Panel Recommends Curb in Episiotomy

Dec. 12, 2007 -- A routine procedure performed on up to 1 million American women per year may be needlessly contributing to incontinence in those women, an expert panel concluded Wednesday.

The procedure, known as episiotomy, involves cutting tissue between the lower vagina and the anus when women are in childbirth. While it is often used to aide delivery in cases of fetal distress or complicated childbirth, its use in routine births should be curtailed, the experts say.

"The routine use of this procedure should be seriously reconsidered," says C. Seth Landefeld, who led an expert consensus panel on fecal and urinary incontinence sponsored by the National Institutes of Health.

The procedure runs the risk of damaging the anal muscles, which in turn may cause up to 1,000 cases of fecal incontinence per year, says Katherine Hartmann, MD, PhD, deputy director of the Institute for Medicine and Public Health at Vanderbilt University Medical Center.

"It has a proven risk of damage," Hartmann says. "The connection is a pretty direct link."

Incontinence is the catch-all term for the involuntary loss of urine or stool. The risk of fecal and urinary incontinence increase with age; they are more common in women than men.

But both sexes are affected: It is estimated 5% of adults 65 to 74 and 20% of those over 85 experience fecal incontinence. One in five women and one in 20 men are estimated to suffer urinary incontinence by the time they're 45, according to the report.

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Incontinence Is Undertreated

While the problem is widespread, it is vastly undertreated, the panel warns.

"The shame, embarrassment, and stigma associated with these conditions pose significant barriers to seeking professional treatment, resulting in many persons who suffer from these conditions [going] without help," the report states.

In addition, most health plans don't pay doctors to do an independent evaluation for incontinence or counsel on weight loss, exercise, or specialized pelvic floor exercises that may help prevent it, says Landefeld, who directs the Center on Aging at the University of California, San Francisco.

And while articles in women's magazines often include suggestions for women to perform Kegel exercises to strengthen the pelvic floor muscles, experts say those exercises are frequently done incorrectly.

They urge more formal training for women to teach them how to isolate the pelvic floor muscles in a way that can be effective against urinary incontinence.

"Many women and men and many practitioners don't have a good idea of what the pelvic floor is," says Eileen Hoffman, MD, an associate professor of medicine at New York University. "You have muscles down there that if you don't have tone in [them], you're much more likely to have incontinence."

A high proportion of incontinence cases occur in nursing homes, according to the report. But instead of physical problems, many cases occur simply because elderly residents don't get to the bathroom in time.

The panel urged new policies that increase staffing at nursing homes so that residents don't sit, sometimes for hours, needing to use the toilet.

"That is probably more expensive then just letting them sit there in diapers," Landefeld says.