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Stress incontinence
Definition
Stress incontinence is losing urine without meaning to during physical activity, such as coughing, sneezing, laughing, or exercise.
Alternative Names
Incontinence - stress
Causes
To hold urine and control urination, the lower urinary tract and nervous system need to be working normally. You must also be able to recognize and respond to the urge to urinate.
The average adult bladder can hold over 2 cups (350 ml - 550 ml) of urine. Two muscles are involved in controlling urine flow:
- The sphincter, which is a circle-shaped muscle around the urethra. You must be able to squeeze this muscle to prevent urine from leaking out.
- The detrusor, which is the muscle of the bladder wall. This must stay relaxed so that the bladder can expand.
In stress incontinence, the sphincter pelvic muscles, which support the bladder and urethra, are weakened. The sphincter is not able to prevent urine from flowing when pressure is placed on the abdomen (such as when you cough, laugh, or lift something heavy).
Stress incontinence may occur from weakened pelvic muscles that support the bladder and urethra or because the urethral sphincter is not working correctly. Weakness may be caused by:
- Childbirth
- Injury to the urethra area
- Some medications
- Surgery in the prostate or pelvic area
Stress urinary incontinence is the most common type of urinary incontinence in women.
Stress incontinence is often seen in women who have had more than one pregnancy and vaginal delivery. It is also common in women whose bladder, urethra, or rectum wall stick out into the vagina (pelvic prolapse).
Risk factors for stress incontinence include:
- Being female
- Childbirth
- Coughing over a long period of time (such as chronic bronchitis and asthma)
- Getting older
- Obesity
- Smoking
Symptoms
The main symptom of stress incontinence is losing urine without your control. It may occur when you:
- Cough
- Exercise
- Have sexual intercourse
- Sneeze
- Stand
- Take part in physical activity
Exams and Tests
The health care provider will perform a physical exam, including a:
- Genital exam in men
- Pelvic exam in women
- Rectal exam
In some women, a pelvic examination may show that the bladder or urethra is bulging into the vagina.
Tests may include:
- Electromyogram (EMG) is (rarely) done to study muscle activity in the urethra or pelvic floor
- Pad test (you are asked to exercise while wearing a sanitary pad-- after you exercise, the pad is weighed to find out how much urine you have lost)
- Pelvic or abdominal ultrasound
- Post-void residual (PVR) to measure the amount of urine left after urination
- Tests to measure pressure and urine flow (urodynamic studies)
- Test to view the inside of the bladder (cystoscopy)
- Urinalysis or urine culture to rule out urinary tract infection
- Urinary stress test (you are asked to stand with a full bladder, and then cough)
- X-rays with contrast dye of the kidneys and bladder
Treatment
Treatment depends on how severe your symptoms are and how much they affect your everyday life.
Your health care provider may ask you to stop smoking (if you smoke) and avoid caffeinated beverages (such as soda) and alcohol. You may be asked to keep a urinary diary, recording how many times you urinate during the day and night, and how often you leak urine.
There are four types of treatment for stress incontinence:
- Behavior changes
- Medication
- Pelvic floor muscle training
- Surgery
BEHAVIOR CHANGES
Examples of behavior changes include:
- Drinking less fluid (if you drink more than normal amounts of fluid)
- Urinating more often to reduce the amount of urine that leaks
- Avoiding jumping or running, which can cause more urine to leak
- Making your bowel movements more regular by taking dietary fiber or laxatives to avoid constipation (which can make incontinence worse)
- Quitting smoking to reduce coughing and bladder irritation (and your risk of bladder cancer)
- Avoiding alcohol and caffeine, which can stimulate the bladder
- Losing weight if you are overweight
- Avoiding food and drinks that irritate the bladder, such as spicy foods, carbonated drinks, and citrus fruits
- Keeping blood sugar under control if you have diabetes
PELVIC FLOOR MUSCLE TRAINING
Pelvic muscle training exercises (called Kegel exercises) may help control urine leakage. These exercises keep the urethral sphincter strong and working properly.
Some women may use a device called a vaginal cone with pelvic exercises. You place the cone into the vagina. Then you try to squeeze the pelvic floor muscles to hold the cone in place. You can wear the cone for up to 15 minutes at a time, twice a day. Within 4 to 6 weeks, most women have some improvement in their symptoms.
Biofeedback and electrical stimulation may be helpful for people who have trouble doing pelvic muscle training exercises. These two methods can help you find the correct muscle group to work. Biofeedback can also help you learn how to control certain body responses.
Electrical stimulation therapy uses a low-voltage electrical current to stimulate and contract the correct group of muscles. The current is delivered using an anal or vaginal probe. The electrical stimulation therapy may be done at the health care provider's office or at home.
Treatment sessions usually last 20 minutes and may be done every 1 to 4 days. Newer techniques are being studied. One new technique uses an electromagnetic chair to make the pelvic floor muscles contract when the person is sitting.
MEDICATIONS
Medicines tend to work better in patients with mild to moderate stress incontinence. There are several types of medications that may be used alone or in combination. They include:
- Anticholinergic drugs control overactive bladder (oxybutynin, tolterodine, Enablex, Sanctura, Vesicare, Oxytrol)
- Antimuscarinic drugs block bladder contractions (many health care providers prescribe these types of drugs first)
- Alpha-adrenergic agonist drugs, such as phenylpropanolamine and pseudoephedrine (common ingredients in over-the-counter cold medications), help increase sphincter strength and improve symptoms in many patients. However, these drugs are rarely prescribed because of possible side effects on the heart.
- Imipramine, a tricyclic antidepressant, works much like the alpha-adrenergic and anticholinergic drugs
Estrogen therapy can be used to improve urinary frequency, urgency, and burning in women who have gone through menopause. It also can improve the tone and blood supply of the urethral sphincter muscles.
However, it is not clear whether estrogen treatment improves stress incontinence. Some hormone treatments given after menopause have been shown more harmful than helpful to women's health. Women who have a history of breast or uterine cancer usually should NOT use estrogen therapy to treat stress urinary incontinence.
SURGERIES
Surgery is only recommended after the exact cause of urinary incontinence has been found. Most of the time, your health care provider will try bladder retraining or Kegel exercises before considering surgery.
- Anterior vaginal repair or paravaginal repair procedures are often done in women when the bladder is bulging into the vagina (called a cystocele). Anterior repair is done through a surgical cut in the vagina. A paravaginal repair is done through a surgical cut in the vagina or abdomen.
- Artificial urinary sphincter is a surgical device used to treat stress incontinence mainly in men (rarely in women).
- Collagen injections make the area around the urethra thicker, which helps control urine leakage (the procedure may need to be repeated after a few months).
- Male sling is a newer procedure that can be done in certain men. It is easier to do than placing an artificial urinary sphincter.
- Retropubic suspensions are a group of surgical procedures done to lift the bladder and urethra. They are done through a surgical cut in the abdomen.
- Tension-free vaginal tape
- Vaginal sling procedures are often the first choice for treating stress incontinence in women (they are rarely done in men). A sling is placed that supports the urethra.
Most health care providers recommend that their patients try other treatments before having surgery.
Depending on the success of treatment and other medical problems you have, you may need a urinary catheter to drain urine from the bladder.
Outlook (Prognosis)
Behavior changes, pelvic floor exercise therapy, and medication usually improve symptoms. However, they will not cure stress incontinence. Surgery can cure patients, if they are good candidates.
Treatment does not work as well in people with:
- Conditions that prevent healing or make surgery more difficult
- Other genital or urinary problems
- Past surgery that did not work
Possible Complications
Complications are rare and usually mild, but they can include:
- Wearing away of materials placed during surgery, such as a sling or artificial sphincter
- Fistulas or abscesses
- Irritation of the vagina lips (vulva)
- Pain during intercourse
- Skin breakdown and sores in people who cannot get out of the bed or chair
- Unpleasant odors
- Urinary tract infections
- Vaginal discharge
The condition may get in the way of social activities, careers, and relationships.
When to Contact a Medical Professional
Call for an appointment with your health care provider if you have symptoms of stress incontinence and they bother you.
Prevention
Performing Kegel exercises (tightening the muscles of the pelvic floor as if trying to stop the urine stream) may help prevent symptoms. Doing Kegel exercises during and after pregnancy can decrease the risk of developing stress urinary incontinence after childbirth.
References
Gerber GS, Brendler CB. Evaluation of the urologic patient: history, physical examination, and urinalysis. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 3.
Resnnick NM. Incontinence. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 25.
Deng DY. Urinary incontinence in women. Med Clin North Am. 2011;95:101-109.
Reviewed By: Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine; and Scott Miller, MD, Urologist in private practice in Atlanta, Georgia. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
