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Stress Urinary Incontinence


Stress urinary incontinence (SUI) refers to the leakage of urine during everyday activities like coughing, sneezing, laughing or exercising. Doctors often treat female SUI with a transvaginal mesh implant called a bladder sling.

As people age, one of the unfortunate side effects is weakened pelvic muscles, which can lead to the embarrassing medical condition of stress urinary incontinence (SUI). When a man or a woman has SUI, he or she leaks urine during normal everyday activities that place pressure on the bladder, such as coughing, sneezing, laughing or exercising.

To control urination, two muscles must be used: the sphincter and the detrusor. The sphincter is a muscle that wraps around the urethra tube, which carries urine out of the body. Squeezing the sphincter stops the flow of urine. The detrusor is the bladder wall muscle, which must be relaxed for the bladder to fill with urine and contracted for it to empty.

If the pressure between these two muscles is even, a person will remain continent. When the pressure on the urethra decreases while it increases on the bladder, a person has the urge to urinate and will void normally. However, someone suffering from SUI does not have control of the sphincter and the pressures are not balanced, causing leakage.

SUI is rare in men, although it can occur after a prostatectomy (removal of the prostate). Women are the primary sufferers, because pregnancy and childbirth weaken the pelvic muscles.

Because SUI is an embarrassing condition, and one patients may not even want to discuss with their doctors, it is under-reported and under-diagnosed. In one 2004 National Institutes of Health study, the rate of SUI in women in the United States varied between 4 percent and 35 percent. The Food and Drug Administration (FDA) says it’s between 20 and 40 percent.

Conservative treatments for SUI include Kegel exercises, losing weight, reducing caffeine intake and avoiding strenuous activities. For mild cases, women can wear absorbent pads. In severe cases, surgery may be necessary to correct incontinence. Bladder slings — narrow strips of tissue or surgical mesh — can be implanted below the bladder to restore continence. However, when these slings are implanted transvaginally, or through the vagina, there can be serious complications.

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By its nature, SUI is likely to affect the quality of life for a woman because it interferes with romantic relationships, social activities and even careers. When a woman cannot be confident she will not leak urine in public, it certainly curtails her desire to engage in personal and professional activities.

Stress Urinary Incontinence Causes

Stress urinary incontinence is most often seen in women who have had more than one pregnancy with vaginal deliveries. It is believed that a woman’s pregnant uterus causes anatomical changes in the urethra and bladder.

“Studies using ultrasound have shown that the angle between the bladder neck and the urethra increases, producing a larger opening of the bladder neck. There is also increased mobility of the bladder due to hormonal changes in pregnancy, which also can affect the pelvic floor complex,” reports Nursing Times.

In addition, second-stage labor, or the active phase, is blamed for a higher risk of SUI because of muscle damage. Multiple vaginal deliveries also jeopardize a woman’s urinary tract, and there is some debate whether the use of forceps during delivery injures pelvic muscles.

Other causes of SUI include:
Age: Pelvic muscles and tissues usually lose elasticity and weaken over time. Plus, lower estrogen levels after menopause contribute to SUI.
Obesity: Excess weight puts unnecessary strain on the bladder and urethra.
Smoking: Chronic coughing increases pressure on the bladder and urethra.
Pelvic surgery (including hysterectomy): Even if pelvic muscles are not damaged during surgery, they can be weakened afterward.
Excessive urine production: When the urethra and bladder cannot keep up with urine production, leakage can occur.
Caffeine intake: Caffeine both stimulates and irritates the bladder.
Medications: Some drugs, such as diuretics, can contribute to SUI.

Symptoms of Stress Urinary Incontinence

It is normal for a woman who experiences an involuntary loss of urine to wonder whether that is a sign of stress urinary incontinence. She may think that the leaking of urine must happen frequently and in great volumes, but that’s not true. Any regular loss of urine — from drops to tablespoons or more — is considered SUI.

Unfortunately, stress urinary incontinence often occurs during the most inopportune times, when physical activities put pressure on the bladder and urethra, causing the leakage. Normal involuntary reactions, such as coughing, sneezing and laughing, are enough to cause the loss of urine when there is pelvic muscle damage. Exercise, and even sexual intercourse, can be the culprits as well. SUI is not preceded by the urge to urinate.

Because of the range in severity of SUI, there are many ways to evaluate and then treat the different levels of the condition.

Diagnosing Stress Urinary Incontinence

Stress urinary incontinence first may be noticed by the patient. It can then be diagnosed by a primary care doctor using a pelvic exam or rectal exam to assess the pelvic floor. The patient will be asked to describe the episodes of leakage, often with the help of a bladder journal kept prior to seeing the doctor. In addition, the doctor will ask about medical history and take a urine sample to test for abnormalities.

Once the initial diagnosis of SUI is made, the doctor will discuss how lifestyle factors, such as diet and exercise, can affect SUI. The patient likely will be referred to a urologist or urogynecologist for confirmation of the type of incontinence and a detailed treatment plan.

These specialists may opt to perform any of the following tests in their evaluations:
Ultrasound Blood work.
X-rays with contrast. Urinary stress test.
Urinalysis. Cystoscopy.

A urinary stress test can be performed in the doctor’s office and involves inserting a catheter into the bladder through the urethra to add fluid. Once the bladder is full, the patient is asked to cough and the doctor measures the fluid loss.

In a cystoscopy, a small, lighted tool is inserted through the urethra into the bladder to study hard-to-view areas. Instruments can be used with the cystoscope to collect tissue and urine samples. This procedure is done with a numbing jelly on the urethra to prevent discomfort, but doctors also may choose to give a sedative or anesthesia intravenously.

Treating Stress Urinary Incontinence

The level of treatment for stress urinary incontinence depends on the doctor, the severity of the condition and the willingness of the patient to participate in treatments. Primary care physicians are not always up to date on the most effective methods for treating SUI, which is why patients may want to see a specialist to direct their care. In turn, patients must be willing to overcome their fears of certain treatments in order to find what will best solve the medical problem for them.

Conservative Treatment

Doctors often will begin treatment by suggesting the least-invasive options. Patients experiencing minimal leakage may be comfortable wearing absorbent pads and not going to extensive measures to stop the urine loss.

Others may be willing to make some lifestyle changes as a trade-off for lessening the symptoms of SUI.

These behavior modifications can include:
Weight loss (for patients who are obese).
Reducing caffeine intake among coffee- and soda-drinkers.
Avoidance of strenuous activities.

In addition, patients can perform Kegel exercises, in which they practice flexing their pelvic muscles. Female patients also might be given the option of using a vaginal pessary, which is a removable silicone device that provides pelvic support. It must be taken out for periodic cleaning, but typically can last up to five years. Topical estrogen is used in connection with a pessary for lubrication and to reduce irritation.

Finally, there are different types of drug therapies. Collagen injections help build up the area around the urethra, preventing urine leakage.

Medications can be used for mild to moderate incontinence and include:
Anticholinergic drugs to control overactive bladder.
Antimuscarinic drugs to block bladder contractions.
Alpha-adrenergic agonist drugs to strengthen the sphincter.
Imipramine, a tricyclic antidepressant.

Surgical Treatment

To repair SUI, a doctor can create an abdominal incision and then stitch together the patient’s tissues to keep the urethra in its correct position. This is called a Burch urethropexy.

Doctors can also surgically insert a “bladder sling” — a strip of material made from the patient’s own tissue or a synthetic mesh that is threaded under the urethra and anchored on both sides, raising and supporting the tube. Wider slings also compress the bladder and top of the urethra to prevent leakage.

Since their debut in the 1990s, bladder slings have become the most common type of surgical treatment for SUI. In 2010, 260,000 women had surgery to repair SUI, and 208,000 of them had mesh bladder slings inserted through the vaginal (transvaginally).

Unfortunately, bladder slings have been linked to serious complications. Between 2008 and 2010, the FDA received 1,371 reports of complications associated with transvaginal placement of bladder slings. The FDA says it will continue to evaluate the data on SUI surgeries using surgical mesh and issue a report later.

After having a bladder sling implanted, patients may have difficulty urinating or their incontinence may return. They also face the risk of infection, internal bleeding, inflammation and pain.

In the worst-case scenario, a bladder sling erodes into nearby tissues and can perforate pelvic organs. Patients may face one or more revision surgeries to address the problems, which are not always reversible.

Another related surgery to correct SUI is bladder repositioning. This surgery uses a patient’s own tissues to reinforce the bladder wall, to restore normal functioning of the bladder.