may counsel patients to avoid constipation and related straining at stool to reduce the risk of prolapse. However, whether the associations between constipation and urinary incontinence and prolapse are causal remains unproven.
Obesity
Increased body mass index (BMI) is a risk factor for pelvic floor disorders. Many studies have shown that obesity is a risk factor for urinary incontinence. In addition, several studies have shown that both stress and urgency incontinence improve when patients lose weight through lifestyle changes and/or bariatric surgery ( ; ). In a clinical trial of women randomized to an active weight loss program compared to educational materials, weight loss was associated with improvements in incontinence episodes among overweight and obese women ( ).
A cross-sectional study of postmenopausal women who enrolled in the WHI Hormone Therapy Clinical Trial found an increased risk of prolapse in women with a BMI of 25 or higher ( ). To further understand the longitudinal effects of obesity on prolapse, performed a secondary analysis of the WHI data to evaluate the relationship between change in weight and prolapse progression/regression in postmenopausal women during a 5-year period. They found being overweight or obese was highly associated with the progression of prolapse when compared to women with a healthy BMI. However, weight loss was not associated with prolapse regression.
Obesity was not associated with fecal incontinence in a large epidemiologic study after adjusting for other factors ( ), but found prevalence rates of anal incontinence to be high among morbidly obese women compared with the general population. In addition, bariatric surgery in morbidly obese women was associated with a decrease in fecal incontinence (solid or liquid stool) from 19.4% to 9.1% at 6 months and 8.6% at 12 months ( P = .018; 95% CI, 2.1–19.4) ( ). Obesity also increases the risk of anal incontinence 1 year postpartum in women with anal sphincter laceration ( ).
Smoking
Several studies suggest a positive association between smoking and urinary incontinence. A large population-based study, the Norwegian Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) study, investigated the association between modifiable lifestyle factors such as smoking and urinary incontinence. In this study both former and current smoking was associated with incontinence, limited to those women who smoked 20 cigarettes a day or who had a 15–pack-year history, suggesting a dose-response relationship ( ). The EPINCONT study found that the effect of smoking on incontinence was reduced after adjusting for coughing and dyspnea; however, there was a persistent effect from smoking not mediated by airway disorders.
Menopause/hormone replacement therapy
The female genital tract and the lower urinary tract arise from the same embryologic origin and thus are both sensitive to the effects of sex hormones. Transition to a hypoestrogenic state during menopause leads to changes in the vaginal and urethral mucosa. This could theoretically impact the development of incontinence. reported on a population-based cohort of women who experienced menopausal transition and found no association with the development of urinary incontinence. This is consistent with other epidemiologic studies that have not found an association between the onset of menopause and an increase in urinary incontinence. It is possible that the effects of a hypoestrogenic state may not be apparent in the first few years. In addition, menopause is associated with age, making it difficult to separate any independent effects of hormonal changes and aging.
Although systemic vaginal estrogen was in the past often promoted as beneficial for lower urinary tract symptoms, in the last 20 years the role of estrogen has become less clear. In the Heart & Estrogen/Progestin Replacement Study, exogenous estrogen and progesterone were associated with worsening incontinence (39% vs. 27%, P = .001). This was evident by 4 months of treatment and true for both urgency and stress incontinence symptoms ( ). Similarly, in the WHI, found that exogenous hormone therapy increased the risk of all types of urinary incontinence at 1 year in women who were continent at baseline. This risk was highest for stress incontinence (estrogen and progesterone: relative risk [RR], 1.87 [95% CI, 1.61–2.18]; estrogen alone: RR, 2.15 [95% CI, 1.77–2.62]), followed by mixed incontinence (estrogen and progesterone: RR, 1.49 [95% CI, 1.10–2.01]; estrogen alone: RR, 1.79 [95% CI, 1.26–2.53]). They also found that menopausal hormone therapy worsened the severity of incontinence among symptomatic women after 1 year.
Research on the treatment of overactive bladder with vaginal estrogen has had conflicting results. Two trials (one comparing vaginal estradiol ring with oral oxybutynin and one comparing vaginal estradiol cream with oral tolterodine) found that vaginal estrogen and the oral medications resulted in similar improvements in overactive bladder symptoms ( ; ). However, other trials compared tolterodine alone to tolterodine plus vaginal estrogen and found no or limited improvement from the addition of vaginal estrogen ( ; ). The Cochrane Incontinence Review Group summarized all studies up to June 2012 ( ) and concluded that urinary incontinence may be improved with the use of local estrogen treatment, although long-term effects are unknown. Conversely, systemic hormone replacement therapy using conjugated equine estrogen may worsen incontinence. There are too few data to reliably address other aspects of estrogen therapy, such as estrogen type and dose, and no direct evidence comparing routes of administration.
Psychosocial impact of pelvic floor disorders
Our women’s problems have been shoved under the rug for so many years. And that’s what I did for a long time too because I was so embarrassed. Anonymous Patient, 2008
The societal and personal burdens of pelvic floor disorders and their associated treatments lie in their major impact on quality of life and functioning. Pelvic floor disorders can have a negative impact on a woman’s physical, social, emotional, and sexual function. Fig. 6.3 shows an abbreviated framework of the effects of urinary incontinence on a woman’s life. These conditions can interfere with both participation in and satisfaction with physical and social activities. Women may restrict or completely eliminate activities outside of the home. At the most severe end, women may become increasingly isolated and homebound. These themes are consistent for pelvic organ prolapse and fecal incontinence as well ( ; ).
