Causes of Urinary Leakage After Childbirth

One of the most common symptoms in the postpartum period is urinary leakage. Women are often told urinary leakage “is normal” after childbirth or just a “part of aging”.  They are relegated to wearing black pants while bringing an extra set of bottoms. The incontinence pads market is a >12 billion dollar industry. Yes, you read that properly. 12 BILLION dollars. However, pelvic floor physical therapy can help those with urinary leakage stay dry. 

Today we will go over the causes of postpartum incontinence. We will go over:

  • The causes of incontinence after birth
  • Symptoms associated with different causes
  • Treatment and tips for leakage

Pelvic Floor Nerve Stretch

There is a nerve, called the pudendal nerve, that goes through the pelvic floor. It weaves around ligaments, muscles and bony prominences. The pudendal nerve splits into different branches, like a tree, and one branch goes to the urethra. The nerve weaving in and out of the different structures contributes to an increased risk of being stretched during birth. During childbirth with a long pushing phase, the pudendal nerve is stretched. The stretched nerve has limited ability to signal the urethra muscle to contract. 

The urethra is the external muscle of the bladder and is a part of the voiding system. There are multiple factors in urethra muscle strength. The tone of the urethra helps keep you dry. 


A prolonged labor and pushing phase can contribute to pelvic floor nerve stretch. Symptoms in general are the typical leakage with coughing, and sneezing. However, chronic constipation can contribute to stretch of the nerve due to bearing down. Bearing down during bowel movements continues to strain the pelvic floor contributing to irritation of the pudendal nerve. Increase in leakage after a bowel movement which you had to bear down to pass stool is a sign of pudendal nerve stretch injury. Meaning there is an increase in leakage with a cough or sneeze after a bowel movement. 


If there is a stretch injury only, it will take 6-8 weeks postpartum, depending on severity of the stretch, for the nerve to recover. During this time, minimizing a stretch to the pelvic floor will allow for healing. One factor to keep in mind is constipation. Constipation is a very common pregnancy and postpartum. When you are constipated, there is an increase in bearing down to have a bowel movement. The bearing down will continuously stretch the pelvic floor and the nerve limiting it’s ability to heal. Continue to take magnesium and stool softeners until bowel movements have normalized. 

If you are experiencing leakage beyond the first 6 weeks of postpartum, schedule an appointment with a pelvic floor physical therapist with advance training in stress urinary incontinence. 

Fascia Tear

There is a connective tissue between the pubic bone and the bladder called the pubocervical fascia. The fascia can be overly stretched or even torn during childbirth. This stretched or torn tissue decreases the support provided to the bladder. When there is an increase in force, the support is decreased which causes urinary leakage. 


When it’s connective tissue integrity you may have progressive symptoms/end of day symptoms as the connective tissue stretches. The reason this occurs is because over the course of the day the connective tissue stretches due to gravity. The prolonged stretch over time limits the ability of the tissue to create firmness to support the bladder. This can cause urinary leakage.


When there is a stretch, or even a tear, to the fascia, the best way to provide the support is using a pessary. A pessary is a device worn internally at the pelvic floor muscles to provide support for the fascia and bladder. This device will allow the fascia to rest and be supported against the downward pressures of gravity. A pessary specific for leakage has a “bump” to provide reinforcement to the urethra.

At this time, Optimize Pelvic Health is the only pelvic floor physical therapy clinic in the South Bay Area that offers pessary fittings. To learn more about pessary fittings. 


Estrogen is the new “buzzword” in women’s health. It’s usually discussed for it’s impact on perimenopause and menopause. However, in the postpartum state, the hormone levels you experience are similar to the hormone levels during perimenopause. This massive drop occurs in the first 24 hours after childbirth.

Hand representation of urethra muscle close and open
Represents urethra with thin muscle and muscle bulk

There are estrogen receptors in the urethra. With normal estrogen levels, the urethra muscle has bulk making it easier to close. However, with the drop in estrogen the urethral tissues are not getting enough estrogen needed to maintain healthy muscle mass. The urethra muscles thin making it more difficult to contract completely to close the urethra.


This is a discussion with your OBGYN. The use of topical estrogen can be helpful to improve muscle bulk of the urethra. The use of topical estrogen needs to be managed due to it’s impact on the surrounding fascia. Estrogen can make our fascia more pliable and stretchy. ESTROGEN is the hormone which allows the body to stretch during pregnancy, not the widely known relaxin. The collagen type that is responsible for making up fascia CHANGES in the presence of estrogen. Adding topical estrogen can impact the surrounding fascia making it stretch which limits the connective tissue support for the bladder. In some women, topical estrogen can actually make leakage worse. 

There is also controversy on how topical estrogen impacts breastfeeding. To date, there is no research to indicate topical estrogen will negatively impact breastfeeding. 

Pelvic floor physical therapists with advance training in the management of stress urinary incontinence, like the therapist at Optimize Pelvic Health, will be able to guide the conversation with your OBGYN.

Summary of Urinary Leakage After Childbirth

There are multiple factors that play a role in urinary leakage after childbirth. Pelvic floor nerve stretch, fascia stretch or tear, and low estrogen are the major causes of urinary leakage after childbirth. I also want to remind you that there is usually more than one factor that impacts urinary leakage after childbirth.

At Optimize Pelvic Health, we figure out how much each cause plays a role in your urinary leakage so that you will have an individualized plan for long lasting symptom relief. When you go to pelvic floor physical therapy, they should be able to tell you how pudendal nerve stretch, fascia tear and estrogen plays a role in your leakage after birth.

Please share this article with anyone you know with urinary leakage after childbirth.

For more extensive reading on urinary leakage please head to the Causes of Urinary Leakage blog.

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