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Definition
Stress incontinence is an
involuntary loss of urine that occurs during physical activity, such as
coughing, sneezing, laughing, or exercise.
Causes
The ability to hold urine and
control urination depends on the normal function of the lower urinary tract,
the kidneys, and the nervous system. You must also have the ability to
recognize and respond to the urge to urinate.
The average adult bladder can hold over 2 cups (350ml - 550 ml) of urine.
Two muscles are involved in the control of urine flow:
1. The sphincter, which is a circular muscle surrounding the urethra. You
must be able to squeeze this muscle to prevent urine from leaking out.
2. 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 muscle and the pelvic muscles, which support the bladder and
urethra, are weakened. The sphincter is not able to prevent urine flow when
there is increased pressure from the abdomen (such as when you cough, laugh,
or lift something heavy).
Stress incontinence may occur as a result of weakened pelvic muscles that
support the bladder and urethra or because of a malfunction of the urethral
sphincter. The weakness may be caused by:
1. Injury to the urethral area
2. Some medications
3. Surgery of 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 multiple pregnancies
and vaginal childbirths, and whose bladder, urethra, or rectal wall stick
out into the vagina (pelvic prolapse).
Risk factors for stress incontinence include:
1. Being female
2. Childbirth
3. Chronic coughing (such as chronic bronchitis and asthma)
4. Getting older
5. Obesity
6. Smoking
Symptoms
The main symptom of stress
incontinence is involuntary loss of urine. It may occur when:
1. Coughing
2. Sneezing
3. Standing
4. Exercising
5. Engaging in other physical activity
6. Engaging in sexual intercourse
Exams and Tests
The health care provider will
perform a physical exam, including a:
1. Genital exam in men
2. Pelvic exam in women
3. Rectal exam
In some women, a pelvic examination
may reveal that the bladder or urethra is bulging into the vaginal space.
Tests may include:
1. Inspection of the inside of the bladder (cystoscopy)
2. Pad test (after placement of a preweighed sanitary pad, the patient is
asked to exercise -- following exercise, the pad is reweighed to determine
the amount of urine loss)
3. Pelvic or abdominal ultrasound
4. Post-void residual (PVR) to measure amount of urine left after urination
5. Rarely, an electromyogram (EMG) is performed to study muscle activity in
the urethra or pelvic floor
6. Tests to measure pressure and urine flow (urodynamic studies)
7. Urinalysis or urine culture to rule out urinary tract infection
8. Urinary stress test (the patient is asked to stand with a full bladder,
and then cough)
9. X-rays with contrast dye of the kidneys and bladder
The health care provider may also
measure the change in the angle of the urethra when at rest and when
straining (Q-tip test). An angle change of greater than 30 degrees often
means there is significant weakness of the muscles and tissues that support
the bladder.
Treatment
Treatment depends on how severe the
symptoms are and how much they interfere with your everyday life.
The doctor may ask that you 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 urinary leaking occurs.
There are four major categories of treatment for stress incontinence:
1. Behavioral changes
2. Medication
3. Pelvic floor muscle training
4. Surgery
BEHAVIORAL CHANGE
Examples of behavior changes include:
1. Decreasing any excessive fluid intake (you should not decrease your fluid
intake if you drink normal amounts of fluid)
2. Urinating more frequently to decrease the amount of urine that leaks
3. Changing physical activities to avoid jumping or running movements, which
can cause more urine leakage
4. Regulating bowel movements with dietary fiber or laxatives to avoid
constipation (which can worsen incontinence)
5. Quitting smoking to reduce coughing and bladder irritation (and your risk
of bladder cancer)
6. Avoiding alcohol and caffeine, which can overstimulate the bladder
7. Losing weight if you are overweight
8. Avoiding food and drinks that irritate the bladder, such as spicy foods,
carbonated beverages, and citrus
9. 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 improve the strength and function of the
urethral sphincter.
Some women may use a device called a vaginal cone along with pelvic
exercises. The cone is placed into the vagina, and the woman tries to
contract the pelvic floor muscles in an effort to hold it in place. The
device may be worn for up to 15 minutes. This procedure should be done two
times a day. Within 4 - 6 weeks, most women have some improvement in their
symptoms.
Biofeedback and electrical stimulation may be helpful for those who have
trouble doing pelvic muscle training exercises. These two methods can help
you identify the correct muscle group to work. Biofeedback is a method that
helps you learn how to control certain involuntary body responses.
Electrical stimulation therapy uses 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 doctor's office or at home.
Treatment sessions usually last 20 minutes and may be done every 1 - 4 days.
Newer techniques are being investigated, including one that uses a specially
designed electromagnetic chair that causes the pelvic floor muscles to
contract when the patient is seated.
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:
1. Anticholinergic agents (oxybutynin, tolterodine, enablex, sanctura,
vesicare, oxytrol)
2. Antimuscarinic drugs block bladder contractions (many doctors prescribe
these types of drugs first)
3. 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
4. Imipramine, a tricyclic antidepressant, works in a similar way to
alpha-adrenergic drugs
Estrogen therapy can be used to
improve urinary frequency, urgency, and burning in postmenopausal women. It
also can improve the tone and blood supply of the urethral sphincter
muscles.
However, whether estrogen treatment improves stress incontinence is
controversial. Women with a history of breast or uterine cancer usually
should NOT use estrogen therapy for the treatment of stress urinary
incontinence.
SURGERIES
Surgical treatment is only recommended after the exact cause of the urinary
incontinence has been determined. Most of the time, your doctor will try
bladder retraining or Kegel exercises before considering surgery.
1. Anterior vaginal repair or paravaginal repair procedures are often done
in women when the bladder is bulging into the vagina (a condition is called
a cystocele). Anterior repair is done through a surgical cut in the vagina,
and a paravaginal repair is done through a surgical cut in the vagina or
abdomen
2. Artificial urinary sphincter is a surgical device used to treat stress
incontinence mainly in men (rarely in women)
3. 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 to achieve bladder control)
4. Retropubic suspension are a group of surgical procedures done to lift the
bladder and urethra. They are done through a surgical cut in the abdomen.
The Burch colposuspension and Marshall-Marchetti-Krantz (MMK) procedures
differ based on the structures that are used to anchor and support the
bladder
5. Tension-free vaginal tape
6. Vaginal sling procedures are often the first choice for the treatment of
uncomplicated stress incontinence in women (it is rarely done in men). A
sling made of synthetic material is placed so that it supports the urethra
Most health care providers advise
their patients to try other treatments before having surgery.
Depending on the success of treatment and other medical problems the person
may have, some people may require a urinary catheter to drain urine from the
bladder.
Outlook (Prognosis)
Behavioral changes, pelvic floor
exercise therapy, and medication usually improve symptoms rather than cure
stress incontinence. Surgery can cure most carefully selected patients.
Treatment does not work as well in people with:
1. Conditions that may prevent healing or make surgery more difficult
2. Other genital or urinary problems
3. Previous surgical failures
Possible
Complications
Complications are rare and usually
mild. They can include:
1. Erosion of surgically placed materials such as a sling or artificial
sphincter
2. Fistulas or abscesses
3. Irritation of the vulva (vaginal lips)
4. Pain during intercourse
5. Skin breakdown and pressure ulcers in bed- or chair-bound patients
6. Unpleasant odors
7. Urinary tract infections
8. Vaginal discharge
The condition may affect or disrupt
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
are bothersome.
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.
Alternative Names
Incontinence - stress
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: Sauders
Elsevier; 2007: chap 3.
Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary
incontinence does this woman have? JAMA. 2008; 299:1446-1456.
Rogers RG. Clinical practice. Urinary stress incontinence in women. N Engl J
Med. 2008; 358:1029-1036.
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