Stress Incontinence

What Is Stress Incontinence? What Causes Stress Incontinence?

Stress urinary incontinence (SUI), also known as effort incontinence, is the unintentional loss of urine. It is due essentially to insufficient strength of the pelvic floor muscles and is provoked by a physical movement or activity (such as coughing, sneezing or exercising) that puts pressure (stress) on the bladder.

Stress incontinence is the most common form of urinary incontinence and is not related to psychological stress. It is much more common in women than in men.

According to Medilexicon's medical dictionary, stress urinary incontinence is "leakage of urine as a result of coughing, straining, or some sudden voluntary movement, due to incompetence of the sphincteric mechanisms."

Someone with stress incontinence may feel embarrassed, isolated and limit their work and social life, especially exercise and leisure activities. With treatment stress incontinence can be managed.

The main treatment is exercise to strengthen the pelvic floor muscles (pelvic floor exercises). If these do not help, another treatment option is surgery to 'tighten' or support the bladder outlet. If surgery is not an option, medication may help in addition to exercises.

The kidneys and bladder

The kidneys make urine all the time. A trickle of urine is constantly passing to the bladder down the ureters (the tubes from the kidneys to the bladder). A person makes different amounts of urine depending on how much they drink, eat and sweat.

The bladder is made of muscle and stores the urine. It expands like a balloon as it fills with urine. The outlet for urine (the urethra) is normally kept closed. This is helped by the pelvic floor muscles.

When a certain amount of urine is in the bladder, a person becomes aware that the bladder is getting full. When going to the toilet to pass urine, the bladder muscle contracts and squeezes, the urethra and pelvic floor muscles relax.

Complex nerve messages are sent between the brain, the bladder, and the pelvic floor muscles. These tell a person how full their bladder is, and tell the right muscles to contract or relax at the right time.

What is stress incontinence?

Stress incontinence is when urine leaks because there is a sudden extra pressure on the bladder. This is because the pelvic floor muscles and urethra cannot withstand the extra pressure. Stress incontinence develops because the pelvic floor muscles are weakened. Small amounts of urine may leak, but sometimes it can be quite a lot and can cause embarrassment. Urine tends to leak most when coughing, laughing, or during exercising (jumping or running). In these situations there is sudden extra pressure within the abdomen and on the bladder.

How common is stress incontinence?

Stress incontinence is the most common form of urinary incontinence. Stress incontinence becomes more common in older women and as many as 1 in 5 women over the age of 40 have some degree of stress incontinence.

Other types of incontinence

The second most common type of incontinence is urge incontinence. It is when a person gets an urgent desire to pass urine from an 'overactive bladder'. Urine may leak before the person has time to get to the toilet. Treatment is different to stress incontinence. Some people have both stress incontinence and urge incontinence. This is known as 'mixed' incontinence.

What are the signs and symptoms of stress incontinence?

A symptom is something the patient senses and describes, while a sign is something other people, such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign.
A person that has stress incontinence may experience urine leakage when:

• Coughing
• Exercising
• Laughing
• Lifting something heavy
• Sneezing
• Standing up

Incontinence may not be experienced every time. However, any pressure-increasing activity can make the person more vulnerable to unintentional urine loss, particularly when the bladder is full.

The bladder may not even feel unusually full when there is a urine leakage due to stress incontinence. Anything that exerts force on the abdominal muscles (sneezing, bending over, lifting and laughing hard) also puts pressure on the bladder.

Seek medical advice if the signs and symptoms of stress incontinence interfere with activities of daily living, such as work, hobbies and social life.

What causes stress incontinence?

Urinary sphincter and pelvic floor muscles may lose tone because of:

• Childbirth: Most cases of stress incontinence are due to weakened pelvic floor muscles. The common reason for the pelvic floor muscles to become weakened is childbirth. The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and rectum. Stress incontinence is common in women who have had children.There can be tissue or nerve damage incurred during delivery of a child. Stress incontinence from this damage may begin soon after delivery or years later.
  
• Age. Stress incontinence is also more common with increasing age as the muscles become weaker, particularly after the menopause. Stress incontinence is also more common in women who are obese.
  
• Prostate surgery. In men, the most common factor leading to stress incontinence is the surgical removal of the prostate gland (prostatectomy) to treat prostate cancer. Because the prostate gland encircles the urethra, a prostatectomy results in less urethral support.

Contributing factors

Other factors that may intensify stress incontinence include:

• Diabetes, which can cause excess urine production and nerve damage
• Excess consumption of caffeine or alcohol
• Illnesses that cause chronic coughing or sneezing
• Medications that cause a rapid increase in urine production
• Obesity
• Smoking, which can cause frequent coughing
• Urinary tract infection
• Sports, such as tennis or running (female high-level athletes, effort incontinence occurs in all sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance).

What are the risk factors for stress incontinence?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.

Factors that increase the risk of developing stress incontinence include the following:

• Age. Stress incontinence is not a normal part of aging. However, physical changes associated with aging, such as the weakening of muscles are linked to stress incontinence. Also, women in menopause lose the beneficial effects of estrogen (strengthening and protecting the tissues of the vagina and urethra) making the development of stress incontinence more likely.
  
• Obesity. People who are obese have a much higher risk of stress incontinence. Excess weight increases pressure on the abdominal organs. Consequently, the pressure on the bladder may be increased even without the additional pressure from a cough or other force.
  
• Previous pelvic surgery. Hysterectomy in women, and particularly prostate surgery in men, can alter the function and support of the bladder and urethra, making it much more likely for a person to develop stress incontinence. This effect can be either immediate or delayed.
  
• Type of delivery. Forceps delivery of a baby may be associated with a greater risk of stress incontinence than is normal vaginal delivery. Multiple deliveries also may be associated with a higher risk.

What are the complications of stress incontinence?

Complications of stress incontinence may include:

• Self-consciousness. The person may feel embarrassed and distressed by the condition. It often disrupts work, social activities, interpersonal relationships and sexual relations.
  
• Mixed incontinence. Mixed incontinence usually involves both stress incontinence and urge incontinence. It is the loss of urine resulting from an involuntary contraction of bladder muscles (overactive bladder).
  
• Skin rash or irritation. Skin that is constantly in contact with urine is likely to be irritated, sore and can break down. This can happen with severe incontinence if precautions are not taken, such as using moisture barriers or incontinence pads. However, use of incontinence products can cause further embarrassment and personal distress.

How is stress incontinence diagnosed?

The medical exam includes:

• Review of medical history
• A complete physical examination with particular focus on the abdomen and genitals
• A urine sample to test for infection, traces of blood or other abnormalities
• A neurological exam to identify sensory problems
• A urinary stress test, if urine loss is observed when the patient coughs or bears down

Specialized tests

Urodynamic tests may be ordered. They are used to assess the function of the bladder. Common tests include:

• Measurements of postvoid residual urine. When the patient urinates or experiences urinary incontinence, the bladder may not empty completely. To measure residual urine after urinating, a thin tube (catheter) is passed through the urethra and into the bladder. The catheter drains the remaining urine, which can then be measured. Also, a specialist may use an ultrasound scan, which translates sound waves into an image of the bladder and its contents.
  
• Cystometry. Cystometry measures pressure in the bladder and in the surrounding region during bladder filling. A catheter is used to fill the bladder slowly with warm water. This procedure, when combined with a voiding study, tells whether the urinary sphincter exerts enough pressure to keep the urethra closed as bladder pressure rises.
  
• Video urodynamics. These procedures use either X-ray or ultrasound waves to create pictures of the bladder as it is filling and emptying. Warm water mixed with a dye that shows up on X-rays is gradually instilled in the bladder via a catheter while the images are recorded. When the bladder is full, the imaging continues as the patient urinates. This test is often combined with cystometry.

According to the results of these tests, a treatment strategy will be recommended.

What are the treatment options for stress incontinence?

To end or reduce the number of incontinence episodes, a combination of treatment strategies can be recommended. If an underlying cause or contributing factor, such as a urinary tract infection, is identified, the patient will also receive treatments to address those conditions.

Behavioral therapies

Behavioral therapies may help to eliminate or lessen episodes of stress incontinence. The stress incontinence treatments that will be recommended may cover the following areas:

• Fluid consumption. The amount and timing of fluid consumption during the day will be reviewed. Also, avoid caffeinated and alcoholic beverages.
  
• Healthy lifestyle changes. Quitting smoking or losing weight may lessen vulnerability to stress incontinence and improve symptoms.
  
• Scheduled toilet trips. A schedule for going to the toilets may be recommended. More frequent voiding of the bladder may reduce the number or severity of stress incontinence episodes.
  
• Pelvic floor muscle exercises. Exercises called Kegels strengthen the pelvic floor muscles and urinary sphincter. Your doctor or a physical therapist can help you learn how to do these exercises correctly. How well Kegels will work depends on the patient's willingness to perform the exercises regularly, just like any other exercise routine.

Strengthening the pelvic floor muscles

The usual first treatment is to strengthen the pelvic floor muscles. About 6 in 10 cases of stress incontinence can be cured or much improved with this treatment. It is important to exercise the correct muscles.

Learning to exercise the right muscles:

• Sit in a chair with knees slightly apart. Imagine you are trying to stop wind escaping from your anus (back passage). Squeeze the muscle just above the entrance to the anus. You should feel some movement in the muscle. Do not move buttocks or legs.
  
• Imagine you are passing urine and are trying to stop the stream. You will find yourself using slightly different parts of the pelvic floor muscles to the first exercise. Those muscles are nearer the front. These are the ones to strengthen. To check that you are exercising the right muscles, put a couple of fingers into your vagina. You should feel a gentle squeeze when doing the exercises.

Doing the exercises:

• Do the exercises every day.
  
• Sit, stand or lie with knees slightly apart. Slowly tighten your pelvic floor muscles under the bladder as hard as you can. Hold to the count of five then relax. Repeat at least five times. These are called slow pull-ups.
  
• Then do the same exercise quickly for a second or two. Repeat at least five times. These are called fast pull-ups.
  
• Keep repeating the five slow pull ups and the five fast pull-ups for five minutes.
  
• Aim to do the above exercises for about five minutes at least three times a day, and preferably 6 to 10 times a day.
  
• Do each five minute set of exercise in a different position each time. That is, sometimes when sitting, sometimes when standing, and sometimes when lying down.
  
• As the muscles become stronger, increase the length of time you hold each slow pull-up. You are doing well if you can hold each slow pull-up for a count of 10 (about 10 seconds).
  
• Do not squeeze other muscles at the same time as you squeeze your pelvic floor muscles. For example, do not use any muscles in your back, thighs, buttocks, or stomach.
  
• In addition to the times you do the exercises, try to get into the habit of doing pelvic floor exercises whilst going about everyday life.
  
• After several weeks the muscles will start to feel stronger. You may find you can squeeze the pelvic floor muscles for much longer without the muscles feeling tired.

It takes time, effort and practice to become good at these exercises. It is advised that you do these exercises for at least three months to start with. You should start to see benefits after a few weeks. However, it often takes 8 to 20 weeks for most improvement to occur. After this time you may be cured from stress incontinence.

If possible, continue exercising as a part of everyday life for the rest of your life to stop the problem recurring.

Once incontinence has gone, you may only need to do 1 to 2 five-minute sets of exercise each day to keep the pelvic floor muscles strong and toned up.

Other ways of exercising pelvic floor muscles

Sometimes extra methods will be recommended if there are problems in performing the pelvic floor exercises. These should be performed in addition to the regular pelvic floor exercises. For example:

• Electrical stimulation. In some cases, a special electrical device is used to stimulate the pelvic floor muscles with the aim of making them contract and become stronger. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This can stabilize overactive muscles and stimulate contraction of urethral muscles.
  
• Biofeedback. This is a technique to the patient make sure that they are exercising the correct muscles. For this, a physiotherapist or continence advisor inserts a small device into the vagina when doing the pelvic floor exercises. When the patient squeezes the right muscles, the device makes a noise to indicate that the correct muscles are used. The patient can gain control over these muscles.
  
• Vaginal cones. These are small plastic cones that are put inside the vagina for about 15 minutes, twice a day. The cones come in a set of different weights. At first, the lightest cone is used. The pelvic floor muscles are used to hold the cone in place. So, it is a way to exercise the pelvic floor muscles. Once the patient can hold onto the lightest one comfortably, they can move up to the next weight, and so on.
  
• Other devices. There are various other devices that are sold to help with pelvic floor exercises. Basically, they all rely on placing the device inside the vagina with the aim of helping the pelvic muscles to exercise and squeeze.
  
  There is little research evidence to show how well these devices work. It is best to get the advice from a continence advisor or physiotherapist before using any.

Devices

Some devices are designed to help women control stress incontinence, including:

• Vaginal pessary. This is a ring-shaped device. It is fitted and put into place by a doctor or a nurse practitioner. It helps support the bladder to prevent urine leakage. A vaginal pessary may be a good choice if the patient wishes to avoid surgery. If a pessary is used, vaginal and urinary tract infections may occur and regular monitoring by a doctor is recommended.
  
• Urethral plug. This small tampon-like disposable device is inserted into the urethra. It acts as a plug to prevent leakage. It is usually used to prevent incontinence during a specific activity.

Surgery

Surgical interventions to treat stress incontinence are usually designed to improve closure of the sphincter or support the bladder neck. Doctors usually suggest surgery to alleviate incontinence only after other treatments have been tried. Many surgical options have high rates of success.

Surgical interventions include:

• Injectable bulking agents. Collagen, synthetic sugars or gels may be injected into tissues around the upper portion of the urethra. These materials increase pressure on the urethra, improving the closing ability of the sphincter. Because this intervention is relatively noninvasive and inexpensive, it may be an appropriate treatment alternative to try before other surgical options.
  
• Open retropubic colposuspension. This procedure is often used. Sutures attached either to ligaments or to bone lift support tissues near the bladder neck and upper portion of the urethra.
  
• Sling procedure. This procedure is most often performed for women. The surgeon uses the person's own tissue or a synthetic material to create a "sling" that supports the urethra.
  
  A sling usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine, porcine) or the patients' own tissue that is placed under the urethra through one vaginal incision and two small abdominal incisions. According to published peer-reviewed studies, slings are approximately 85% effective.
  
  Slings for men are used less frequently, but this surgical approach is under investigation. A recently developed technique using a mesh sling has proved effective in easing symptoms of stress incontinence in men.
  
• Inflatable artificial sphincter. This surgically implanted device is more often used to treat men. A cuff, which fits around the upper portion of the urethra, replaces the function of the sphincter. Tubes connect the cuff to a pressure-regulating balloon in the pelvic region and a manually operated pump in the scrotum.
  
  If the device is implanted in a woman, the pump is in the labia.

Medication

Duloxetine is a medicine that is usually used to treat depression. However, it was found to help with stress incontinence separate to its effect on depression. It is thought to work by interfering with certain chemicals that are used in transmitting nerve impulses to muscles. This helps the muscles around the urethra to contract more strongly.

Duloxetine on its own is not likely to cure the incontinence but may help to make it less of a problem. However, duloxetine in addition to pelvic floor exercises may give a better chance of curing the incontinence than either treatment alone.

The alpha-1 adrenergic receptor mediates contraction of the neck of urinary bladder and the urethra.

Alpha blockers (pseudoephedrine, phenylpropanolamine) are sometimes used to act at these receptors.

General lifestyle measures

Healthy lifestyle practices can help easing symptoms of stress incontinence.

Continence advisors can give advice on treatments, especially pelvic floor exercises. If incontinence remains a problem, they can also give advice on how to cope. For example, they may be able to supply various appliances and aids to help such as incontinence pads etc.

• Getting to the toilet. Make this as easy as possible. If you have difficulty moving around, consider special adaptations like a handrail or a raised seat in your toilet.
  
• Lose weight. It is known that stress incontinence is more common in women who are obese. If you are overweight (body mass index (BMI) is over 25), losing excess pounds can help reduce the overall pressure on the bladder and pelvic floor muscles. Losing 5 to 10 percent of body weight may help improve stress incontinence.
  
• Do not smoke. Smoking can cause coughing which can aggravate symptoms
  
• Add fiber to your diet. Constipation contributes to incontinence, especially if you often strain during bowel movements. Keeping bowel movements soft and regular allows urine to flow freely and reduces the strain that is placed on the pelvic floor muscles. Eat high-fiber foods (whole grains, legumes, fruits and vegetables) to relieve and prevent constipation.
  
• Avoid eating or drinking substances that can irritate the bladder. For instance, if drinking coffee throughout the day tends to increase trips to the bathroom more frequently, try reducing the amount you drink.
  
• Maintain proper fluid intake. Drinking too much fluid can make you urinate more frequently. But not drinking enough can lead to a concentration of waste in your urine, which can irritate your bladder, too.

Can stress incontinence be prevented?

Doing regular pelvic floor exercises during pregnancy and after having a baby can reduce the risk of developing stress incontinence following childbirth and in later life.

Coping and support

Nowadays, treatments for stress incontinence can substantially reduce, if not eliminate, urinary leakage. Still, patients may need to cope with the effects of incontinence while waiting for surgery or for medication or behavior therapies to gain effectiveness.

Maintain connection with family, friends and colleagues. This can prevent feelings of isolation and depression that can accompany incontinence. Being prepared may help you feel more comfortable when going out:

• Stock up on supplies. Take along sufficient incontinence pads or protective undergarments and possibly a change of clothes. Incontinence products are discreet and often can be stored in a roomy purse or a small backpack.
  
• Check out destination. Familiarize yourself with the restrooms available at your destination. Choose seating that allows easy access to restrooms.
  
• Take good care of yourself. Prolonged contact with wet clothing can cause skin irritation or sores. Keep skin as dry as possible to prevent this.

Sexuality and incontinence

Leaking urine during sexual intercourse can be disturbing. However, it does not necessarily have to get in the way of intimacy:

• Talk with your partner. It may be difficult at first. Be up front with your partner about your condition.
  
• Empty your bladder. To reduce chances of leakage, avoid drinking fluids for an hour or so before sex. Empty your bladder immediately before starting.
  
• Try a different position. Altering positions may make intercourse easier. For women, being on top generally gives better control of pelvic muscles.
  
• Do Kegels. Pelvic floor muscle exercises (Kegel exercises) can help strengthen the pelvic floor muscles and reduce urine leakage.
  
• Be prepared. Having towels handy or using disposable pads on your bed may help ease some of your anxiety.