VOL: 98, ISSUE: 04, PAGE NO: 50
Gurminder Matharu, MRCOG, is clinical research fellow, Department of Epidemiology and Public Health, University of LeicesterThis was a multicentre randomised controlled trial to assess the effect of nurse assessment with reinforcement of pelvic floor exercises and bladder training compared with standard management among women with persistent incontinence three months postnatally. The nurse intervention had previously been tested in a pilot study (Sleep and Grant, 1987).
This was a multicentre randomised controlled trial to assess the effect of nurse assessment with reinforcement of pelvic floor exercises and bladder training compared with standard management among women with persistent incontinence three months postnatally. The nurse intervention had previously been tested in a pilot study (Sleep and Grant, 1987).
Women who had delivered in the three participating units were sent a postal questionnaire three months after delivery. Questions related to urinary and faecal incontinence, associated symptoms and general wellbeing. Women reporting any involuntary loss of urine in the preceding month were eligible for the trial. They were randomly allocated by computer to receive the nurse assessment and treatment programme or to a control group. Before allocation, the samples were stratified by parity (four versus fewer), mode of delivery (Caesarean section versus other) and frequency of incontinence (at least once a week versus less).
The nurses comprised a midwife, a health visitor and a continence adviser, each trained in the conservative management of urinary incontinence. The intervention comprised a structured home interview designed to identify different types of incontinence at five months after delivery. Anatomical diagrams and instructions were used to teach the women pelvic floor muscle contraction. They were asked to follow a basic exercise programme, which was reinforced two and four months later by a nurse visit. Women with symptoms of frequency and urgency also received instruction on bladder training and to avoid caffeine. The control group had no contact with the above nurses but, like the intervention group, they had received peripartum advice, which sometimes included pelvic floor exercises, and they could seek medical advice. Women were followed up by repeat questionnaire at 12 months after delivery.
The primary outcome measure was persistence of any urinary incontinence. Secondary outcomes included 'severe' urinary incontinence, faecal incontinence, the use and frequency of pelvic floor exercises, use of pads, an overall rating of severity of urinary incontinence, and a measure of general wellbeing, anxiety and depression.
There was a 79% response rate to the 10,985 questionnaires sent to women three months postnatally; 2632 (33%) women were eligible for the study and 747 (28%) of these agreed to participate. The baseline characteristics were similar for the intervention group and the control group.
At follow up, women in the intervention group were significantly more likely to report performing some pelvic floor exercises in the previous month (79% versus 48%) and to be performing more contractions per day (20 versus five). These women were also significantly less likely to have any incontinence, which was reflected in a statistically significant difference in severe incontinence. Overall ratings of severity, use of pads and the number of pad changes were lower in the intervention group, which also reported less faecal incontinence to motions and less severe faecal incontinence. Although there were no significant differences in general wellbeing or depression, women in the intervention group were less anxious than those in the control group.
The results of the stratified analyses were consistent with the overall results in favouring the intervention group. More women in the intervention group returned a completed follow-up questionnaire (75% versus 65%). Women who did not respond were more likely to have had severe incontinence at baseline, although this was not affected by trial allocation among non-responders.
This study has demonstrated that nurse assessment and conservative treatment targeted at women with incontinence three months after delivery reduces the risk of urinary incontinence a year later. Women with severe incontinence seemed to benefit most. Women in the intervention group were also significantly less likely to have persistent faecal incontinence, but this should be interpreted with caution as this was not the primary outcome and other details of bowel symptoms are lacking. There was no difference in the effects if women initially reported stress, urge or mixed incontinence. The authors looked at the issue of non-responders at 12 months and report that severity of incontinence did not contribute to their differential response rate.
The information generated from this paper is important, as both urinary and faecal incontinence commonly result from childbirth, and in recent years a greater emphasis has been placed on early recognition and implementation of treatment. The reduction in incontinence contrasts with the findings of a similar study (Wilson and Herbison, 1998), but in this earlier study treatment was provided to all women immediately after delivery.
All the outcome measures were subjective. It would have been interesting to know if the greater reported use of pelvic floor exercises and improvement in symptoms were supported by objective measures, such as an exercise diary or pad tests, vaginal examination or perineometry. An important factor, which may have influenced randomisation and therefore affected the results, is whether more women in the control group were unable to contract their pelvic floor muscles at initial assessment.
Having accepted that pelvic floor exercises improve incontinence, the question arises whether contact with a nurse provides any additional benefit in terms of exercise reinforcement and 'social support'. This study does not provide the answer, but this issue would be important if one was introducing a programme of postnatal exercises into practice.
This paper is a valuable addition to our growing knowledge of a problem which causes a considerable amount of suffering and is deservedly receiving our attention.