to compare primiparae undergoing elective cesarean delivery,
avoiding the trauma associated with labor, to those delivering
vaginally. Data on this issue is scarce and conclusions are incon-
sistent. Recently, Rortveit et al. [2003b] investigated the associa-
tion between childbirth and urinary incontinence in a large
community-based cohort of 15,307 women who were younger
than 65 years of age, and who were either nulliparous, or had
undergone only cesarean or only vaginal deliveries. The preva-
lence of SUI was 4.7% in the nulliparous group,6.9% in the cesar-
ean section group and 12.2% in the vaginal delivery group.
Further classi¢cation of cesarean sections into elective versus
non-elective, performed in a subgroup of 239 primiparae, failed
to reveal a statistically signi¢cant di¡erence. However, non-elec-
tive cesarean sections were analyzed as one group with no
further di¡erentiation between cesarean sections for obstructed
labor and other obstetric conditions (i.e., fetal distress, maternal
indications, etc). Grouping all cesarean section deliveries into
one category may be associated with an overestimation bias, as
it is possible that in cases of cesarean section performed for
obstructed labor, pelvic £oor injury is already too extensive to
be reversed by surgical intervention. A previous study by our
group [Groutz et al., 2004] was designed to include only primi-
parae, and categorized indications for cesarean section. Our data
demonstrated a similar prevalence of SUI 1 year postpartum
among primiparae after vaginal deliver y and after cesarean sec-
tion for obstructed labor (10.3% and 12%). Conversely, elective
cesarean section,with no trial of labor,was associated with a sig-
ni¢cantly lower prevalence of postpartum SUI (3.4%), suggest-
ing a protective e¡ect. A similarly constructed study by Chin
et al.  compared the prevalence of postpartum SUI among
women undergoing elective cesarean section, emergent cesarean
section and vaginal delivery. Elective cesarean section was found
to be associated with a lower prevalence of SUI 1 year postpar-
tum compared to both vagi nal delivery and emergent cesarean
Results of our present investigation ¢nd a sign i¢cantly
lo wer prevalence of SUI 1^2 years postpartum among
primiparae who underwent elective cesarean sect ion com-
pared to those delivered vaginally within the elderly age group
(16.7 % and 38.5%, respectively; P ¼ 0.02). This suggests that
the mechanical strain of labor and deliver y makes a sign i¢cant
contribution to the devel opment of postpa rtum SUI, in addi-
tion to maternal age and to the hormonal and mechanical
e¡ects of pregnancy. Whether the prevention of pelvic £oor
injur y should be an indication for elective cesarean section
remains controversial becau se the issue is complex: how hi gh
would the rate of cesarean section have to be in order to
achieve a signi¢cant reduction in the prevalence of postpar-
tum SUI? What would be the price of the rise in cesarean
section rates in terms of mate rnal morbidity and e¡ect on
future pregna ncies and deliveries? And what would be the
long term bene ¢t of such a change in policy ?
In conclusion, ¢rst vaginal d elivery at an older age carries
an increased risk for SUI. Whether the p revention of further
pelvic £oor injury should be an indicat ion for elective cesarean
section in this age group rema ins to be establi shed. It should
be borne in mind that cesarean section may expose women
to greate r morbidity and mortality, and that the apparently
protective e¡ect of cesarean section may vanish with aging,
or with further surgical interv entions. Better understanding
of path ophysiologic mechanisms associated wit h p elvic
£oor dysfunction, may provide the possibility to use appro-
priate preventive measures, or alternat ively to suggest elective
cesarean section in selected cases.
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Neurourology and Urodynamics DOI 10.1002/nau