International Urogynecology Journal

, Volume 19, Issue 3, pp 441–448

Pregnancy and delivery after mid-urethral sling procedures for stress urinary incontinence: case reports and a review of literature

  • Rian Groenen
  • M. Caroline Vos
  • Christine Willekes
  • Harry A. M. Vervest
Review

DOI: 10.1007/s00192-007-0509-3

Cite this article as:
Groenen, R., Vos, M.C., Willekes, C. et al. Int Urogynecol J (2008) 19: 441. doi:10.1007/s00192-007-0509-3

Abstract

In this article, the effects of pregnancy and delivery on the development of stress urinary incontinence are described with special emphasis on the obstetrical management in women who wish to become pregnant or are pregnant after a preceding mid-urethral sling procedure. Three case histories and a review of literature are presented. Pregnancy after a preceding incontinence operation is rare and makes it quite difficult to formulate guidelines about delivery when a pregnancy occurs. The best advice is to postpone incontinence surgery until after the last pregnancy. There is evidence that an elective caesarean delivery protects against stress urinary incontinence in case of pregnancy after bladder neck suspension. For mid-urethral sling procedures, this evidence is not available. The presented case reports do not clearly demonstrate that caesarean delivery is necessary in case of pregnancy and delivery after a mid-urethral sling procedure. Furthermore, a second mid-urethral sling operation is a minor procedure compared to a caesarean section, and there is evidence that a second mid-urethral sling operation has the same success rate as the first procedure.

Keywords

Stress urinary incontinence Pregnancy Delivery 

Introduction

Urinary incontinence is a common condition in the female population with a prevalence ranging between 26 and 57% [1, 2, 3]. Around 50% of these women have stress urinary incontinence (SUI), while another 40% suffer from mixed (stress and urge) incontinence [1, 3]. Rortveit et al. [4] have shown that parity and especially the first delivery contributed most to the development of stress urinary incontinence. The association was strongest in the age group 20 to 34 years with a relative risk of 2.2 (95% CI 1.8–2.6). With the high prevalence of SUI and its relationship to pregnancy and young age groups in mind, it may not be surprising that treatment for incontinence is often requested at a relatively young age when the potential of childbearing is not completed. There are many treatment modalities for SUI ranging from symptom alleviating treatments (like pharmacological treatment, behavioral intervention, and the use of support devices), pelvic floor physiotherapy to surgical treatments (like colposuspension and mid-urethral sling procedures). Usually, these treatments, especially surgical procedures, are recommended after the completion of childbearing, as pregnancy and delivery often provoke and worsen stress urinary incontinence [5]. In the past, postponing surgical treatment for SUI until after the last pregnancy seemed logical for the mere reason that these treatments (i.e., colposuspension) were major surgical procedures. With the development of less invasive procedures as mid-urethral slings and as women nowadays are less willing to accept the burden of incontinence, it may be expected that more women with a desire for future pregnancy do request treatment for SUI even before their families are complete.

There is not much known about the influence of pregnancy and delivery on SUI in women having had anti-incontinence procedures before pregnancy. Dainer et al. [6] describe 152 cases of deliveries after previous bladder neck suspension procedures. A clear protective effect of a caesarean section was found. As far as mid-urethral slings are concerned, little is known and only case reports exist. Today, mid-urethral slings not only have replaced the Burch colposuspension as the gold standard in the treatment of SUI but also are even more often performed than colposuspension [7]. Although this does not necessarily implicate that also more pregnancies will be observed after previous incontinence surgery, it seems appropriate to address the issue of pregnancy after mid-urethral sling surgery to advise women who want to conceive after these surgical procedures. Intriguing questions in this respect are: (1) What is known about pregnancy, delivery, and the development of SUI? (2) Are there any changes in continence status during pregnancy and after delivery after previous mid-urethral sling procedures? (3) What happens with a mid-urethral sling or colposuspension during pregnancy? (4) Which treatment should be recommended in women opting for pregnancy after a mid-urethral sling operation? (5) What to do if SUI develops during the next pregnancy? (6) What is the most optimal way to deliver after a preceding mid-urethral sling procedure?

In this article, we describe our experiences with three cases of pregnancy after mid-urethral sling procedures, and on the basis of a literature review, we try to answer the above formulated questions.

Review of literature

Pregnancy, delivery, and the development of stress urinary incontinence

There are numerous reports about the influence of pregnancy and delivery on the pelvic floor. During pregnancy, changes in the elastic properties of fascial structures and decreased collagen type I in multiparous women with stress incontinence have been described [8]. King and Freeman [9] found that women with postpartum stress incontinence have significantly greater antenatal bladder neck mobility compared to continent women, indicating that biochemical changes in the connective tissues do occur. During pregnancy, the enlarged uterus may be responsible for a reduced bladder capacity. Pregnant women also gain weight during pregnancy. All these factors may contribute to the development of lower urinary tract symptoms during pregnancy. The prevalence of stress urinary incontinence in nulliparous women is 18% at 12 weeks and increases to 42% at 36 weeks [10] However, the percentage of women experiencing bothersome stress incontinence was much lower, respectively, 2.3 and 5.6%. Furthermore, they showed that stress incontinence during pregnancy (between 12 and 36 weeks) may arise in 66%, but also resolve in 23% [10].

During a vaginal delivery, damage to the pelvic floor may occur due to direct injury, the continuation of biochemical changes in connective tissues, and due to neural injury. Direct injury is caused by the distension of the pelvis, episiotomy, perineal injury, and anal injury (either direct visible or occult). Dietz and Lanzarone [11] showed, by introital ultrasound examinations, that occult injury to the levator muscle occurs in 36% of primiparous women with a vaginal delivery. This was significantly related to the development of stress incontinence (stress incontinence in women with levator avulsion 43% compared to 11% without avulsion). Episiotomy and third-degree tears also may enhance the chance of developing stress incontinence. These latter coincident factors might reflect increased damage as a result of a prolonged second stage of labor [12, 13]. Neural injury during delivery has been demonstrated by an increase in the motor unit potential and an increase in single-fiber density, which are associated to the development of stress incontinence [14, 15].

Some pregnant women might be more prone for developing stress incontinence. The most determining factor for stress urinary incontinence 1 year postpartum seems to be stress urinary incontinence at 12 weeks of gestation [16]. At that time, pregnancy is of relatively short duration, uterus size is relatively small, maternal weight gain is limited, and placental hormones are not maximal. There must be some other contributing factors not yet identified. Van Brummen et al. [16] also showed that the prevalence of lower urinary tract symptoms like frequency and urgency are significantly lower 12 months after delivery compared to 12 weeks gestation, but for stress incontinence, the reverse occurred. Bothersome stress incontinence increased from 7.6% at 12 weeks to 15.4% at 36 weeks and declined to 10.5% at 12 months postpartum (p < 0.05). Furthermore, older maternal age appeared to be predictive for bothersome stress urinary incontinence 1 year postpartum. Another important issue is that the first pregnancy and delivery contribute most to the development of urinary incontinence after delivery [4].

The mode of delivery may be of importance for the development of stress incontinence. Van Brummen et al. [17] found stress incontinence (any and not just bothersome) to be present 3 months after vaginal delivery and caesarean section in 34 and 7%, respectively (p < 0.001), and after 12 months in 40 and 22%, respectively (p < 0.019). The most determining risk factor for the development of stress incontinence was the presence of this symptom at 12 weeks gestation both for vaginal and caesarean delivery: Women with a vaginal delivery and stress incontinence early in pregnancy had a five-time increased risk of stress incontinence 1 year postpartum, whereas women with a caesarean section had an 18-time higher risk.

Urge incontinence appeared to be more common after 12 months after vaginal compared to caesarean delivery (17 and 9%, respectively), but interestingly, women with urge incontinence after a caesarean delivery felt emotionally more limitations than women who delivered vaginally. In addition, in trying to identify risk factors for urge incontinence, the presence of urge incontinence early in pregnancy was clearly related to urge incontinence after 12 months in women with a caesarean section (odds ratio, 20; 95% CI, 1.8–22), but no risk factor for urge incontinence in the vaginal delivery group was found. A possible risk factor that explains these findings is increased body weight. A normal pregnancy causes an increase of body mass index. There are several studies that report an association between body mass index and all types of urinary incontinence [18, 19].

The Norwegian Epincont Study found the prevalence of stress incontinence in nulliparous women to be 4.7%, in women with only vaginal deliveries 12.2%, and in women with only caesarean deliveries 6.9%, respectively [20]. The odds ratio for the development of stress incontinence associated with vaginal deliveries as compared with nulliparous women is 3.0 (95% CI, 2.5–3.5), comparing caesarean sections to nulliparous women 1.4 (95% CI, 1.0–2.0), and comparing vaginal deliveries to caesarean sections 2.4 (95% CI, 1.7–3.2) [20].

These data imply that stress incontinence is already highly prevalent during pregnancy, but also that delivery itself may contribute to the development of stress incontinence. While stress incontinence is more prevalent after vaginal delivery, the protective effect of a caesarean section is limited. Furthermore, whereas numerous studies indicate a detrimental effect of pregnancy and delivery on lower urinary tract function, apparently, the healing process is tremendous and the majority of women recover spontaneously.

Are there any changes in continence status during pregnancy and after delivery after previous mid-urethral sling procedures?

Few reports about pregnancy and delivery after mid-urethral sling procedures have been published. They are summarized in Table 1. Iskander and Kapoor [21] were the first to describe a case of pregnancy after tension-free vaginal taping (TVT) in a woman with a history of two spontaneous vaginal deliveries. She conceived 9 months after the TVT and remained continent during her pregnancy. An elective caesarean section was performed at 38 weeks of gestation. Postnatally, she remained continent.
Table 1

Pregnancy and mode of delivery after mid-urethral slings, case reports in literature

Author(s)

Age

Gravida/Para

Type of incontinence surgery

Moment of surgery

Continence status during pregnancy

Mode of delivery

Continence after delivery

Iskander et al. [21]

34

3/2

TVT

9 months before third pregnancy

Continent

Caesarean section at 38 weeks of gestation

Continent after 6 months

Lynch et al. [22]

26

3/2

Vesica suburethral sling

1 month before third pregnancy

Continenta

Caesarean section at 37 weeks of gestation

Recurrence of incontinence after 3 months

Gauruder-Burmester and Tunn [23]

39

5/4

TVT

3 months before sixth pregnancy

Continent

Caesarean section at 37 weeks of gestation

Continent after 2 months

Seeger et al. [5]

37

2/1

TVT

1 month before second pregnancy

Unknown

Spontaneous delivery at 40 weeks of gestation

Continent after 5 months

Vella et al. [24]

42

2/1

TVT

3 years before second pregnancy

Continent

Spontaneous delivery at 40 weeks of gestation

Continent after 2 years

Vella et al. [24]

42

3/2

TVT

4 years before third pregnancy

Continent

Caesarean section at 38 + 4 weeks of gestation

Continent after 3 years

Hassan et al. [25]

36

2/1

TOT (Boston Scientific)

At 3 weeks of gestation

Continent

Spontaneous delivery at 39 weeks of gestation

Continent after 2 months

Panel et al. [26]

  

14 case with TVT, TOT, 2 unknown

mean interval 21.9 months

Continent 10; SUI 1; 3 voiding difficulty

Caesarean section in 6; 7 vaginally; 1 ongoing pregnancy

After caesarean section: all 6 continent; after vaginal delivery 2 SUI (28.6%)

This study

28

2/1

TVT

2 years before second pregnancy

Continent

Caesarean section at 38 weeks of gestation

Urge incontinence, IVS posterior. Continent after 2 years

This study

33

5/2

TVT

4 months before third pregnancy

SUI

Spontaneous delivery at 35 + 1 weeks of gestation

SUI, TVT-O. Continent after 13 months

This study

38

3/2

IVS anterior

5 months before third pregnancy

Continent

Spontaneous delivery at 40 weeks of gestation

Continent

aPyelonephritis and intermittent urethral obstruction requiring Foley catheter placement

Lynch et al. [22] reported a case of a gravida 3, para 2 with a prior history of a Pereya urethropexy followed by a Vesica suburethral sling. Her pregnancy was complicated by pyelonephritis and intermittent urethral obstruction requiring Foley catheter placement. At 37 weeks of gestation, a primary caesarean section was performed. Three months after delivery, she presented with pyelonephritis and recurrence of her incontinence.

Gauruder-Burmester and Tunn [23] describe a pregnancy after TVT in a para 4 with a history of stress incontinence after four spontaneous deliveries. The patient became pregnant 3 months after the intervention. She remained continent during pregnancy. She delivered by elective caesarean section at 38 weeks of gestation. Three months later, the continence was preserved. The decision to perform a caesarean section was partly based on a tentative risk of dislocation of the tape on the urethra due to sharing forces in the birth canal and the risk of retropubic loosening of the tape during labor.

Seeger et al. [5] reported about a para 2 who delivered spontaneously at 40 weeks of gestation after TVT procedure performed 10 months before because of stress urinary incontinence. Five months after delivery, the patient was continent.

Vella et al. [24] describe a para 1 who conceived 3.5 years after a TVT procedure. She remained continent during pregnancy and spontaneously delivered at 40 weeks of gestation. Postpartum, she remained continent.

Another para 2 became pregnant 4 years after a TVT procedure. She was continent during pregnancy, and at 38 weeks, she delivered by caesarean section. She remained continent in follow-up. The mode of delivery was an informed decision of the patient.

Hassan et al. [25] report about a para 1 with no wish for further childbearing. After conservative treatment a transvaginal obturator tape (TOT) procedure was performed. Two weeks postoperatively, she appeared to be 5 weeks pregnant. She decided to continue her unplanned pregnancy. There was no stress incontinence antenatal and she spontaneously delivered at 39 weeks of gestation. In the reported follow-up time of 8 weeks, she remained continent.

Panel et al. [26] report on 14 pregnancies after TVT and TOT. During pregnancy, one woman developed SUI at 27 weeks gestation, and three women had voiding difficulty and urgency. Six women delivered by caesarean section (six because of previous SUI surgery and one due to dystocia), seven women delivered vaginally, and in one woman, pregnancy was still going on. All women with caesarean delivery remained continent, while two women became stress incontinent after vaginal delivery.

Our case reports

Case 1

In 1999, a 28-year-old woman presented with stress urinary incontinence and fecal urgency 3 months after her first, spontaneous vaginal delivery. Because of the short interval between delivery and her complaints, full recovery of the connective tissue was awaited and conservative therapy (i.e., pelvic floor exercise) was advised.

However, no improvement of the stress incontinence was observed after 9 months, but her fecal urgency disappeared. Urodynamic examination revealed urodynamic stress incontinence without detrusor overactivity, maximum urethral closure pressure of 58 cm H2O, and a maximum cystometric capacity of 350 ml.

Treatment options were extensively discussed. Our patient expressed a latent desire for further childbearing, but she felt that due to the disabling nature of her incontinence and the immense impact on her daily activities, she would probably postpone any further pregnancy if her stress incontinence stayed that way. A decision was made to perform a surgical anti-incontinence procedure and not wait until after a second pregnancy. A TVT procedure was carried out, which led to complete resolution of her stress incontinence.

Two years after this operation, she became pregnant again. She did not suffer any incontinence during pregnancy. In July 2003, at 38 weeks of gestation, an elective caesarean section was performed. There were no intraoperative or immediate postoperative complications. Shortly after the caesarean section, she developed urge incontinence. An expectative policy was instituted, but 1 year later, she still suffered urgency and urge incontinence. At moments of intra-abdominal pressure rises, she was fully continent. Urodynamic examination revealed a normal bladder capacity without symptoms of detrusor overactivity. There was a normal bladder expulsion function with a maximum flow rate of 26 ml/s. Cystoscopic examination revealed no abnormalities. Anticholinergic treatment was installed, but without any result. Pelvic floor physiotherapy, electrostimulation, and a posterior intravaginal slingplasty (IVS) gave no improvement. Treatment options like sacral neuromodulation and Botox injections were offered, but rejected by the patient. An expectative policy was followed by spontaneous satisfactory recovery of the urge incontinence 2 years after the delivery.

Case 2

In July 2001, a 33-year-old woman was seen with stress and urge (mixed) urinary incontinence since her second delivery 7 months before. This delivery was complicated by a prolonged second stage, followed by a vacuum extraction and a postpartum bleeding of 1,000 ml. The latter was probably due to an extended rupture of the vaginal wall. The perineum was intact.

An expectative policy up to a year postpartum was agreed upon. She was referred for pelvic floor physiotherapy, which improved her urge incontinence. Subjectively, she kept suffering stress urinary incontinence. This could not be confirmed with physical examination. Because of persisting stress incontinence, urodynamic investigation was carried out. This revealed a slightly limited maximum cystometric capacity of 300 ml with a normal urethral closure pressure. There was no urodynamic stress incontinence. After counseling, she opted for a TVT procedure, which was performed in February 2003.

Unfortunately, she kept suffering from stress urinary incontinence after this operation. A second urodynamic examination showed a normal bladder capacity and compliance and no stress incontinence. There were no signs of detrusor overactivity, a maximum flow rate of 26 ml/s, and a maximum urethral closure pressure of 30 cm H2O.

In June 2003 (4 months after the TVT procedure), she became pregnant again. During this pregnancy, her urinary incontinence deteriorated slightly. At 24 weeks gestation, she visited our hospital for a second opinion. Physical examination revealed a hypermobile urethra without genital prolapse. There was urinary loss upon coughing, and with unilateral bladder neck elevation, this loss of urine disappeared. Introital ultrasound showed the prolene tape in the middle third of the urethra.

In February 2004, she had a spontaneous vaginal delivery. Three months later, stress urinary incontinence was clearly less than during pregnancy, but nevertheless, the loss of urine occurred daily. There were no signs of urgency or urge incontinence. Physical examination showed still a hypermobile urethra, and again, there was no loss of urine upon coughing with unilateral bladder neck elevation. Treatment options were again extensively discussed. The severity of stress urinary incontinence made her decide to undergo a second incontinence surgery. A transobturator tape (TVT-O) procedure was performed in March 2005, which cured the stress incontinence.

Case 3

The third case concerns a 38-year-old gravida 2, para 2. Her medical history reveals meningitis at the age of 7 years. In 2004, she underwent a lumpectomy and radiotherapy for a breast carcinoma. Her obstetric history consists of two spontaneous vaginal deliveries in 1993 and 1994.

In July 2003, she presented herself with stress urinary incontinence persisting after pelvic floor physiotherapy. Urodynamic examination showed significant urinary loss on coughing, no detrusor overactivity, and normal urethral closure pressures. In July 2004, an anterior IVS procedure was performed, which improved the stress incontinence. Five months later, she became pregnant again. Her continence status did not change during pregnancy. She spontaneously delivered at term without any rupture and an intact perineum. One month after delivery, she reported some slight urgency complaints. Four months postpartum, she sometimes experienced some loss of urine upon moments of high intra-abdominal pressure rises. However, there was no loss of urine with horseback riding. Physical examination revealed a grade I cystocele. No further treatment was necessary.

What happens with a mid-urethral sling or colposuspension during pregnancy?

There are some case reports confirming that the TVT remains intact during pregnancy and after delivery. Ultrasound assessment during pregnancy by Gauruder-Burmester and Tunn [23] revealed an unchanged topography of the prolene tape at the level of the transition between the middle and distal third of the urethra. Three months after caesarean section, the position of the tape continued to be unchanged. Seeger et al. [5] performed an introital ultrasound 5 months after spontaneous delivery. This showed a correct position of the prolene tape. Panel et al. [26] found in 14 cases no tape related complications during pregnancy and delivery.

Cutner et al. [27] describe a para 2 who underwent a Burch colposuspension. Five years afterwards, she became pregnant. The patient remained continent during pregnancy. At 28 and 36 weeks of gestation and 6 weeks postpartum, a full urodynamic assessment was performed. This showed a decreased urethral pressure profile at rest at 36 weeks of gestation compared to pre-pregnancy measurements. An elective caesarean section was performed at 37 weeks of gestation, as subjective incontinence was absent, and to preserve urethra-vaginal supporting structures. Postnatal, urethral pressure profile increased.

What is the success rate of repetitive stress urinary incontinence surgery?

To advise about pregnancy and mode of delivery after previous incontinence surgery, it is of importance to know what the success rates are for a second incontinence surgical procedure. Amaye-Obu and Drutz [28] evaluated the efficacy and failure rates of surgical treatment of recurrent stress urinary incontinence. Cure rates of 81, 25, and 0% (P = 0.001) were achieved with a Burch colposuspension after one, two and three previous anti-incontinence procedures, respectively. Eighty eight percent of the failures of Burch colposuspension happened within 2 years after the operation.

After repeat pubovaginal sling procedure with autologous fascia for recurrent stress urinary incontinence, 86% of the patients considered themselves cured or improved [29]. Based on the Blaivas–Groutz incontinence scale, 50% were cured, 7% had a good response, 29% had a fair response, and none had treatment failure.

In a prospective long-term follow-up study, the results of a TVT procedure were evaluated in women with recurrent stress urinary incontinence in whom previous other surgical procedures had failed [30]. The mean follow-up period was 4 years. Evaluation included gynecological examination, urodynamic investigation, quality of life evaluation, and 24-h pad test. Eighty-two percent of the patients were cured, and 9% significantly improved.

The pubovaginal sling procedure is popular because of its minimal invasive character and the proven long-term cure rates. The question is whether a second TVT procedure leads to the same success rates as a first mid-urethral sling. Riachi et al. [31] described two patients with recurrent stress urinary incontinence. They had repeat TVT slings performed 6 and 9 months after the initial procedure without removal of the previous sling. There were no intraoperative or postoperative complications, and both patients were continent.

To our knowledge, no other studies on long-term cure rates after second TVT procedure have been reported so far.

How to advise women?

Based on these data from our own experiences and from this literature review, we like to formulate answers to the last three questions that we raised in “Introduction”.

What treatment to recommend in women opting for pregnancy after a mid-urethral sling operation?

The first important issue in women who had anti-incontinence surgery and are planning to become pregnant is to reduce the risk of becoming incontinent again. Risk factors for developing SUI are maternal age, smoking, obesity, and an increased body mass index [32]. Counseling about these risk factors and advising women to address these conditions if applicable seems appropriate.

If the woman is nulliparous and young (with a life expectancy of 40 to 50 years), probably the best advice is to postpone incontinence surgery until after the last pregnancy. Reasons are that the first pregnancy contributes the most to the development of incontinence [4] and that the successful outcome of incontinence surgery diminishes over time [33]. While this appears to be the case for bladder neck suspension surgery, there is some evidence that this might be different for TVT. Rezapour et al. [34] showed that cure rates in women undergoing a TVT after other traditional surgical procedures are comparable to a primary TVT procedure.

What to do if SUI develops during the next pregnancy?

What to do if a woman, who had incontinence surgery, becomes pregnant? If she remains continent during pregnancy, no special measures need to be taken. If she develops stress urinary incontinence again, there is no place for surgical treatment for SUI during pregnancy in our opinion. However, conservative treatment modalities like behavioral interventions and physiotherapy can be employed. After physiotherapy, Glazener et al. [35] found a reduction of urinary incontinence (60 vs 69%) and fecal incontinence (4 vs 11%) 1 year after delivery. No significant difference was found 6 years later.

What is the most optimal way to deliver after a preceding mid-urethral sling procedure?

If no stress incontinence develops during pregnancy, it is quite difficult to advise about the mode of delivery. If the patient is nulliparous, there are the following arguments to counsel for an elective caesarean delivery. As the above listed review of pregnancy, delivery, and the occurrence of SUI shows, a vaginal delivery contributes significantly more to the development of SUI than a caesarean section. On the basis of the Epincont Study, the risk of SUI after a vaginal delivery is 2.4 times higher compared to a caesarean section. Dainer et al. [6] found postpartum continence rates after preceding bladder neck suspension of 73% after vaginal delivery and 92% after caesarean section. The continence rate after vaginal delivery is to a certain degree equal to the findings of van Brummen et al. [17] (in women without previous incontinence surgery), but after caesarean section, certainly much better.

An argument against an elective caesarean delivery is that this represents major surgery with considerable impact on future pregnancies like the risk of uterine rupture [36]. If she is multiparous, the discussion is perhaps more difficult, as more pregnancies contributes less to the development of SUI than the first pregnancy and delivery.

In cases where SUI develops during pregnancy after preceding incontinence surgery, there is a tendency in literature not to advise an elective caesarean delivery, as damage to the urethral sphincter apparently has already occurred. Another argument in favor of a vaginal delivery is that the natural course of SUI after pregnancy indicates that SUI resolves in a significant percentage of women [16]. Furthermore, the treatment of SUI by means of a mid-urethral sling is a minimally invasive procedure compared to an elective caesarean delivery. In addition, a second mid-urethral sling is likely to be as effective as the first one. One reason for an elective caesarean delivery might be that increased damage to the urethral sphincter due to a vaginal delivery can be prevented [37]. However, there is no evidence to support this.

What should be the treatment of choice if SUI develops or remains present after delivery in women with previous incontinence surgery? The first option is to wait at least to all effects of pregnancy and delivery on the connective tissues have subsided, like should be done before the first incontinence surgical procedure. Thereafter, all treatment modalities according to current guidelines may be used. There are no differences between guidelines for first or recurrent procedures.

Discussion

Our results are, to a certain extent, contradictory to the cases described above where all women were continent after a caesarean section. In our first case, we describe a para 1 who delivered by elective caesarean section after TVT procedure 2 years before. The primary caesarean section was performed because she remained continent during her pregnancy. New incontinence problems could be caused by a vaginal delivery, and restoring this would not be easy. In contrast to our expectations, the patient developed urge incontinence postpartum. Despite extensive treatments, she kept suffering from urge incontinence, but after 2 years, spontaneous recovery of her urge incontinence occurred. In the second case, a para 2 conceived 4 months after a TVT-O procedure. After this operation, she kept suffering from stress urinary incontinence. During pregnancy, her incontinence deteriorated slightly. She had a spontaneous vaginal delivery. After 3 months, her incontinence was less, but still of a severity to make her decide undergoing a second incontinence surgery. This was performed 13 months postpartum with satisfactory results. The third case describes a pregnancy after anterior IVS in a para 2. During pregnancy, she was continent. She spontaneously delivered at term. One month afterwards, she had slight urgency complaints. After four months however, there was a spontaneous satisfactory recovery. Currently, she is pregnant again, without any additional SUI complaints.

Our case reports of pregnancy after a mid-urethral sling show that caesarean delivery not necessarily protects against any incontinence, that repeat incontinence surgery is successful after a previous vaginal delivery, and that even continence may be unchanged during pregnancy.

Based on our own observations and the reviewed literature, we like to recommend the following policy for women who are stress incontinent and still want to conceive or for women who want to become pregnant after previous mid-urethral sling surgery:
  1. 1.

    Try to complete childbearing before any incontinence surgery.

     
  2. 2.

    If a woman is pregnant after mid-urethral sling surgery, institute conservative treatment during pregnancy.

     
  3. 3.

    Advice vaginal delivery in an otherwise uncomplicated pregnancy irrespective of recurrent incontinence.

     
  4. 4.

    If incontinence occurs or persists postpartum, await spontaneous recovery during at least 6 months up to 1 year.

     
  5. 5.

    Repeated mid-urethral sling procedure, if necessary, is most likely safe and effective (not enough data).

     

In conclusion, the development of mid-urethral sling procedures for incontinence surgery has not only improved the care for women with stress urinary incontinence in general but also lessened our worries about their future reproductive career due to the effective and minimal invasive character of these procedures. Because of the scarcity of data on pregnancy after mid-urethral sling procedures, we need to collect more data to support this. Future research should focus on determining risk factors for developing SUI after delivery in women with previous TVT. With this knowledge, an optimal management can be established. However, this will not be easy, as the best advice is still to postpone incontinence surgery until childbearing is completed.

Acknowledgments

We thank Dr Dorette Courtar of University Hospital Maastricht for the synopsis of pregnancy and labor of the third patient.

Conflicts of interest

None.

Copyright information

© International Urogynecology Journal 2007

Authors and Affiliations

  • Rian Groenen
    • 1
  • M. Caroline Vos
    • 1
  • Christine Willekes
    • 2
  • Harry A. M. Vervest
    • 1
  1. 1.Department of Gynecology and ObstetricsSt. Elisabeth HospitalTilburgThe Netherlands
  2. 2.Department of Gynecology and ObstetricsUniversity Medical CenterMaastrichtThe Netherlands

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