SHORT COMMUNICATION Caesarean section is protective against stress urinary incontinence: an analysis of women with multiple deliveries Charlotte Chaliha, Alex Digesu, Anna Hutchings, Marco Soligo, Vik Khullar All women who had three elective caesarean sections were selected from a database of 40,000 women delivering between 1977 and 1998, and age-matched with women having three vaginal births. They all completed a (validated) urinary and bowel symptom questionnaire. Women who had vaginal births had a significantly higher prevalence of stress incontinence but not other urinary or faecal symptoms compared with those delivered by caesarean section. The prevalence of faecal incontinence was lower than the prevalence of urinary incontinence. Although the prevalence of faecal incontinence was lower after caesarean delivery, this was not statistically different. These data have shown that caesarean section was associated with a lower risk of urinary incontinence, although a protective effect on development of faecal symptoms was not seen. Introduction The development of pelvic floor disorders such as urinary and faecal incontinence and pelvic organ prolapse have been associated with pregnancy and vaginal delivery. The prevalence of urinary incontinence has been reported to be up to 34% after a vaginal delivery and is associated with denervation injury to the pelvic floor or mechanical trauma to the urethral sphincter mechanism. 1–3 Anal in- continence is reported in 10% of women at 12 weeks post- partum and has been related to vaginal delivery and anal sphincter injury. 4,5 It is unclear how protective an elective caesarean section is for the development of these disorders as after multiple caesarean births the prevalence of urinary incontinence is similar to women having vaginal births. 1 There are very few data on women who have had multiple elective caesarean sections alone, and it may be that the risk of postpartum incontinence is different in those who have had a history of prelabour (elective) caesarean section alone compared with those who have undergone a caesar- ean section in labour. The aim of our study was to investigate whether multiple deliveries by elective caesarean section reduced the risk of urinary and faecal incontinence compared with a group of women who had spontaneous vaginal deliveries. Methods Forty women who had three elective caesarean sec- tions were identified from a database of 40,000 women delivering between 1977 and 1998, and age-matched with 80 women having three spontaneous vaginal deliveries. The database identified 256 women who had three caesarean sections but on hand searching the notes only 40 had three elective caesarean sections. A validated urinary symptom questionnaire (King’s Health Questionnaire 6 ) was posted to all women, to assess the presence and severity of urinary symptoms and their impact on quality of life. Additional questions regarding incontinence of flatus and solid and liquid stool were also asked (derived from a validated questionnaire, the Manchester Health Questionnaire). 7 All terms and definitions are in accordance with the International Continence Society. Data are reported as number (%) or mean [SD]. Analysis was performed using SPSS software (version 10.0, SPSS). Fisher’s exact test was used to compare urinary and faecal symptoms and Mann – Whitney U test to compare the total domain scores in the King’s Health Questionnaire. Results Thirty-three (82.5%) of women in the caesarean section group, and 50 (62.5%) in the vaginal delivery group responded. Women in the caesarean section group were older at first delivery than those who had a vaginal delivery (27 F 4.5 years vs 24 F 5.4). They were also older at the time of completion of the questionnaire (37 F 4.5 years vs 34 F 5.2 years). BJOG: an International Journal of Obstetrics and Gynaecology July 2004, Vol. 111, pp. 754–755 D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology www.blackwellpublishing.com/bjog Department of Urogynaecology, St Mary’s Hospital, Imperial College School of Medicine, London, UK Correspondence: Dr C. Chaliha, Department of Urogynaecology, St Mary’s Hospital, Imperial College School of Medicine, London, UK. DOI:10.1111/j.1471-0528.2004.00155.x