Postpartum Incontinence and the Pelvic Floor

How common this is

Common enough that the NHS describes it as an expected part of the postnatal period: "After having a baby, it's quite common to leak a bit of pee if you laugh, cough or move suddenly."

The HSE explains why: "Pee can leak as a result of trauma to the pelvic floor or the bladder tube during birth. This will improve as your body heals." It describes bowel symptoms the same way — difficulty controlling wind or poo happens "because a nerve that controls the muscles at the opening of the anus (anal sphincter) has been stretched."

The RCOG adds the sensation people find most unnerving: "Your pelvic floor will not be very strong initially after childbirth. You may also feel that you have difficulties working with your pelvic floor and that you have little sensation." Being unable to feel the muscle at all is a normal early finding, not a sign of permanent damage.

What "common" must not mean is "acceptable indefinitely". The whole point of NICE's guideline on pelvic floor dysfunction (NG210) is that these symptoms are treatable and are systematically under-reported.

Who is at higher risk

NICE lists the risk factors related to pregnancy and labour: being over 30 when you have a baby; having given birth before; assisted vaginal birth with forceps or vacuum; a vaginal birth with the baby lying face up (occipito-posterior); an active second stage lasting more than an hour; and injury to the anal sphincter during birth.

It also lists modifiable factors that apply at any time: a BMI over 25, smoking, lack of exercise, constipation and diabetes. Constipation is the one most within your control in the early weeks, and it is the one most often overlooked.

What the symptoms actually are

The NHS distinguishes the main types of urinary incontinence: stress incontinence, "when urine leaks out at times when your bladder is under pressure; for example, when you cough or laugh"; urge incontinence, "when urine leaks as you feel a sudden, intense urge to pee, or soon afterwards"; and mixed symptoms of both. Stress incontinence "is usually the result of the weakening of or damage to the muscles used to prevent urination, such as the pelvic floor muscles and the urethral sphincter."

Bowel symptoms sit alongside. The RCOG defines anal incontinence as "sudden, uncontrollable urges to open your bowels, or not being able to control passing wind", and possibly soiling or leaking.

Prolapse is a third strand. The HSE lists its symptoms: feeling or seeing a bulge in your vagina, a feeling of pressure in your pelvis, leaking or difficulty holding pee, feeling you cannot fully empty your bladder or bowel, pain during sex, decreased sensation, and aching in the lower tummy or back. Its verdict: "A prolapse is not dangerous, but it can cause pain or make you feel uncomfortable. Treatment is available."

When to call

Contact your GP, health visitor, public health nurse or a physiotherapist if:

• symptoms have not improved in the six weeks after the birth. That is the HSE's threshold
• you are leaking urine, wind or stool at all beyond the early weeks
• you cannot feel your pelvic floor contract when you try
• you feel or see a bulge in your vagina, or a heaviness or dragging sensation
• sex is painful

The NHS puts it simply for urinary symptoms: "See a GP if you have any type of urinary incontinence. Urinary incontinence is a common problem and you should not feel embarrassed talking to them about your symptoms." It also asks you to tell your midwife or GP "if poo is leaking or you're pooing when you don't mean to."

Get urgent advice if you cannot pass urine at all, if it is very painful to pee, or if your urine smells strong or unpleasant — the HSE lists these as reasons to contact your midwife or GP immediately.

What actually works

Pelvic floor muscle training is the intervention with the strongest support behind it, and NICE recommends it broadly and repeatedly. It tells clinicians to "encourage women who are pregnant or who have recently given birth to do pelvic floor muscle training", to encourage it before discharge from maternity services and during routine postnatal care, and to encourage women to continue it throughout life "because long-term training continues to help prevent symptoms."

For higher-risk births, NICE goes further: consider a three-month programme of supervised pelvic floor muscle training during postnatal care for women who had an assisted vaginal birth, a back-to-back birth, or an anal sphincter injury. Supervised means supervised — NICE says programmes "should be supervised by a physiotherapist or other healthcare professional with the appropriate expertise", who should check you can actually contract and relax the muscle before tailoring the programme.

How to do them

The RCOG's method: "Tighten your pelvic floor... by imagining you are desperate to pass urine and you are trying to stop yourself. Hold this for as many seconds as you can, up to a maximum of 10 seconds. Release and rest for 5 seconds." Aim for 10 in a row, plus 10 fast squeezes, at least twice a day. Work from your own starting level: "if you can hold the contraction for 2 seconds and repeat 4 times, this is your starting level."

The NHS version adds two rules people break constantly: "It's important to keep breathing normally while you do these exercises. Make sure you do not pull in your stomach when you squeeze." It suggests building to 10 repeats of long and short squeezes, at least three times a day.

The RCOG adds one prohibition: "do not do them whilst you are passing urine."

The HSE recommends anal sphincter squeezes as part of the routine — "squeeze your back passage like you are passing and stopping wind" — at least 10 squeezes three times daily, to help with control of wind and sudden urges. It also advises waiting six weeks before starting if labour was difficult, for example with a large baby or an assisted birth.

The rest

The NHS lists lifestyle changes such as losing weight and cutting down on caffeine and alcohol, and bladder training to lengthen the gap between visits. NICE recommends enough fibre and appropriate fluid intake, because stool consistency directly affects faecal incontinence. Medicine and surgery exist for symptoms that do not respond, but they come after the conservative measures, not instead of them.

What to let go of

Leaking is not the price of having a baby, and it is not something to solve by buying bigger pads forever. NICE built an entire guideline around the fact that women delay reporting these symptoms out of embarrassment. The clinicians you would be telling have a national guideline instructing them to expect exactly this conversation and to avoid clinical language that makes it harder.