Stress urinary incontinence

Definition
Urinary incontinence is the loss of bladder control or involuntary leakage of urine. Stress urinary incontinence (SUI) is the most common type of incontinence, particularly among women. It happens when a sneeze, cough, laugh, exercise or any other activity puts pressure on the bladder, causing urine to leak.

Causes/associated factors
Two important muscle groups help hold urine in the bladder. The urethral sphincter is a ring of muscle at the bottom of the urethra (the tube that carries urine from the bladder to the outside of the body) that squeezes to hold the urine in the bladder. Pelvic floor muscles lie under the bladder and work with the sphincter muscle to prevent urine leakage.
When these muscles weaken, the bladder drops down and stress urinary incontinence results. Although men may develop stress urinary incontinence after having certain types of surgery or radiation, the condition is much more common in women, particularly after menopause.

For women, the weakening can be caused by various factors. Some common causes are:

Childbirth: Vaginal delivery can result in the weakening of pelvic floor muscles from delivering the baby through the vagina. A forceps birth or other instruments to assist delivery may also further weaken the muscles.

Aging and menopause: Aging causes all muscles to weaken, including pelvic floor muscles. During menopause, the body produces less estrogen. Estrogen helps keep muscles healthy, especially the urethral sphincter muscle. During menopause, the sphincter muscle may weaken.

Obesity: Extra weight can put more pressure on the muscles around the bladder, causing them to weaken.

Pelvic surgery: Damage to muscles in the pelvic area from a cesarean section, hysterectomy or other surgery in the pelvic area is not common, but can lead to stress incontinence.

Signs/symptoms
Again, stress urinary incontinence is characterized by involuntary urine loss when there's a sudden increase in pressure on the bladder, such as coughing or sneezing. More severe stress urinary incontinence may occur with less stress on the bladder, such as walking up stairs or standing.

Diagnosis
Your doctor will ask about your medical history and do a physical exam. Women may have a pelvic exam to check for changes in the normal shape and position of the uterus and bladder. Your doctor may do certain tests, such as:
cough stress test (a test in which you cough with a full bladder to see if you leak urine)
urinalysis (a lab test to analyze your urine for possible infection or other causes of incontinence)
post-void residual measurement (a test in which your bladder is checked for the amount of urine it contains after you urinate), which can be done by catheterization (insertion of a small sterile tube directly into your bladder to drain the urine) or ultrasound (using sound waves to create an image of internal body parts)
urodynamic testing (a test used to measure the pressure in your bladder and the flow of urine)
cystoscopy (a test in which the bladder is examined through a tiny tube and camera inserted through the urethra)
You may also be asked to keep a voiding diary, in which you record the amount and type of fluid you drink, the time of day you urinate, the amount you urinate, and any incontinence episodes. Depending on the circumstances, you may be referred to a urologist (a doctor who specializes in the male genital tract and the urinary tract of both sexes) or a urogynecologist (a doctor who specializes in the urinary tract of women).


Treatment
Although incontinence can be embarrassing to discuss with your doctor, the earlier it's diagnosed and treated, the more likely the results will be successful. A wide variety of treatment options can be used alone or in combination with other options. Some treatments will improve incontinence, while others may provide a cure.
Muscle-strengthening exercises

Pelvic floor muscle exercises, also known as Kegel exercises, strengthen the muscles used to stay dry. You can identify the muscles you need to exercise while you're urinating by slowly tightening the muscles of your pelvic floor until you stop the flow of urine. To perform your daily Kegels, contract these same muscles while sitting, standing or lying down. Hold for about 10 seconds, then release. Repeat 10 times, three times a day.
Benefits: Muscle-strengthening exercises are the best treatment for stress incontinence that doesn't involve surgery. They are safe, free and painless.

Risks: You must continue to do the exercises to keep dry. It may take six to 12 weeks to see results.


Vaginal cones help you use the correct pelvic floor muscles. They come as a set of five identical-sized cones in graduated weights. Start with the weight that can be held in the vagina for almost one minute. Work up to holding that cone 15 minutes twice a day, then move to the next higher cone weight.
Benefits: Vaginal cones may reduce leakage.

Risks: Vaginal cones don't work any better than Kegel excercises. Many women have difficulty getting motivated enough to use them consistently.


Biofeedback uses a tampon-shaped sensor that's placed in the vagina or rectum, and a second sensor is placed on the abdomen. When the correct muscles are squeezed, the signals are registered on a computer screen.
Benefits: Direct feedback is provided to ensure the correct muscles are being tightened.

Risks: Once the muscles are identified and the exercises can be done correctly, they must be continue at home to maintain the benefit.


Electrical stimulation uses a probe in or near the vagina to pass a mild electrical current through the pelvic floor muscles to make them contract. This should be done for 20 to 60 minutes a day for about four weeks.
Benefits: This therapy is especially helpful if you can't contract your pelvic floor muscles at all.

Risks: Possible side effects include vaginal pain, urinary tract infections and vaginal bleeding.

Behavioral therapy

Bladder training involves working with a therapist to train the bladder to hold more urine. For example, if you urinate every two hours, try to extend that time by 30 minutes. Each week, the time between urinating will increase. The therapist teaches techniques such as relaxation and positive thinking to help increase the time interval. The goal is three to four hours between bathroom breaks.
Benefits: Bladder training can help you gain mental control over your bladder and reduce leakage.

Risks: Bladder training does not work as well in older, frail women.

Medication


Estrogen may be prescribed for treatment. Estrogen levels fall around the time of menopause. The urethra, bladder and pelvic floor muscles use estrogen to stay healthy.
Benefits: Estrogen may reduce leakage.

Risks: There is no evidence to suggest estrogen works for stress incontinence. Possible side effects (for oral estrogen) include increased risk of blood clots, cardiovascular illness, irregular bleeding and certain types of cancer.


Alpha-adrenergic medications, such as pseudoephedrine (Sudafed, for example), stimulate contraction of the urethral sphincter muscles to help prevent incontinence.
Benefits: The medication may reduce leakage.

Risks: The medication may have limited effects. Also, side effects such as anxiety, insomnia and headaches may limit long-term use.

Surgery
If stress urinary incontinence is severe or more conservative measures fail to control the condition, your doctor may recommend surgery.

Colposuspension (bladder neck suspension) is a procedure used to lift the bladder back into the correct position. When the bladder sags back toward the vagina, the urethral sphincter muscle can leak when you cough or sneeze. This surgery can be done through an open incision or an endoscopic (using a thin, flexible tube equipped with a camera lens and light) procedure.
Benefits: Colposuspension is a very successful surgery. Most women are completely dry or much better for at least five years. The open surgical procedure has a better outcome than the endoscopic procedure.

Risks: Recovery may take two months or more to return to a normal routine. There's a small risk of increased urination, leakage or even difficulty passing urine. About one-third of women develop a prolapsed vagina, a condition in which the vagina weakens and collapses. A second operation is then necessary to repair the vagina. There's a small risk of a pulling pain because the vagina has also been lifted. There's a chance of injury to the bladder or ureters (tubes that lead from the kidney to bladder) during the surgery. A second operation may be necessary to repair any injuries.


Slings work like a hammock to support the bladder and urethra. A strip of material, either synthetic (such as Gore-Tex) or strip of tissue taken from the abdomen, is passed behind the bladder neck (where the urethra connects to the bottom of the bladder). The strip is anchored to help restore the urethra into its correct position.
Benefits: Synthetic slings work better than slings made with strips of tissue. For most women, slings keep them dry or improve their condition.

Risks: There is a chance of longer hospitalization due to infection. Urinating may be difficult because the sling works so well. This usually improves over time, but a second operation may be necessary. The synthetic slings can erode into the urethra, requiring removal of the sling.


Vaginal tape (short for tension-free vaginal tape or TVT) is a modification of the sling procedure. It's a newer procedure that shows promise. The 30-minute operation (compared to one hour or more for other surgeries) uses a synthetic tape, such as Prolene, to make a U-shaped sling under the middle of the urethra. The tape is anchored with dissolvable stitches. Scar tissue then grows into the tape to hold it in place.
Benefits: With vaginal tape, recovery time is reduced -- two weeks compared to two months for the colposuspension. There may also be less need for strong painkillers, and you may have a shorter hospital stay -- you can usually leave after a few days.

Risks: You may need to pass urine more often and urgently due to surgery close to the bladder, but this should pass. There's a small risk of difficulty urinating and injury to the bladder during the surgery. As with other surgeries, there's also a small risk of infection, bleeding or blood clots in surgical area. Initial results of the procedure are good, but longer-term studies are still needed to ensure continued success.


Implants that involve injecting a "bulking" material around the urethra can be used to keep the urethra closed. The material may have to be injected multiple times to maintain dryness. Bearing down to urinate allows urine to flow past the bulked-up urethra.
Benefits: The implants are an alternative for women who are poor surgical candidates, such as elderly women.

Risks: There is a lack of good, quality studies to show the long-term success with the implants. Complications include the inability to urinate and urinary tract infections.


Artificial sphincters are surgically implanted devices that work like the urethral sphincter muscle. A fluid-filled ring is implanted around the urethra, squeezing it closed. The bladder is emptied by pressing a pump in the labia that lets fluid out of the ring so urine can flow through the open urethra. The pump is pressed a second time to allow fluid back into the ring.
Benefits: Artificial sphincters are an option if all other surgical procedures have failed.

Risks: There is a possibility of device malfunction, the ring eroding into the urethra from the constant pressure, and infection.

Devices
The following devices help prevent urine leakage, but do not cure urinary incontinence.

Pessary: A stiff ring placed in the vagina to support the urethra and bladder neck.
Benefits: The pessary must be worn for days to weeks at a time.

Risks: There is a risk of vaginal or urinary tract infection. You may notice more vaginal discharge or an odor due to the discharge. Also, the ring can fall out of the vagina.


Urethral insert: A small device, similar to a plug, that can be inserted in the urethra to prevent urine leakage.
Benefits: The insert is most appropriate for someone who is active, but does not want surgery.

Risks: The insert must be removed after several hours or each time you urinate. Changing the insert can be difficult for some people. There is the possibility of the plug moving up into bladder or falling out of the urethra.


Urine seal: A small foam pad placed over the urethral meatus (the opening of the urethra). It stays in place by suction or an adhesive surface.
Benefits: The pad seals the urethra, preventing urine leakage.

Risks: The seal must be replaced after urinating.

Lifestyle measures

Weight loss: Losing excess weight may help by reducing the extra pressure of your abdomen on your pelvic floor muscles. There's currently insufficient evidence to support weight loss to help with stress incontinence, however.

Dietary changes: Certain foods and beverages can irritate the bladder. Caffeine, for example, is a natural diuretic (causes increased urination) and stimulant for the bladder. Hot spices such as curry, chili pepper or cayenne pepper may contribute to incontinence. Also, citrus juices that are more acidic --such as grapefruit, oranges, limes and lemons -- may worsen symptoms.

Complications
Untreated stress urinary incontinence may cause you to withdraw socially for fear of embarrassing accidents. Constant urine leakage may lead to skin breakdown, and incomplete emptying of the bladder can increase the risk of urinary infections.

Pregnancy-specific information
Again, pregnancy and childbirth may affect the supporting structures of the bladder and urethra, increasing the risk of developing stress urinary incontinence.

Senior-specific information
Although the risk of developing stress urinary incontinence increases with age, incontinence is not a normal part of aging process. If you have symptoms of urinary incontinence, consult your doctor.

Prevention
Make sure to drink enough fluids to help keep your bladder and urinary system flushed out (1.5 to 2 quarts per day) unless otherwise advised by your doctor (such as with fluid-restriction diets, etc.) Kegel excercises should be done regularly to maintain dryness. It's also helpful to learn to tighten those muscles right before sneezing, coughing, jumping or lifting.
If you experience incontinence while you exercise, avoid alcohol and caffeinated beverages (such as coffee or soda) two to three hours before exercising, and urinate right before your workout. To prevent dehydration, drink plenty of other fluids to regularly replace your fluid loss while exercising.